Quality in trauma care: improving the discharge procedure of patients by means of Lean Six Sigma.

PubMed

Niemeijer, Gerard C; Trip, Albert; Ahaus, Kees T B; Does, Ronald J M M; Wendt, Klaus W

2010-09-01

The University Medical Center Groningen is a level I trauma center in the northern part of the Netherlands. Sixty-three percent of all the patients admitted at the Trauma Nursing Department (TND) are acute patients who are admitted directly after trauma. In 2006 and 2007, the University Medical Center Groningen was not always capable of admitting all trauma patients to the TND due to the relatively high-bed occupation. Therefore, the reduction of the average length of stay (LOS) formed the objective of the project described in this study. We used the process-focused method of Lean Six Sigma to reduce hospital stay by improving the discharge procedure of patients in the care processes and eliminating waste and waiting time. We used the "Dutch Appropriateness Evaluation Protocol" to identify the possible causes of inappropriate hospital stay. The average LOS of trauma patients at the TND at the beginning of the project was 10.4 days. Thirty percent of the LOS was unnecessary. The main causes of the inappropriate hospital stay were delays in several areas. The implementation of the improvement plan reduced almost 50% of the inappropriate hospital stay, enabling the trauma center to admit almost all trauma patients to the TND. After the implementation of the improvements, the average LOS was 8.5 days. Our study shows that Lean Six Sigma is an effective method to reduce inappropriate hospital stay, thereby improving the quality and financial efficiency of trauma care.

Bystander first aid in trauma - prevalence and quality: a prospective observational study.

PubMed

Bakke, H K; Steinvik, T; Eidissen, S-I; Gilbert, M; Wisborg, T

2015-10-01

Bystander first aid and basic life support can likely improve victim survival in trauma. In contrast to bystander first aid and out-of-hospital cardiac arrest, little is known about the role of bystanders in trauma response. Our aim was to determine how frequently first aid is given to trauma victims by bystanders, the quality of this aid, the professional background of first-aid providers, and whether previous first-aid training affects aid quality. We conducted a prospective 18-month study in two mixed urban-rural Norwegian counties. The personnel on the first ambulance responding to trauma calls assessed and documented first aid performed by bystanders using a standard form. A total of 330 trauma calls were included, with bystanders present in 97% of cases. Securing an open airway was correctly performed for 76% of the 43 patients in need of this first-aid measure. Bleeding control was provided correctly for 81% of 63 patients for whom this measure was indicated, and prevention of hypothermia for 62% of 204 patients. Among the first-aid providers studied, 35% had some training in first aid. Bystanders with documented first-aid training gave better first aid than those where first-aid training status was unknown. A majority of the trauma patients studied received correct pre-hospital first aid, but still there is need for considerable improvement, particularly hypothermia prevention. Previous first-aid training seems to improve the quality of first aid provided. The effect on patient survival needs to be investigated. © 2015 The Authors. The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.

Donabedian's structure-process-outcome quality of care model: Validation in an integrated trauma system.

PubMed

Moore, Lynne; Lavoie, André; Bourgeois, Gilles; Lapointe, Jean

2015-06-01

According to Donabedian's health care quality model, improvements in the structure of care should lead to improvements in clinical processes that should in turn improve patient outcome. This model has been widely adopted by the trauma community but has not yet been validated in a trauma system. The objective of this study was to assess the performance of an integrated trauma system in terms of structure, process, and outcome and evaluate the correlation between quality domains. Quality of care was evaluated for patients treated in a Canadian provincial trauma system (2005-2010; 57 centers, n = 63,971) using quality indicators (QIs) developed and validated previously. Structural performance was measured by transposing on-site accreditation visit reports onto an evaluation grid according to American College of Surgeons criteria. The composite process QI was calculated as the average sum of proportions of conformity to 15 process QIs derived from literature review and expert opinion. Outcome performance was measured using risk-adjusted rates of mortality, complications, and readmission as well as hospital length of stay (LOS). Correlation was assessed with Pearson's correlation coefficients. Statistically significant correlations were observed between structure and process QIs (r = 0.33), and process and outcome QIs (r = -0.33 for readmission, r = -0.27 for LOS). Significant positive correlations were also observed between outcome QIs (r = 0.37 for mortality-readmission; r = 0.39 for mortality-LOS and readmission-LOS; r = 0.45 for mortality-complications; r = 0.34 for readmission-complications; 0.63 for complications-LOS). Significant correlations between quality domains observed in this study suggest that Donabedian's structure-process-outcome model is a valid model for evaluating trauma care. Trauma centers that perform well in terms of structure also tend to perform well in terms of clinical processes, which in turn has a favorable influence on patient outcomes. Prognostic study, level III.

Trauma quality improvement: The Pietermaritzburg Metropolitan Trauma Service experience with the development of a comprehensive structure to facilitate quality improvement in rural trauma and acute care in KwaZulu-Natal, South Africa.

PubMed

Clarke, Damian Luiz

2015-01-03

Improving the delivery of efficient and effective surgical care in rural South Africa is a mammoth task bedevilled by conflict between the stakeholders, who include rural doctors, surgeons, ancillary staff, researchers, educators and administrators. Management training is not part of most medical school curricula, yet as they progress in their careers, many clinicians are required to manage a health system and find the shift from caring for individual patients to managing a complex system difficult. Conflict arises when management-type interventions are imposed in a top-down manner on surgical staff suspicious of an unfamiliar field of study. Another area of conflict concerns the place of surgical research. Researchers are often accused of not being sufficiently focused on or concerned about the tasks of service delivery. This article provides an overview of management theory and describes a comprehensive management structure that integrates a model for health systems with a strategic planning process, strategic planning tools and appropriate quality metrics, and shows how the Pietermaritzburg Metropolitan Trauma Service in KwaZulu-Natal Province, South Africa, successfully used this structure to facilitate and contextualise a diverse number of quality improvement programmes and research initiatives in the realm of rural acute surgery and trauma. We have found this structure to be useful, and hope that it may be applied to other acute healthcare systems.

Nursing role innovations: improved outcomes in a trauma center.

PubMed

Holmquist, P J; Yamamoto, L; DiDonna, D; Sise, M J

1996-01-01

Trauma systems operate on the principle that people with severe injuries require special medical capabilities if they are to have their best chance of recovery. However, optimal trauma care is threatened by the problems of inadequate financial reimbursement. This threatens the ability to deliver trauma patient care. A variety of strategies is necessary to continue to provide care. Two specific nursing role innovations provide the opportunity to improve the ability to provide coordinated, efficient, and cost-effective quality care.

Health care reform at trauma centers--mortality, complications, and length of stay.

PubMed

Shafi, Shahid; Barnes, Sunni; Nicewander, David; Ballard, David; Nathens, Avery B; Ingraham, Angela M; Hemmila, Mark; Goble, Sandra; Neal, Melanie; Pasquale, Michael; Fildes, John J; Gentilello, Larry M

2010-12-01

The Trauma Quality Improvement Program has demonstrated existence of significant variations in risk-adjusted mortality across trauma centers. However, it is unknown whether centers with lower mortality rates also have reduced length of stay (LOS), with associated cost savings. We hypothesized that LOS is not primarily determined by unmodifiable factors, such as age and injury severity, but is primarily dependent on the development of potentially preventable complications. The National Trauma Data Bank (2002-2006) was used to include patients (older than 16 years) with at least one severe injury (Abbreviated Injury Scale score ≥ 3) from Level I and II trauma centers (217,610 patients, 151 centers). A previously validated risk-adjustment algorithm was used to calculate observed-to-expected mortality ratios for each center. Poisson regression was used to determine the relationship between LOS, observed-to-expected mortality ratios, and complications while controlling for confounding factors, such as age, gender, mechanism, insurance status, comorbidities, and injuries and their severity. Large variations in LOS (median, 4-8 days) were observed across trauma centers. There was no relationship between mortality and LOS. The most important predictor of LOS was complications, which were associated with a 62% increase. Injury severity score, shock, gunshot wounds, brain injuries, intensive care unit admission, and comorbidities were less important predictors of LOS. Quality improvement programs focusing on mortality alone may not be associated with reduced LOS. Hence, the Trauma Quality Improvement Program should also focus on processes of care that reduce complications, thereby shortening LOS, which may lead to significant cost savings at trauma centers.

Assessment of trauma quality improvement activities at public hospitals in Thailand.

PubMed

Fuangworawong, Phuphit; LaGrone, Lacey N; Chadbunchachai, Witaya; Sornsrivichai, Vorasith; Mock, Charles N; Vavilala, Monica S

2016-09-01

Given the current exceptional burden of injury in Thailand, the proven efficacy of quality improvement programs, and the current scarcity of national-level information on trauma quality improvement program (TQIP) implementation in Thailand, we aimed to examine the use of TQIPs and barriers to TQIP adoption in Thai public trauma centers. We distributed a survey to 110 public hospitals which are designated to provide trauma care in Thailand. The survey assessed the presence or absence of the four core elements of the World Health Organization (WHO) recommended TQIPs (morbidity and mortality (M&M) conferences, preventable death panels, trauma registries, and audit filters), and provider perception of barriers and priorities in TQIP implementation. Responses were received from 80 (72%) respondents. Seventy-two (90%) reported having a trauma registry and seventy (88%) respondents reported use of audit filters. Seventy (88%) respondents reported conducting regular M&M conferences, and 45 (56%) respondents reported the presence of preventable death panels. Thirty-eight (48%) respondents reported presence of all four elements of WHO TQIPs. The most commonly reported barriers to implementing TQIPs were lack of interest (55; 68%) and lack of time (39; 48%)to implement TQIPs. Audit filters were reported by only 25 (31%) of respondents and optimization of audit filters was the most frequently identified next-step in further development of TQIP. Just under half of responding Thai public trauma centers reported implementation of all four elements of the WHO recommended TQIPs. Priority strategies to facilitate TQIP maturation in Thailand should address staff motivation, provision of staff time for TQIP development, and optimization of audit filter use to monitor quality of care. Copyright © 2016 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.

Understanding and Addressing the Global Need for Orthopaedic Trauma Care.

PubMed

Agarwal-Harding, Kiran J; von Keudell, Arvind; Zirkle, Lewis G; Meara, John G; Dyer, George S M

2016-11-02

➤The burden of musculoskeletal trauma is high worldwide, disproportionately affecting the poor, who have the least access to quality orthopaedic trauma care.➤Orthopaedic trauma care is essential, and must be a priority in the horizontal development of global health systems.➤The education of surgeons, nonphysician clinicians, and ancillary staff in low and middle income countries is central to improving access to and quality of care.➤Volunteer surgical missions from rich countries can sustainably expand and strengthen orthopaedic trauma care only when they serve a local need and build local capacity.➤Innovative business models may help to pay for care of the poor. Examples include reducing costs through process improvements and cross-subsidizing from profitable high-volume activities.➤Resource-poor settings may foster innovations in devices or systems with universal applicability in orthopaedics. Copyright © 2016 by The Journal of Bone and Joint Surgery, Incorporated.

Portrait of trauma care in Quebec's rural emergency departments and identification of priority intervention needs to improve the quality of care: a study protocol

PubMed Central

Fleet, Richard; Tounkara, Fatoumata Korika; Ouimet, Mathieu; Dupuis, Gilles; Poitras, Julien; Tanguay, Alain; Fortin, Jean Paul; Trottier, Jean-Guy; Ouellet, Jean; Lortie, Gilles; Plant, Jeff; Morris, Judy; Chauny, Jean Marc; Lauzier, François; Légaré, France

2016-01-01

Introduction Trauma remains the primary cause of death in individuals under 40 years of age in Canada. In Quebec, the Trauma Care Continuum (TCC) has been demonstrated to be effective in decreasing the mortality rate among trauma victims. Although rural citizens are at greater risk for trauma and trauma death, no empirical data concerning the effectiveness of the TCC for the rural population in Quebec are available. The emergency departments (EDs) are important safety nets for rural citizens. However, our data indicate that access to diagnostic support services, such as intensive care units and CT is limited in rural areas. The objectives are to (1) draw a portrait of trauma services in rural EDs; (2) explore geographical variations in trauma care in Quebec; (3) identify adaptable factors that could reduce variation; and (4) establish consensus solutions for improving the quality of care. Methods and analysis The study will take place from November 2015 to November 2018. A mixed methodology (qualitative and quantitative) will be used. We will include data (2009–2013) from all trauma victims treated in the 26 rural EDs and tertiary/secondary care centres in Quebec. To meet objectives 1 and 2, data will be gathered from the Ministry's Database of the Quebec Trauma Registry Information System. For objectives 3 and 4, the project will use the Delphi method to develop consensus solutions for improving the quality of trauma care in rural areas. Data will be analysed using a Poisson regression to compare mortality rate during hospital stay or death on ED arrival (objectives 1 and 2). Average scores and 95% CI will be calculated for the Delphi questionnaire (objectives 3 and 4). Ethics and dissemination This protocol has been approved by CSSS Alphonse-Desjardins research ethics committee (Project MP-HDL-2016-003). The results will be published in peer-reviewed journals. PMID:27098826

Effectiveness of prehospital trauma triage systems in selecting severely injured patients: Is comparative analysis possible?

PubMed

van Rein, Eveline A J; van der Sluijs, Rogier; Houwert, R Marijn; Gunning, Amy C; Lichtveld, Rob A; Leenen, Luke P H; van Heijl, Mark

2018-01-27

In an optimal trauma system, prehospital trauma triage ensures transport of the right patient to the right hospital. Incorrect triage results in undertriage and overtriage. The aim of this systematic review is to evaluate and compare prehospital trauma triage system quality worldwide and determine effectiveness in terms of undertriage and overtriage for trauma patients. A systematic search of Pubmed/MEDLINE, Embase, and Cochrane Library databases was performed, using "trauma", "trauma center," or "trauma system", combined with "triage", "undertriage," or "overtriage", as search terms. All studies describing ground transport and actual destination hospital of patients with and without severe injuries, using prehospital triage, published before November 2017, were eligible for inclusion. To assess the quality of these studies, a critical appraisal tool was developed. A total of 33 articles were included. The percentage of undertriage ranged from 1% to 68%; overtriage from 5% to 99%. Older age and increased geographical distance were associated with undertriage. Mortality was lower for severely injured patients transferred to a higher-level trauma center. The majority of the included studies were of poor methodological quality. The studies of good quality showed poor performance of the triage protocol, but additional value of EMS provider judgment in the identification of severely injured patients. In most of the evaluated trauma systems, a substantial part of the severely injured patients is not transported to the appropriate level trauma center. Future research should come up with new innovative ways to improve the quality of prehospital triage in trauma patients. Copyright © 2018. Published by Elsevier Inc.

Quality of Care Delivered Before vs After a Quality-Improvement Intervention for Acute Geriatric Trauma.

PubMed

Min, Lillian; Cryer, Henry; Chan, Chiao-Li; Roth, Carol; Tillou, Areti

2015-05-01

Older trauma-injury patients had improved recovery after we implemented routine geriatric consultation for patients aged 65 years and older admitted to the trauma service of a Level I academic trauma center. The intervention aimed to improve quality of geriatric care. However, the specific care processes that improved are unknown. We conducted a prospective observation comparing medical care after (December 2007 to November 2009) vs before (December 2006 to November 2007) implementation of the geriatric consult-based intervention. To measure quality of care (QOC), we used 33 previously validated care-process quality indicators (QIs) from the Assessing the Care of Vulnerable Elders (ACOVE) study, measured by review of medical records for 76 geriatric consult (GC) vs 71 control group patients. As prespecified subgroup analyses, we aggregated QIs by type: geriatric (eg, delirium screening) vs nongeriatric condition-based care (eg, thrombosis prophylaxis) and compared QI scores by type of care. Last, we aggregated QI scores into overall, geriatric, and nongeriatric QOC scores for each patient (number of QIs passed/number of QIs eligible), and compared patient-level QOC for the GC vs control group, adjusting for age, sex, ethnicity, comorbidity, and injury severity. Sixty-three percent of the GC patients vs 11% of the control group patients received a geriatric consultation. We evaluated 2,505 QIs overall (1,664 geriatric type and 841 nongeriatric QIs). In general, fewer geriatric-type QIs were passed than nongeriatric QIs (71% vs 81%; p < 0.001). We provided better overall QOC to the GC (77%) than control group patients (73%; p < 0.05). However, the difference was not statistically significant after multivariable adjustment (p = 0.08). We improved geriatric QOC for the GC (74%) compared with the control group (68%; p < 0.01), a difference that was significant after multivariable adjustment (p = 0.01). Geriatricians and surgeons can collaboratively improve geriatric QOC for older trauma patients. Published by Elsevier Inc.

Scoring systems of severity in patients with multiple trauma.

PubMed

Rapsang, Amy Grace; Shyam, Devajit Chowlek

2015-04-01

Trauma is a major cause of morbidity and mortality; hence severity scales are important adjuncts to trauma care in order to characterize the nature and extent of injury. Trauma scoring models can assist with triage and help in evaluation and prediction of prognosis in order to organise and improve trauma systems. Given the wide variety of scoring instruments available to assess the injured patient, it is imperative that the choice of the severity score accurately match the application. Even though trauma scores are not the key elements of trauma treatment, they are however, an essential part of improvement in triage decisions and in identifying patients with unexpected outcomes. This article provides the reader with a compendium of trauma severity scales along with their predicted death rate calculation, which can be adopted in order to improve decision making, trauma care, research and in comparative analyses in quality assessment. Copyright © 2013 AEC. Publicado por Elsevier España, S.L.U. All rights reserved.

Accuracy of prehospital triage protocols in selecting severely injured patients: A systematic review.

PubMed

van Rein, Eveline A J; Houwert, R Marijn; Gunning, Amy C; Lichtveld, Rob A; Leenen, Luke P H; van Heijl, Mark

2017-08-01

Prehospital trauma triage ensures proper transport of patients at risk of severe injury to hospitals with an appropriate corresponding level of trauma care. Incorrect triage results in undertriage and overtriage. The American College of Surgeons Committee on Trauma recommends an undertriage rate below 5% and an overtriage rate below 50% for prehospital trauma triage protocols. To find the most accurate prehospital trauma triage protocol, a clear overview of all currently available protocols and corresponding outcomes is necessary. The aim of this systematic review was to evaluate the current literature on all available prehospital trauma triage protocols and determine accuracy of protocol-based triage quality in terms of sensitivity and specificity. A search of Pubmed, Embase, and Cochrane Library databases was performed to identify all studies describing prehospital trauma triage protocols before November 2016. The search terms included "trauma," "trauma center," or "trauma system" combined with "triage," "undertriage," or "overtriage." All studies describing protocol-based triage quality were reviewed. To assess the quality of these type of studies, a new critical appraisal tool was developed. In this review, 21 articles were included with numbers of patients ranging from 130 to over 1 million. Significant predictors for severe injury were: vital signs, suspicion of certain anatomic injuries, mechanism of injury, and age. Sensitivity ranged from 10% to 100%; specificity from 9% to 100%. Nearly all protocols had a low sensitivity, thereby failing to identify severely injured patients. Additionally, the critical appraisal showed poor quality of the majority of included studies. This systematic review shows that nearly all protocols are incapable of identifying severely injured patients. Future studies of high methodological quality should be performed to improve prehospital trauma triage protocols. Systematic review, level III.

International trauma teleconference: evaluating trauma care and facilitating quality improvement.

PubMed

Parra, Michael W; Castillo, Roberto C; Rodas, Edgar B; Suarez-Becerra, Jose M; Puentes-Manosalva, Fabian E; Wendt, Luke M

2013-09-01

Evaluation, development, and implementation of trauma systems in Latin America are challenging undertakings as no model is currently in place that can be easily replicated throughout the region. The use of teleconferencing has been essential in overcoming other challenges in the medical field and improving medical care. This article describes the use of international videoconferencing in the field of trauma and critical care as a tool to evaluate differences in care based on local resources, as well as facilitating quality improvement and system development in Latin America. In February 2009, the International Trauma and Critical Care Improvement Project was created and held monthly teleconferences between U.S. trauma surgeons and Latin American general surgeons, emergency physicians, and intensivists. In-depth discussions and prospective evaluations of each case presented were conducted by all participants based on resources available. Care rendered was divided in four stages: (1) pre-hospital setting, (2) emergency room or trauma room, (3) operating room, and (4) subsequent postoperative care. Furthermore, the participating institutions completed an electronic survey of trauma resources based on World Health Organization/International Association for Trauma and Surgical Intensive Care guidelines. During a 17-month period, 15 cases in total were presented from a Level I and a Level II U.S. hospital (n=3) and five Latin American hospitals (n=12). Presentations followed the Advanced Trauma Life Support sequence in all U.S. cases but in only 3 of the 12 Latin American cases. The following deficiencies were observed in cases presented from Latin America: pre-hospital communication was nonexistent in all cases; pre-hospital services were absent in 60% of cases presented; lack of trauma team structure was evident in the emergency departments; during the initial evaluation and resuscitation, the Advanced Trauma Life Support protocol was followed one time and the Clinical Randomization of an Antifibrinolytic in Significant Hemorrhage protocol on two occasions; it was determined that imaging resources were adequately used in half of the cases; the initial care was mostly provided by emergency room physicians; and a surgeon, operating room, and intensive care unit were not readily available 83% of the time. The ease of patient flow was cumbersome because of a lack of a structured system for trauma care except for one academic urban center. Adequate trauma resources are present in less than 50% of the time. Multidisciplinary resources, quality improvement programs, protocols, and guidelines were deficient. A well-structured international teleconference can be used as a dynamic window of observation to evaluate and identify deficiencies in trauma care in the Latin American region. These findings can be used to formulate specific recommendations based on local resources. Furthermore, by raising local awareness, leaders could be identified to become the executors of more efficient healthcare policies that can potentially affect trauma care.

Portrait of trauma care in Quebec's rural emergency departments and identification of priority intervention needs to improve the quality of care: a study protocol.

PubMed

Fleet, Richard; Tounkara, Fatoumata Korika; Ouimet, Mathieu; Dupuis, Gilles; Poitras, Julien; Tanguay, Alain; Fortin, Jean Paul; Trottier, Jean-Guy; Ouellet, Jean; Lortie, Gilles; Plant, Jeff; Morris, Judy; Chauny, Jean Marc; Lauzier, François; Légaré, France

2016-04-20

Trauma remains the primary cause of death in individuals under 40 years of age in Canada. In Quebec, the Trauma Care Continuum (TCC) has been demonstrated to be effective in decreasing the mortality rate among trauma victims. Although rural citizens are at greater risk for trauma and trauma death, no empirical data concerning the effectiveness of the TCC for the rural population in Quebec are available. The emergency departments (EDs) are important safety nets for rural citizens. However, our data indicate that access to diagnostic support services, such as intensive care units and CT is limited in rural areas. The objectives are to (1) draw a portrait of trauma services in rural EDs; (2) explore geographical variations in trauma care in Quebec; (3) identify adaptable factors that could reduce variation; and (4) establish consensus solutions for improving the quality of care. The study will take place from November 2015 to November 2018. A mixed methodology (qualitative and quantitative) will be used. We will include data (2009-2013) from all trauma victims treated in the 26 rural EDs and tertiary/secondary care centres in Quebec. To meet objectives 1 and 2, data will be gathered from the Ministry's Database of the Quebec Trauma Registry Information System. For objectives 3 and 4, the project will use the Delphi method to develop consensus solutions for improving the quality of trauma care in rural areas. Data will be analysed using a Poisson regression to compare mortality rate during hospital stay or death on ED arrival (objectives 1 and 2). Average scores and 95% CI will be calculated for the Delphi questionnaire (objectives 3 and 4). This protocol has been approved by CSSS Alphonse-Desjardins research ethics committee (Project MP-HDL-2016-003). The results will be published in peer-reviewed journals. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Trauma care in Africa: a status report from Botswana, guided by the World Health Organization's "Guidelines for Essential Trauma Care".

PubMed

Hanche-Olsen, Terje Peder; Alemu, Lulseged; Viste, Asgaut; Wisborg, Torben; Hansen, Kari S

2012-10-01

Trauma represents a significant and increasing challenge to health care systems all over the world. This study aimed to evaluate the trauma care capabilities of Botswana, a middle-income African country, by applying the World Health Organization's Guidelines for Essential Trauma Care. All 27 government (16 primary, 9 district, 2 referral) hospitals were surveyed. A questionnaire and checklist, based on "Guidelines for Essential Trauma Care" and locally adapted, were developed as situation analysis tools. The questionnaire assessed local trauma organization, capacity, and the presence of quality improvement activity. The checklist assessed physical availability of equipment and timely availability of trauma-related skills. Information was collected by interviews with hospital administrators, key personnel within trauma care, and through on-site physical inspection. Hospitals in Botswana are reasonably well supplied with human and physical resources for trauma care, although deficiencies were noted. At the primary and district levels, both capacity and equipment for airway/breathing management and vascular access was limited. Trauma administrative functions were largely absent at all levels. No hospital in Botswana had any plans for trauma education, separate from or incorporated into other improvement activities. Team organization was nonexistent, and training activities in the emergency room were limited. This study draws a picture of trauma care capabilities of an entire African country. Despite good organizational structures, Botswana has room for substantial improvement. Administrative functions, training, and human and physical resources could be improved. By applying the guidelines, this study creates an objective foundation for improved trauma care in Botswana.

Evaluating trauma care capabilities in Mexico with the World Health Organization's Guidelines for Essential Trauma Care publication.

PubMed

Arreola-Risa, Carlos; Mock, Charles; Vega Rivera, Felipe; Romero Hicks, Eduardo; Guzmán Solana, Felipe; Porras Ramírez, Giovanni; Montiel Amoroso, Gilberto; de Boer, Melanie

2006-02-01

To identify affordable, sustainable methods to strengthen trauma care capabilities in Mexico, using the standards in the Guidelines for Essential Trauma Care, a publication that was developed by the World Health Organization and the International Society of Surgery to provide recommendations on elements of trauma care that should be in place in the various levels of health facilities in all countries. The Guidelines publication was used as a basis for needs assessments conducted in 2003 and 2004 in three Mexican states. The states were selected to represent the range of geographic and economic conditions in the country: Oaxaca (south, lower economic status), Puebla (center, middle economic status), and Nuevo León (north, higher economic status). The sixteen facilities that were assessed included rural clinics, small hospitals, and large hospitals. Site visits incorporated direct inspection of physical resources as well as interviews with key administrative and clinical staff. Human and physical resources for trauma care were adequate in the hospitals, especially the larger ones. The survey did identify some deficiencies, such as shortages of stiff suction tips, pulse oximetry equipment, and some trauma-related medications. All of the clinics had difficulties with basic supplies for resuscitation, even though some received substantial numbers of trauma patients. In all levels of facilities there was room for improvement in administrative functions to assure quality trauma care, including trauma registries, trauma-related quality improvement programs, and uniform in-service training. This study identified several low-cost ways to strengthen trauma care in Mexico. The study also highlighted the usefulness of the recommended norms in the Guidelines for Essential Trauma Care publication in providing a standardized template by which to assess trauma care capabilities in nations worldwide.

Improving prehospital trauma care in Rwanda through continuous quality improvement: an interrupted time series analysis.

PubMed

Scott, John W; Nyinawankusi, Jeanne D'Arc; Enumah, Samuel; Maine, Rebecca; Uwitonze, Eric; Hu, Yihan; Kabagema, Ignace; Byiringiro, Jean Claude; Riviello, Robert; Jayaraman, Sudha

2017-07-01

Injury is a major cause of premature death and disability in East Africa, and high-quality pre-hospital care is essential for optimal trauma outcomes. The Rwandan pre-hospital emergency care service (SAMU) uses an electronic database to evaluate and optimize pre-hospital care through a continuous quality improvement programme (CQIP), beginning March 2014. The SAMU database was used to assess pre-hospital quality metrics including supplementary oxygen for hypoxia (O2), intravenous fluids for hypotension (IVF), cervical collar placement for head injuries (c-collar), and either splinting (splint) or administration of pain medications (pain) for long bone fractures. Targets of >90% were set for each metric and daily team meetings and monthly feedback sessions were implemented to address opportunities for improvement. These five pre-hospital quality metrics were assessed monthly before and after implementation of the CQIP. Met and unmet needs for O2, IVF, and c-collar were combined into a summative monthly SAMU Trauma Quality Scores (STQ score). An interrupted time series linear regression model compared the STQ score during 14 months before the CQIP implementation to the first 14 months after. During the 29-month study period 3,822 patients met study criteria. 1,028 patients needed one or more of the five studied interventions during the study period. All five endpoints had a significant increase between the pre-CQI and post-CQI periods (p<0.05 for all), and all five achieved a post-CQI average of at least 90% completion. The monthly composite STQ scores ranged from 76.5 to 97.9 pre-CQI, but tightened to 86.1-98.7 during the post-CQI period. Interrupted time series analysis of the STQ score showed that CQI programme led to both an immediate improvement of +6.1% (p=0.017) and sustained monthly improvements in care delivery-improving at a rate of 0.7% per month (p=0.028). The SAMU experience demonstrates the utility of a responsive, data-driven quality improvement programme to yield significant immediate and sustained improvements in pre-hospital care for trauma in Rwanda. This programme may be used as an example for additional efforts engaging frontline staff with real-time data feedback in order to rapidly translate data collection efforts into improved care for the injured in a resource-limited setting. Copyright © 2017 Elsevier Ltd. All rights reserved.

Temporal distribution of trauma deaths: quality of trauma care in a developing country.

PubMed

Masella, Cesar Augusto; Pinho, Vitor Ferreira; Costa Passos, Afonso Dinis; Spencer Netto, Fernando A C; Rizoli, Sandro; Scarpelini, Sandro

2008-09-01

Examination of the epidemiology and timing of trauma deaths has been deemed a useful method to evaluate the quality of trauma care. The purpose of this study was to evaluate the quality of trauma care in a regional trauma system and in a university hospital in Brazil by comparing the timing of deaths in the studied prehospital and in-hospital settings to those published for trauma systems in other areas. We analyzed the National Health Minister's System of Deaths Information for the prehospital mortality and we retrospectively collected the demographics, timelines, and trauma severity scores of all in-hospital patients who died after admission through the Emergency Unit of Hospital das Clinicas de Ribeirao Preto between 2000 and 2001. During the study period, there were 787 trauma fatalities in the city: 448 (56.9%) died in the prehospital setting and 339 (43.1%) died after being admitted to a medical facility. In 2 years, 238 trauma deaths occurred in the studied hospital, and we found a complete clinical set of data for 224 of these patients. The majority of deaths in the prehospital setting were caused by penetrating injuries (66.7%), whereas in-hospital mortality was mainly because of blunt traumas (59.1%). The largest number of in-hospital deaths occurred beyond 72 hours of stay (107 patients-47%). The region studied showed some deficiencies in prehospital and in-hospitals settings, in particular in the critical care and short-term follow-up of trauma patients when compared with the literature. Particularly, the late mortality may be related to training and human resources deficiency. Based on the timeline of trauma deaths, we can suggest that the studied region needs improvements in the prehospital trauma system and in hospital critical care.

Trauma Quality Improvement: Reducing Triage Errors by Automating the Level Assignment Process.

PubMed

Stonko, David P; O Neill, Dillon C; Dennis, Bradley M; Smith, Melissa; Gray, Jeffrey; Guillamondegui, Oscar D

2018-04-12

Trauma patients are triaged by the severity of their injury or need for intervention while en route to the trauma center according to trauma activation protocols that are institution specific. Significant research has been aimed at improving these protocols in order to optimize patient outcomes while striving for efficiency in care. However, it is known that patients are often undertriaged or overtriaged because protocol adherence remains imperfect. The goal of this quality improvement (QI) project was to improve this adherence, and thereby reduce the triage error. It was conducted as part of the formal undergraduate medical education curriculum at this institution. A QI team was assembled and baseline data were collected, then 2 Plan-Do-Study-Act (PDSA) cycles were implemented sequentially. During the first cycle, a novel web tool was developed and implemented in order to automate the level assignment process (it takes EMS-provided data and automatically determines the level); the tool was based on the existing trauma activation protocol. The second PDSA cycle focused on improving triage accuracy in isolated, less than 10% total body surface area burns, which we identified to be a point of common error. Traumas were reviewed and tabulated at the end of each PDSA cycle, and triage accuracy was followed with a run chart. This study was performed at Vanderbilt University Medical Center and Medical School, which has a large level 1 trauma center covering over 75,000 square miles, and which sees urban, suburban, and rural trauma. The baseline assessment period and each PDSA cycle lasted 2 weeks. During this time, all activated, adult, direct traumas were reviewed. There were 180 patients during the baseline period, 189 after the first test of change, and 150 after the second test of change. All were included in analysis. Of 180 patients, 30 were inappropriately triaged during baseline analysis (3 undertriaged and 27 overtriaged) versus 16 of 189 (3 undertriaged and 13 overtriaged) following implementation of the web tool (p = 0.017 for combined errors). Overtriage dropped further from baseline to 10/150 after the second test of change (p = 0.005). The total number of triaged patients dropped from 92.3/week to 75.5/week after the second test of change. There was no statistically significant change in the undertriage rate. The combination of web tool implementation and protocol refinement decreased the combined triage error rate by over 50% (from 16.7%-7.9%). We developed and tested a web tool that improved triage accuracy, and provided a sustainable method to enact future quality improvement. This web tool and QI framework would be easily expandable to other hospitals. Copyright © 2018 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

The design, construction and implementation of a computerised trauma registry in a developing South African metropolitan trauma service.

PubMed

Laing, G L; Bruce, J L; Aldous, C; Clarke, D L

2014-01-01

The Pietermaritzburg Metropolitan Trauma Service formerly lacked a robust computerised trauma registry. This made surgical audit difficult for the purpose of quality of care improvement and development. We aimed to design, construct and implement a computerised trauma registry within our service. Twelve months following its implementation, we sought to examine and report on the quality of the registry. Formal ethical approval to maintain a computerised trauma registry was obtained prior to undertaking any design and development. Appropriate commercial software was sourced to develop this project. The registry was designed as a flat file. A flat file is a plain text or mixed text and binary file which usually contains one record per line or physical record. Thereafter the registry file was launched onto a secure server. This provided the benefits of access security and automated backups. Registry training was provided to clients by the developer. The exercise of data capture was then integrated into the process of service delivery, taking place at the endpoint of patient care (discharge, transfer or death). Twelve months following its implementation, the compliance rates of data entry were measured. The developer of this project managed to design, construct and implement an electronic trauma registry into the service. Twelve months following its implementation the data were extracted and audited to assess the quality. A total of 2640 patient entries were captured onto the registry. Compliance rates were in the order of eighty percent and client satisfaction rates were high. A number of deficits were identified. These included the omission of weekend discharges and underreporting of deaths. The construction and implementation of the computerised trauma registry was the beginning of an endeavour to continue improvements in the quality of care within our service. The registry provided a reliable audit at twelve months post implementation. Deficits and limitations were identified and new strategies have been planned to overcome these problems and integrate the trauma registry into the process of clinical care. Copyright © 2013 Elsevier Ltd. All rights reserved.

Use of a Novel Accounting and Grouping Method for Major Trunk Injury-Analysis of Data from a Statewide Trauma Financial Survey.

PubMed

Joubert, Kyla D; Mabry, Charles D; Kalkwarf, Kyle J; Betzold, Richard D; Spencer, Horace J; Spinks, Kara M; Porter, Austin; Karim, Saleema; Robertson, Ronald D; Sutherland, Michael J; Maxson, Robert T

2016-09-01

Major trunk trauma is common and costly, but comparisons of costs between trauma centers (TCs) are rare. Understanding cost is essential to improve quality, manage trauma service lines, and to facilitate institutional commitment for trauma. We have used results of a statewide trauma financial survey of Levels I to IV TC to develop a useful grouping method for costs and clinical characteristics of major trunk trauma. The trauma financial survey collected billing and clinical data on 75 per cent of the state trauma registry patients for fiscal year 2012. Cost was calculated by separately accounting for embedded costs of trauma response and verification, and then adjusting reasonable costs from the Medicare cost report for each TC. The cost-to-charge ratios were then recalculated and used to determine uniform cost estimates for each patient. From the 13,215 patients submitted for the survey, we selected 1,094 patients with major trunk trauma: lengths of stay ≥ 48 hours and a maximum injury of AIS ≥3 for either thorax or abdominal trauma. These patients were then divided into three Injury Severity Score (ISS) groups of 9 to 15, 16 to 24, or 25+ to stratify patients into similar injury groups for analysis of cost and cost drivers. For abdominal injury, average total cost for patients with ISS 9 to 15 was $17,429. Total cost and cost per day increased with severity of injury, with $51,585 being the total cost for those with ISS 25. Similar trends existed for thoracic injury. Use of the Medicare cost report and cost-to-charge ratios to compute uniform costs with an innovative grouping method applied to data collected across a statewide trauma system provides unique information regarding cost and outcomes, which affects quality improvement, trauma service line management, and decisions on TC participation.

Childhood trauma and resilience in psoriatic patients: A preliminary report.

PubMed

Crosta, Maria Luigia; De Simone, Clara; Di Pietro, Salvatore; Acanfora, Mariateresa; Caldarola, Giacomo; Moccia, Lorenzo; Callea, Antonino; Panaccione, Isabella; Peris, Ketty; Rinaldi, Lucio; Janiri, Luigi; Di Nicola, Marco

2018-03-01

Psoriasis is a chronic inflammatory skin disease with a complex etiology, involving the immune system, genetic factors, and external/internal triggers, with psychosomatic aspects. The aim of the study was to investigate childhood trauma and resilience in a psoriatic sample compared with healthy controls. Correlations between childhood trauma, resilience, quality of life, clinical data and psoriatic features were also evaluated. Seventy-seven psoriatic patients and seventy-six homogeneous healthy controls were enrolled. We used the Psoriasis Area and Severity Index (PASI) to assess the severity of psoriasis and the Skindex-29 to measure health-related quality of life. The psychometric battery included the Childhood Trauma Questionnaire (CTQ) and the Connor-Davidson Resilience Scale (CD-Risc) to assess trauma exposure and resilience, respectively. Psoriatic patients showed a significant prevalence of childhood trauma and a lower resilience level compared to healthy controls. Associations between traumatic experiences, low resilience and reduced quality of life in psoriatic subjects were also observed. A multidisciplinary approach is helpful to investigate clinical aspects, trigger factors and psychophysiological stress response in psoriatic subjects. Improving resilience with an early psychological intervention focused on self-motivation and strengthening of self-efficacy could facilitate the management of psoriasis. Copyright © 2018 Elsevier Inc. All rights reserved.

Exploring the characteristics of high-performing hospitals that influence trauma triage and transfer.

PubMed

Gagliardi, Anna R; Nathens, Avery B

2015-02-01

Many trauma patients might be first cared for at nondesignated centers before transfer to a trauma center. Limited research has investigated determinants of timely triage and transfer to identify those amenable to quality improvement. This study explored factors influencing timely triage and transfer in a regional trauma system. Centers (n = 15) with both long and short transfer times (emergency department length of stay before transfer) in Ontario were identified using a regional trauma registry. Physicians and nurses in these centers were interviewed with a view to determining factors that either impeded or enabled rapid decisions regarding the need for transfer to a trauma center. A grounded theory approach and constant comparative technique were used to collect and analyze data. Nineteen physicians and eight nurses participated. Clinician level (experience, training, personality, fear of judgment, nursing role), institutional level (guidelines, continuing education, trauma infrastructure, human resources) and system-level (bed availability, referral center, air transport, communication with trauma centers) factors influenced timely decision making. Participants offered several recommendations to improve care. These included guidelines for transfer, a "no refusal" policy at trauma centers, improved air transport and referral center services, as well as further regionalization. Additional features of hospitals with shorter transfer times included coaching of new staff, team meetings, leadership engagement, sharing of performance data, and minimum work hours for physicians. Numerous interacting factors that may influence trauma triage and transfer were identified. These findings can be used by policy makers, health care managers, and clinicians in emergency departments or trauma centers to evaluate and improve trauma triage and transfer, or plan new services. The findings can also be used by researchers to examine the relevance of these factors in other settings or to implement and evaluate the impact of interventions informed by recommendations generated here.

Lower Health-Related Quality of Life in Polytrauma Patients

PubMed Central

Zwingmann, Jörn; Hagelschuer, Paul; Langenmair, Elia; Bode, Gerrit; Herget, Georg; Südkamp, Norbert P.; Hammer, Thorsten

2016-01-01

Abstract Although trauma-associated mortality has fallen in recent decades, and medical care has continued to improve in many fields, the quality of life after experiencing polytrauma has attracted little attention in the literature. This group of patients suffer from persisting physical disabilities. Moreover, they experience long-term social, emotional, and psychological effects that limit/lower considerably their quality of life. We analyzed retrospective data on 147 polytraumatized patients by administering written questionnaires and conducting face-to-face interviews 6 ± 0.8 years after the trauma in consideration of the following validated scores: Glasgow Outcome Scale, European Quality of Life Score, Short Form-36, Trauma Outcome Profile, and Beck Depressions Inventory II. Our analysis of these results reveals that polytraumatized patients suffer from persistent pain and functional disabilities after >5 years. We also observed changes in their socioeconomic situation, as well as psychological after-effects. The rehabilitation of this particular group of patients should not only address their physical disabilities. The psychological after-effects of trauma must be acknowledged and addressed for an even longer period of time. PMID:27175646

Eliminating Health Care Disparities With Mandatory Clinical Decision Support: The Venous Thromboembolism (VTE) Example.

PubMed

Lau, Brandyn D; Haider, Adil H; Streiff, Michael B; Lehmann, Christoph U; Kraus, Peggy S; Hobson, Deborah B; Kraenzlin, Franca S; Zeidan, Amer M; Pronovost, Peter J; Haut, Elliott R

2015-01-01

All hospitalized patients should be assessed for venous thromboembolism (VTE) risk factors and prescribed appropriate prophylaxis. To improve best-practice VTE prophylaxis prescription for all hospitalized patients, we implemented a mandatory computerized clinical decision support (CCDS) tool. The tool requires completion of checklists to evaluate VTE risk factors and contraindications to pharmacological prophylaxis, and then recommends the risk-appropriate VTE prophylaxis regimen. The objective of the study was to examine the effect of a quality improvement intervention on race-based and sex-based health care disparities across 2 distinct clinical services. This was a retrospective cohort study of a quality improvement intervention. The study included 1942 hospitalized medical patients and 1599 hospitalized adult trauma patients. In this study, the proportion of patients prescribed risk-appropriate, best-practice VTE prophylaxis was evaluated. Racial disparities existed in prescription of best-practice VTE prophylaxis in the preimplementation period between black and white patients on both the trauma (70.1% vs. 56.6%, P=0.025) and medicine (69.5% vs. 61.7%, P=0.015) services. After implementation of the CCDS tool, compliance improved for all patients, and disparities in best-practice prophylaxis prescription between black and white patients were eliminated on both services: trauma (84.5% vs. 85.5%, P=0.99) and medicine (91.8% vs. 88.0%, P=0.082). Similar findings were noted for sex disparities in the trauma cohort. Despite the fact that risk-appropriate prophylaxis should be prescribed equally to all hospitalized patients regardless of race and sex, practice varied widely before our quality improvement intervention. Our CCDS tool eliminated racial disparities in VTE prophylaxis prescription across 2 distinct clinical services. Health information technology approaches to care standardization are effective to eliminate health care disparities.

Effect of trauma on quality of life as mediated by mental distress and moderated by coping and social support among postconflict displaced Ethiopians.

PubMed

Araya, Mesfin; Chotai, Jayanti; Komproe, Ivan H; de Jong, Joop T V M

2007-08-01

An understanding of how quality of life is affected by severe trauma and mental distress may facilitate better intervention strategies for postconflict internally displaced persons, by identifying mediators, moderators, and independent risk factors. We investigate the pathways involved in this process and also study the moderating roles of coping strategies and perceived social support. A random sample of 1193 (62% women) internally displaced Ethiopian adults living in shelters in Addis Ababa were interviewed with instruments capturing the relevant concepts, including SCL-90-R and WHOQOL-BREF. Path analysis was employed to elaborate the mediating and moderating effects. Self-reported living conditions were also assessed. Mental distress increased and quality of life decreased with age. Mental distress mediated the effects of trauma in reducing the quality of life, and some trauma also reduced quality of life directly. These effects remained after adjusting for living conditions. Living conditions were related to quality of life also on their own. Coping strategies and perceived social support influenced mental distress and quality of life directly as well as indirectly by moderation, in part gender specific. Intervention strategies aimed at reducing mental distress, modifying coping strategies, and encouraging social support may turn out to be useful in increasing the overall quality of life in postconflict situations, and are worth considering as complements to strategies that improve the living conditions.

Variability in interhospital trauma data coding and scoring: A challenge to the accuracy of aggregated trauma registries.

PubMed

Arabian, Sandra S; Marcus, Michael; Captain, Kevin; Pomphrey, Michelle; Breeze, Janis; Wolfe, Jennefer; Bugaev, Nikolay; Rabinovici, Reuven

2015-09-01

Analyses of data aggregated in state and national trauma registries provide the platform for clinical, research, development, and quality improvement efforts in trauma systems. However, the interhospital variability and accuracy in data abstraction and coding have not yet been directly evaluated. This multi-institutional, Web-based, anonymous study examines interhospital variability and accuracy in data coding and scoring by registrars. Eighty-two American College of Surgeons (ACS)/state-verified Level I and II trauma centers were invited to determine different data elements including diagnostic, procedure, and Abbreviated Injury Scale (AIS) coding as well as selected National Trauma Data Bank definitions for the same fictitious case. Variability and accuracy in data entries were assessed by the maximal percent agreement among the registrars for the tested data elements, and 95% confidence intervals were computed to compare this level of agreement to the ideal value of 100%. Variability and accuracy in all elements were compared (χ testing) based on Trauma Quality Improvement Program (TQIP) membership, level of trauma center, ACS verification, and registrar's certifications. Fifty registrars (61%) completed the survey. The overall accuracy for all tested elements was 64%. Variability was noted in all examined parameters except for the place of occurrence code in all groups and the lower extremity AIS code in Level II trauma centers and in the Certified Specialist in Trauma Registry- and Certified Abbreviated Injury Scale Specialist-certified registrar groups. No differences in variability were noted when groups were compared based on TQIP membership, level of center, ACS verification, and registrar's certifications, except for prehospital Glasgow Coma Scale (GCS), where TQIP respondents agreed more than non-TQIP centers (p = 0.004). There is variability and inaccuracy in interhospital data coding and scoring of injury information. This finding casts doubt on the validity of registry data used in all aspects of trauma care and injury surveillance.

The organizational and financial viability of an orthopedic trauma service.

PubMed

Harris, Mitchel B; Cayen, Barry

2009-12-01

This study was designed to explore the effect of establishing an Orthopedic Trauma Service (OTS) on departmental revenue within an academic orthopedic department. The effect of the OTS on physician and resident perceptions of job satisfaction, education, and quality of patient care were also evaluated. A proforma financial analysis was undertaken using an optimization model to predict the potential financial performance of an OTS before its implementation. Financial data were then collected prospectively for the first year of the OTS and compared with the preceding year's financial data. All residents and faculty in the department completed visual analog scale surveys after the formation of the service. While maintaining a fixed amount of work production (work relative value units [WRVUs]) per year, our model predicted an $111,000 increase in departmental charges as a result of a shift in the elective case mix. After implementation of the OTS, elective charges/WRVU increased by 7.4% while trauma charges/WRVU increased by 2.6%. This, combined with a minor increase in departmental work volume (115,661 WRVUs pre-OTS vs. 117,577 WRVUs post-OTS) and an improvement in collections/charge (47-48%), yielded a departmental collection increase of 11% ($1.1 million). Resident and faculty job satisfaction improved, as did the perception of the quality of trauma care that was being provided. The organization and implementation of an OTS within an academic orthopedic department can lead to an improved professional experience for residents and faculty, the perception of improved patient care for the trauma patient, and an increase in departmental revenue.

A population-based analysis of injury-related deaths and access to trauma care in rural-remote Northwest British Columbia.

PubMed

Simons, Richard; Brasher, Penelope; Taulu, Tracey; Lakha, Nasira; Molnar, Nadine; Caron, Nadine; Schuurman, Nadine; Evans, David; Hameed, Morad

2010-07-01

Injury rates and injury mortality rates are generally higher in rural and remote communities compared with urban jurisdictions as has been shown to be the case in the rural-remote area of Northwest (NW) British Columbia (BC). The purpose of study was to identify: (1) the place and timing of death following injury in NW BC, (2) access to and quality of local trauma services, and (3) opportunities to improve trauma outcomes. Quantitative data from demographic and geographic databases, the BC Trauma Registry, Hospital discharge abstract database, and the BC Coroner's Office, along with qualitative data from chart reviews of selected major trauma cases, and interviews with front-line trauma care providers were collated and analyzed for patients sustaining injury in NW BC from April 2001 to March 2006. The majority of trauma deaths (82%) in NW BC occur prehospital. Patients arriving alive to NW hospitals have low hospital mortality (1.0%), and patients transferring from NW BC to tertiary centers have better outcomes than matched patients achieving direct entry into the tertiary center by way of geographic proximity. Access to local trauma services was compromised by: incident discovery, limited phone service (land lines/cell), incomplete 911 emergency medical services system access, geographical and climate challenges compounded by limited transportation options, airport capabilities and paramedic training level, dysfunctional hospital no-refusal policies, lack of a hospital destination policies, and lack of system leadership and coordination. Improving trauma outcomes in this rural-remote jurisdiction requires a systems approach to address root causes of delays in access to care, focusing on improved access to emergency medical services, hospital bypass and destination protocols, improved transportation options, advanced life support transfer capability, and designated, coordinated local trauma services.

[Trauma network of the German Association of Trauma Surgery (DGU). Establishment, organization, and quality assurance of a regional trauma network of the DGU].

PubMed

Ruchholtz, S; Kühne, C A; Siebert, H

2007-04-01

The quality of care in Germany for seriously injured patients varies greatly in individual hospitals due to geographic variations among States and differences in resource allocation and treatment concepts. To assure and enhance treatment quality it seems sensible to establish a structured, quality assured network of clinics, which participate in the management of seriously injured patients according to different specified assignments. The conditions necessary for this type of network on a regional scale and for the clinics charged with the care of the seriously injured were summarized in the White Paper entitled "Management of the Seriously Injured-Recommendations for the Structure and Organization of Facilities in Germany for the Treatment of Seriously Injured Persons." The goal of this action is to ensure that every seriously injured person in Germany receives the best possible round-the-clock care in adherence to standardized quality criteria. This requires specialized expertise and the willingness of all involved parties-care providers, cost bearers, and hospital owners-to cooperate in further improving existing treatment concepts. As a logical consequence of long years of experience and scientific knowledge, the German Association of Trauma Surgery has developed a concept for establishing a regional trauma network of clinics, adapted to local conditions, for management of seriously injured patients. The participating facilities assume different responsibilities in the network depending on their equipment and structure. This article describes the individual steps toward establishing and organizing a network.

Prehospital Blood Product Resuscitation for Trauma: A Systematic Review

PubMed Central

Smith, Iain M.; James, Robert H.; Dretzke, Janine; Midwinter, Mark J.

2016-01-01

ABSTRACT Introduction: Administration of high ratios of plasma to packed red blood cells is a routine practice for in-hospital trauma resuscitation. Military and civilian emergency teams are increasingly carrying prehospital blood products (PHBP) for trauma resuscitation. This study systematically reviewed the clinical literature to determine the extent to which the available evidence supports this practice. Methods: Bibliographic databases and other sources were searched to July 2015 using keywords and index terms related to the intervention, setting, and condition. Standard systematic review methodology aimed at minimizing bias was used for study selection, data extraction, and quality assessment (protocol registration PROSPERO: CRD42014013794). Synthesis was mainly narrative with random effects model meta-analysis limited to mortality outcomes. Results: No prospective comparative or randomized studies were identified. Sixteen case series and 11 comparative studies were included in the review. Seven studies included mixed populations of trauma and non-trauma patients. Twenty-five of 27 studies provided only very low quality evidence. No association between PHBP and survival was found (OR for mortality: 1.29, 95% CI: 0.84–1.96, P = 0.24). A single study showed improved survival in the first 24 h. No consistent physiological or biochemical benefit was identified, nor was there evidence of reduced in-hospital transfusion requirements. Transfusion reactions were rare, suggesting the short-term safety of PHBP administration. Conclusions: While PHBP resuscitation appears logical, the clinical literature is limited, provides only poor quality evidence, and does not demonstrate improved outcomes. No conclusions as to efficacy can be drawn. The results of randomized controlled trials are awaited. PMID:26825635

[Advanced Trauma Life Support (ATLS) in the emergency room. Is it suitable as an SOP?].

PubMed

Shafizadeh, S; Tjardes, T; Steinhausen, E; Balke, M; Paffrath, T; Bouillon, B; Bäthis, H

2010-08-01

There is clinical evidence that a standardized management of trauma patients in the emergency room improves outcome. ATLS is a training course that teaches a systematic approach to the trauma patient in the emergency room. The aims are a rapid and accurate assessment of the patient's physiologic status, treatment according to priorities, and making decisions on whether the local resources are sufficient for adequate definitive treatment of the patient or if transfer to a trauma center is necessary. Above all it is important to prevent secondary injury, to realize timing as a relevant factor in the initial treatment, and to assure a high standard of care. A standard operating procedure (SOP) exactly regulates the approach to trauma patients and determines the responsibilities of the involved faculties. An SOP moreover incorporates the organizational structure in the treatment of trauma patients as well as the necessary technical equipment and staff requirements. To optimize process and result quality, priorities are in the fields of medical fundamentals of trauma care, education, and fault management. SOPs and training courses increase the process and result quality in the treatment of the trauma patient in the emergency room. These programs should be based on the special demands of the physiology of the trauma as well as the structural specifics of the hospital. ATLS does not equal an SOP but it qualifies as a standardized concept for management of trauma patients in the emergency room.

The ISTSS/Rand guidelines on mental health training of primary healthcare providers for trauma-exposed populations in conflict-affected countries.

PubMed

Eisenman, David; Weine, Stevan; Green, Bonnie; de Jong, Joop; Rayburn, Nadine; Ventevogel, Peter; Keller, Allen; Agani, Ferid

2006-02-01

Mental health care for trauma-exposed populations in conflict-affected developing countries often is provided by primary healthcare providers (PHPs), including doctors, nurses, and lay health workers. The Task Force on International Trauma Training, through an initiative sponsored by the International Society for Traumatic Stress Studies and the RAND Corporation, has developed evidence- and consensus-based guidelines for the mental health training of PHPs in conflict-affected developing countries. This article presents the Guidelines, which provide a conceptual framework and specific principles for improving the quality of mental health training for PHPs working with trauma-exposed populations.

A Statewide Collaboration: Ohio Level III Trauma Centers' Approach to the Development of a Benchmarking System.

PubMed

Lang, Carrie L; Simon, Diane; Kilgore, Jane

The American College of Surgeons Committee on Trauma revised the Resources for Optimal Care of the Injured Patient to include the criteria for trauma centers to participate in a risk-adjusted benchmarking system. Trauma Quality Improvement Program is currently the risk-adjusted benchmarking program sponsored by the American College of Surgeons, which will be required of all trauma centers to participate in early 2017. Prior to this, there were no risk-adjusted programs for Level III verified trauma centers. The Ohio Society of Trauma Nurse Leaders is a collaborative group made up of trauma program managers, coordinators, and other trauma leaders who meet 6 times a year. Within this group, a Level III Subcommittee was formed initially to provide a place for the Level III centers to discuss issues specific to the Level III centers. When the new requirement regarding risk-adjustment became official, the subcommittee agreed to begin reporting simple data points with the idea to risk adjust in the future.

Health literacy and quality of physician-trauma patient communication: Opportunity for improvement.

PubMed

Dameworth, Jonathan L; Weinberg, Jordan A; Goslar, Pamela W; Stout, Dana J; Israr, Sharjeel; Jacobs, Jordan V; Gillespie, Thomas L; Thompson, Terrell M; Petersen, Scott R

2018-07-01

Although physician-patient communication and health literacy (HL) have been studied in diverse patient groups, there has been little focus on trauma patients. A quality improvement project was undertaken at our Level I trauma center to improve patient perception of physician-patient communication, with consideration of the effect of HL. We report the first phase of this project, namely the reference level of satisfaction with physician-patient communication as measured by levels of interpersonal care among patients at an urban Level I trauma center. Level I trauma center patients were interviewed during hospitalization (August 2016 to January 2017). Short Assessment of Health Literacy tool was used to stratify subjects by deficient versus adequate HL. Interpersonal Processes of Care survey was administered to assess perception of physician-patient communication. This survey allowed patients to rate physician-patient interaction across six domains: "clarity," "elicited concerns," "explained results," "worked together (on decision making)," "compassion and respect," and "lack of discrimination by race/ethnicity." Each is scored on a five-point scale. Frequencies of "top-box" (5/5) scores were compared for significance (p < 0.05) between HL-deficient and HL-adequate patients. One hundred ninety-nine patients participated. Average age was 42 years, 33% female. Forty-nine (25%) patients had deficient HL. The majority of patients in both groups rated communication below 5/5 across all domains except "compassion and respect" and "lack of discrimination by race/ethnicity." Health literacy-deficient patients were consistently less likely to give physicians top-box scores, most notably in the "elicited concerns" domain (35% vs. 54%, p = 0.012). Health literacy-deficient patients appear relatively less satisfied with physician communication, particularly with respect to perceiving that their concerns are being heard. Overall, however, the majority of patients in both groups were unlikely to score physician communication in the "top box." Efforts to improve physician-trauma patient communication are warranted, with attention directed toward meeting the needs of HL-deficient patients. Prognostic/Epidemiologic, level I.

The orthopaedic research scene and strategies to improve it.

PubMed

Rankin, K S; Sprowson, A P; McNamara, I; Akiyama, T; Buchbinder, R; Costa, M L; Rasmussen, S; Nathan, S S; Kumta, S; Rangan, A

2014-12-01

Trauma and orthopaedics is the largest of the surgical specialties and yet attracts a disproportionately small fraction of available national and international funding for health research. With the burden of musculoskeletal disease increasing, high-quality research is required to improve the evidence base for orthopaedic practice. Using the current research landscape in the United Kingdom as an example, but also addressing the international perspective, we highlight the issues surrounding poor levels of research funding in trauma and orthopaedics and indicate avenues for improving the impact and success of surgical musculoskeletal research. ©2014 The British Editorial Society of Bone & Joint Surgery.

Expressive writing in early breast cancer survivors.

PubMed

Craft, Melissa A; Davis, Gail C; Paulson, René M

2013-02-01

This article is the report of a study aimed at determining whether or not expressive writing improves the quality-of-life of early breast cancer survivors. An additional aim is the investigation of whether or not the type of writing prompt makes a difference in results. The risk of distress can extend well beyond the time of a breast cancer diagnosis. Emotional expression may assist in dealing with this. Randomized controlled study. Participants (n = 120) were randomized into one of four groups: a control group (no writing) or one of three expressive writing groups: breast cancer trauma, any self-selected trauma and facts related to breast cancer. Participants wrote 20 minutes a day for 4 consecutive days. Their quality-of-life was measured, using the 'Functional Assessment of Cancer Therapy-Breast Cancer Version', at baseline and at 1 month and 6 months after writing. Paired t-tests, multivariate analysis of variance and multiple regression were used to analyse the data of the 97 participants who completed the journaling assignment and at least the first assessment, collected in 2006. Intention-to-treat analysis was used. Expressive writing about one's breast cancer, breast cancer trauma and facts related to breast cancer, significantly improved the quality-of-life outcome. Expressive writing, focusing the instructions on writing about one's living and dealing with a diagnosis of breast cancer, is recommended for early breast cancer survivors as a feasible and easily implemented treatment approach to improve quality-of-life. © 2012 Blackwell Publishing Ltd.

Assessment of the effects and limitations of the 1998 to 2008 Abbreviated Injury Scale map using a large population-based dataset.

PubMed

Palmer, Cameron S; Franklyn, Melanie

2011-01-07

Trauma systems should consistently monitor a given trauma population over a period of time. The Abbreviated Injury Scale (AIS) and derived scores such as the Injury Severity Score (ISS) are commonly used to quantify injury severities in trauma registries. To reflect contemporary trauma management and treatment, the most recent version of the AIS (AIS08) contains many codes which differ in severity from their equivalents in the earlier 1998 version (AIS98). Consequently, the adoption of AIS08 may impede comparisons between data coded using different AIS versions. It may also affect the number of patients classified as major trauma. The entire AIS98-coded injury dataset of a large population based trauma registry was retrieved and mapped to AIS08 using the currently available AIS98-AIS08 dictionary map. The percentage of codes which had increased or decreased in severity, or could not be mapped, was examined in conjunction with the effect of these changes to the calculated ISS. The potential for free text information accompanying AIS coding to improve the quality of AIS mapping was explored. A total of 128280 AIS98-coded injuries were evaluated in 32134 patients, 15471 patients of whom were classified as major trauma. Although only 4.5% of dictionary codes decreased in severity from AIS98 to AIS08, this represented almost 13% of injuries in the registry. In 4.9% of patients, no injuries could be mapped. ISS was potentially unreliable in one-third of patients, as they had at least one AIS98 code which could not be mapped. Using AIS08, the number of patients classified as major trauma decreased by between 17.3% and 30.3%. Evaluation of free text descriptions for some injuries demonstrated the potential to improve mapping between AIS versions. Converting AIS98-coded data to AIS08 results in a significant decrease in the number of patients classified as major trauma. Many AIS98 codes are missing from the existing AIS map, and across a trauma population the AIS08 dataset estimates which it produces are of insufficient quality to be used in practice. However, it may be possible to improve AIS98 to AIS08 mapping to the point where it is useful to established registries.

Assessment of the effects and limitations of the 1998 to 2008 Abbreviated Injury Scale map using a large population-based dataset

PubMed Central

2011-01-01

Background Trauma systems should consistently monitor a given trauma population over a period of time. The Abbreviated Injury Scale (AIS) and derived scores such as the Injury Severity Score (ISS) are commonly used to quantify injury severities in trauma registries. To reflect contemporary trauma management and treatment, the most recent version of the AIS (AIS08) contains many codes which differ in severity from their equivalents in the earlier 1998 version (AIS98). Consequently, the adoption of AIS08 may impede comparisons between data coded using different AIS versions. It may also affect the number of patients classified as major trauma. Methods The entire AIS98-coded injury dataset of a large population based trauma registry was retrieved and mapped to AIS08 using the currently available AIS98-AIS08 dictionary map. The percentage of codes which had increased or decreased in severity, or could not be mapped, was examined in conjunction with the effect of these changes to the calculated ISS. The potential for free text information accompanying AIS coding to improve the quality of AIS mapping was explored. Results A total of 128280 AIS98-coded injuries were evaluated in 32134 patients, 15471 patients of whom were classified as major trauma. Although only 4.5% of dictionary codes decreased in severity from AIS98 to AIS08, this represented almost 13% of injuries in the registry. In 4.9% of patients, no injuries could be mapped. ISS was potentially unreliable in one-third of patients, as they had at least one AIS98 code which could not be mapped. Using AIS08, the number of patients classified as major trauma decreased by between 17.3% and 30.3%. Evaluation of free text descriptions for some injuries demonstrated the potential to improve mapping between AIS versions. Conclusions Converting AIS98-coded data to AIS08 results in a significant decrease in the number of patients classified as major trauma. Many AIS98 codes are missing from the existing AIS map, and across a trauma population the AIS08 dataset estimates which it produces are of insufficient quality to be used in practice. However, it may be possible to improve AIS98 to AIS08 mapping to the point where it is useful to established registries. PMID:21214906

Multiple trauma in children: critical care overview.

PubMed

Wetzel, Randall C; Burns, R Cartland

2002-11-01

Multiple trauma is more than the sum of the injuries. Management not only of the physiologic injury but also of the pathophysiologic responses, along with integration of the child's emotional and developmental needs and the child's family, forms the basis of trauma care. Multiple trauma in children also elicits profound psychological responses from the healthcare providers involved with these children. This overview will address the pathophysiology of multiple trauma in children and the general principles of trauma management by an integrated trauma team. Trauma is a systemic disease. Multiple trauma stimulates the release of multiple inflammatory mediators. A lethal triad of hypothermia, acidosis, and coagulopathy is the direct result of trauma and secondary injury from the systemic response to trauma. Controlling and responding to the secondary pathophysiologic sequelae of trauma is the cornerstone of trauma management in the multiply injured, critically ill child. Damage control surgery is a new, rational approach to the child with multiple trauma. The selection of children for damage control surgery depends on the severity of injury. Major abdominal vascular injuries and multiple visceral injuries are best considered for this approach. The effective management of childhood multiple trauma requires a combined team approach, consideration of the child and family, an organized trauma system, and an effective quality assurance and improvement mechanism.

The New Zealand Major Trauma Registry: the foundation for a data-driven approach in a contemporary trauma system.

PubMed

Isles, Siobhan; Christey, Grant; Civil, Ian; Hicks, Peter

2017-10-06

To describe the development of the New Zealand Major Trauma Registry (NZ-MTR) and the initial experiences of its use. The background to the development of the NZ-MTR was reviewed and the processes undertaken to implement a single-instance of a web-based national registry described. A national minimum dataset was defined and utilised. Key structures to support the Registry such as a data governance group were established. The NZ-MTR was successfully implemented and is the foundation for a new, data-driven model of quality improvement. In its first year of operation over 1,300 patients were entered into the Registry although coverage is not yet universal. Overall incidence is 40.8 major trauma cases/100,000 population. The incidence in the Māori population was 69/100,000 compared with 31/100,000 in the non-Māori population. Case fatality rate was 9%. Three age peaks were observed at 20-24 years, 50-59 years and above 85 years. Road traffic crashes accounted for 50% of all caseload. A significant proportion of major trauma patients (21%) were transferred to one or more hospitals before reaching a definitive care facility. Despite the challenges working across multiple jurisdictions, initiation of a single-instance web-based registry has been achieved. The NZ-MTR enables New Zealand to have a national view of trauma treatment and outcomes for the first time. It will inform quality improvement and injury prevention initiatives and potentially decrease the burden of injury on all New Zealanders.

Emotional intelligence--essential for trauma nursing.

PubMed

Holbery, Natalie

2015-01-01

Patients and their relatives are increasingly considered partners in health and social care decision-making. Numerous political drivers in the UK reflect a commitment to this partnership and to improving the experience of patients and relatives in emergency care environments. As a Lecturer/Practitioner in Emergency Care I recently experienced the London Trauma System as a relative. My dual perspective, as nurse and relative, allowed me to identify a gap in the quality of care akin to emotional intelligence. This paper aims to raise awareness of emotional intelligence (EI), highlight its importance in trauma care and contribute to the development of this concept in trauma nursing and education across the globe. Copyright © 2014 Elsevier Ltd. All rights reserved.

[Quality of life after multiple trauma].

PubMed

Mörsdorf, P; Becker, S C; Holstein, J H; Burkhardt, M; Pohlemann, T

2014-03-01

Multiple trauma is an independent injury pattern which, because of its complexity, is responsible for 25 % of the costs for the treatment of all injured patients. Because of the often long-lasting physical impairment and the high incidence of residual permanent handicaps, it is apparent that multiple trauma can lead to a reduction in patient quality of life. The aim of this study was to give an overview of the known data concerning the change in quality of life for multiple trauma patients. Furthermore, predictors for the reduction of quality of life after multiple trauma will be identified. A MedLine search was performed to identify studies dealing with the outcome after multiple trauma. In addition to functional outcome parameters, the term quality of life has become more important in recent years when it comes to evaluating the outcome following injury. While the mortality after multiple trauma could be significantly reduced over the years, there is no comparable effect on the quality of life. Predictors for a worse quality of life after multiple trauma are female gender, high age, low social status, concomitant head injuries and injury to the lower extremities. The fact that mortality after multiple trauma has decreased but not impairment of the quality of life makes it clear that in addition to the acute medical treatment, a follow-up treatment including not only physiotherapy but also psychotherapy is crucial for multiple trauma patients.

The crisis in United States hospital emergency services.

PubMed

Harrison, Jeffrey P; Ferguson, Emily D

2011-01-01

Emergency services are critical for high-quality healthcare service provision to support acute illness, trauma and disaster response. The greater availability of emergency services decreases waiting time, improves clinical outcomes and enhances local community well being. This study aims to assess United States (U.S.) acute care hospital staffs ability to provide emergency medical services by evaluating the number of emergency departments and trauma centers. Data were obtained from the 2003 and 2007 American Hospital Association (AHA) annual surveys, which included over 5000 US hospitals and provided extensive information on their infrastructure and healthcare capabilities. U.S. acute care hospital numbers decreased by 59 or 1.1 percent from 2003 to 2007. Similarly, U.S. emergency rooms and trauma centers declined by 125, or 3 percent. The results indicate that US hospital staffs ability to respond to traumatic injury and disasters has declined. Therefore, US hospital managers need to increase their investment in emergency department beds as well as provide state-of-the-art clinical technology to improve emergency service quality. These investments, when linked to other clinical information systems and the electronic medical record, support further healthcare quality improvement. This research uses the AHA annual surveys,which represent self-reported data by individual hospital staff. However, the AHA expendssignificant resources to validate reported information and the annual survey data are widely used for hospital research. The declining US emergency rooms and trauma centers have negative implications for patients needing emergency services. More importantly, this research has significant policy implications because it documents a decline in the US emergency healthcare service infrastructure. This article has important information on US emergency service availability in the hospital industry.

The association of adverse childhood experiences with mid-life depressive symptoms and quality of life among incarcerated males: exploring multiple mediation.

PubMed

Skarupski, Kimberly A; Parisi, Jeanine M; Thorpe, Roland; Tanner, Elizabeth; Gross, Deborah

2016-01-01

To explore the association of experiencing death, trauma, and abuse during childhood with depressive symptoms and quality of life at mid-life among incarcerated men and to understand how current social support and coping strategies mediate the impact of childhood trauma histories on mental health. Study participants were 192 male inmates in a maximum security prison. Participants completed measures of adverse childhood experiences related to death, trauma, and abuse, and depressive symptoms and quality of life. Data were analyzed using multiple mediation modeling. Men who reported having experienced adverse childhood experiences reported more depressive symptoms and lower quality of life than their counterparts. The results showed that in models both unadjusted and adjusted for age, race, education, number of years served, and whether the inmate had a life sentence, the association between adverse childhood experiences and quality of life were partially explained by the total of the indirect effects (point estimate = -.5052; CI.95 = -1.0364, -.0429 and point estimate = -.7792; CI.95 = -1.6369, -.0381), primarily via social support. However, the associations between adverse childhood experiences and depressive symptoms were not explained by social support and coping. Adverse childhood experiences are associated with deleterious mental health effects in later life. Social support and coping partially mediate the association between adverse childhood experiences and quality of life. The high prevalence of childhood trauma among aging prison inmates warrants attention to increasing social support mechanisms to improve mental health.

A ward round proforma improves documentation and communication.

PubMed

Alazzawi, Sulaiman; Silk, Zacharia; Saha, Urmila U; Auplish, Sunil; Masterson, Sean

2016-12-02

This article present the results of an audit cycle which evaluated the quality of inpatient ward round documentation in a busy district general hospital before and after the implementation of a standardized proforma which was specifically designed for trauma and orthopaedic patients. In each cycle, 20 case notes were examined and the data analysed to examine three main areas: Diagnosis, management and/or discharge plan Objective assessments including neurovascular status, weight-bearing status, surgical wound review, observations, results of investigations and decision from the daily trauma meeting Logistics of the documentation such as legibility, date and time, name and grade of the doctor and contact number. This audit demonstrated that using a ward round proforma can significantly enhance the quality of documentation and improve communication between multidisciplinary team members.

Emergency Preparedness Education for Nurses: Core Competency Familiarity Measured Utilizing an Adapted Emergency Preparedness Information Questionnaire.

PubMed

Georgino, Madeline M; Kress, Terri; Alexander, Sheila; Beach, Michael

2015-01-01

The purpose of this project was to measure trauma nurse improvement in familiarity with emergency preparedness and disaster response core competencies as originally defined by the Emergency Preparedness Information Questionnaire after a focused educational program. An adapted version of the Emergency Preparedness Information Questionnaire was utilized to measure familiarity of nurses with core competencies pertinent to first responder capabilities. This project utilized a pre- and postsurvey descriptive design and integrated education sessions into the preexisting, mandatory "Trauma Nurse Course" at large, level I trauma center. A total of 63 nurses completed the intervention during May and September 2014 sessions. Overall, all 8 competencies demonstrated significant (P < .001; 98% confidence interval) improvements in familiarity. In conclusion, this pilot quality improvement project demonstrated a unique approach to educating nurses to be more ready and comfortable when treating victims of a disaster.

Health-related quality of life and rehabilitation cost following intensive care unit stay in multiple trauma patients.

PubMed

Stergiannis, Pantelis; Katsoulas, Theodoros; Fildissis, George; Intas, George; Galanis, Peter; Kosta, Natalia; Zidianakis, Vasilios; Baltopoulos, George

2014-01-01

The objective of this study was to assess changes in health-related quality of life (HRQOL) in multiple trauma patients due to motor vehicle crashes during a follow-up period of 2 years after discharge from an intensive care unit (ICU) and the effect of income and financial cost of rehabilitation in HRQOL. The study was a prospective observational study of multiple trauma patients from January 2009 to January 2011 who were hospitalized in a general, medical, and surgical ICU of a district hospital in Athens, Greece. Eighty-five patients with multiple traumas due to motor vehicle crashes and with an ICU stay of more than 24 hours were included in the study. HRQOL was assessed by a general questionnaire, the EuroQol 5D. Increased monthly household income and absence of traumatic brain injuries were associated with an improved EQ-VAS score. The frequency of severe problems in mobility, self-care, usual activities, pain/discomfort, and anxiety/depression decreased over time. The financial cost of rehabilitation was initially high but decreased over time. Severely injured victims of motor vehicle crashes suffer from serious problems in terms of HRQOL which is gradually improved even 2 years after hospital discharge. In addition, HRQOL is significantly related to income. Resources used for rehabilitation decrease over time, but even at 24 months, the patients still use half of the amount as compared with the cost of the first 6 months after trauma.

Implementing Major Trauma Audit in Ireland.

PubMed

Deasy, Conor; Cronin, Marina; Cahill, Fiona; Geary, Una; Houlihan, Patricia; Woodford, Maralyn; Lecky, Fiona; Mealy, Ken; Crowley, Philip

2016-01-01

There are 27 receiving trauma hospitals in the Republic of Ireland. There has not been an audit system in place to monitor and measure processes and outcomes of care. The National Office of Clinical Audit (NOCA) is now working to implement Major Trauma Audit (MTA) in Ireland using the well-established National Health Service (NHS) UK Trauma Audit and Research Network (TARN). The aim of this report is to highlight the implementation process of MTA in Ireland to raise awareness of MTA nationally and share lessons that may be of value to other health systems undertaking the development of MTA. The National Trauma Audit Committee of the Royal College of Surgeons in Ireland, consisting of champions and stakeholders in trauma care, in 2010 advised on the adaptation of TARN for Ireland. In 2012, the Emergency Medicine Program endorsed TARN and in setting up the National Emergency Medicine Audit chose MTA as the first audit project. A major trauma governance group was established representing stakeholders in trauma care, a national project co-ordinator was recruited and a clinical lead nominated. Using Survey Monkey, the chief executives of all trauma receiving hospitals were asked to identify their hospital's trauma governance committee, trauma clinical lead and their local trauma data co-ordinator. Hospital Inpatient Enquiry systems were used to identify to hospitals an estimate of their anticipated trauma audit workload. There are 25 of 27 hospitals now collecting data using the TARN trauma audit platform. These hospitals have provided MTA Clinical Leads, allocated data co-ordinators and incorporated MTA reports formally into their clinical governance, quality and safety committee meetings. There has been broad acceptance of the NOCA escalation policy by hospitals in appreciation of the necessity for unexpected audit findings to stimulate action. Major trauma audit measures trauma patient care processes and outcomes of care to drive quality improvement at hospital and national level. MTA will facilitate the strategic development of trauma care in Ireland by monitoring processes and outcomes and the effects of changes in trauma service provision. Copyright © 2015 Elsevier Ltd. All rights reserved.

Improving communication in level 1 trauma centers: replacing pagers with smartphones.

PubMed

Joseph, Bellal; Pandit, Viraj; Khreiss, Mohammad; Aziz, Hassan; Kulvatunyou, Narong; Tang, Andrew; Wynne, Julie; O'Keeffe, Terence; Friese, Randall S; Weinstein, Ronald S; Rhee, Peter

2013-03-01

Communication among healthcare providers continues to change, and 90% of healthcare providers are now carrying cellular phones. Compared with pagers, the rate and amount of information immediately available via cellular phones are far superior. Wireless devices such as smartphones are ideal in acute trauma settings as they can transfer patient information quickly in a coordinate manner to all the team members responsible for patient care. A questionnaire survey was distributed among all the trauma surgeons, surgery residents, and nurse practitioners who were a part of the trauma surgery team at a Level 1 trauma center. Answers to each question were recorded on a 5-point Likert scale. The completed survey questionnaires were analyzed using Statistical Package for Social Sciences software (SPSS version 17; SPSS, Inc., Chicago, IL). The respondents had an overall positive experience with the usage of the third-generation (3G) smartphones, with 94% of respondents in favor of having wireless means of communication at a Level 1 trauma center. Of respondents, 78% found the device very user friendly, 98% stated that use of smartphones had improved the speed and quality of communication, 96% indicated that 3G smartphones were a useful teaching tool, 90% of the individuals felt there was improvement in the physician's response time to both routine and critical patients, and 88% of respondents were aware of the rules and regulations of the Health Insurance Portability and Accountability Act. Smartphones in an acute trauma setting are easy to use and improve the means of communication among the team members by providing accurate and reliable information in real time. Smartphones are effective in patient follow-up and as a teaching tool. Strict rules need to be used to govern the use of smartphones to secure the safety and secrecy of patient information.

Beneficial "halo effects" of surgical resident performance feedback.

PubMed

Lau, Brandyn D; Streiff, Michael B; Hobson, Deborah B; Kraus, Peggy S; Shaffer, Dauryne L; Popoola, Victor O; Farrow, Norma E; Efron, David T; Haut, Elliott R

2016-09-01

Venous thromboembolism (VTE) prevention is one of the most frequent measures of quality in hospital settings. In 2013, we began providing individualized feedback to general surgery residents about their VTE prophylaxis prescribing habits for general surgical patients. The purpose of this study was to investigate the indirect, or "halo effects" of providing individualized performance feedback to residents regarding prescription of appropriate VTE prophylaxis. This retrospective cohort study compared appropriate VTE prophylaxis prescription for all patients admitted to the adult trauma service from July 1, 2012 to May 31, 2015 at The Johns Hopkins Hospital, an academic hospital and Level 1 trauma center in Baltimore, Maryland. On October 1, 2013, we began providing monthly performance feedback to general surgery residents regarding their VTE prophylaxis prescribing habits for general surgery patients. Data were not provided about their prescription practice for trauma patients, or to any other prescribers within the hospital. During the study period, 931 adult trauma patients were admitted to the adult trauma service. After providing individualized feedback about general surgery patients, general surgery residents' prescribing practice for writing appropriate VTE prophylaxis orders for adult trauma patients significantly improved (93.9% versus 78.1%, P < 0.001). Prescription practice significantly improved among all other prescribers although they did not receive any specific individualized feedback, (84.9% versus 75.1%, P = 0.025); however, practice was significantly better among general surgery residents versus other providers (93.9% versus 84.9%, P = 0.003). There is a beneficial "halo effect" for patients treated by residents receiving individualized feedback about practice habits. Individualized feedback regarding practice habits for one patient type has both a direct and indirect effect on the quality of care patients receive and should be implemented for all providers. Copyright © 2016 Elsevier Inc. All rights reserved.

Non-compliance with ACS-COT recommended criteria for full trauma team activation is associated with undertriage deaths.

PubMed

Tignanelli, Christopher J; Vander Kolk, Wayne E; Mikhail, Judy N; Delano, Matthew J; Hemmila, Mark R

2017-11-21

The appropriate triage of acutely injured patients within a trauma system is associated with improved rates of mortality and optimal resource utilization. The American College of Surgeons Committee on Trauma (ACS-COT) put forward six minimum criteria (ACS-6) for full trauma team activation (TTA). We hypothesized that ACS-COT verified trauma center compliance with these criteria is associated with low under-triage rates and improved overall mortality. Data from a state-wide collaborative quality initiative was utilized. We used data collected from 2014 through 2016 at 29 ACS verified level 1 and 2 trauma centers. Inclusion criteria were: adult patients (≥16 years) and ISS ≥5. Quantitative data existed to analyze four of the ACS-6 criteria (ED SBP≤90 mmHg, respiratory compromise/intubation, central GSW, and GCS<9). Patients were considered to be under-triaged if they had major trauma (ISS>15) and did not receive a full TTA. 51,792 patients were included in the study. Compliance with ACS-6 minimum criteria for full TTA varied from 51% to 82%. Presence of any ACS-6 criteria was associated with a high intervention rate and significant risk of mortality (OR 16.7, 95% CI 15.2-18.3, p<0.001). Of the 1004 deaths that were not a full activation, 433 (43%) were classified as under-triaged, and 301 (30%) had at least one ACS-6 criteria present. Under-triaged patients with any ACS-6 criteria were more likely to die than those who were not under-triaged (30% vs 21%, p=0.001). GCS<9 and need for emergent intubation were the ACS-6 criteria most frequently associated with under-triage mortality. Compliance with ACS-COT minimum criteria for full TTA remains sub-optimal and undertriage is associated with increased mortality. This data suggests that the most efficient quality improvement measure around triage should be ensuring compliance with the ACS-6 criteria. This study suggests that practice pattern modification to more strictly adhere to the minimum ACS-COT criteria for full TTA will save lives. Diagnostic Tests or Criteria, Level III.

Association Between Real-time Electronic Injury Surveillance Applications and Clinical Documentation and Data Acquisition in a South African Trauma Center.

PubMed

Zargaran, Eiman; Spence, Richard; Adolph, Lauren; Nicol, Andrew; Schuurman, Nadine; Navsaria, Pradeep; Ramsey, Damon; Hameed, S Morad

2018-03-14

Collection and analysis of up-to-date and accurate injury surveillance data are a key step in the maturation of trauma systems. Trauma registries have proven to be difficult to establish in low- and middle-income countries owing to the burden of trauma volume, cost, and complexity. To determine whether an electronic trauma health record (eTHR) used by physicians can serve as simultaneous clinical documentation and data acquisition tools. This 2-part quality improvement study included (1) preimplementation and postimplementation eTHR study with assessments of satisfaction by 41 trauma physicians, time to completion, and quality of data collected comparing paper and electronic charting; and (2) prospective ecologic study describing the burden of trauma seen at a Level I trauma center, using real-time data collected by the eTHR on consecutive patients during a 12-month study period. The study was conducted from October 1, 2010, to September 30, 2011, at Groote Schuur Hospital, Cape Town, South Africa. Data analysis was performed from October 15, 2011, to January 15, 2013. The primary outcome of part 1 was data field competition rates of pertinent trauma registry items obtained through electronic or paper documentation. The main measures of part 2 were to identify risk factors to trauma in Cape Town and quality indicators recommended for trauma system evaluation at Groote Schuur Hospital. The 41 physicians included in the study found the electronic patient documentation to be more efficient and preferable. A total of 11 612 trauma presentations were accurately documented and promptly analyzed. Fields relevant to injury surveillance in the eTHR (n = 11 612) had statistically significant higher completion rates compared with paper records (n = 9236) (for all comparisons, P < .001). The eTHR successfully captured quality indicators recommended for trauma system evaluation which were previously challenging to collect in a timely and accurate manner. Of the 11 612 patient admissions over the study period, injury location was captured 11 075 times (95.4%), injury mechanism 11 135 times (95.9%), systolic blood pressure 11 106 times (95.6%), and Glasgow Coma Scale 11 140 times (95.9%). These fields were successfully captured with statistically higher rates than previous paper documentation. Epidemiologic analysis confirmed a heavy burden of violence-related injury (51.8% of all injuries) and motor vehicle crash injuries (14.3% of all injuries). Mapping analysis demonstrated clusters of injuries originating mainly from vulnerable and low-income neighborhoods and their respective referring trauma facilities, Mitchell's Plain Hospital (734 [10.1%]), Guguletu Community Health Center (654 [9.0%]), and New Somerset Hospital (400 [5.5%]). Accurate capture and simultaneous analysis of trauma data in low-resource trauma settings are feasible through the integration of surveillance into clinical workflow and the timely analysis of electronic data.

Automatic Pre-Hospital Vital Signs Waveform and Trend Data Capture Fills Quality Management, Triage and Outcome Prediction Gaps

PubMed Central

Mackenzie, Colin F; Hu, Peter; Sen, Ayan; Dutton, Rick; Seebode, Steve; Floccare, Doug; Scalea, Tom

2008-01-01

Trauma Triage errors are frequent and costly. What happens in pre-hospital care remains anecdotal because of the dual responsibility of treatment (resuscitation and stabilization) and documentation in a time-critical environment. Continuous pre-hospital vital signs waveforms and numerical trends were automatically collected in our study. Abnormalities of pulse oximeter oxygen saturation (< 95%) and validated heart rate (> 100/min) showed better prediction of injury severity, need for immediate blood transfusion, intra-abdominal surgery, tracheal intubation and chest tube insertion than Trauma Registry data or Pre-hospital provider estimations. Automated means of data collection introduced the potential for more accurate and objective reporting of patient vital signs helping in evaluating quality of care and establishing performance indicators and benchmarks. Addition of novel and existing non-invasive monitors and waveform analyses could make the pulse oximeter the decision aid of choice to improve trauma patient triage. PMID:18999022

Development of the major trauma case review tool.

PubMed

Curtis, Kate; Mitchell, Rebecca; McCarthy, Amy; Wilson, Kellie; Van, Connie; Kennedy, Belinda; Tall, Gary; Holland, Andrew; Foster, Kim; Dickinson, Stuart; Stelfox, Henry T

2017-02-28

As many as half of all patients with major traumatic injuries do not receive the recommended care, with variance in preventable mortality reported across the globe. This variance highlights the need for a comprehensive process for monitoring and reviewing patient care, central to which is a consistent peer-review process that includes trauma system safety and human factors. There is no published, evidence-informed standardised tool that considers these factors for use in adult or paediatric trauma case peer-review. The aim of this research was to develop and validate a trauma case review tool to facilitate clinical review of paediatric trauma patient care in extracting information to facilitate monitoring, inform change and enable loop closure. Development of the trauma case review tool was multi-faceted, beginning with a review of the trauma audit tool literature. Data were extracted from the literature to inform iterative tool development using a consensus approach. Inter-rater agreement was assessed for both the pilot and finalised versions of the tool. The final trauma case review tool contained ten sections, including patient factors (such as pre-existing conditions), presenting problem, a timeline of events, factors contributing to the care delivery problem (including equipment, work environment, staff action, organizational factors), positive aspects of care and the outcome of panel discussion. After refinement, the inter-rater reliability of the human factors and outcome components of the tool improved with an average 86% agreement between raters. This research developed an evidence-informed tool for use in paediatric trauma case review that considers both system safety and human factors to facilitate clinical review of trauma patient care. This tool can be used to identify opportunities for improvement in trauma care and guide quality assurance activities. Validation is required in the adult population.

A trauma outreach program provided by a level I trauma center is an effective way to initiate peer review at referring hospitals and foster process improvements.

PubMed

Byrnes, Matthew C; Irwin, Eric; Becker, Leslie; Thorson, Melissa; Beilman, Greg; Horst, Patrick; Croston, Kevin

2010-04-01

The initial care of critically injured patients has profound effects on ultimate outcomes. The "golden hour" of trauma care is often provided by rural hospitals before definitive transfer. There are, however, no standardized methods for providing educational feedback to these hospitals for the purposes of performance improvement. We hypothesized that an outreach program would stimulate peer review and identify systematic deficiencies in the care of patients with injuries. We developed a quality improvement program aimed at providing educational feedback to hospitals that referred patients to our American College of Surgeons-verified level I trauma center. We traveled to each referral center to provide feedback on the initial treatment and ultimate outcome of patients that were transferred to us. These feedback sessions were presented in the format of case presentations and case discussions. The outreach program was presented at each hospital every 3 months to 6 months. Nine hospitals were included in our program. We received 334 patients in transfer from these hospitals during the study period. Formal peer review that focused on trauma patients increased from 14% of hospitals to 100% of hospitals after institution of the program. Eighty-five percent of hospitals thought that the care of patients with injuries was improved as a result of the program. Eighty-five percent of hospitals developed process improvement initiatives as a result of the program. A formal outreach program can stimulate peer review at rural hospitals, provide continuing education in the care of patients with injuries, and foster process improvements at referring hospitals.

Chronic consequences of acute injuries: worse survival after discharge.

PubMed

Shafi, Shahid; Renfro, Lindsay A; Barnes, Sunni; Rayan, Nadine; Gentilello, Larry M; Fleming, Neil; Ballard, David

2012-09-01

The Trauma Quality Improvement Program uses inhospital mortality to measure quality of care, which assumes patients who survive injury are not likely to suffer higher mortality after discharge. We hypothesized that survival rates in trauma patients who survive to discharge remain stable afterward. Patients treated at an urban Level I trauma center (2006-2008) were linked with the Social Security Administration Death Master File. Survival rates were measured at 30, 90, and 180 days and 1 and 2 years from injury among two groups of trauma patients who survived to discharge: major trauma (Abbreviated Injury Scale score ≥ 3 injuries, n = 2,238) and minor trauma (Abbreviated Injury Scale score ≤ 2 injuries, n = 1,171). Control groups matched to each trauma group by age and sex were simulated from the US general population using annual survival probabilities from census data. Kaplan-Meier and log-rank analyses conditional upon survival to each time point were used to determine changes in risk of mortality after discharge. Cox proportional hazards models with left truncation at the time of discharge were used to determine independent predictors of mortality after discharge. The survival rate in trauma patients with major injuries was 92% at 30 days posttrauma and declined to 84% by 3 years (p > 0.05 compared with general population). Minor trauma patients experienced a survival rate similar to the general population. Age and injury severity were the only independent predictors of long-term mortality given survival to discharge. Log-rank tests conditional on survival to each time point showed that mortality risk in patients with major injuries remained significantly higher than the general population for up to 6 months after injury. The survival rate of trauma patients with major injuries remains significantly lower than survival for minor trauma patients and the general population for several months postdischarge. Surveillance for early identification and treatment of complications may be needed for trauma patients with major injuries. Prognostic study, level III.

Consolidation of trauma programs in the era of large health care delivery networks.

PubMed

Trooskin, S Z; Faucher, M B; Santora, T A; Talucci, R C

1999-03-01

To review the development of an integrated trauma program at two separate campuses brought about by the merger of two medical-affiliated hospitals, each with an integrated program and a common trauma administrator, medical director, and educational coordinator. Each campus has an associate trauma medical director for on-site administrative management, a nurse coordinator, and a registrar. The integration resulted in a reduction of 1.5 full-time equivalents and "cost" savings by consolidated use of the helicopter, outreach, prevention, research, and educational programs. Regular "integration meetings," ad hoc committees, and video-linked conferences were used to institute common quality improvement programs, morbidity and mortality discussions, policies, and clinical management protocols. Reaccreditation by an outside agency, elimination of duplicated services, and maintenance of pre-merger clinical volume results. This integrated trauma program may serve as a model in this era of individual hospitals merging into large health care delivery networks.

[Abdominal trauma].

PubMed

Sido, B; Grenacher, L; Friess, H; Büchler, M W

2005-09-01

Blunt abdominal trauma is much more frequent than penetrating abdominal trauma in Europe. As a consequence of improved quality of computed tomography, even complex liver injuries are increasingly being treated conservatively. However, missed hollow viscus injuries still remain a problem, as they considerably increase mortality in multiply injured patients. Laparoscopy decreases the rate of unnecessary laparotomies in perforating abdominal trauma and helps to diagnose injuries of solid organs and the diaphragm. However, the sensitivity in detecting hollow viscus injuries is low and the role of laparoscopy in blunt abdominal injury has not been defined. If intra-abdominal bleeding is difficult to control in hemodynamically unstable patients, damage control surgery with packing of the liver, total splenectomy, and provisional closure of hollow viscus injuries is of importance. Definitive surgical treatment follows hemodynamic stabilization and restoration of hemostasis. Injuries of the duodenum and pancreas after blunt abdominal trauma are often associated with other intra-abdominal injuries and the treatment depends on their location and severity.

Standardising trauma monitoring: the development of a minimum dataset for trauma registries in Australia and New Zealand.

PubMed

Palmer, Cameron S; Davey, Tamzyn M; Mok, Meng Tuck; McClure, Rod J; Farrow, Nathan C; Gruen, Russell L; Pollard, Cliff W

2013-06-01

Trauma registries are central to the implementation of effective trauma systems. However, differences between trauma registry datasets make comparisons between trauma systems difficult. In 2005, the collaborative Australian and New Zealand National Trauma Registry Consortium began a process to develop a bi-national minimum dataset (BMDS) for use in Australasian trauma registries. This study aims to describe the steps taken in the development and preliminary evaluation of the BMDS. A working party comprising sixteen representatives from across Australasia identified and discussed the collectability and utility of potential BMDS fields. This included evaluating existing national and international trauma registry datasets, as well as reviewing all quality indicators and audit filters in use in Australasian trauma centres. After the working party activities concluded, this process was continued by a number of interested individuals, with broader feedback sought from the Australasian trauma community on a number of occasions. Once the BMDS had reached a suitable stage of development, an email survey was conducted across Australasian trauma centres to assess whether BMDS fields met an ideal minimum standard of field collectability. The BMDS was also compared with three prominent international datasets to assess the extent of dataset overlap. Following this, the BMDS was encapsulated in a data dictionary, which was introduced in late 2010. The finalised BMDS contained 67 data fields. Forty-seven of these fields met a previously published criterion of 80% collectability across respondent trauma institutions; the majority of the remaining fields either could be collected without any change in resources, or could be calculated from other data fields in the BMDS. However, comparability with international registry datasets was poor. Only nine BMDS fields had corresponding, directly comparable fields in all the national and international-level registry datasets evaluated. A draft BMDS has been developed for use in trauma registries across Australia and New Zealand. The email survey provided strong indications of the utility of the fields contained in the BMDS. The BMDS has been adopted as the dataset to be used by an ongoing Australian Trauma Quality Improvement Program. Copyright © 2012 Elsevier Ltd. All rights reserved.

The Prevalence and Determinants of Controlled Substance Discrepancies in a Level I Trauma Hospital

PubMed Central

Anyanwu, Chukwuma; Egwim, Oliver

2016-01-01

Background Healthcare institutions are often faced with challenges and accreditation requirements for improving treatment quality, reducing waste, and avoiding diversion of drugs, particularly controlled substances. Many automated systems have replaced manual systems but may be fraught with challenges, especially when multiple users are involved. Objective To describe the characteristics of controlled substance discrepancies observed in a Level I trauma hospital for Medicare. Methods Discrepancy data were captured for each user involved in a transaction for a controlled substance at the Level I trauma hospital (in Ben Taub Hospital, Houston, TX), and the information was stored in a computerized database repository. Data for the 1-year study period (from January 1 through December 31, 2013) were collected for Medicare beneficiaries, using an Excel 2013 spreadsheet, and were analyzed according to basic discrepancy characteristics and descriptive statistics. Results During the 12-month study period, 114,000 controlled substance discrepancies were found for 100,000 Medicare patients at this Level I trauma hospital. Vending activities accounted for the majority (52.6%) of these discrepancies. Discrepancies were most likely to occur on Wednesdays, and the medications involved most frequently were combination drugs of hydrocodone and acetaminophen. Conclusion Approximately 1 (1.14) discrepancy involving a controlled substance occurred for each Medicare patient treated at the study facility. Healthcare institutions need to improve their efforts to ensure high-quality care and prevent diversion of drugs. PMID:27606038

Pre-hospital and early in-hospital management of severe injuries: changes and trends.

PubMed

Hussmann, Bjoern; Lendemans, Sven

2014-10-01

The pre-hospital and early in-hospital management of most severely injured patients has dramatically changed over the last 20 years. In this context, the factor time has gained more and more attention, particularly in German-speaking countries. While the management in the early 1990s aimed at comprehensive and complete therapy at the accident site, the premise today is to stabilise trauma patients at the accident site and transfer them into the hospital rapidly. In addition, the introduction of training and education programmes such as Pre-hospital Trauma Life Support (PHTLS(®)), Advanced Trauma Life Support (ATLS(®)) concept or the TEAM(®) concept has increased the quality of treatment of most severely injured trauma patients both in the preclinical field and in the emergency trauma room. Today, all emergency surgical procedures in severely injured patients are generally performed in accordance with the Damage Control Orthopaedics (DCO) principle. The advancements described in this article provide examples for the improved quality of the management of severely injured patients in the preclinical field and during the initial in-hospital treatment phase. The implementation of trauma networks, the release of the S3 polytrauma guidelines, and the DGU "Weißbuch" have contributed to a more structured management of most severely injured patients. Copyright © 2014 Elsevier Ltd. All rights reserved.

Lost in translation: Focused documentation improvement benefits trauma surgeons.

PubMed

Fox, Nicole; Swierczynski, Patricia; Willcutt, Rebecca; Elberfeld, Adrienne; Mazzarelli, Anthony J

2016-09-01

There is a translational gap between physicians who document in the medical record and coders, who ultimately determine which codes are submitted. This gap exists because physicians are never formally educated about documentation strategies despite the fact that the quality of physician documentation directly affects revenue, outcomes and public profiling. We evaluated the effect of a formal model of focused documentation improvement (FDI) on the trauma/critical care division. We hypothesized that FDI would improve physician documentation, resulting in revenue recovery and a shift in the case mix index (CMI) to more accurately reflect the clinical complexity of trauma patients. FDI is defined as targeted physician education followed by concurrent inpatient chart review for documentation improvement opportunities by a clinical documentation specialist (CDS). All trauma surgeons (n=9) at our Level 1 trauma center first completed three hours of mandatory training on documentation improvement. A CDS was subsequently assigned to the trauma service. They reviewed the charts of Medicare patients (n=776) from January-December 2014 to identify opportunities for documentation improvement, participated in ICU rounds and provided ongoing education. Requests to clarify documentation (queries) were posted in the electronic medical record (EMR) and physicians were required to respond within 48h. Data was collected on physician response rate, CMI and revenue recovery. 411 of 776 (57%) charts were reviewed. Opportunities for FDI were identified in 177 (43%) cases. The physician response rate to queries was 100%. The CMI for reviewed cases increased (1.80 (SD 0.15) vs. 2.11 (SD 0.19); p<0.001) after FDI. Overall revenue recovery was $1,132,581 with an average of $154,092 in revenue recovery/clinical full time equivalent. The total cost for administration of FDI was $353,265 resulting in a 220% return on investment (ROI). FDI is an effective strategy to engage physicians in documentation improvement. It provides an infrastructure to assist physicians and yields a significant ROI. Copyright © 2016 Elsevier Ltd. All rights reserved.

American Association for the Surgery of Trauma Prevention Committee topical overview: National Trauma Data Bank, geographic information systems, and teaching injury prevention.

PubMed

Crandall, Marie; Zarzaur, Ben; Tinkoff, Glen

2013-11-01

Injury is the leading cause of death for all Americans aged 1 to 35 years, and injury-related costs exceed $100 billion per year in the United States. Trauma centers can be important resources for risk identification and prevention strategies. The authors review 3 important resources for injury prevention education and research: the National Trauma Data Bank, geographic information systems, and an overview of injury prevention education. The National Trauma Data Bank and the Trauma Quality Improvement Program are available through the Web site of the American College of Surgeons. Links to research examples using geographic information systems software and the National Trauma Data Bank are provided in the text. Finally, resources for surgical educators in the area of injury prevention are summarized and examples provided. Database research, geographic information systems, and injury prevention education are important tools in the field of injury prevention. This article provides an overview of current research and education strategies and resources. Copyright © 2013 Elsevier Inc. All rights reserved.

Status of trauma quality improvement programs in the Andean region: What foundation do we have to build on.

PubMed

LaGrone, Lacey N; Romaní Pozo, Diego A; Figueroa, Juan F; Artunduaga, Maria A; Huaman Egoavil, Eduardo; Rodriguez Castro, Manuel J A; Foianini, Jorge Esteban; Rubiano, Andrés M; Rodas, Edgar B; Mock, Charles N

2017-09-01

Trauma quality improvement (QI) programs have been shown to improve outcomes and decrease cost. These are high priorities in low- and middle-income countries (LMICs), where 2,000,000 deaths due to survivable injuries occur each year. We sought to define areas for improvement in trauma QI programs in four LMICs. We conducted a survey among trauma care providers in four Andean middle-income countries: Bolivia, Colombia, Ecuador, and Peru. 336 physicians, medical students, nurses, administrators and paramedical professionals responded to the cross-sectional survey with a response rate greater than 90% in all included countries except Bolivia, where the response rate was 14%. Eighty-seven percent of respondents reported morbidity and mortality (M&M) conferences occur at their hospital. Conferences were often reported as infrequent - 45% occurred less than every three months and poorly attended - 63% had five or fewer staff physicians present. Only 23% of conferences had standardized selection criteria, most lacked documentation - notes were taken at only 35% of conferences. Importantly, only 13% of participants indicated that discussions were routinely followed-up with any sort of corrective action. Multivariable analysis revealed the presence of standardized case selection criteria (OR 3.48, 95% CI 1.16-10.46), written documentation of the M&M conferences (OR 5.73, 95% CI 1.73-19.06), and a clear plan for follow-up (OR 4.80, 95% CI 1.59-14.50) to be associated with effective M&M conferences. Twenty-two percent of respondents worked at hospitals with a trauma registry. Fifty-two percent worked at institutions where autopsies were conducted, but only 32% of those reported the autopsy results to ever be used to improve hospital practice. M&M conferences are frequently practiced in the Andean region of Latin America but often lack methodologic rigor and thus effectiveness. Next steps in the maturation of QI programs include optimizing use of data from autopsies and registries, and systematic follow-up of M&M conferences with corrective action to ensure that these activities result in appreciable changes in clinical care. Copyright © 2017 Elsevier Ltd. All rights reserved.

Real money: complications and hospital costs in trauma patients.

PubMed

Hemmila, Mark R; Jakubus, Jill L; Maggio, Paul M; Wahl, Wendy L; Dimick, Justin B; Campbell, Darrell A; Taheri, Paul A

2008-08-01

Major postoperative complications are associated with a substantial increase in hospital costs. Trauma patients are known to have a higher rate of complications than the general surgery population. We used the National Surgical Quality Improvement Program (NSQIP) methodology to evaluate hospital costs, duration of stay, and payment associated with complications in trauma patients. Using NSQIP principles, patient data were collected for 512 adult patients admitted to the trauma service for > 24 hours at a Level 1 trauma center (2004-2005). Patients were placed in 1 of 3 groups: no complications (none), >or=1 minor complication (minor, eg, urinary tract infection), or >or=1 major complication (major, eg, pneumonia). Total hospital charges, costs, payment, and duration of stay associated with each complication group were determined from a cost-accounting database. Multiple regression was used to determine the costs of each type of complication after adjusting for differences in age, sex, new injury severity score, Glasgow coma scale score, maximum head abbreviated injury scale, and first emergency department systolic blood pressure. A total of 330 (64%) patients had no complications, 53 (10%) had >or= 1 minor complication, and 129 (25%) had >or= 1 major complication. Median hospital charges increased from $33,833 (none) to $81,936 (minor) and $150,885 (major). The mean contribution to margin per day was similar for the no complication and minor complication groups ($994 vs $1,115, P = .7). Despite higher costs, the patients in the major complication group generated a higher mean contribution to margin per day compared to the no complication group ($2,168, P < .001). The attributable increase in median total hospital costs when adjusted for confounding variables was $19,915 for the minor complication group (P < .001), and $40,555 for the major complication group (P < .001). Understanding the costs associated with traumatic injury provides a window for assessing the potential cost reductions associated with improved quality care. To optimize system benefits, payers and providers should develop integrated reimbursement methodologies that align incentives to provide quality care.

Delta Alert: Expanding Gerotrauma Criteria to Improve Patient Outcomes: A 2-Year Study.

PubMed

Wiles, Lynn L; Day, Mark D

Because of their decreased physical reserve and increased risk of complications, the geriatric trauma patient (GTP) population warrants heightened awareness by clinical staff. The purpose of this study is to determine whether the institution of a third-tier trauma protocol results in a change in GTP outcomes, complications, and mortality rates. Researchers conducted a retrospective review of 2 years of data from the trauma registry, hospital quality improvement audits, and patient charts to examine what, if any, patient outcomes were impacted by the institution of the expanded GTP protocol. Sample homogeneity was determined. Emergency department (ED) length of stay and time to the operating room decreased in the protocol cohort. The rate of complications decreased from 16.4% preprotocol to 1.6% postprotocol. Discharge to home rates in the GTP population improved from 31% preprotocol to nearly 77% postimplementation of the protocol. The expanded GTP protocol front loads evaluation and resuscitation to be consistent with ED trauma protocols already in place. By fast-tracking radiology and laboratory testing, patients injuries are identified and the appropriate consultations are initiated. Appropriate inpatient nursing unit placement is identified or treatment and discharge from the ED are expedited. The expanded GTP protocol provided early and comprehensive evaluation and interventions for GTPs who fall outside of traditional trauma alert criteria. Patients spend less time in the ED and the hospital. Patients had decreased length of stay in the ED, less complications, and return to home rates showed significant improvement after the protocol was implemented.

The impact of post-traumatic stress disorder symptomatology on quality of life: The sentinel experience of anger, hypervigilance and restricted affect.

PubMed

Forbes, David; Nickerson, Angela; Bryant, Richard A; Creamer, Mark; Silove, Derrick; McFarlane, Alexander C; Van Hooff, Miranda; Phelps, Andrea; Felmingham, Kim L; Malhi, Gin S; Steel, Zachary; Fredrickson, Julia; Alkemade, Nathan; O'Donnell, Meaghan

2018-05-01

It is unclear which specific symptoms of post-traumatic stress disorder are related to poor perceived quality of life. To investigate the influence of post-traumatic stress disorder symptomatology on quality of life in traumatic injury survivors. Traumatic injury survivors completed questionnaires on post-traumatic stress disorder symptomatology and quality of life at 3 months ( n = 987), 12 months ( n = 862), 24 months ( n = 830) and 6 years ( n = 613) post trauma. Low quality of life was reported by 14.5% of injury survivors at 3 months and 8% at 6 years post event. The post-traumatic stress disorder symptom clusters that contributed most to poor perceived quality of life were numbing and arousal, the individual symptoms that contributed most were anger, hypervigilance and restricted affect. There was variability in the quality of life of traumatic injury survivors in the 6 years following trauma and a consistent proportion reported low quality of life. Early intervention to reduce anger, hypervigilance and restricted affect symptoms may provide a means to improving the quality of life of traumatic injury survivors.

Model for Team Training Using the Advanced Trauma Operative Management Course: Pilot Study Analysis.

PubMed

Perkins, R Serene; Lehner, Kathryn A; Armstrong, Randy; Gardiner, Stuart K; Karmy-Jones, Riyad C; Izenberg, Seth D; Long, William B; Wackym, P Ashley

2015-01-01

Education and training of surgeons has traditionally focused on the development of individual knowledge, technical skills, and decision making. Team training with the surgeon's operating room staff has not been prioritized in existing educational paradigms, particularly in trauma surgery. We aimed to determine whether a pilot curriculum for surgical technicians and nurses, based on the American College of Surgeons' Advanced Trauma Operative Management (ATOM) course, would improve staff knowledge if conducted in a team-training environment. Between December 2012 and December 2014, 22 surgical technicians and nurses participated in a curriculum complementary to the ATOM course, consisting of 8 individual 8-hour training sessions designed by and conducted at our institution. Didactic and practical sessions included educational content, hands-on instruction, and alternating role play during 5 system-specific injury scenarios in a simulated operating room environment. A pre- and postcourse examination was administered to participants to assess for improvements in team members' didactic knowledge. Course participants displayed a significant improvement in didactic knowledge after working in a team setting with trauma surgeons during the ATOM course, with a 9-point improvement on the postcourse examination (83%-92%, p = 0.0008). Most participants (90.5%) completing postcourse surveys reported being "highly satisfied" with course content and quality after working in our simulated team-training setting. Team training is critical to improving the knowledge base of surgical technicians and nurses in the trauma operative setting. Improved communication, efficiency, appropriate equipment use, and staff awareness are the desired outcomes when shifting the paradigm from individual to surgical team training so that improved patient outcomes, decreased risk, and cost savings can be achieved. Determine whether a pilot curriculum for surgical technicians and nurses, based on the American College of Surgeons' ATOM course, improves staff knowledge if conducted in a team-training environment. Surgical technicians and nurses participated in a curriculum complementary to the ATOM course. In all, 8 individual 8-hour training sessions were conducted at our institution and contained both didactic and practical content, as well as alternating role play during 5 system-specific injury scenarios. A pre- and postcourse examination was administered to assess for improvements in didactic knowledge. The course was conducted in a simulated team-training setting at the Legacy Institute for Surgical Education and Innovation (Portland, OR), an American College of Surgeons Accredited Educational Institute. In all, 22 surgical technicians and operating room nurses participated in 8 separate ATOM(s) courses and had at least 1 year of surgical scrubbing experience in general surgery with little or no exposure to Level I trauma surgical care. Of these participants, 16 completed the postcourse examination. Participants displayed a significant improvement in didactic knowledge (83%-92%, p = 0.0008) after the ATOM(s) course. Of the 14 participants who completed postcourse surveys, 90.5% were "highly satisfied" with the course content and quality. Team training is critical to improving the knowledge base of surgical technicians and nurses in the trauma operative setting and may contribute to improved patient outcomes, decreased risk, and hospital cost savings. Copyright © 2015 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Decreasing the Use of Damage Control Laparotomy in Trauma: A Quality Improvement Project.

PubMed

Harvin, John A; Kao, Lillian S; Liang, Mike K; Adams, Sasha D; McNutt, Michelle K; Love, Joseph D; Moore, Laura J; Wade, Charles E; Cotton, Bryan A; Holcomb, John B

2017-08-01

Our institution has published damage control laparotomy (DCL) rates of 30% and documented the substantial morbidity associated with the open abdomen. The purpose of this quality improvement (QI) project was to decrease the rate of DCL at a busy, Level I trauma center in the US. A prospective cohort of all emergent trauma laparotomies from November 2013 to October 2015 (QI group) was followed. The QI intervention was multifaceted and included audit and feedback for every DCL case. Morbidity and mortality of the QI patients were compared with those from a published control (control group: emergent laparotomy from January 2011 to October 2013). A significant decrease was observed immediately on beginning the QI project, from a 39% DCL rate in the control period to 23% in the QI group (p < 0.001). This decrease was sustained over the 2-year study period. There were no differences in demographics, Injury Severity Score, or transfusions between the groups. No differences organ/space infection (control 16% vs QI 12%; p = 0.15), fascial dehiscence (6% vs 8%; p = 0.20), unplanned relaparotomy (11% vs 10%; p = 0.58), or mortality (9% vs 10%; p = 0.69) were observed. The reduction in use resulted in a decrease of 68 DCLs over the 2-year period. There was a further reduction in the rate of DCL to 17% after completion of the QI project. A QI initiative rapidly changed the use of DCL and improved quality of care by decreasing resource use without an increase morbidity or mortality. This decrease was sustained during the QI period and further improved upon after its completion. Copyright © 2017 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Benchmarking statewide trauma mortality using Agency for Healthcare Research and Quality's patient safety indicators.

PubMed

Ang, Darwin; McKenney, Mark; Norwood, Scott; Kurek, Stanley; Kimbrell, Brian; Liu, Huazhi; Ziglar, Michele; Hurst, James

2015-09-01

Improving clinical outcomes of trauma patients is a challenging problem at a statewide level, particularly if data from the state's registry are not publicly available. Promotion of optimal care throughout the state is not possible unless clinical benchmarks are available for comparison. Using publicly available administrative data from the State Department of Health and the Agency for Healthcare Research and Quality (AHRQ) patient safety indicators (PSIs), we sought to create a statewide method for benchmarking trauma mortality and at the same time also identifying a pattern of unique complications that have an independent influence on mortality. Data for this study were obtained from State of Florida Agency for Health Care Administration. Adult trauma patients were identified as having International Classification of Disease ninth edition codes defined by the state. Multivariate logistic regression was used to create a predictive inpatient expected mortality model. The expected value of PSIs was created using the multivariate model and their beta coefficients provided by the AHRQ. Case-mix adjusted mortality results were reported as observed to expected (O/E) ratios to examine mortality, PSIs, failure to prevent complications, and failure to rescue from death. There were 50,596 trauma patients evaluated during the study period. The overall fit of the expected mortality model was very strong at a c-statistic of 0.93. Twelve of 25 trauma centers had O/E ratios <1 or better than expected. Nine statewide PSIs had failure to prevent O/E ratios higher than expected. Five statewide PSIs had failure to rescue O/E ratios higher than expected. The PSI that had the strongest influence on trauma mortality for the state was PSI no. 9 or perioperative hemorrhage or hematoma. Mortality could be further substratified by PSI complications at the hospital level. AHRQ PSIs can have an integral role in an adjusted benchmarking method that screens at risk trauma centers in the state for higher than expected mortality. Stratifying mortality based on failure to prevent PSIs may identify areas of needed improvement at a statewide level. Copyright © 2015 Elsevier Inc. All rights reserved.

[When should a patient with musculoskeletal trauma be referred to emergency ward?].

PubMed

Feiner, Adam-Scott; Duruz, Henri

2010-08-25

Standardized clinical examination can obviate the need for osteoarticular radiographs for trauma. This paper summarizes a number of decision rules that allow clinical exclusion of significant fracture of the cervical spine, elbow, knee or ankle, making radiographs unnecessary. These criteria were all derived from large cohort studies (Nexus, Ottawa, CCS, etc..., and have been prospectively validated. The rigorous use of these criteria in daily practice improves treatment times and costs with no adverse effect on treatment quality.

Association Between Real-time Electronic Injury Surveillance Applications and Clinical Documentation and Data Acquisition in a South African Trauma Center

PubMed Central

Zargaran, Eiman; Spence, Richard; Adolph, Lauren; Nicol, Andrew; Schuurman, Nadine; Navsaria, Pradeep; Ramsey, Damon

2018-01-01

Importance Collection and analysis of up-to-date and accurate injury surveillance data are a key step in the maturation of trauma systems. Trauma registries have proven to be difficult to establish in low- and middle-income countries owing to the burden of trauma volume, cost, and complexity. Objective To determine whether an electronic trauma health record (eTHR) used by physicians can serve as simultaneous clinical documentation and data acquisition tools. Design, Setting, and Participants This 2-part quality improvement study included (1) preimplementation and postimplementation eTHR study with assessments of satisfaction by 41 trauma physicians, time to completion, and quality of data collected comparing paper and electronic charting; and (2) prospective ecologic study describing the burden of trauma seen at a Level I trauma center, using real-time data collected by the eTHR on consecutive patients during a 12-month study period. The study was conducted from October 1, 2010, to September 30, 2011, at Groote Schuur Hospital, Cape Town, South Africa. Data analysis was performed from October 15, 2011, to January 15, 2013. Main Outcomes and Measures The primary outcome of part 1 was data field competition rates of pertinent trauma registry items obtained through electronic or paper documentation. The main measures of part 2 were to identify risk factors to trauma in Cape Town and quality indicators recommended for trauma system evaluation at Groote Schuur Hospital. Results The 41 physicians included in the study found the electronic patient documentation to be more efficient and preferable. A total of 11 612 trauma presentations were accurately documented and promptly analyzed. Fields relevant to injury surveillance in the eTHR (n = 11 612) had statistically significant higher completion rates compared with paper records (n = 9236) (for all comparisons, P < .001). The eTHR successfully captured quality indicators recommended for trauma system evaluation which were previously challenging to collect in a timely and accurate manner. Of the 11 612 patient admissions over the study period, injury location was captured 11 075 times (95.4%), injury mechanism 11 135 times (95.9%), systolic blood pressure 11 106 times (95.6%), and Glasgow Coma Scale 11 140 times (95.9%). These fields were successfully captured with statistically higher rates than previous paper documentation. Epidemiologic analysis confirmed a heavy burden of violence-related injury (51.8% of all injuries) and motor vehicle crash injuries (14.3% of all injuries). Mapping analysis demonstrated clusters of injuries originating mainly from vulnerable and low-income neighborhoods and their respective referring trauma facilities, Mitchell’s Plain Hospital (734 [10.1%]), Guguletu Community Health Center (654 [9.0%]), and New Somerset Hospital (400 [5.5%]). Conclusions and Relevance Accurate capture and simultaneous analysis of trauma data in low-resource trauma settings are feasible through the integration of surveillance into clinical workflow and the timely analysis of electronic data. PMID:29541765

The Highest-Impact Combat Orthopedic and Extremity Injury Articles in the Past 70 Years: A Citation Analysis.

PubMed

Nam, Jason; Do, Woo S; Stinner, Daniel J; Wenke, Joseph C; Orman, Jean A; Kragh, John F

The objective of this study was to identify the most-cited peer-reviewed combat orthopedic and extremity injury articles published during the past 70 years. Orthopedic trauma presents ongoing challenges to both US civilian and military healthcare personnel. Improvements in combat trauma and extremity injury survival and quality of life are the result of advances in orthopedic trauma research. The Web of Science (including Science Citation Index) was searched for the most cited articles related to combat orthopedic trauma, published from 1940 to 2013. The most-cited article was by Owens et al. (Journal of Orthopaedic Trauma, 2007; 137 citations). Between the 1990s and 2000s, there was a 256% increase in the number of highly cited publications. A total of 69% of the articles were on the topics of comorbid vascular trauma (25%), epidemiology (23%), or orthopedic trauma (21%). This study identifies some of the most important contributions to combat orthopedic trauma and research and the areas of greatest scientific interest to the specialty during the past seven decades and highlights key research that has contributed to the evolution of modern combat orthopedic traumatology. 2017.

Implementation of Trauma-Informed Care and Brief Solution-Focused Therapy: A Quality Improvement Project Aimed at Increasing Engagement on an Inpatient Psychiatric Unit.

PubMed

Aremu, Babatunde; Hill, Pamela D; McNeal, Joanne M; Petersen, Mary A; Swanberg, Debbie; Delaney, Kathleen R

2018-03-14

Addressing tense and escalating situations with noncoercive measures is an important element of inpatient psychiatric treatment. Although restraint rates are frequently monitored, the use of pro re nata (PRN) intramuscular (IM) injections to address agitation is also an important indicator. In 2015, at the current study site, a significant increase was noted in PRN IM medication use despite unit leadership's efforts to build a culture of trauma-informed care (TIC). The purpose of the current quality improvement project was to educate staff on methods to incorporate TIC into daily practice and the use of brief solution-focused therapy techniques in escalating situations. Measurement of attitudes toward patient aggression and engagement with patients followed two waves of staff education. Upon completion of the project, a decrease in PRN IM medications, improvement in staff attitudes toward patient aggression, and improved sense of staff competency in handling tense situations were noted. [Journal of Psychosocial Nursing and Mental Health Services, xx(x), xx-xx.]. Copyright 2018, SLACK Incorporated.

Development of electronic software for the management of trauma patients on the orthopaedic unit.

PubMed

Patel, Vishal P; Raptis, Demitri; Christofi, T; Mathew, Rajeev; Horwitz, M D; Eleftheriou, K; McGovern, Paul D; Youngman, J; Patel, J V; Haddad, F S

2009-04-01

Continuity of patient care is an essential prerequisite for the successful running of a trauma surgery service. This is becoming increasingly difficult because of the new working arrangements of junior doctors. Handover is now central to ensure continuity of care following shift change over. The purpose of this study was to compare the quality of information handed over using the traditional ad hoc method of a handover sheet versus a web-based electronic software programme. It was hoped that through improved quality of handover the new system would have a positive impact on clinical care, risk and time management. Data was prospectively collected and analyzed using the SPSS 14 statistical package. The handover data of 350 patients using a paper-based system was compared to the data of 357 cases using the web-based system. Key data included basic demographic data, responsible surgeon, location of patient, injury site including site, whether fractures were open or closed, concomitant injuries and the treatment plan. A survey was conducted amongst health care providers to assess the impact of the new software. With the introduction of the electronic handover system, patients with missing demographic data reduced from 35.1% to 0.8% (p<0.0001) and missing patient location from 18.6% to 3.6% (p<0.0001). Missing consultant information and missing diagnosis dropped from 12.9% to 2.0% (p<0.0001) and from 11.7% to 0.8% (p<0.0001), respectively. The missing information regarding side and anatomical site of the injury was reduced from 31.4% to 0.8% (p<0.0001) and from 13.7% to 1.1% (p<0.0001), respectively. In 96.6% of paper ad hoc handovers it was not stated whether the injury was 'closed' or 'open', whereas in the electronic group this information was evident in all 357 patients (p<0.0001). A treatment plan was included only in 52.3% of paper handovers compared to 94.7% (p<0.0001) of electronic handovers. A survey revealed 96% of members of the trauma team felt an improvement of handover since the introduction of the software, and 94% of members were satisfied with the software. The findings of our study show that the use of web-based electronic software is effective in facilitating and improving the quality of information passed during handover. Structured software also aids in improving work flow amongst the trauma team. We argue that an improvement in the quality of handover is an improvement in clinical practice.

Effectiveness of trauma team on medical resource utilization and quality of care for patients with major trauma.

PubMed

Wang, Chih-Jung; Yen, Shu-Ting; Huang, Shih-Fang; Hsu, Su-Chen; Ying, Jeremy C; Shan, Yan-Shen

2017-07-24

Trauma is one of the leading causes of death in Taiwan, and its medical expenditure escalated drastically. This study aimed to explore the effectiveness of trauma team, which was established in September 2010, on medical resource utilization and quality of care among major trauma patients. This was a retrospective study, using trauma registry data bank and inpatient medical service charge databases. Study subjects were major trauma patients admitted to a medical center in Tainan during 2009 and 2013, and was divided into case group (from January, 2011 to August, 2013) and comparison group (from January, 2009 to August, 2010). Significant reductions in several items of medical resource utilization were identified after the establishment of trauma team. In the sub-group of patients who survived to discharge, examination, radiology and operation charges declined significantly. The radiation and examination charges reduced significantly in the subcategories of ISS = 16 ~ 24 and ISS > 24 respectively. However, no significant effectiveness on quality of care was identified. The establishment of trauma team is effective in containing medical resource utilization. In order to verify the effectiveness on quality of care, extended time frame and extra study subjects are needed.

The Impact of the 2011 Accreditation Council for Graduate Medical Education Duty Hour Reform on Quality and Safety in Trauma Care.

PubMed

Marwaha, Jayson S; Drolet, Brian C; Maddox, Suma S; Adams, Charles A

2016-06-01

In 2011, the ACGME limited duty hours for residents. Although studies evaluating the 2011 policy have not shown improvements in general measures of morbidity or mortality, these outcomes might not reflect changes in specialty-specific practice patterns and secondary quality measures. All trauma admissions from July 2009 through June 2013 at an academic Level I trauma center were evaluated for 5 primary outcomes (eg, mortality and length of stay), and 10 secondary quality measures and practice patterns (eg, operating room [OR] visits). All variables were compared before and after the reform (July 1, 2011). Piecewise regression was used to study temporal trends in quality. There were 11,740 admissions studied. The reform was not strongly associated with changes in any primary outcomes except length of stay (7.98 to 7.36 days; p = 0.01). However, many secondary quality metrics changed. The total number of OR and bedside procedures per admission (6.72 to 7.34; p < 0.001) and OR visits per admission (0.76 to 0.91; p < 0.001) were higher in the post-reform group, representing an additional 9,559 procedures and 1,584 OR visits. Use of minor bedside procedures, such as laboratory and imaging studies, increased most significantly. Although most major outcomes were unaffected, quality of care might have changed after the reform. Indeed, a consistent change in resource use patterns was manifested by substantial post-reform increases in measures such as bedside procedures and OR visits. No secondary quality measures exhibited improvements strongly associated with the reform. Several factors, including attending oversight, might have insulated major outcomes from change. Our findings show that some less-commonly studied quality metrics related to costs of care changed after the 2011 reform at our institution. Copyright © 2016 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Improving the ability to review preoperative radiographs intraoperatively in trauma and orthopaedic theatres at Lancashire teaching hospitals

PubMed Central

Jump, Christopher

2017-01-01

Background The ability to review preoperative radiographs during trauma and orthopaedic surgery is essential for the surgeon to provide optimum treatment to the patient. However, due to current information technology (IT) systems, screen-savers frequently interrupt the ability to review images and theatre staff are not routinely available to deactivate the screen-saver. This prolongs theatre time for the patient and affects the quality of care provided. The aim of this quality improvement project was to improve the availability of radiographs for the surgeon to review intraoperatively. Method/results Data were collected from all trauma and orthopaedic theatres at two hospital sites covering all subspecialties and including emergency and elective cases. Baseline measurements showed that the frequency of preoperative radiographs not interrupted during an operation was 0% (0/50). Following this the Trust’s IT systems were improved to prevent activation of the screen-saver on the theatre computers using the generic theatre login details. After the first-cycle intervention, data were collected showing 52% (14/27) of preoperative radiographs were not interrupted by a screen-saver. The cause for this result being less than expected was investigated and found to be due to an alternative computer login being used on the theatre computers at one of the hospital sites. Education of theatre staff was then undertaken to ensure the correct theatre login was used and notices to remind staff placed on the theatre computers. After the second-cycle intervention, data were collected showing that 100% (26/26) of preoperative radiographs were not interrupted during operative time allowing the surgeon to review images when required. Conclusion/implications This quality improvement project has made changes to theatre IT systems and practices of theatre staff which has resulted in a significant improvement in the ability for the operating surgeon to review preoperative radiographs intraoperatively. PMID:29450269

Improving the ability to review preoperative radiographs intraoperatively in trauma and orthopaedic theatres at Lancashire teaching hospitals.

PubMed

Jump, Christopher

2017-01-01

The ability to review preoperative radiographs during trauma and orthopaedic surgery is essential for the surgeon to provide optimum treatment to the patient. However, due to current information technology (IT) systems, screen-savers frequently interrupt the ability to review images and theatre staff are not routinely available to deactivate the screen-saver. This prolongs theatre time for the patient and affects the quality of care provided. The aim of this quality improvement project was to improve the availability of radiographs for the surgeon to review intraoperatively. Data were collected from all trauma and orthopaedic theatres at two hospital sites covering all subspecialties and including emergency and elective cases. Baseline measurements showed that the frequency of preoperative radiographs not interrupted during an operation was 0% (0/50). Following this the Trust's IT systems were improved to prevent activation of the screen-saver on the theatre computers using the generic theatre login details. After the first-cycle intervention, data were collected showing 52% (14/27) of preoperative radiographs were not interrupted by a screen-saver. The cause for this result being less than expected was investigated and found to be due to an alternative computer login being used on the theatre computers at one of the hospital sites. Education of theatre staff was then undertaken to ensure the correct theatre login was used and notices to remind staff placed on the theatre computers. After the second-cycle intervention, data were collected showing that 100% (26/26) of preoperative radiographs were not interrupted during operative time allowing the surgeon to review images when required. This quality improvement project has made changes to theatre IT systems and practices of theatre staff which has resulted in a significant improvement in the ability for the operating surgeon to review preoperative radiographs intraoperatively.

Influence of the National Trauma Data Bank on the study of trauma outcomes: is it time to set research best practices to further enhance its impact?

PubMed

Haider, Adil H; Saleem, Taimur; Leow, Jeffrey J; Villegas, Cassandra V; Kisat, Mehreen; Schneider, Eric B; Haut, Elliott R; Stevens, Kent A; Cornwell, Edward E; MacKenzie, Ellen J; Efron, David T

2012-05-01

Risk-adjusted analyses are critical in evaluating trauma outcomes. The National Trauma Data Bank (NTDB) is a statistically robust registry that allows such analyses; however, analytical techniques are not yet standardized. In this study, we examined peer-reviewed manuscripts published using NTDB data, with particular attention to characteristics strongly associated with trauma outcomes. Our objective was to determine if there are substantial variations in the methodology and quality of risk-adjusted analyses and therefore, whether development of best practices for risk-adjusted analyses is warranted. A database of all studies using NTDB data published through December 2010 was created by searching PubMed and Embase. Studies with multivariate risk-adjusted analyses were examined for their central question, main outcomes measures, analytical techniques, covariates in adjusted analyses, and handling of missing data. Of 286 NTDB publications, 122 performed a multivariable adjusted analysis. These studies focused on clinical outcomes (51 studies), public health policy or injury prevention (30), quality (16), disparities (15), trauma center designation (6), or scoring systems (4). Mortality was the main outcome in 98 of these studies. There were considerable differences in the covariates used for case adjustment. The 3 covariates most frequently controlled for were age (95%), Injury Severity Score (85%), and sex (78%). Up to 43% of studies did not control for the 5 basic covariates necessary to conduct a risk-adjusted analysis of trauma mortality. Less than 10% of studies used clustering to adjust for facility differences or imputation to handle missing data. There is significant variability in how risk-adjusted analyses using data from the NTDB are performed. Best practices are needed to further improve the quality of research from the NTDB. Copyright © 2012 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

High risk of hypogonadism after traumatic brain injury: clinical implications.

PubMed

Agha, Amar; Thompson, Christopher J

2005-01-01

Several recent studies have convincingly documented a close association between traumatic brain injury (TBI) and pituitary dysfunction. Post-traumatic hypogonadism is very common in the acute post-TBI phase, though most cases recover within six to twelve months following trauma. The functional significance of early hypogonadism, which may reflect adaptation to acute illness, is not known. Hypogonadism persists, however, in 10-17% of long-term survivors. Sex steroid deficiency has implications beyond psychosexual function and fertility for survivors of TBI. Muscle weakness may impair functional recovery from trauma and osteoporosis may be exacerbated by immobility secondary to trauma. Identification and appropriate and timely management of post-traumatic hypogonadism is important in order to optimise patient recovery from head trauma, improve quality of life and avoid the long-term adverse consequences of untreated sex steroid deficiency.

Minimizing preventable trauma deaths in a limited-resource setting: a test-case of a multidisciplinary panel review approach at the Komfo Anokye Teaching Hospital in Ghana.

PubMed

Yeboah, Dominic; Mock, Charles; Karikari, Patrick; Agyei-Baffour, Peter; Donkor, Peter; Ebel, Beth

2014-07-01

Our objectives were to determine the proportion of preventable trauma deaths at a large trauma hospital in Kumasi, Ghana, and to identify opportunities for the improvement of trauma care. A multidisciplinary panel of experts evaluated pre-hospital, hospital, and postmortem data of consecutive trauma patients who died over a 5-month period in 2006-2007 at the Komfo Anokye Teaching Hospital. The panel judged the preventability of each death. For preventable and potentially preventable deaths, deficiencies in care that contributed to their deaths were identified. The panel reviewed 231 trauma deaths. Of these, 84 charts had sufficient information to review preventable factors. The panel determined that 23 % of trauma deaths were definitely preventable, 37 % were potentially preventable, and 40 % were not preventable. One main deficiency in care was identified for each of the 50 definitely preventable and potentially preventable deaths. The most common deficiencies were pre-hospital delays (44 % of the 50 deficiencies), delay in treatment (32 %), and inadequate fluid resuscitation (22 %). Among the 19 definitely preventable deaths, the most common cause of death was hemorrhage (47 %), and the most common deficiencies were inadequate fluid resuscitation (37 % of deficiencies in this group) and pre-hospital delay (37 %). A high proportion of trauma fatalities might have been preventable by decreasing pre-hospital delays, adequate resuscitation in hospital, and earlier initiation of care, including definitive surgical management. The study also showed that preventable death panel reviews are a feasible and useful quality improvement method in the study setting.

Leadership and Teamwork in Trauma and Resuscitation.

PubMed

Ford, Kelsey; Menchine, Michael; Burner, Elizabeth; Arora, Sanjay; Inaba, Kenji; Demetriades, Demetrios; Yersin, Bertrand

2016-09-01

Leadership skills are described by the American College of Surgeons' Advanced Trauma Life Support (ATLS) course as necessary to provide care for patients during resuscitations. However, leadership is a complex concept, and the tools used to assess the quality of leadership are poorly described, inadequately validated, and infrequently used. Despite its importance, dedicated leadership education is rarely part of physician training programs. The goals of this investigation were the following: 1. Describe how leadership and leadership style affect patient care; 2. Describe how effective leadership is measured; and 3. Describe how to train future physician leaders. We searched the PubMed database using the keywords "leadership" and then either "trauma" or "resuscitation" as title search terms, and an expert in emergency medicine and trauma then identified prospective observational and randomized controlled studies measuring leadership and teamwork quality. Study results were categorized as follows: 1) how leadership affects patient care; 2) which tools are available to measure leadership; and 3) methods to train physicians to become better leaders. We included 16 relevant studies in this review. Overall, these studies showed that strong leadership improves processes of care in trauma resuscitation including speed and completion of the primary and secondary surveys. The optimal style and structure of leadership are influenced by patient characteristics and team composition. Directive leadership is most effective when Injury Severity Score (ISS) is high or teams are inexperienced, while empowering leadership is most effective when ISS is low or teams more experienced. Many scales were employed to measure leadership. The Leader Behavior Description Questionnaire (LBDQ) was the only scale used in more than one study. Seven studies described methods for training leaders. Leadership training programs included didactic teaching followed by simulations. Although programs differed in length, intensity, and training level of participants, all programs demonstrated improved team performance. Despite the relative paucity of literature on leadership in resuscitations, this review found leadership improves processes of care in trauma and can be enhanced through dedicated training. Future research is needed to validate leadership assessment scales, develop optimal training mechanisms, and demonstrate leadership's effect on patient-level outcome.

Trauma scoring systems and databases.

PubMed

Lecky, F; Woodford, M; Edwards, A; Bouamra, O; Coats, T

2014-08-01

This review considers current trauma scoring systems and databases and their relevance to improving patient care. Single physiological measures such as systolic arterial pressure have limited ability to diagnose severe trauma by reflecting raised intracranial pressure, or significant haemorrhage. The Glasgow coma score has the greatest prognostic value in head-injured and other trauma patients. Trauma triage tools and imaging decision rules-using combinations of physiological cut-off measures with mechanism of injury and other categorical variables-bring both increased sophistication and increased complexity. It is important for clinicians and managers to be aware of the diagnostic properties (over- and under-triage rates) of any triage tool or decision rule used in their trauma system. Trauma registries are able to collate definitive injury descriptors and use survival prediction models to guide trauma system governance, through individual patient review and case-mix-adjusted benchmarking of hospital and network performance with robust outlier identification. Interrupted time series allow observation in the changes in care processes and outcomes at national level, which can feed back into clinical quality-based commissioning of healthcare. Registry data are also a valuable resource for trauma epidemiological and comparative effectiveness research studies. © The Author 2014. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

[The Academy of Trauma Surgery (AUC). Service provider and management organization of the DGU].

PubMed

Sturm, J A; Hoffmann, R

2016-02-01

At the beginning of this century the German Trauma Society (DGU) became extensively active with an initiative on quality promotion, development of quality assurance and transparency regarding treatment of the severely injured. A white book on "Medical care of the severely injured" was published, focusing on the requirements on structural quality and especially procedural quality. The impact of the white book was immense and a trauma network with approved trauma centers, structured and graded for their individual trauma care performance, was developed. In order to monitor and document the required quality of care, a registry was needed. Furthermore, for cooperation within the trauma networks innovative methods for digital transfer of radiological images and patient documents became necessary. Finally, the auditing criteria for trauma centers had and still have to be completed with advanced medical education and training programs. In order to realize the implementation of such a broad spectrum of economically relevant and increasingly complex activities the Academy of Trauma Surgery (AUC) was established as a subsidiary of the DGU in 2004. The AUC currently has four divisions: 1) networks and health care structures, 2) registries and research management, 3) telemedicine, 4) medical education and training, all of which serve the goal of the initiative. The AUC is a full service provider and management organization in compliance with the statutes of the DGU. According to these statutes the business operations of the AUC also cover projects for numerous groups of patients, projects for the joint society the German Society for Orthopedics and Trauma (DGOU) as well as other medical institutions. This article describes the success stories of the trauma network (TraumaNetzwerk DGU®), the TraumaRegister DGU®, the telecooperation platform TKmed®, the new and fast-growing orthogeriatric center initiative (AltersTraumaZentrum DGU®) and the division of medical education and training, e.g. advanced trauma life support (ATLS®) and other training programs including the innovative interpersonal competence (IC) course.

Accuracy of Pediatric Trauma Field Triage: A Systematic Review.

PubMed

van der Sluijs, Rogier; van Rein, Eveline A J; Wijnand, Joep G J; Leenen, Luke P H; van Heijl, Mark

2018-05-16

Field triage of pediatric patients with trauma is critical for transporting the right patient to the right hospital. Mortality and lifelong disabilities are potentially attributable to erroneously transporting a patient in need of specialized care to a lower-level trauma center. To quantify the accuracy of field triage and associated diagnostic protocols used to identify children in need of specialized trauma care. MEDLINE, Embase, PsycINFO, and Cochrane Register of Controlled Trials were searched from database inception to November 6, 2017, for studies describing the accuracy of diagnostic tests to identify children in need of specialized trauma care in a prehospital setting. Identified articles with a study population including patients not transported by emergency medical services were excluded. Quality assessment was performed using a modified version of the Quality Assessment of Diagnostic Accuracy Studies-2. After deduplication, 1430 relevant articles were assessed, a full-text review of 38 articles was conducted, and 5 of those articles were included. All studies were observational, published between 1996 and 2017, and conducted in the United States, and data collection was prospective in 1 study. Three different protocols were studied that analyzed a combined total of 1222 children in need of specialized trauma care. One protocol was specifically developed for a pediatric out-of-hospital cohort. The percentage of pediatric patients requiring specialized trauma care in each study varied between 2.6% (110 of 4197) and 54.7% (58 of 106). The sensitivity of the prehospital triage tools ranged from 49.1% to 87.3%, and the specificity ranged from 41.7% to 84.8%. No prehospital triage protocol alone complied with the international standard of 95% or greater sensitivity. Undertriage and overtriage rates, representative of the quality of the full diagnostic strategy to transport a patient to the right hospital, were not reported for inclusive trauma systems or emergency medical services regions. It is crucial to transport the right patient to the right hospital. Yet the quality of the full diagnostic strategy to determine the optimal receiving hospital is unknown. None of the investigated field triage protocols complied with current sensitivity targets. Improved efforts are needed to develop accurate child-specific tools to prevent undertriage and its potential life-threatening consequences.

Hypoxia and hypotension in patients intubated by physician staffed helicopter emergency medical services - a prospective observational multi-centre study.

PubMed

Sunde, Geir Arne; Sandberg, Mårten; Lyon, Richard; Fredriksen, Knut; Burns, Brian; Hufthammer, Karl Ove; Røislien, Jo; Soti, Akos; Jäntti, Helena; Lockey, David; Heltne, Jon-Kenneth; Sollid, Stephen J M

2017-07-11

The effective treatment of airway compromise in trauma and non-trauma patients is important. Hypoxia and hypotension are predictors of negative patient outcomes and increased mortality, and may be important quality indicators of care provided by emergency medical services. Excluding cardiac arrests, critical trauma and non-trauma patients remain the two major groups to which helicopter emergency medical services (HEMS) are dispatched. Several studies describe the impact of pre-hospital hypoxia or hypotension on trauma patients, but few studies compare this in trauma and non-trauma patients. The primary aim was to describe the incidence of pre-hospital hypoxia and hypotension in the two groups receiving pre-hospital tracheal intubation (TI) by physician-staffed HEMS. Data were collected prospectively over a 12-month period, using a uniform Utstein-style airway template. Twenty-one physician-staffed HEMS in Europe and Australia participated. We compared peripheral oxygen saturation and systolic blood pressure before and after definitive airway management. Data were analysed using Cochran-Mantel-Haenszel methods and mixed-effects models. Eight hundred forty three trauma patients and 422 non-trauma patients receiving pre-hospital TI were included. Non-trauma patients had significantly lower predicted mean pre-intervention SpO 2 compared to trauma patients. Post-intervention and admission SpO 2 for the two groups were comparable. However, 3% in both groups were still hypoxic at admission. For hypotension, the differences between the groups were less prominent. However, 9% of trauma and 10% of non-trauma patients were still hypotensive at admission. There was no difference in short-term survival between trauma (97%) and non-trauma patients (95%). Decreased level of consciousness was the most frequent indication for TI, and was associated with increased survival to hospital (cOR 2.8; 95% CI: 1.4-5.4). Our results showed that non-trauma patients had a higher incidence of hypoxia before TI than trauma patients, but few were hypoxic at admission. The difference for hypotension was less prominent, but one in ten patients were still hypotensive at admission. Further investigations are needed to identify reversible causes that may be corrected to improve haemodynamics in the pre-hospital setting. We found high survival rates to hospital in both groups, suggesting that physician-staffed HEMS provide high-quality emergency airway management in trauma and non-trauma patients. Clinicaltrials.gov Identifier: NCT01502111 . Registered 22 Desember 2011.

The efficacy of initial hydrocortisone administration at preventing posttraumatic distress in adult trauma patients: a randomized trial

PubMed Central

Delahanty, Douglas L.; Gabert-Quillen, Crystal; Ostrowski, Sarah A.; Nugent, Nicole R.; Fischer, Beth; Morris, Adam; Pitman, Roger K.; Bon, John; Fallon, William

2013-01-01

Objective/Introduction Secondary pharmacological interventions have shown promise at reducing the development of posttraumatic stress disorder symptoms (PTSS) in preclinical studies. The present study examined the preliminary efficacy of a 10-day low-dose (20 mg bid) course of hydrocortisone at preventing PTSS in traumatic injury victims. Methods Sixty-four traumatic injury patients (34% female) were randomly assigned in a double-blind protocol to receive either a 10-day course of hydrocortisone or placebo initiated within 12 hours of the trauma. One-month and 3-months posttrauma participants completed an interview to assess PTSS and self-report measures of depression and health-related quality of life. Results Hydrocortisone recipients reported fewer PTSD and depression symptoms, and had greater improvements in health-related quality of life during the first 3 months posttrauma than did placebo recipients. Hydrocortisone recipients who had never received prior mental health treatment had the lowest PTSD scores. Conclusion Low-dose hydrocortisone may be a promising approach to the prevention of PTSD in acutely injured trauma patients, and may be particularly efficacious in acutely injured trauma victims without a history of significant psychopathology. PMID:23557627

District-level hospital trauma care audit filters: Delphi technique for defining context-appropriate indicators for quality improvement initiative evaluation in developing countries

PubMed Central

Stewart, Barclay T; Gyedu, Adam; Quansah, Robert; Addo, Wilfred Larbi; Afoko, Akis; Agbenorku, Pius; Amponsah-Manu, Forster; Ankomah, James; Appiah-Denkyira, Ebenezer; Baffoe, Peter; Debrah, Sam; Donkor, Peter; Dorvlo, Theodor; Japiong, Kennedy; Kushner, Adam L; Morna, Martin; Ofosu, Anthony; Oppong-Nketia, Victor; Tabiri, Stephen; Mock, Charles

2015-01-01

Introduction Prospective clinical audit of trauma care improves outcomes for the injured in high-income countries (HICs). However, equivalent, context-appropriate audit filters for use in low- and middle-income country (LMIC) district-level hospitals have not been well established. We aimed to develop context-appropriate trauma care audit filters for district-level hospitals in Ghana, was well as other LMICs more broadly. Methods Consensus on trauma care audit filters was built between twenty panelists using a Delphi technique with four anonymous, iterative surveys designed to elicit: i) trauma care processes to be measured; ii) important features of audit filters for the district-level hospital setting; and iii) potentially useful filters. Filters were ranked on a scale from 0 – 10 (10 being very useful). Consensus was measured with average percent majority opinion (APMO) cut-off rate. Target consensus was defined a priori as: a median rank of ≥9 for each filter and an APMO cut-off rate of ≥0.8. Results Panelists agreed on trauma care processes to target (e.g. triage, phases of trauma assessment, early referral if needed) and specific features of filters for district-level hospital use (e.g. simplicity, unassuming of resource capacity). APMO cut-off rate increased successively: Round 1 - 0.58; Round 2 - 0.66; Round 3 - 0.76; and Round 4 - 0.82. After Round 4, target consensus on 22 trauma care and referral-specific filters was reached. Example filters include: triage - vital signs are recorded within 15 minutes of arrival (must include breathing assessment, heart rate, blood pressure, oxygen saturation if available); circulation - a large bore IV was placed within 15 minutes of patient arrival; referral - if referral is activated, the referring clinician and receiving facility communicate by phone or radio prior to transfer. Conclusion This study proposes trauma care audit filters appropriate for LMIC district-level hospitals. Given the successes of similar filters in HICs and obstetric care filters in LMICs, the collection and reporting of prospective trauma care audit filters may be an important step toward improving care for the injured at district-level hospitals in LMICs. PMID:26492882

Current concepts in simulation-based trauma education.

PubMed

Cherry, Robert A; Ali, Jameel

2008-11-01

The use of simulation-based technology in trauma education has focused on providing a safe and effective alternative to the more traditional methods that are used to teach technical skills and critical concepts in trauma resuscitation. Trauma team training using simulation-based technology is also being used to develop skills in leadership, team-information sharing, communication, and decision-making. The integration of simulators into medical student curriculum, residency training, and continuing medical education has been strongly recommended by the American College of Surgeons as an innovative means of enhancing patient safety, reducing medical errors, and performing a systematic evaluation of various competencies. Advanced human patient simulators are increasingly being used in trauma as an evaluation tool to assess clinical performance and to teach and reinforce essential knowledge, skills, and abilities. A number of specialty simulators in trauma and critical care have also been designed to meet these educational objectives. Ongoing educational research is still needed to validate long-term retention of knowledge and skills, provide reliable methods to evaluate teaching effectiveness and performance, and to demonstrate improvement in patient safety and overall quality of care.

Social support among releasing men prisoners with lifetime trauma experiences.

PubMed

Pettus-Davis, Carrie

2014-01-01

High rates of lifetime trauma experiences exist among men incarcerated in US state and federal prisons. Because lifetime trauma experiences have been linked to problematic behavioral and psychiatric outcomes for incarcerated populations, trauma-informed interventions could improve post-release well-being of releasing men prisoners with trauma histories. Social support has consistently been found to have a positive impact on trauma-related outcomes in non-incarcerated populations. Therefore, it is reasonable to hypothesize that social support may be an important intervention component for releasing men prisoners with trauma experiences; yet, the relationship between trauma experiences, psychiatric and behavioral factors, and social support has received almost no attention in research with men prisoners. Using a probability sample of 165 soon-to-be-released men, the present study examined differences in certain demographic, criminal justice history, mental health, substance abuse, and social support (type, quality, amount, and source) variables between releasing men prisoners with and without lifetime trauma experiences. Results indicate that men with trauma histories had more negative social support experiences and fewer positive social support resources before prison than their counterparts. Men with trauma histories also had more lifetime experiences with mental health and substance use problems. On further investigation of the subsample of men with trauma histories, those who were older, had substance use disorders, and histories of mental health problems anticipated fewer post-release social support resources. Study findings underscore the nuances of social support for men prisoners with trauma experiences and point to implications for future directions in targeted trauma-informed intervention development for releasing men prisoners. Copyright © 2014 Elsevier Ltd. All rights reserved.

Videotape review leads to rapid and sustained learning.

PubMed

Scherer, Lynette A; Chang, Michael C; Meredith, J Wayne; Battistella, Felix D

2003-06-01

Performance review using videotapes is a strategy employed to improve future performance. We postulated that videotape review of trauma resuscitations would improve compliance with a treatment algorithm. Trauma resuscitations were taped and reviewed during a 6-month period. For 3 months, team members were given verbal feedback regarding performance. During the next 3 months, new teams attended videotape reviews of their performance. Data on targeted behaviors were compared between the two groups. Behavior did not change after 3 months of verbal feedback; however, behavior improved after 1 month of videotape feedback (P <0.05) and total time to disposition was reduced by 50% (P <0.01). This response was sustained for the remainder of the study. Videotape review can be an important learning tool as it was more effective than verbal feedback in achieving behavioral changes and algorithm compliance. Videotape review can be an important quality assurance adjunct, as improved algorithm compliance should be associated with improved patient care.

Evolution of the operative management of colon trauma

PubMed Central

Sharpe, John P; Magnotti, Louis J; Fabian, Timothy C; Croce, Martin A

2017-01-01

For any trauma surgeon, colon wounds remain a relatively common, yet sometimes challenging, clinical problem. Evolution in operative technique and improvements in antimicrobial therapy during the past two centuries have brought remarkable improvements in both morbidity and mortality after injury to the colon. Much of the early progress in management and patient survival after colon trauma evolved from wartime experience. Multiple evidence-based studies during the last several decades have allowed for more aggressive management, with most wounds undergoing primary repair or resection and anastomosis with an acceptably low suture line failure rate. Despite the abundance of quality evidence regarding management of colon trauma obtained from both military and civilian experience, there remains some debate among institutions regarding management of specific injuries. This is especially true with respect to destructive wounds, injuries to the left colon, blunt colon trauma and those wounds requiring colonic discontinuity during an abbreviated laparotomy. Some programs have developed data-driven protocols that have simplified management of destructive colon wounds, clearly identifying those high-risk patients who should undergo diversion, regardless of mechanism or anatomic location. This update will describe the progression in the approach to colon injuries through history while providing a current review of the literature regarding management of the more controversial wounds.

Evolution of the operative management of colon trauma.

PubMed

Sharpe, John P; Magnotti, Louis J; Fabian, Timothy C; Croce, Martin A

2017-01-01

For any trauma surgeon, colon wounds remain a relatively common, yet sometimes challenging, clinical problem. Evolution in operative technique and improvements in antimicrobial therapy during the past two centuries have brought remarkable improvements in both morbidity and mortality after injury to the colon. Much of the early progress in management and patient survival after colon trauma evolved from wartime experience. Multiple evidence-based studies during the last several decades have allowed for more aggressive management, with most wounds undergoing primary repair or resection and anastomosis with an acceptably low suture line failure rate. Despite the abundance of quality evidence regarding management of colon trauma obtained from both military and civilian experience, there remains some debate among institutions regarding management of specific injuries. This is especially true with respect to destructive wounds, injuries to the left colon, blunt colon trauma and those wounds requiring colonic discontinuity during an abbreviated laparotomy. Some programs have developed data-driven protocols that have simplified management of destructive colon wounds, clearly identifying those high-risk patients who should undergo diversion, regardless of mechanism or anatomic location. This update will describe the progression in the approach to colon injuries through history while providing a current review of the literature regarding management of the more controversial wounds.

Post-traumatic cognitions and quality of life in terrorism victims: the role of well-being in indirect versus direct exposure.

PubMed

Bajo, Miriam; Blanco, Amalio; Stavraki, Maria; Gandarillas, Beatriz; Cancela, Ana; Requero, Blanca; Díaz, Darío

2018-05-15

The effect of indirect (versus direct) exposure to a traumatic event on the quality of life of terrorist attack victims has received considerable attention in the literature. However, more research is required to examine whether the symptoms and underlying processes caused by both types of exposure are equivalent. Our main hypothesis is that well-being plays a different role depending on indirect vs. direct trauma exposure. In this cross-sectional study, eighty direct victims of 11-M terrorist attacks (people who were traveling in trains where bombs were placed) and two-hundred indirect victims (individuals highly exposed to the 11-M terrorist attacks through communications media) voluntarily participated without compensation. To test our hypothesis regarding the mediating role of indirect exposure, we conducted a biased corrected bootstrapping procedure. To test our hypothesis regarding the moderating role of direct exposure, data were subjected to a hierarchical regression analysis. As predicted, for indirect trauma exposure, well-being mediated the relationship between post-traumatic dysfunctional cognitions and trauma symptoms. However, for direct trauma exposure, well-being moderated the relationship between post-traumatic dysfunctional cognitions and trauma symptoms. The results of our study indicate that the different role of well-being found between indirect (causal factor) and direct exposure (protective factor) should be taken into consideration in interventions designed to improve victims' health.

Impact of Dual Disorders, Trauma, and Social Support on Quality of Life Among Women in Treatment for Substance Dependence.

PubMed

Brown, Suzanne; Jun, Min Kyoung; Min, Meeyoung Oh; Tracy, Elizabeth M

2013-01-01

Women with dual disorders report lower levels of social support than women with substance dependence alone, and lower levels of social support have been associated with lower quality of life among individuals with substance use disorders. However, little is known about the impact of trauma symptoms and violence exposure on quality of life for women with dual disorders. The purpose of this study was to examine the impact of dual disorders, trauma, and social support related to recovery on various domains of quality of life among women in substance abuse treatment. This study utilized multiple standardized measures and hierarchical ordinary least squares regression to examine quality of life, trauma, and social support in women with dual disorders. Four domains of quality of life were measured (Physical, Psychological, Social, and Environmental Domains). Participants ( N =369) were recruited from three inner city women only addiction treatment programs. IRB approval was obtained prior to sample recruitment. Presence of a dual disorder was significantly associated with lower quality of life in the Physical and Psychological domains. However, this difference was no longer significant when trauma symptoms were added to the model. Trauma symptoms and Support for Recovery significantly predicted quality of life across all four domains and Friends Support for Abstinence across three domains. Findings suggest that the presence of a dual disorder in women may indicate a history of trauma. They also support the importance of both friend's support for abstinence and recovery support as predictors of quality of life in women with dual disorders. Interventions that focus on social support and quality of life in treatment with women with substance use disorders may potentially enhance treatment outcomes.

A new chart to assist with advanced trauma life support.

PubMed

Palmer, I P; Baskett, P J; McCabe, S E

1992-10-01

Many studies have drawn attention to deficiencies in the management of major trauma, both in the UK and elsewhere. One area that has received little attention is the documentation of such cases in the Emergency Room. When outcome may be sub-optimal, documentation assumes greater importance if advances are to be made in the organisation of trauma care. Based upon the American College of Surgeons Advanced Trauma Life Support (ATLS) protocols, the authors have designed a document that records dynamically what happens to the multiply injured victim on arrival in the Emergency Room. It unifies the recording of vital signs, whilst acting as an assessment and resuscitation template. By ensuring no life-threatening illness is missed it is likely to improve patient survival. The document can act as a basis for teaching and a medico-legal record, whilst providing the necessary data for quality assurance and outcome audit.

Multicenter collaborative for orthopaedic research in India: An opportunity for global leadership

PubMed Central

Mathew, George; Sancheti, Parag; Jain, Anil; Bhandari, Mohit

2008-01-01

Road traffic accidents are increasing at an alarming rate and have become a major public health concern in India. In addition, there is a lack of trauma research output and reliable data from India. There are several issues and challenges that have presented an opportunity for researchers and surgeons in India to develop a collaborative aimed at improving the quality and productivity of orthopaedic trauma research. Establishing a network of surgical researchers across India is a necessary first step towards global leadership in orthopaedic surgery trials. PMID:19826521

IMPACT OF DENTAL TRAUMA AND ESTHETIC IMPAIRMENT ON THE QUALITY OF LIFE OF PRESCHOOL CHILDREN

PubMed Central

Gonçalves, Bruna Miroski; Dias, Loraine Fernandes; Pereira, Carla da Silva; Ponte, Marcos Ximenes; Konrath, Andréa Cristina; Bolan, Michele da Silva; Cardoso, Mariane

2017-01-01

ABSTRACT Objective: To evaluate the impact of dental trauma and impaired esthetics on the quality of life (QoL) of preschool children and their relatives. Methods: Study conducted with 192 children aged 2 to 5 years in 11 preschools in Florianópolis, Santa Catarina, South of Brazil. Parents/caregivers completed a questionnaire on quality of life (Brazilian version of the Early Childhood Oral Health Impact Scales - B-ECOHIS), a socioeconomic survey, and then answered specific questions related to dental trauma. The subjects were examined by three accordant examiners (Kappa>0.7). Dental trauma was evaluated on the basis of indexes adopted by the World Health Organization, and esthetic impairment was then classified. Data were descriptively analyzed and put to bivariate analysis by chi-square and Fisher tests, with significance level at 5%. Results: The prevalence of dental trauma was 62.5% with 15.6% of esthetic impairment. Almost 12% of parents reported impact on the quality of life of their children. Dental trauma was not significantly associated with gender, age or QoL. Crown color change by trauma was associated with esthetic impairment. Also esthetic impairment had a negative impact on QoL (p<0.05) and was associated with oral limitations (p<0.05). Conclusions: Esthetic impairment had a negative impact on children’s quality of life, while dental trauma was not associated to it. PMID:28977132

[First aid for multiple trauma patients: investigative survey in the Firenze-Bologna area].

PubMed

Crescioli, G L; Donati, D; Federici, A; Rasero, L

1999-01-01

Overall mortality ascribable to multiple traumas, that in Italy is responsible for about 8,000 death/year, is strictly dependent on the function of the so called Trauma Care System. This study reports on an epidemiological survey conducted in the urban area of Florence along a 23-month period (from Jan 97 to Nov 99), with the aim to identify the typology of traumas and the first aid care delivered to the person until hospital admission. These data were compared to those collected in the urban area of Bologna because the composition of the first-aid team is different, being nurses, in Bologna, an integral component of the first aid system. On a total of 118 multiple traumas, 17% was represented by isolated head trauma, while in 72% involvement of other organs was present in addition to the head; 11% of cases were abdominal or thoracic traumas, 1% of lower extremities. In 46% the cause of trauma was a car accident. The complexity of care delivered to the person with trauma was less in the Florence survey, as indicated by the immobilization of patients, performed in only 11% of cases as compared to 47% in Bologna, by the application of the cervical collar, applied in 12% versus 62% of traumas. Although the two samples are not strictly comparable, these data suggest that the presence of nurses in the Trauma Care System can be one of the elements of improvement of the quality of delivered care.

Presenting an evaluation model of the trauma registry software.

PubMed

Asadi, Farkhondeh; Paydar, Somayeh

2018-04-01

Trauma is a major cause of 10% death in the worldwide and is considered as a global concern. This problem has made healthcare policy makers and managers to adopt a basic strategy in this context. Trauma registry has an important and basic role in decreasing the mortality and the disabilities due to injuries resulted from trauma. Today, different software are designed for trauma registry. Evaluation of this software improves management, increases efficiency and effectiveness of these systems. Therefore, the aim of this study is to present an evaluation model for trauma registry software. The present study is an applied research. In this study, general and specific criteria of trauma registry software were identified by reviewing literature including books, articles, scientific documents, valid websites and related software in this domain. According to general and specific criteria and related software, a model for evaluating trauma registry software was proposed. Based on the proposed model, a checklist designed and its validity and reliability evaluated. Mentioned model by using of the Delphi technique presented to 12 experts and specialists. To analyze the results, an agreed coefficient of %75 was determined in order to apply changes. Finally, when the model was approved by the experts and professionals, the final version of the evaluation model for the trauma registry software was presented. For evaluating of criteria of trauma registry software, two groups were presented: 1- General criteria, 2- Specific criteria. General criteria of trauma registry software were classified into four main categories including: 1- usability, 2- security, 3- maintainability, and 4-interoperability. Specific criteria were divided into four main categories including: 1- data submission and entry, 2- reporting, 3- quality control, 4- decision and research support. The presented model in this research has introduced important general and specific criteria of trauma registry software and sub criteria related to each main criteria separately. This model was validated by experts in this field. Therefore, this model can be used as a comprehensive model and a standard evaluation tool for measuring efficiency and effectiveness and performance improvement of trauma registry software. Copyright © 2018 Elsevier B.V. All rights reserved.

Trauma care systems in Saudi Arabia: an agenda for action

PubMed Central

Al-Naami, Mohammed Y.; Arafah, Maria A.; Al-Ibrahim, Fatimah S.

2010-01-01

Saudi Arabia is undergoing a rapid population growth that along with improved socioeconomics has led many individuals to own a car or even a number of cars per family, resulting in a greater number of vehicles on the roads. The reduced focus on good public transportation systems and the dependence on cars for transportation have created a diversity of drivers who are unfamiliar with the local driving rules and lack the basic skills for safe driving. This is in addition to some young drivers who frequently violate traffic laws and tend to speed most of the time. This unplanned expansion in road traffic has resulted in more car accidents, injuries, disabilities, and deaths. Accompanying that is an increased socioeconomic burden, depletion of human resources, emotional and psychological stress on families, and a strain on healthcare facilities. If this continues without prompt intervention, it will lead to increased insurance premiums and may become unmanageable. To minimize this impact, a national or regional multidisciplinary trauma system has to be developed and implemented. A trauma system is a preplanned, comprehensive, and coordinated regional injury response network that includes all facilities with the capability to care for the injured. Essential components of the system include trauma prevention, prehospital care, hospital care, rehabilitation, system administration, trauma care education and training, trauma care evaluation and quality improvement, along with the participation of society. Research has documented a significant decrease in morbidity and mortality from trauma after the implementation of such systems, depending on their efficiency. The purpose of this review is to discuss the problem of road traffic accidents in this country and address the trauma care system as an effective solution. PMID:20103958

Hazard Regression Models of Early Mortality in Trauma Centers

PubMed Central

Clark, David E; Qian, Jing; Winchell, Robert J; Betensky, Rebecca A

2013-01-01

Background Factors affecting early hospital deaths after trauma may be different from factors affecting later hospital deaths, and the distribution of short and long prehospital times may vary among hospitals. Hazard regression (HR) models may therefore be more useful than logistic regression (LR) models for analysis of trauma mortality, especially when treatment effects at different time points are of interest. Study Design We obtained data for trauma center patients from the 2008–9 National Trauma Data Bank (NTDB). Cases were included if they had complete data for prehospital times, hospital times, survival outcome, age, vital signs, and severity scores. Cases were excluded if pulseless on admission, transferred in or out, or ISS<9. Using covariates proposed for the Trauma Quality Improvement Program and an indicator for each hospital, we compared LR models predicting survival at 8 hours after injury to HR models with survival censored at 8 hours. HR models were then modified to allow time-varying hospital effects. Results 85,327 patients in 161 hospitals met inclusion criteria. Crude hazards peaked initially, then steadily declined. When hazard ratios were assumed constant in HR models, they were similar to odds ratios in LR models associating increased mortality with increased age, firearm mechanism, increased severity, more deranged physiology, and estimated hospital-specific effects. However, when hospital effects were allowed to vary by time, HR models demonstrated that hospital outliers were not the same at different times after injury. Conclusions HR models with time-varying hazard ratios reveal inconsistencies in treatment effects, data quality, and/or timing of early death among trauma centers. HR models are generally more flexible than LR models, can be adapted for censored data, and potentially offer a better tool for analysis of factors affecting early death after injury. PMID:23036828

Multidisciplinary team approach to traumatic spinal cord injuries: a single institution's quality improvement project.

PubMed

Alizo, Georgina; Sciarretta, Jason D; Gibson, Stefanie; Muertos, Keely; Holmes, Sharon; Denittis, Felicia; Cheatle, Joseph; Davis, John; Pepe, Antonio

2018-04-01

A stepwise multidisciplinary team (MDT) approach to the injured trauma patient has been reported to have an overall benefit, with reduction in mortality and improved morbidity. Based on clinical experience, we hypothesized that implementation of a dedicated Spinal Cord Injury Service (SCIS) would impact outcomes of a patient specific population on the trauma service. The trauma center registry was retrospectively queried, from January 2011 through December 2015, for patients presenting with a spinal cord injury. In 2013, a twice weekly rounding SCIS MDT was initiated. This new multidisciplinary service, the post-SCIS, was compared to the 2011-2012 pre-SCIS. The two groups were compared across patient demographics, mechanism of injury, surgical procedures, and disposition at discharge. The primary outcome was mortality. Secondary endpoints also included the incidence of complications, hospital length of stay (HLOS), ICU LOS, ventilator free days, and all hospital-acquired infectious complications. Logistic regression and Student's t test were used to analyze data. Ninety-five patients were identified. Of these patients, 41 (43%) pre-SCIS and 54 (57%) post-SCIS patients were compared. Mean age was 46.9 years and 79% male. Overall, adjusted mortality rate between the two groups was significant with the implementation of the post-SCIS (p = 0.033). In comparison, the post-SCIS revealed shorter HLOS (23 vs 34.8 days, p = 0.004), increased ventilator free days (20.2 vs 63.3 days, p < 0.001), and less nosocomial infections (1.8 vs 22%, p = 0.002). While the post-SCIS mean ICU LOS was shorter (12 vs 17.9 days, p = 0.089), this relationship was not significant. The application of an SCIS team in addition to the trauma service suggests that a structured coordinated approach can have an expected improvement in hospital outcomes and shorter length of stays. We believe that this clinical collaboration provides distinct specialist perspectives and, therefore, optimizes quality improvement. Level of evidence Epidemiologic study, level III.

Patient perspectives of care in a regionalised trauma system: lessons from the Victorian State Trauma System.

PubMed

Gabbe, Belinda J; Sleney, Jude S; Gosling, Cameron M; Wilson, Krystle; Hart, Melissa J; Sutherland, Ann M; Christie, Nicola

2013-02-18

To explore injured patients' experiences of trauma care to identify areas for improvement in service delivery. Qualitative study using in-depth, semi-structured interviews, conducted from 1 April 2011 to 31 January 2012, with 120 trauma patients registered by the Victorian State Trauma Registry and the Victorian Orthopaedic Trauma Outcomes Registry and managed at the major adult trauma services (MTS) in Victoria. Emergent themes from patients' experiences of acute, rehabilitation and post-discharge care in the Victorian State Trauma System (VSTS). Patients perceived their acute hospital care as high quality, although 3s with communication and surgical management delays were common. Discharge from hospital was perceived as stressful, and many felt ill prepared for discharge. A consistent emerging theme was the sense of a lack of coordination of post-discharge care, and the absence of a consistent point of contact for ongoing management. Most patients' primary point of contact after discharge was outpatient clinics at the MTS, which were widely criticised because of substantial delays in receiving an appointment, prolonged waiting times, limited time with clinicians, lack of continuity of care and inability to see senior clinicians. This study highlights perceived 3s in the patient care pathway in the VSTS, especially those relating to communication, information provision and post-discharge care. Trauma patients perceived the need for a single point of contact for coordination of post-discharge care.

Quality and Dose Optimized CT Trauma Protocol - Recommendation from a University Level-I Trauma Center.

PubMed

Kahn, Johannes; Kaul, David; Böning, Georg; Rotzinger, Roman; Freyhardt, Patrick; Schwabe, Philipp; Maurer, Martin H; Renz, Diane Miriam; Streitparth, Florian

2017-09-01

Purpose  As a supra-regional level-I trauma center, we evaluated computed tomography (CT) acquisitions of polytraumatized patients for quality and dose optimization purposes. Adapted statistical iterative reconstruction [(AS)IR] levels, tube voltage reduction as well as a split-bolus contrast agent (CA) protocol were applied. Materials and Methods  61 patients were split into 3 different groups that differed with respect to tube voltage (120 - 140 kVp) and level of applied ASIR reconstruction (ASIR 20 - 50 %). The CT protocol included a native acquisition of the head followed by a single contrast-enhanced acquisition of the whole body (64-MSCT). CA (350 mg/ml iodine) was administered as a split bolus injection of 100 ml (2 ml/s), 20 ml NaCl (1 ml/s), 60 ml (4 ml/s), 40 ml NaCl (4 ml/s) with a scan delay of 85 s to detect injuries of both the arterial system and parenchymal organs in a single acquisition. Both the quantitative (SNR/CNR) and qualitative (5-point Likert scale) image quality was evaluated in parenchymal organs that are often injured in trauma patients. Radiation exposure was assessed. Results  The use of IR combined with a reduction of tube voltage resulted in good qualitative and quantitative image quality and a significant reduction in radiation exposure of more than 40 % (DLP 1087 vs. 647 mGyxcm). Image quality could be improved due to a dedicated protocol that included different levels of IR adapted to different slice thicknesses, kernels and the examined area for the evaluation of head, lung, body and bone injury patterns. In synopsis of our results, we recommend the implementation of a polytrauma protocol with a tube voltage of 120 kVp and the following IR levels: cCT 5mm: ASIR 20; cCT 0.625 mm: ASIR 40; lung 2.5 mm: ASIR 30, body 5 mm: ASIR 40; body 1.25 mm: ASIR 50; body 0.625 mm: ASIR 0. Conclusion  A dedicated adaptation of the CT trauma protocol (level of reduction of tube voltage and of IR) according to the examined body region (head, lung, body, bone) combined with a split bolus CA injection protocol allows for a high-quality CT examination and a relevant reduction of radiation exposure in the examination of polytraumatized patients Key Points   · Dedicated adaption of the CT trauma protocol allows for an optimized examination.. · Different levels of iterative reconstruction, tube voltage and the CA injection protocol are crucial.. · A reduction of radiation exposure of more than 40 % with good image quality is possible.. Citation Format · Kahn J, Kaul D, Böning G et al. Quality and Dose Optimized CT Trauma Protocol - Recommendation from a University Level-I Trauma Center. Fortschr Röntgenstr 2017; 189: 844 - 854. © Georg Thieme Verlag KG Stuttgart · New York.

Relationship of Pretreatment Rorschach Factors to Symptoms, Quality of Life, and Real-Life Functioning in a 3-Year Follow-Up of Traumatized Refugee Patients

PubMed Central

Opaas, Marianne; Hartmann, Ellen; Wentzel-Larsen, Tore; Varvin, Sverre

2016-01-01

ABSTRACT Response to mental health treatment varies highly among refugee patients. Research has not established which factors relate to differences in outcome. This study is a follow-up of Opaas and Hartmann's (2013) Rorschach Inkblot Method (RIM; Exner, 2003) pretreatment study of traumatized refugees, where 2 RIM principal components, Trauma Response and Reality Testing, were found descriptive of participants’ trauma-related personality functioning. This study's aims were to examine relationships of the RIM components with measures of anxiety, depression, posttraumatic stress, quality of life (QOL), employment, and exile language skills throughout 3 years. We found that impaired Reality Testing was related to more mental health symptoms and poorer QOL; furthermore, individuals with adequate Reality Testing improved in posttraumatic stress symptoms the first year and retained their improvement. Individuals with impaired Reality Testing deteriorated the first year and improved only slightly the next 2 years. The results of this study imply that traumatized refugee patients with impaired Reality Testing might need specific treatment approaches. Research follow-up periods should be long enough to detect changes. The reality testing impairment revealed by the RIM, mainly perceptual in quality, might not be easily detected by diagnostic interviews and self-report. PMID:26528822

Implementation of a trauma registry in a Brazilian public hospital: the first 1,000 patients.

PubMed

Carreiro, Paulo Roberto Lima; Drumond, Domingos André Fernandes; Starling, Sizenando Vieira; Moritz, Mônica; Ladeira, Roberto Marini

2014-01-01

Show the steps of a Trauma Registry (TR) implementation in a Brazilian public hospital and evaluate the initial data from the database. Descriptive study of the a TR implementation in João XXIII Hospital (Hospital Foundation of the state of Minas Gerais) and analysis of the initial results of the first 1,000 patients. The project was initiated in 2011 and from January 2013 we began collecting data for the TR. In January 2014 the registration of the first 1000 patients was completed. The greatest difficulties in the TR implementation were obtaining funds to finance the project and the lack of information within the medical records. The variables with the lowest completion percentage on the physiological conditions were: pulse, blood pressure, respiratory rate and Glasgow coma scale. Consequently, the Revised Trauma Score (RTS) could be calculated in only 31% of cases and the TRISS methodology applied to 30.3% of patients. The main epidemiological characteristics showed a predominance of young male victims (84.7%) and the importance of aggression as a cause of injuries in our environment (47.5%), surpassing traffic accidents. The average length of stay was 6 days, and mortality 13.7%. Trauma registries are invaluable tools in improving the care of trauma victims. It is necessary to improve the quality of data recorded in medical records. The involvement of public authorities is critical for the successful implementation and maintenance of trauma registries in Brazilian hospitals.

Characteristics of ACS-verified Level I and Level II trauma centers: A study linking trauma center verification review data and the National Trauma Data Bank of the American College of Surgeons Committee on Trauma.

PubMed

Shafi, Shahid; Barnes, Sunni; Ahn, Chul; Hemilla, Mark R; Cryer, H Gill; Nathens, Avery; Neal, Melanie; Fildes, John

2016-10-01

The Trauma Quality Improvement Project of the American College of Surgeons (ACS) has demonstrated variations in trauma center outcomes despite similar verification status. The purpose of this study was to identify structural characteristics of trauma centers that affect patient outcomes. Trauma registry data on 361,187 patients treated at 222 ACS-verified Level I and Level II trauma centers were obtained from the National Trauma Data Bank of ACS. These data were used to estimate each center's observed-to-expected (O-E) mortality ratio with 95% confidence intervals using multivariate logistic regression analysis. De-identified data on structural characteristics of these trauma centers were obtained from the ACS Verification Review Committee. Centers in the lowest quartile of mortality based on O-E ratio (n = 56) were compared to the rest (n = 166) using Classification and Regression Tree (CART) analysis to identify institutional characteristics independently associated with high-performing centers. Of the 72 structural characteristics explored, only 3 were independently associated with high-performing centers: annual patient visits to the emergency department of fewer than 61,000; proportion of patients on Medicare greater than 20%; and continuing medical education for emergency department physician liaison to the trauma program ranging from 55 and 113 hours annually. Each 5% increase in O-E mortality ratio was associated with an increase in total length of stay of one day (r = 0.25; p < 0.001). Very few structural characteristics of ACS-verified trauma centers are associated with risk-adjusted mortality. Thus, variations in patient outcomes across trauma centers are likely related to variations in clinical practices. Therapeutic study, level III.

Measuring US Army medical evacuation: Metrics for performance improvement.

PubMed

Galvagno, Samuel M; Mabry, Robert L; Maddry, Joseph; Kharod, Chetan U; Walrath, Benjamin D; Powell, Elizabeth; Shackelford, Stacy

2018-01-01

The US Army medical evacuation (MEDEVAC) community has maintained a reputation for high levels of success in transporting casualties from the point of injury to definitive care. This work served as a demonstration project to advance a model of quality assurance surveillance and medical direction for prehospital MEDEVAC providers within the Joint Trauma System. A retrospective interrupted time series analysis using prospectively collected data was performed as a process improvement project. Records were reviewed during two distinct periods: 2009 and 2014 to 2015. MEDEVAC records were matched to outcomes data available in the Department of Defense Trauma Registry. Abstracted deidentified data were reviewed for specific outcomes, procedures, and processes of care. Descriptive statistics were applied as appropriate. A total of 1,008 patients were included in this study. Nine quality assurance metrics were assessed. These metrics were: airway management, management of hypoxemia, compliance with a blood transfusion protocol, interventions for hypotensive patients, quality of battlefield analgesia, temperature measurement and interventions, proportion of traumatic brain injury (TBI) patients with hypoxemia and/or hypotension, proportion of traumatic brain injury patients with an appropriate assessment, and proportion of missing data. Overall survival in the subset of patients with outcomes data available in the Department of Defense Trauma Registry was 97.5%. The data analyzed for this study suggest overall high compliance with established tactical combat casualty care guidelines. In the present study, nearly 7% of patients had at least one documented oxygen saturation of less than 90%, and 13% of these patients had no documentation of any intervention for hypoxemia, indicating a need for training focus on airway management for hypoxemia. Advances in battlefield analgesia continued to evolve over the period when data for this study was collected. Given the inherent high-risk, high-acuity nature of prehospital advanced life support and emphasis on the use of nonphysician practitioners in an out-of-hospital setting, the need for ongoing medical oversight and quality improvement assessment is crucial. Care management, level IV.

How the changes in the system affect trauma care provision: The assessment of and implications for Lithuanian trauma service performance in 2007-2012.

PubMed

Dambrauskas, Žilvinas; Aukštakalnis, Vytautas; Karbonskienė, Aurika; Kačiurinas, Dmitrijus; Vokietienė, Jolanta; Lapka, Robertas; Pamerneckas, Algimantas; Porvaneckas, Narūnas; Stašaitis, Kęstutis; Jasinskas, Nedas; Dobožinskas, Paulius; Vaitkaitis, Dinas; Lunevičius, Raimundas

2017-01-01

The aim of this study was to identify and assess the effects of changes in the Lithuanian trauma service from 2007 to 2012. We postulate that the implications derived from this study will be of importance to trauma policy planners and makers in Lithuania and throughout other countries of Eastern and Central Europe. Out of 10,390 trauma admissions to four trauma centers in 2007, 294 patients (2.8%) were randomly selected for the first arm of a representative study sample. Similarly, of 9918 trauma admissions in 2012, 250 (2.5%) were randomly chosen for comparison in the study arm. Only cases with a diagnosis falling into the ICD-10 "S" and "T" codes were included. A survey of whom regarding changes in quality of trauma care from 2007 to 2012 was carried out by emergency medical service (EMS) providers. The Revised Trauma Score (RTS) mean value was 7.45±1.04 for the 2007 year arm; it was 7.53±0.93 for the 2012 year arm (P=0.33). Mean time from the moment of a call from the site of the traumatic event to the patient's arrival at the trauma center did not differ between the arms of the sample: 49.95min in 2007 vs. 51.6min in 2012 (P=0.81). An application of the operational procedures such as a cervical spine protection using a hard collar, oxygen therapy, infusion of intravenous fluids, and pain relief on the trauma scene was more frequent in 2012 than in 2007. Management of trauma patients in the emergency department improved regarding the availability of 24/7 computed tomography scanner facilities and an on-site radiographer. Time to CT-scanning was reduced by 38.8%, and time to decision-making was reduced by 16.5% in 2012. Changes in operational procedures in the Lithuanian pre-hospital care provision and management of trauma patients in emergency departments of trauma centers improved the efficiency of trauma care delivery over the 2007-2012 period. Copyright © 2017 The Lithuanian University of Health Sciences. Production and hosting by Elsevier Sp. z o.o. All rights reserved.

Empathetic Leadership in Critical Situations: How Can Leaders Lead with Empathy in Times of Trauma

DTIC Science & Technology

2010-03-01

success (Sellnow & Vidollof, 2009). These concepts are not just an improvement methodology, such as Six Sigma, which aims to improve the quality of...process outputs by eliminating the causes of defects (Noreen, 2008). Instead, they are concepts through which a leader improves the way of thinking...Weick & Sutcliffe, 2001). The ways in which they do this should serve as a template for all organizations that need to improve their reliability

Coadjuvant treatment with surgery and pirfenidone in severe facial trauma due to dog bite.

PubMed

Cantú-Cantú, María Zulema; Lyra-González, Iván; Armendáriz-Borunda, Juan

2013-03-01

This case report assesses the effectiveness of surgery plus pirfenidone (PFD) as a concomitant therapy in the management of facial trauma after severe dog bite. A 16-month-old female patient who suffered a severe attack by a big-sized dog (Rottweiler) in the midface area was managed with surgery/PFD combination and followed up for 20 months to evaluate the efficacy to control, prevent, and improve injury sequels. Surgery/PFD combination offered a good complementary therapy downregulating inflammatory activity, improving blood supply, and activating cytokine modulation and collagen synthesis/biosynthesis (scar control). No side effects were reported in this case report. Surgery/PFD management for severe facial dog bites represents a safe and effective therapeutic option to protect and improve a patient's quality of life, minimizing long-time sequels.

Burden of traumatic injuries in Saudi Arabia: lessons from a major trauma registry in Riyadh, Saudi Arabia.

PubMed

Alghnam, Suliman; Alkelya, Muhamad; Al-Bedah, Khalid; Al-Enazi, Saleem

2014-01-01

In Saudi Arabia (SA), injuries are the second leading cause of death; however, little is known about their frequencies and outcomes. Trauma registries play a major role in measuring the burden on population health. This study aims to describe the population of the only hospital-based trauma registry in the country and highlight challenges and potential opportunities to improve trauma data collection and research in SA. Using data between 2001 and 2010, this retrospective study included patients from a large trauma center in Riyadh, SA. A staff nurse utilized a structured checklist to gather information on patients' demographic, physiologic, anatomic, and outcome variables. Basic descriptive statistics by age group ( 14 years) were calculated, and differences were assessed using student t and chi-square tests. In addition, the mechanism of injury and the frequency of missing data were evaluated. 10 847 patients from the trauma registry were included. Over 9% of all patients died either before or after being treated at the hospital. Patients who were older than 14 years of age (more likely to be male) sustained traffic-related injuries and died in the hospital as compared to patients who were younger than or equal to years of age. Deceased patients were severely injured as measured by injury severity score and Glasgow Coma Scale (P < .001). Overall, the most frequent type of injury was related to traffic (52.0%), followed by falls (23.4%). Missing values were mostly prevalent in traffic-related variables, such as seatbelt use (70.2%). This registry is a key step toward addressing the burden of injuries in SA. Improved injury classification using the International Classification of Disease-external cause codes may improve the quality of the registry and allow comparison with other populations. Most importantly, injury prevention in SA requires further investment in data collection and research to improve outcomes.

Trauma system in Greece: Quo Vadis?

PubMed

Anagnostou, Evangelos; Larentzakis, Andreas; Vassiliu, Pantelis

2018-05-23

Implementation of trauma systems has markedly assisted in improving outcomes of the injured patient. However, differences exist internationally as diverse social factors, economic conditions and national particularities are placing obstacles. The purpose of this paper is to critically evaluate the current Greek trauma system, provide a comprehensive review and suggest key actions. An exhaustive search of the - scarce on this subject - English and Greek literature was carried out to analyze all the main components of the Greek trauma system, according to American College of Surgeons' criteria, as well as the WHO Trauma Systems Maturity Index. Regarding prevention, efforts are in the right direction lowering the road traffic incidents-related death rate, however rural and insular regions remain behind. Hellenic Emergency Medical Service (EKAB) has well-defined communications and emergency phone line but faces problems with educating people on how to use it properly. In addition, equal and systematic training of ambulance personnel is a challenge, with the lack of pre-hospital registry and EMS quality assessment posing a question on where the related services are currently standing. Redistribution of facilities' roles with the establishment of the first formal trauma centre in the existing infrastructure would facilitate the development of a national registry and introduction of the trauma surgeon subspecialty with proper training potential. Definite rehabilitation institutional protocols that include both inpatient and outpatient care are needed. Disaster preparedness entails an extensive national plan and regular drills, mainly at the pre-hospital level. The lack, however, of any accompanying quality assurance programs hampers the effort to yield the desirable results. Despite recent economic crisis in Greece, actions solving logistics and organising issues may offer a well-defined, integrated trauma system without uncontrollably raising the costs. Political will is needed for reforms that use pre-existing infrastructure and working power in a more efficient way, with a first line priority being the establishment of the first major trauma centre that could function as the cornerstone for the building of the Greek trauma system. Copyright © 2018 Elsevier Ltd. All rights reserved.

Japanese Higher-Education Reformers Weigh Elitism, Academic Laxness, and "Exam Hell."

ERIC Educational Resources Information Center

Fararo, Kim

1987-01-01

Reform proposals for Japan's large higher education system include diminishing the trauma of university entrance examinations, strengthening the quality and diversity of undergraduate education, improving graduate school offerings, establishing a lifelong education system, and expanding the scope of international exchange programs. Politics are…

The relationship between processes and outcomes for injured older adults: a study of a statewide trauma system.

PubMed

Saillant, N N; Earl-Royal, E; Pascual, J L; Allen, S R; Kim, P K; Delgado, M K; Carr, B G; Wiebe, D; Holena, D N

2017-02-01

Age is a risk factor for death, adverse outcomes, and health care use following trauma. The American College of Surgeons' Trauma Quality Improvement Program (TQIP) has published "best practices" of geriatric trauma care; adoption of these guidelines is unknown. We sought to determine which evidence-based geriatric protocols, including TQIP guidelines, were correlated with decreased mortality in Pennsylvania's trauma centers. PA's level I and II trauma centers self-reported adoption of geriatric protocols. Survey data were merged with risk-adjusted mortality data for patients ≥65 from a statewide database, the Pennsylvania Trauma Systems Foundation (PTSF), to compare mortality outlier status and processes of care. Exposures of interest were center-specific processes of care; outcome of interest was PTSF mortality outlier status. 26 of 27 eligible trauma centers participated. There was wide variation in care processes. Four trauma centers were low outliers; three centers were high outliers for risk-adjusted mortality rates in adults ≥65. Results remained consistent when accounting for center volume. The only process associated with mortality outlier status was age-specific solid organ injury protocols (p = 0.04). There was no cumulative effect of multiple evidence-based processes on mortality rate (p = 0.50). We did not see a link between adoption of geriatric best-practices trauma guidelines and reduced mortality at PA trauma centers. The increased susceptibility of elderly to adverse consequences of injury, combined with the rapid growth rate of this demographic, emphasizes the importance of identifying interventions tailored to this population. III. Descriptive.

Second language acquisition after traumatic brain injury: a case study.

PubMed

Połczyńska-Fiszer, M; Mazaux, J M

2008-01-01

Post-traumatic language and memory impairment, as well as a subsequent recovery in monolinguals have been widely documented in the literature, yet little is known about learning the second language after a severe head trauma followed by coma, as well as the relationship of this process with cognitive recovery, psychological status and quality of life. The present study investigates the relationship of learning the second language (English) in the process of rehabilitation, with quality of life in a Polish female university student who, as a result of a car accident, suffered a major closed-head injury and was comatose for a month. The subject was enrolled in an English learning program nine months after the trauma. The experiment lasted six months and comprised monthly meetings. The patient improved the major components of the second language, including vocabulary. Within the 6 months, the subject was gradually capable of learning additional and more complex lexical items. Learning the second language after traumatic brain injury may positively influence emotional well-being, self-esteem, and, perhaps, recovery of quality of life. A long-term beneficial effect of learning L2 was a consequential improvement of the patient's memory.

District-level hospital trauma care audit filters: Delphi technique for defining context-appropriate indicators for quality improvement initiative evaluation in developing countries.

PubMed

Stewart, Barclay T; Gyedu, Adam; Quansah, Robert; Addo, Wilfred Larbi; Afoko, Akis; Agbenorku, Pius; Amponsah-Manu, Forster; Ankomah, James; Appiah-Denkyira, Ebenezer; Baffoe, Peter; Debrah, Sam; Donkor, Peter; Dorvlo, Theodor; Japiong, Kennedy; Kushner, Adam L; Morna, Martin; Ofosu, Anthony; Oppong-Nketia, Victor; Tabiri, Stephen; Mock, Charles

2016-01-01

Prospective clinical audit of trauma care improves outcomes for the injured in high-income countries (HICs). However, equivalent, context-appropriate audit filters for use in low- and middle-income country (LMIC) district-level hospitals have not been well established. We aimed to develop context-appropriate trauma care audit filters for district-level hospitals in Ghana, was well as other LMICs more broadly. Consensus on trauma care audit filters was built between twenty panellists using a Delphi technique with four anonymous, iterative surveys designed to elicit: (i) trauma care processes to be measured; (ii) important features of audit filters for the district-level hospital setting; and (iii) potentially useful filters. Filters were ranked on a scale from 0 to 10 (10 being very useful). Consensus was measured with average percent majority opinion (APMO) cut-off rate. Target consensus was defined a priori as: a median rank of ≥9 for each filter and an APMO cut-off rate of ≥0.8. Panellists agreed on trauma care processes to target (e.g. triage, phases of trauma assessment, early referral if needed) and specific features of filters for district-level hospital use (e.g. simplicity, unassuming of resource capacity). APMO cut-off rate increased successively: Round 1--0.58; Round 2--0.66; Round 3--0.76; and Round 4--0.82. After Round 4, target consensus on 22 trauma care and referral-specific filters was reached. Example filters include: triage--vital signs are recorded within 15 min of arrival (must include breathing assessment, heart rate, blood pressure, oxygen saturation if available); circulation--a large bore IV was placed within 15 min of patient arrival; referral--if referral is activated, the referring clinician and receiving facility communicate by phone or radio prior to transfer. This study proposes trauma care audit filters appropriate for LMIC district-level hospitals. Given the successes of similar filters in HICs and obstetric care filters in LMICs, the collection and reporting of prospective trauma care audit filters may be an important step towards improving care for the injured at district-level hospitals in LMICs. Copyright © 2015 Elsevier Ltd. All rights reserved.

Leadership and Teamwork in Trauma and Resuscitation

PubMed Central

Ford, Kelsey; Menchine, Michael; Burner, Elizabeth; Arora, Sanjay; Inaba, Kenji; Demetriades, Demetrios; Yersin, Bertrand

2016-01-01

Introduction Leadership skills are described by the American College of Surgeons’ Advanced Trauma Life Support (ATLS) course as necessary to provide care for patients during resuscitations. However, leadership is a complex concept, and the tools used to assess the quality of leadership are poorly described, inadequately validated, and infrequently used. Despite its importance, dedicated leadership education is rarely part of physician training programs. The goals of this investigation were the following: 1. Describe how leadership and leadership style affect patient care; 2. Describe how effective leadership is measured; and 3. Describe how to train future physician leaders. Methods We searched the PubMed database using the keywords “leadership” and then either “trauma” or “resuscitation” as title search terms, and an expert in emergency medicine and trauma then identified prospective observational and randomized controlled studies measuring leadership and teamwork quality. Study results were categorized as follows: 1) how leadership affects patient care; 2) which tools are available to measure leadership; and 3) methods to train physicians to become better leaders. Results We included 16 relevant studies in this review. Overall, these studies showed that strong leadership improves processes of care in trauma resuscitation including speed and completion of the primary and secondary surveys. The optimal style and structure of leadership are influenced by patient characteristics and team composition. Directive leadership is most effective when Injury Severity Score (ISS) is high or teams are inexperienced, while empowering leadership is most effective when ISS is low or teams more experienced. Many scales were employed to measure leadership. The Leader Behavior Description Questionnaire (LBDQ) was the only scale used in more than one study. Seven studies described methods for training leaders. Leadership training programs included didactic teaching followed by simulations. Although programs differed in length, intensity, and training level of participants, all programs demonstrated improved team performance. Conclusion Despite the relative paucity of literature on leadership in resuscitations, this review found leadership improves processes of care in trauma and can be enhanced through dedicated training. Future research is needed to validate leadership assessment scales, develop optimal training mechanisms, and demonstrate leadership’s effect on patient-level outcome. PMID:27625718

What is the quality of reporting on guideline, protocol or algorithm implementation in adult trauma centres? Protocol for a systematic review.

PubMed

Gotlib Conn, Lesley; Nathens, Avery B; Perrier, Laure; Haas, Barbara; Watamaniuk, Aaron; Daniel Pereira, Diego; Zwaiman, Ashley; da Luz, Luis Teodoro

2018-05-09

Quality improvement (QI) is mandatory in trauma centres but there is no prescription for doing successful QI. Considerable variation in implementation strategies and inconsistent use of evidence-based protocols therefore exist across centres. The quality of reporting on these strategies may limit the transferability of successful initiatives across centres. This systematic review will assess the quality of reporting on guideline, protocol or algorithm implementation within a trauma centre in terms of the Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0). We will search for English language articles published after 2010 in EMBASE, MEDLINE, CINAHL electronic databases and the Cochrane Central Register of Controlled Trials. The database search will be supplemented by searching trial registries and grey literature online. Included studies will evaluate the effectiveness of guideline implementation in terms of change in clinical practice or improvement in patient outcomes. The primary outcome will be a global score reporting the proportion of studies respecting at least 80% of the SQUIRE 2.0 criteria and will be obtained based on the 18-items identified in the SQUIRE 2.0 guidelines. Secondary outcome will be the risk of bias assessed with the Risk Of Bias In Non-randomised Studies- of Interventions tool for observational cohort studies and with the Cochrane Collaboration tool for randomised controlled trials. Meta-analyses will be conducted in randomised controlled trials to estimate the effectiveness of guideline implementation if studies are not heterogeneous. If meta-analyses are conducted, we will combine studies according to the risk of bias (low, moderate or high/unclear) in subgroup analyses. All study titles, abstracts and full-text screening will be completed independently and in duplicate by the review team members. Data extraction and risk of bias assessment will also be done independently and in duplicate. Results will be disseminated through scientific publication and conferences. CRD42018084273. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

[Quality of case allocation of orthopedics and trauma surgery in the 2004 and 2014 versions of the German DRG system. An interim assessment of the development process].

PubMed

Franz, D; Schemmann, F; Selter, D D; Auhuber, T; Gehweiler, D; Roeder, N; Siebert, H; Mahlke, L

2014-10-01

Since 2004 the German diagnosis-related groups (DRG) system has been applied nationwide in all German somatic hospitals. The G-DRG system is updated annually in order to increase the quality of case allocation. What developments have occurred since 2004 from the perspective of orthopedics and trauma surgery? This article takes stock of the developments between 2004 and 2014. Analysis of relevant diagnoses, medical procedures and G-DRGs in the versions 2004 and 2014 based on the publications of the German DRG Institute (InEK) and the German Institute of Medical Documentation and Information (DIMDI). The number of G-DRGs in the whole system increased by 45.1 % between 2004 and 2014. The number of G-DRGs in the major diagnostic category (MDC) 08 that contains the majority of orthopedic and trauma surgery categories increased in the same period by 61.6 %. The reduction of variance of inlier costs in the MDC 08 category, a statistical measure of the performance of the G-DRG system, was below the corresponding value of the total system in 2004 as well in 2014. However, the reduction of variance of inlier costs in MDC 08 (+ 30.0 %) rose more from 2004 to 2014 than the corresponding value of the overall system (+ 21.5 %). Many modifications of the classification systems of diagnoses (ICD-10-GM) and medical procedures (OPS) and the structures of the G-DRG system could significantly improve the quality of case allocation from the perspective of orthopedics and trauma surgery between 2004 and 2014. Th assignment of cases could be differentiated so that complex cases with more utilization of resources were allocated to higher rated G-DRGs and vice versa. However, further improvements of the G-DRG system are necessary. Only correct and complete documentation and coding can provide a high quality of calculation of costs as a basis for a correct case allocation in future G-DRG systems.

Systematic review of multidisciplinary rehabilitation in patients with multiple trauma.

PubMed

Khan, F; Amatya, B; Hoffman, K

2012-01-01

Multiple trauma is a cause of significant disability in adults of working age. Despite the implementation of trauma systems for improved coordination and organization of care, rehabilitation services are not yet routinely considered integral to trauma care processes. MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, Allied and Complementary Medicine, Physiotherapy Evidence Database, Latin American and Caribbean Literature on Health Sciences and Cochrane Library databases were searched up to May 2011 for randomized clinical trials, as well as observational studies, reporting outcomes of injured patients following multidisciplinary rehabilitation that addressed functional restoration and societal reintegration based on the International Classification of Functioning, Disability and Health. No randomized and/or controlled clinical trials were identified. Fifteen observational studies involving 2386 participants with injuries were included. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach assessed methodological quality as 'poor' in all studies, with selection and observer bias. Although patients with low functional scores showed improvement after rehabilitation, they were unable to resume their pretrauma level of activity. Their functional ability was significantly associated with motor independence on admission and early acute rehabilitation, which contributed to a shorter hospital stay. Injury location, age, co-morbidity and education predicted long-term functional consequences. Trauma care systems were associated with reduced mortality. The gaps in evidence include: rehabilitation settings, components, intensity, duration and types of therapy, and long-term outcomes for survivors of multiple trauma. Rehabilitation is an expensive resource and the evidence to support its justification is needed urgently. The issues in study design and research methodology in rehabilitation are challenging. Opportunities to prioritize trauma rehabilitation, disability management and social reintegration of multiple injury survivors are discussed. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

[The challenge of adequate reimbursement for the seriously injured patient in the German DRG system].

PubMed

Franz, D; Lefering, R; Siebert, H; Windolf, J; Roeder, N; Mahlke, L

2013-02-01

Critically injured patients are a very heterogeneous group, medically and economically. Their treatment is a major challenge for both the medical care and the appropriate financial reimbursement. Systematic underfunding can have a significant impact on the quality of patient care. In 2009 the German Trauma Society and the DRG-Research Group of the University Hospital Muenster initialised a DRG evaluation project to analyse the validity of case allocation of critically injured patients within the German DRG system versions 2008 and 2011 with additional consideration of clinical data from the trauma registry of the German Trauma Society. Severe deficits within the G-DRG structure were identified and specific solutions were designed and realised. A retrospective analysis was undertaken of standardised G-DRG data (§ 21 KHEntgG) including case-related cost data from 3 362 critically injured patients in the periods 2007 and 2008 from 10 university hospitals and 7 large municipal hospitals. For 1 241 cases of the sample, complementary detailed information was available from the trauma registry of the German Trauma Society to monitor the case allocation of critically injured patients within the G-DRG system. Analyses of coding and grouping, performance of case allocation, and the homogeneity of costs in the G-DRG versions 2008 and 2011 were done. The following situations were found: (i) systematic underfunding of trauma patients in the G-DRG-Version 2008, especially trauma patients with acute paraplegia; (ii) participation in the official G-DRG development for 2011 with 13 proposals which were largely realised; (ii) the majority of cases with cost-covering in the G-DRG version 2011; (iv) significant improvements in the quality of statistical criteria; (v) overfunded trauma patients with high intensive care costs; (vi) underfunding for clinically relevant critically injured patients not identified in the G-DRG system. The quality of the G-DRG system is measured by the ability to obtain adequate case allocations for highly complex and heterogeneous cases. Specific modifications of the G-DRG structures could increase the appropriateness of case allocation of critically injured patients. Additional consideration of the ISS clinical data must be further evaluated. Data-based analysis is an essential prerequisite for a constructive development of the G-DRG system and a necessary tool for the active participation of medical societies in this process. © Georg Thieme Verlag KG Stuttgart · New York.

In My Opinion: The Role of Counseling in the Reform of Marriage and Divorce Procedures

ERIC Educational Resources Information Center

Shipman, Gordon

1977-01-01

This article contains recommendations for the integration of knowledge and competence from the fields of family law, marriage counseling, judicial administration, and eugenics. The goal is to find ways to minimize marital trauma and thereby improve the quality of family life. (Author)

The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition.

PubMed

Rossaint, Rolf; Bouillon, Bertil; Cerny, Vladimir; Coats, Timothy J; Duranteau, Jacques; Fernández-Mondéjar, Enrique; Filipescu, Daniela; Hunt, Beverley J; Komadina, Radko; Nardi, Giuseppe; Neugebauer, Edmund A M; Ozier, Yves; Riddez, Louis; Schultz, Arthur; Vincent, Jean-Louis; Spahn, Donat R

2016-04-12

Severe trauma continues to represent a global public health issue and mortality and morbidity in trauma patients remains substantial. A number of initiatives have aimed to provide guidance on the management of trauma patients. This document focuses on the management of major bleeding and coagulopathy following trauma and encourages adaptation of the guiding principles to each local situation and implementation within each institution. The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004 and included representatives of six relevant European professional societies. The group used a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were reconsidered and revised based on new scientific evidence and observed shifts in clinical practice; new recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. This guideline represents the fourth edition of a document first published in 2007 and updated in 2010 and 2013. The guideline now recommends that patients be transferred directly to an appropriate trauma treatment centre and encourages use of a restricted volume replacement strategy during initial resuscitation. Best-practice use of blood products during further resuscitation continues to evolve and should be guided by a goal-directed strategy. The identification and management of patients pre-treated with anticoagulant agents continues to pose a real challenge, despite accumulating experience and awareness. The present guideline should be viewed as an educational aid to improve and standardise the care of the bleeding trauma patients across Europe and beyond. This document may also serve as a basis for local implementation. Furthermore, local quality and safety management systems need to be established to specifically assess key measures of bleeding control and outcome. A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. The implementation of locally adapted treatment algorithms should strive to achieve measureable improvements in patient outcome.

The impact of patient volume on surgical trauma training in a Scandinavian trauma centre.

PubMed

Gaarder, Christine; Skaga, Nils Oddvar; Eken, Torsten; Pillgram-Larsen, Johan; Buanes, Trond; Naess, Paal Aksel

2005-11-01

Some of the problems faced in trauma surgery are increasing non-operative management of abdominal injuries, decreasing work hours and increasing sub-specialisation. We wanted to document the experience of trauma team leaders at the largest trauma centre in Norway, hypothesising that the patient volume would be inadequate to secure optimal trauma care. Patients registered in the hospital based Trauma Registry during the 2-year period from 1 August 2000 to 31 July 2002 were included. Of a total of 1667 patients registered, 645 patients (39%) had an Injury Severity Score (ISS)>15. Abdominal injuries were diagnosed in 205 patients with a median ISS of 30. An average trauma team leader assessed a total of 119 trauma cases a year (46 patients with ISS>15) and participated in 10 trauma laparotomies. Although the total number of trauma cases seems adequate, the experience of the trauma team leaders with challenging abdominal injuries is limited. With increasing sub-specialisation and general surgery vanishing, fewer surgical specialties provide operative competence in dealing with complicated torso trauma. A system of additional education and quality assurance measures is a prerequisite of high quality, and has consequently been introduced in our institution.

The salutary effect of an integrated system on the rate of repeat CT scanning in transferred trauma patients: Improved costs and efficiencies.

PubMed

Bledsoe, Joseph; Liepert, Amy E; Allen, Todd L; Dong, Li; Hemingway, Jamon; Majercik, Sarah; Gardner, Scott; Stevens, Mark H

2017-08-01

Duplication of Computed Tomography (CT) scanning in trauma patients has been a source of quality waste in healthcare and potential harm for patients. Integrated and regional health systems have been shown to promote opportunities for efficiencies, cost savings and increased safety. This study evaluated traumatically injured patients who required transfer to a Level One Trauma Center (TC) from either within a vertically integrated healthcare system (IN) or from an out-of-network (OON) hospital. We found the rate of repeat CT scanning, radiology costs and total costs for day one of hospitalization to be significantly lower for trauma patients transferred from an IN hospital as compared to those patients transferred from OON hospitals. The inefficiencies and waste often associated with transferred patients can be mitigated and strategies to do so are necessary to reduce costs in the current healthcare environment. Copyright © 2017 Elsevier Inc. All rights reserved.

Blood Volume: Importance and Adaptations to Exercise Training, Environmental Stresses and Trauma/Sickness

NASA Technical Reports Server (NTRS)

Sawka, Michael N.; Convertino, Victor A.; Eichner, E. Randy; Schnieder, Suzanne M.; Young, Andrew J.

2000-01-01

This paper reviews the influence of several perturbations (physical exercise, heat stress, terrestrial altitude, microgravity, and trauma/sickness) on adaptations of blood volume (BV), erythrocyte volume (EV), and plasma volume (PV). Exercise training can induced BV expansion; PV expansion usually occurs immediately, but EV expansion takes weeks. EV and PV expansion contribute to aerobic power improvements associated with exercise training. Repeated heat exposure induces PV expansion but does not alter EV. PV expansion does not improve thermoregulation, but EV expansion improves thermoregulation during exercise in the heat. Dehydration decreases PV (and increases plasma tonicity) which elevates heat strain and reduces exercise performance. High altitude exposure causes rapid (hours) plasma loss. During initial weeks at altitude, EV is unaffected, but a gradual expansion occurs with extended acclimatization. BV adjustments contribute, but are not key, to altitude acclimatization. Microgravity decreases PV and EV which contribute to orthostatic intolerance and decreased exercise capacity in astronauts. PV decreases may result from lower set points for total body water and central venous pressure, which EV decrease bay result form increased erythrocyte destruction. Trauma, renal disease, and chronic diseases cause anemia from hemorrhage and immune activation, which suppressions erythropoiesis. The re-establishment of EV is associated with healing, improved life quality, and exercise capabilities for these injured/sick persons.

Factors influencing the relationship between sexual trauma and risky sexual behavior in college students.

PubMed

Johnson, Nicole L; Johnson, Dawn M

2013-07-01

While the relationship between sexual trauma and risky sexual behavior (RSB) has received much attention, only a handful of studies have investigated the factors that protect victims of sexual trauma from developing this maladaptive pattern of behavior. The current study investigated the protective role of social support, quality and quantity, in developing RSB, through the mechanism of problematic substance use. Two hundred and seventy-five female college students completed a series of self-reports assessing sexual trauma, problematic substance use, social support quality and quantity, and RSB. The results indicated a positive relationship between sexual trauma severity and RSB. Further, this relationship was mediated by participants' problematic substance use. Social support quality acted as a buffer against the relationship described above where quantity exacerbated this relationship. Implications will be discussed.

[Pay close attention to the quality of life of patients and look to the future of burn rehabilitation].

PubMed

Wu, Jun; Chen, Jian

2013-04-01

After 50 years' development, a rather comprehensive burn care system has been built up in China, and it has played key roles in wound healing and salvaging victims of burn trauma. Since survival is no longer the main priority of treatment, more efforts should be made to cut down the incidence of disabilities and to improve the quality of life of the survivors. The further progress on burn rehabilitation therapies, including functional improvement, psychological rehabilitation, aesthetic recovery, and occupational and social recuperation, would bring new perspectives to our burn care system.

Measuring the Quality of Care for Psychological Health Conditions in the Military Health System: Candidate Quality Measures for Posttraumatic Stress Disorder and Major Depressive Disorder

DTIC Science & Technology

2015-01-01

therapy CDC Centers for Disease Control and Prevention CESD Center for Epidemiologic Studies Depression Scale CGI-BP Clinical Global Impressions Scale for...dimensions GDS Geriatric Depression Scale HEDIS Healthcare Effectiveness Data and Information Set HOS Health Outcomes Survey HRQOL health-related quality of...TBI traumatic brain injury TF-CBT Trauma-Focused Cognitive–Behavioral Therapy TSC-40 Trauma Symptom Checklist—40 TSI Trauma Symptom Inventory VA U.S

Structure, Process, and Culture of Intensive Care Units Treating Patients with Severe Traumatic Brain Injury: Survey of Centers Participating in the American College of Surgeons Trauma Quality Improvement Program.

PubMed

Alali, Aziz S; McCredie, Victoria A; Mainprize, Todd G; Gomez, David; Nathens, Avery B

2017-10-01

Outcome after severe traumatic brain injury (TBI) differs substantially between hospitals. Explaining this variation begins with understanding the differences in structures and processes of care, particularly at intensive care units (ICUs) where acute TBI care takes place. We invited trauma medical directors (TMDs) from 187 centers participating in the American College of Surgeons Trauma Quality Improvement Program (ACS TQIP) to complete a survey. The survey domains included ICU model, type, availability of specialized units, staff, training programs, standard protocols and order sets, approach to withdrawal of life support, and perceived level of neurosurgeons' engagement in the ICU management of TBI. One hundred forty-two TMDs (76%) completed the survey. Severe TBI patients are admitted to dedicated neurocritical care units in 52 hospitals (37%), trauma ICUs in 44 hospitals (31%), general ICUs in 34 hospitals (24%), and surgical ICUs in 11 hospitals (8%). Fifty-seven percent are closed units. Board-certified intensivists directed 89% of ICUs, whereas 17% were led by neurointensivists. Sixty percent of ICU directors were general surgeons. Thirty-nine percent of hospitals had critical care fellowships and 11% had neurocritical care fellowships. Fifty-nine percent of ICUs had standard order sets and 61% had standard protocols specific for TBI, with the most common protocol relating to intracranial pressure management (53%). Only 43% of TMDs were satisfied with the current level of neurosurgeons' engagement in the ICU management of TBI; 46% believed that neurosurgeons should be more engaged; 11% believed they should be less engaged. In the largest survey of North American ICUs caring for TBI patients, there is substantial variation in the current approaches to ICU care for TBI, highlighting multiple opportunities for comparative effectiveness research.

Implications of the Trauma Quality Improvement Project inclusion of nonsurvivable injuries in performance benchmarking.

PubMed

Heaney, Jiselle Bock; Schroll, Rebecca; Turney, Jennifer; Stuke, Lance; Marr, Alan B; Greiffenstein, Patrick; Robledo, Rosemarie; Theriot, Amanda; Duchesne, Juan; Hunt, John

2017-10-01

The Trauma Quality Improvement Project (TQIP) uses an injury prediction model for performance benchmarking. We hypothesize that at a Level I high-volume penetrating trauma center, performance outcomes will be biased due to inclusion of patients with nonsurvivable injuries. Retrospective chart review was conducted for all patients included in the institutional TQIP analysis from 2013 to 2014 with length of stay (LOS) less than 1 day to determine survivability of the injuries. Observed (O)/expected (E) mortality ratios were calculated before and after exclusion of these patients. Completeness of data reported to TQIP was examined. Eight hundred twenty-six patients were reported to TQIP including 119 deaths. Nonsurvivable injuries accounted 90.9% of the deaths in patients with an LOS of 1 day or less. The O/E mortality ratio for all patients was 1.061, and the O/E ratio after excluding all patients with LOS less than 1 day found to have nonsurvivable injuries was 0.895. Data for key variables were missing in 63.3% of patients who died in the emergency department, 50% of those taken to the operating room and 0% of those admitted to the intensive care unit. Charts for patients who died with LOS less than 1 day were significantly more likely than those who lived to be missing crucial. This study shows TQIP inclusion of patients with nonsurvivable injuries biases outcomes at an urban trauma center. Missing data results in imputation of values, increasing inaccuracy. Further investigation is needed to determine if these findings exist at other institutions, and whether the current TQIP model needs revision to accurately identify and exclude patients with nonsurvivable injuries. Prognostic and epidemiological, level III.

[First aid system for trauma: development and status].

PubMed

Chen, D K; Lin, W C; Zhang, P; Kuang, S J; Huang, W; Wang, T B

2017-04-18

With the great progress of the economy, the level of industrialization has been increasing year by year, which leads to an increase in accidental trauma accidents. Chinese annual death of trauma is already more than 400 000, which makes trauma the fifth most common cause of death, following malignant tumor, heart, brain and respiratory diseases. Trauma is the leading cause of the death of young adults. At the same time, trauma has become a serious social problem in peace time. Trauma throws great treats on human health and life. As an important part in the medical and social security system, the emergency of trauma system occupies a very important position in the emergency medical service system. In European countries as well as the United States and also many other developed countries, trauma service system had a long history, and progressed to an advanced stage. However, Chinese trauma service system started late and is still developing. It has not turned into a complete and standardized system yet. This review summarizes the histories and current situations of the development of traumatic first aid system separately in European countries, the United States and our country. Special attentions are paid to the effects of the pre- and in-hospital emergency care. We also further try to explore the Chinese trauma emergency model that adapts to the situations of China and characteristics of different regions of China. Our review also introduces the trauma service system that suits the situations of China proposed by Professor Jiang Baoguo's team in details, taking Chinese conditions into account, they conducted a thematic study and made an expert consensus on pre-hospital emergency treatment of severe trauma, providing a basic routine and guidance of severe trauma treatment for those pre-hospital emergency physicians. They also advised to establish independent trauma disciplines and trauma specialist training systems, and to build the regional trauma care system as well as the standards for graded treatment, thus establishing a multiple disciplinary team (MDT) of severe trauma. In this way, we can reduce the mortality and disability risks of severe trauma, improve the quality of patients' life, and save more lives.

Evaluation of a new imaging tool for use with major trauma cases in the emergency department.

PubMed

Crönlein, Moritz; Holzapfel, Konstantin; Beirer, Marc; Postl, Lukas; Kanz, Karl-Georg; Pförringer, Dominik; Huber-Wagner, Stefan; Biberthaler, Peter; Kirchhoff, Chlodwig

2016-11-17

The aim of this study was to evaluate potential benefits of a new diagnostic software prototype (Trauma Viewer, TV) automatically reformatting computed tomography (CT) data on diagnostic speed and quality, compared to CT-image data evaluation using a conventional CT console. Multiple trauma CT data sets were analysed by one expert radiology and one expert traumatology fellow independently twice, once using the TV and once using the secondary conventional CT console placed in the CT control room. Actual analysis time and precision of diagnoses assessment were evaluated. The TV and CT-console results were compared respectively, but also a comparison to the initial multiple trauma CT reports assessed by emergency radiology fellows considered as the gold standard was performed. Finally, design and function of the Trauma Viewer were evaluated in a descriptive manner. CT data sets of 30 multiple trauma patients were enrolled. Mean time needed for analysis of one CT dataset was 2.43 min using the CT console and 3.58 min using the TV respectively. Thus, secondary conventional CT console analysis was on average 1.15 min shorter compared to the TV analysis. Both readers missed a total of 11 diagnoses using the secondary conventional CT console compared to 12 missed diagnoses using the TV. However, none of these overlooked diagnoses resulted in an Abbreviated Injury Scale (AIS) > 2 corresponding to life threatening injuries. Even though it took the two expert fellows a little longer to analyse the CT scans on the prototype TV compared to the CT console, which can be explained by the new user interface of the TV, our preliminary results demonstrate that, after further development, the TV might serve as a new diagnostic feature in the trauma room management. Its high potential to improve time and quality of CT-based diagnoses might help in fast decision making regarding treatment of severely injured patients.

Development of a Performance Improvement Program: A Workplace-Based Educational Intervention on Magnetic Resonance Imaging in Spinal Trauma.

PubMed

Kraus, Michael David; Mueller, Marguerite; Schmitz, Bernd; Cunningham, Michael; Gebhard, Florian

2016-01-01

Performance improvement (PI) programs are an educational tool used to analyze clinical performance of clinicians. The effect of this tool has not been fully explored in orthopedic and trauma surgery. A needs assessment was conducted in connection with a worldwide webinar on magnetic resonance imaging in spinal injuries to identify the clinical need for an educational intervention. A 3-step PI process was defined and implemented over a 6-month period in 1 hospital department. Opportunities for improvement were identified by applying a 10-item quality checklist to 26 cases. A focused educational intervention was delivered to address the identified gaps, and a set of 22 posteducation cases was compared. The department of radiology and the department of trauma surgery of a level I university hospital participated in this study. A total of 26 cases collected before the educational intervention showed several areas for potential improvement. Important information was not provided by the surgeons in their communication with the radiologist. The educational intervention outlined the data and suggested actions. Comparing the information transfer of the preintervention and postintervention data, there was a significant improvement following the intervention (p = 0.0013). Our PI program was able to demonstrate a significant influence on the behavior and the attitude of surgeons and radiologists. Copyright © 2016 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Cost-Effectiveness of Helicopter Versus Ground Emergency Medical Services for Trauma Scene Transport in the United States

PubMed Central

Delgado, M. Kit; Staudenmayer, Kristan L.; Wang, N. Ewen; Spain, David A.; Weir, Sharada; Owens, Douglas K.; Goldhaber-Fiebert, Jeremy D.

2014-01-01

Objective We determined the minimum mortality reduction that helicopter emergency medical services (HEMS) should provide relative to ground EMS for the scene transport of trauma victims to offset higher costs, inherent transport risks, and inevitable overtriage of minor injury patients. Methods We developed a decision-analytic model to compare the costs and outcomes of helicopter versus ground EMS transport to a trauma center from a societal perspective over a patient's lifetime. We determined the mortality reduction needed to make helicopter transport cost less than $100,000 and $50,000 per quality adjusted life year (QALY) gained compared to ground EMS. Model inputs were derived from the National Study on the Costs and Outcomes of Trauma (NSCOT), National Trauma Data Bank, Medicare reimbursements, and literature. We assessed robustness with probabilistic sensitivity analyses. Results HEMS must provide a minimum of a 17% relative risk reduction in mortality (1.6 lives saved/100 patients with the mean characteristics of the NSCOT cohort) to cost less than $100,000 per QALY gained and a reduction of at least 33% (3.7 lives saved/100 patients) to cost less than $50,000 per QALY. HEMS becomes more cost-effective with significant reductions in minor injury patients triaged to air transport or if long-term disability outcomes are improved. Conclusions HEMS needs to provide at least a 17% mortality reduction or a measurable improvement in long-term disability to compare favorably to other interventions considered cost-effective. Given current evidence, it is not clear that HEMS achieves this mortality or disability reduction. Reducing overtriage of minor injury patients to HEMS would improve its cost-effectiveness. PMID:23582619

Effects on mortality, treatment, and time management as a result of routine use of total body computed tomography in blunt high-energy trauma patients.

PubMed

van Vugt, Raoul; Kool, Digna R; Deunk, Jaap; Edwards, Michael J R

2012-03-01

Currently, total body computed tomography (TBCT) is rapidly implemented in the evaluation of trauma patients. With this review, we aim to evaluate the clinical implications-mortality, change in treatment, and time management-of the routine use of TBCT in adult blunt high-energy trauma patients compared with a conservative approach with the use of conventional radiography, ultrasound, and selective computed tomography. A literature search for original studies on TBCT in blunt high-energy trauma patients was performed. Two independent observers included studies concerning mortality, change of treatment, and/or time management as outcome measures. For each article, relevant data were extracted and analyzed. In addition, the quality according to the Oxford levels of evidence was assessed. From 183 articles initially identified, the observers included nine original studies in consensus. One of three studies described a significant difference in mortality; four described a change of treatment in 2% to 27% of patients because of the use of TBCT. Five studies found a gain in time with the use of immediate routine TBCT. Eight studies scored a level of evidence of 2b and one of 3b. Current literature has predominantly suboptimal design to prove terminally that the routine use of TBCT results in improved survival of blunt high-energy trauma patients. TBCT can give a change of treatment and improves time intervals in the emergency department as compared with its selective use.

Traumatic dental injury research: on children or with children?

PubMed

Wallace, Ann; Rogers, Helen J; Zaitoun, Halla; Rodd, Helen D; Gilchrist, Fiona; Marshman, Zoe

2017-06-01

It is widely acknowledged that children should participate in healthcare decisions, service development and even setting research agendas. Dental traumatology is a major component of paediatric dentistry practice and research. However, little is known about young patients' contribution to new knowledge in this field. The aim of the study was to establish the extent to which children are involved in contemporary dental trauma research and to evaluate the quality of the related literature. A systematic review of the dental trauma literature was conducted from 2006 to 2014. The electronic databases, MEDLINE and Scopus, were used to identify relevant studies. The selected papers were independently examined by five calibrated reviewers. Studies were categorized by the degree of children's involvement and appraised using a validated quality assessment tool. The initial search yielded 4374 papers. After application of the inclusion and exclusion criteria, only 96 studies remained. Research on children accounted for 87.5% of papers, and a proxy was involved in 4.2%. Children were engaged to some degree in only 8.3% of studies, and there were no studies where children were active research participants. In the quality assessment exercise, papers scored, on average, 57% (range = 14-86%). There is scope to encourage more active participation of children in dental trauma research in the future. Furthermore, there are some areas where the quality of research could be improved overall. © 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Impact of childhood trauma on functionality and quality of life in HIV-infected women.

PubMed

Troeman, Zyrhea C E; Spies, Georgina; Cherner, Mariana; Archibald, Sarah L; Fennema-Notestine, Christine; Theilmann, Rebecca J; Spottiswoode, Bruce; Stein, Dan J; Seedat, Soraya

2011-09-30

While there are many published studies on HIV and functional limitations, there are few in the context of early abuse and its impact on functionality and Quality of Life (QoL) in HIV. The present study focused on HIV in the context of childhood trauma and its impact on functionality and Quality of Life (QoL) by evaluating 85 HIV-positive (48 with childhood trauma and 37 without) and 52 HIV-negative (21 with childhood trauma and 31 without) South African women infected with Clade C HIV. QoL was assessed using the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q), the Patient's Assessment of Own Functioning Inventory (PAOFI), the Activities of Daily Living (ADL) scale and the Sheehan Disability Scale (SDS). Furthermore, participants were assessed using the Center for Epidemiologic Studies Depression Scale (CES-D) and the Childhood Trauma Questionnaire (CTQ). Subjects had a mean age of 30.1 years. After controlling for age, level of education and CES-D scores, analysis of covariance (ANCOVA) demonstrated significant individual effects of HIV status and childhood trauma on self-reported QoL. No significant interactional effects were evident. Functional limitation was, however, negatively correlated with CD4 lymphocyte count. In assessing QoL in HIV-infected women, we were able to demonstrate the impact of childhood trauma on functional limitations in HIV.

Quality of Documentation as a Surrogate Marker for Awareness and Training Effectiveness of PHTLS-Courses. Part of the Prospective Longitudinal Mixed-Methods EPPTC-Trial.

PubMed

Häske, David; Beckers, Stefan K; Hofmann, Marzellus; Lefering, Rolf; Gliwitzky, Bernhard; Wölfl, Christoph C; Grützner, Paul; Stöckle, Ulrich; Dieroff, Marc; Münzberg, Matthias

2017-01-01

Care for severely injured patients requires multidisciplinary teamwork. A decrease in the number of accident victims ultimately affects the routine and skills. PHTLS ("Pre-Hospital Trauma Life Support") courses are established two-day courses for medical and non-medical rescue service personnel, aimed at improving the pre-hospital care of trauma patients worldwide. The study aims the examination of the quality of documentation before and after PHTLS courses as a surrogate endpoint of training effectiveness and awareness. This was a prospective pre-post intervention trial and was part of the mixed-method longitudinal EPPTC (Effect of Paramedic Training on Pre-Hospital Trauma Care) study, evaluating subjective and objective changes among participants and real patient care, as a result of PHTLS courses. The courses provide an overview of the SAMPLE approach for interrogation of anamnestic information, which is believed to be responsible for patient safety as relevant, among others, "Allergies," "Medication," and "Patient History" (AMP). The focus of the course is not the documentation. In total, 320 protocols were analyzed before and after the training. The PHTLS course led to a significant increase (p < 0.001) in the "AMP" information in the documentation. The subgroups analysis of "allergies" (+47.2%), "drugs" (+38.1%), and "medical history" (+27.8%) before and after the PHTLS course showed a significant increase in the information content. In summary, we showed that PHTLS training improves documentation quality, which we used as a surrogate endpoint for learning effectiveness and awareness. In this regard, we demonstrated that participants use certain parts of training in real life, thereby suggesting that the learning methods of PHTLS training are effective. These results, however, do not indicate whether patient care has changed.

Mechanical Blood Trauma in Assisted Circulation: Sublethal RBC Damage Preceding Hemolysis

PubMed Central

Olia, Salim E.; Maul, Timothy M.; Antaki, James F.; Kameneva, Marina V.

2016-01-01

After many decades of improvements in mechanical circulatory assist devices (CADs), blood damage remains a serious problem during support contributing to variety of adverse events, and consequently affecting patient survival and quality of life. The mechanisms of cumulative cell damage in continuous-flow blood pumps are still not fully understood despite numerous in vitro, in vivo, and in silico studies of blood trauma. Previous investigations have almost exclusively focused on lethal blood damage, namely hemolysis, which is typically negligible during normal operation of current generation CADs. The measurement of plasma free hemoglobin (plfHb) concentration to characterize hemolysis is straightforward, however sublethal trauma is more difficult to detect and quantify since no simple direct test exists. Similarly, while multiple studies have focused on thrombosis within blood pumps and accessories, sublethal blood trauma and its sequelae have yet to be adequately documented or characterized. This review summarizes the current understanding of sublethal trauma to red blood cells (RBCs) produced by exposure of blood to flow parameters and conditions similar to those within CADs. It also suggests potential strategies to reduce and/or prevent RBC sublethal damage in a clinically-relevant context, and encourages new research into this relatively uncharted territory. PMID:27034320

Assuring optimal trauma care: the role of trauma centre accreditation

PubMed Central

Simons, Richard; Kirkpatrick, Andrew

2002-01-01

Optimal care of the injured patient requires the delivery of appropriate, definitive care shortly after injury. Over the last 30 to 40 years, civilian trauma systems and trauma centres have been developed in the United States based on experience gained in military conflicts, particularly in Korea and Vietnam. A similar process is evolving in Canada. National trauma committees in the US and Canada have defined optimal resources to meet the goal of rapid, appropriate care in trauma centres. They have introduced programs (verification or accreditation) to externally audit trauma centre performance based on these guidelines. It is generally accepted that implementing trauma systems results in decreased preventable death and improved survival after trauma. What is less clear is the degree to which each facet of trauma system development contributes to this improvement. The relative importance of national performance guidelines and trauma centre audit as integral steps toward improved outcomes following injury are reviewed. Current Trauma Association of Canada guidelines for trauma centres are presented and the process of trauma centre accreditation is discussed. PMID:12174987

Surgeons' and Trauma Care Physicians' Perception of the Impact of the Globalization of Medical Education on Quality of Care in Lima, Peru.

PubMed

LaGrone, Lacey N; Isquith-Dicker, Leah N; Huaman Egoavil, Eduardo; Rodriguez Castro, Manuel J A; Allagual, Alfredo; Revoredo, Fernando; Mock, Charles N

2017-03-01

The globalization of medical education-the process by which trainees in any region gain access to international training (electronic or in-person)-is a growing trend. More data are needed to inform next steps in the responsible stewardship of this process, from the perspective of trainees and institutions at all income levels, and for use by national and international policymakers. To describe the impact of the globalization of medical education on surgical care in Peru from the perspective of Peruvian surgeons who received international training. Observational study of qualitative interviews conducted from September 2015 to January 2016 using grounded theory qualitative research methods. The study was conducted at 10 large public institutions that provide most of the trauma care in Lima, Peru, and included urban resident and faculty surgery and trauma care physicians. Access to international surgical rotations and medical information. Outcome measures defining the impact of globalization on surgical care were developed as part of simultaneous data collection and analysis during qualitative research as part of a larger project on trauma quality improvement practices in Peru. Fifty qualitative interviews of surgeons and emergency medicine physicians were conducted at 10 hospitals, including multiple from the public and social security systems. A median of 4 interviews were conducted at each hospital, and fewer than 3 interviews were conducted at only 1 hospital. From the broader theme of globalization emerged subthemes of an eroded sense of agency and a perception of inadequate training on the adaptation of international standards as negative effects of globalization on surgical care in Peru. Access to research funds, provision of incentives for acquisition of advanced clinical training, increased expectations for patient outcomes, and education in quality improvement skills are ways in which globalization positively affected surgeons and their patients in Peru. Short-term overseas training of surgeons from low- and middle-income countries may improve care in the surgeons' country of origin through the acquisition of skills and altered expectations for excellence. Prioritization of evidence-based medical education is necessary given widespread internet access and thus clinician exposure to variable quality medical information. Finally, the establishment of centers of excellence in low- and middle-income countries may address the eroded sense of agency attributable to globalization and offer a local example of world-class surgical outcomes, diminishing surgeons' most frequently cited reason for emigration: access to better surgical training.

Prehospital care for multiple trauma patients in Germany.

PubMed

Maegele, Marc

2015-01-01

For the German speaking countries, Tscherne's definition of "polytrauma" which represents an injury of at least two body regions with one or a combination being life-threatening is still valid. The timely and adequate management including quick referral of the trauma patient into a designated trauma center may limit secondary injury and may thus improve outcomes already during the prehospital phase of care. The professional treatment of multiple injured trauma patients begins at the scene in the context of a well structured prehospital emergency medical system. The "Primary Survey" is performed by the emergency physician at the scene according to the Prehospital Trauma Life Support (PHTLS)-concept. The overall aim is to rapidly assess and treat life-threatening conditions even in the absence of patient history and diagnosis ("treat-first-what-kills-first"). If no immediate treatment is necessary, a "Secondary Sur- vey" follows with careful and structured body examination and detailed assessment of the trauma mechanism. Massive and life-threatening states of hemorrhage should be addressed immediately even disregarding the ABCDE-scheme. Critical trauma patients should be referred without any delay ("work and go")toTR-DGU® certified trauma centers of the local trauma networks. Due to the difficult pre- hospital environment the number of quality studies in the field is low and, as consequence, the level of evidence for most recommendations is also low. Much information has been obtained from different care systems and the interchangeability of results is limited. The present article provides a synopsis of rec- ommendations for early prehospital care for the severely injured based upon the 2011 updated multi- disciplinary S3-Guideline "Polytrauma/Schwerstverletzten Behandlung", the most recently updated European Trauma guideline and the current PHTLS-algorithms including grades of recommendation whenever possible.

Biomarkers predicting sepsis in polytrauma patients: Current evidence.

PubMed

Ciriello, Vincenzo; Gudipati, Suribabu; Stavrou, Petros Z; Kanakaris, Nikolaos K; Bellamy, Mark C; Giannoudis, Peter V

2013-12-01

Major trauma still represents one of the leading causes of death in the first four decades of life. Septic complications represent the predominant causes of late death (45% of overall mortality) in polytrauma patients. The ability of clinicians to early differentiate between systemic inflammatory response syndrome (SIRS) and sepsis is demonstrated to improve clinical outcome and mortality. The identification of an "ideal" biomarker able to early recognize incoming septic complications in trauma patients is still a challenge for researchers. To evaluate the existing evidence regarding the role of biomarkers to predict or facilitate early diagnosis of sepsis in trauma patients, trying to compile some recommendations for the clinical setting. An Internet-based search of the MEDLINE, EMBASE and Cochrane Library databases was performed using the search terms: "Biomarkers", "Sepsis" and "Trauma" in various combinations. The methodological quality of the included studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies Checklist (QUADAS). After data extraction, the level of evidence available for each bio-marker was rated and presented using the "best-evidence synthesis" method, in line with the US Agency for Healthcare Research and Quality. Thirty studies were eligible for the final analysis: 13 case-control studies and 17 cohort studies. The "strong evidence" available demonstrated the potential use of procalcitonin as an early indicator of post-traumatic septic complications and reported the inability of c-reactive protein (CRP) to specifically identify infective complications. Moderate, conflicting and limited evidence are available for the other 31 biomarkers. Several biomarkers have been evaluated for predicting or making early diagnosis of sepsis in trauma patients. Current evidence does not support the use of a single biomarker in diagnosing sepsis. However, procalcitonin trend was found to be useful in early identification of post-traumatic septic course and its use is suggested (Recommendation Grade: B) in clinical practice. Copyright © 2013 Elsevier Ltd. All rights reserved.

Surgery and Trauma Care Providers’ Perception of the Impact of Dual-Practice Employment on Quality of Care Provided in an Andean Country

PubMed Central

LaGrone, Lacey N.; Isquith-Dicker, Leah N.; Egoavil, Eduardo Huaman; Herrera-Matta, Juan Jaime; Fuhs, Amy K.; Checa, David Ortega; Revoredo, Fernando; Rodriguez Castro, Manuel J.A.; Mock, Charles N.

2017-01-01

Background Dual practice, simultaneous employment by healthcare workers in the public and private sector, is pervasive worldwide. Although an estimated 30% of the global burden of disease is surgical, the implications of dual practice on surgical care are not well studied. Methods We conducted anonymous in-depth individual interviews on trauma quality improvement practices with healthcare providers who participate in the care of the injured at ten large hospitals in Peru’s capital city, Lima. A grounded theory approach to qualitative data analysis was employed to identify salient themes. Results Fifty interviews were conducted. A group of themes that emerged related to the perceived negative and positive impacts of dual practice on the quality of surgical care. Participants asserted that the majority of physicians in Lima working in the public sector also worked in the private sector. Dual practice has negative impacts on physicians’ time, the quality of care in the public sector, and surgical education. Dual practice positively affects patient care by allowing physicians to acquire management and quality improvement skills and providing incentives for research and academic productivity. In addition, dual practice provides opportunities for clinical innovations and raises the economic status of the physician. Conclusions Surgeons in Peru report that dual practice negatively impacts patient care by creating time and human resource conflicts. Participants assert that these conflicts widen the gap in quality of care between rich and poor. This practice warrants redirection through national-level regulation of physician schedules and reorganization of public investment in health via physician remuneration. PMID:28251600

Adapting to the changing paradigm of management of colon injuries.

PubMed

Woo, Karen; Wilson, Matthew T; Killeen, Kelly; Margulies, Daniel R

2007-12-01

Based on the evolution that the management of colonic trauma has undergone since the early 1990s, we hypothesized that the use of diversion has decreased at our institution over the last decade. A retrospective review was performed of all patients who presented to our trauma center with colon injuries between 1995 and 2006. A total of 81 patients were analyzed. Twenty-five patients (31%) were treated with diversion and 56 patients (69%) underwent primary repair or resection with anastomosis. The rate of diversion in the first half of the study period as well as the second half of the study period was 31%. There was no difference in the complication rates. The usage of diversion remains higher than current literature would indicate. As a result, we are implementing a program that will actively encourage our trauma surgeons to improve the quality of patient care by incorporating evidence-based medicine into clinical practice.

[Orthopedic and trauma surgery in the German-DRG-System 2009].

PubMed

Franz, D; Windolf, J; Siebert, C H; Roeder, N

2009-01-01

The German DRG-System was advanced into version 2009. For orthopedic and trauma surgery significant changes concerning coding of diagnoses, medical procedures and concerning the DRG-structure were made. Analysis of relevant diagnoses, medical procedures and G-DRGs in the versions 2008 and 2009 based on the publications of the German DRG-institute (InEK) and the German Institute of Medical Documentation and Information (DIMDI). Changes for 2009 focussed on the development of DRG-structure, DRG-validation and codes for medical procedures to be used for very complex cases. The outcome of these changes for German hospitals may vary depending in the range of activities. G-DRG-System gained complexity again. High demands are made on correct and complete coding of complex orthopedic and trauma surgery cases. Quality of case-allocation within the G-DRG-System was improved. Nevertheless, further adjustments of the G-DRG-System especially for cases with severe injuries are necessary.

Building Capacity for Trauma-Informed Care in the Child Welfare System: Initial Results of a Statewide Implementation.

PubMed

Lang, Jason M; Campbell, Kimberly; Shanley, Paul; Crusto, Cindy A; Connell, Christian M

2016-05-01

Exposure to childhood trauma is a major public health concern and is especially prevalent among children in the child welfare system (CWS). State and tribal CWSs are increasingly focusing efforts on identifying and serving children exposed to trauma through the creation of trauma-informed systems. This evaluation of a statewide initiative in Connecticut describes the strategies used to create a trauma-informed CWS, including workforce development, trauma screening, policy change, and improved access to evidence-based trauma-focused treatments during the initial 2-year implementation period. Changes in system readiness and capacity to deliver trauma-informed care were evaluated using stratified random samples of child welfare staff who completed a comprehensive assessment prior to (N = 223) and 2 years following implementation (N = 231). Results indicated significant improvements in trauma-informed knowledge, practice, and collaboration across nearly all child welfare domains assessed, suggesting system-wide improvements in readiness and capacity to provide trauma-informed care. Variability across domains was observed, and frontline staff reported greater improvements than supervisors/managers in some domains. Lessons learned and recommendations for implementation and evaluation of trauma-informed care in child welfare and other child-serving systems are discussed. © The Author(s) 2016.

Surfing the net for medical information about psychological trauma: an empirical study of the quality and accuracy of trauma-related websites.

PubMed

Bremner, J Douglas; Quinn, John; Quinn, William; Veledar, Emir

2006-09-01

Psychological trauma is a major public-health problem, and trauma victims frequently turn to the Internet for medical information related to trauma. The Internet has many advantages for trauma victims, including low cost, privacy, use of access, and reduced direct social interactions. However, there are no regulations on what is posted on the Internet, or by whom, and little is known about the quality of information currently available related to the topic of psychological trauma. The purpose of this study was to evaluate the quality of Internet sites related to the topic of psychological trauma. The top 20 hits for searches on Google, AllTheWeb, and Yahoo were tabulated, using search words of 'psychological trauma', 'stress', 'PTSD', and 'trauma'. From these searches, a list of 94 unique unsponsored hits that represented accessible websites was generated. Fourteen sites were unrelated or only peripherally related, and eight were related but were not comprehensively evaluated because they represented brochures, online book sales, etc. Seventy-two websites underwent evaluation of the content, design, disclosure, ease of use, and other factors based on published guidelines for medical information sites. Forty-two per cent of sites had inaccurate information, 82% did not provide a source of their information, and 41% did not use a mental-health professional in the development of the content. Ratings of content (e.g. accuracy, reliability, etc.) were 4 (2 SD) on a scale of 1 - 10, with 10 being the best. There were similar ratings for the other variables assessed. These findings suggest that although abundant, websites providing information about psychological trauma are often not useful, and can sometimes provide inaccurate and potentially harmful information to consumers of medical information.

Advanced Practice Nursing Committee on Process Improvement in Trauma: An Innovative Application of the Strong Model.

PubMed

West, Sarah Katherine

2016-01-01

This article aims to summarize the successes and future implications for a nurse practitioner-driven committee on process improvement in trauma. The trauma nurse practitioner is uniquely positioned to recognize the need for clinical process improvement and enact change within the clinical setting. Application of the Strong Model of Advanced Practice proves to actively engage the trauma nurse practitioner in process improvement initiatives. Through enhancing nurse practitioner professional engagement, the committee aims to improve health care delivery to the traumatically injured patient. A retrospective review of the committee's first year reveals trauma nurse practitioner success in the domains of direct comprehensive care, support of systems, education, and leadership. The need for increased trauma nurse practitioner involvement has been identified for the domains of research and publication.

[Optimized resource mobilization and quality of treatment of severely injured patients through a structured trauma room alarm system].

PubMed

Spering, C; Roessler, M; Kurlemann, T; Dresing, K; Stürmer, K M; Lehmann, W; Sehmisch, S

2017-12-12

The treatment of severely injured patients in the trauma resuscitation unit (TRU) requires an interdisciplinary and highly professional trauma team approach. The complete team needs to be waiting for the patient in the TRU on arrival. Treating severely injured patients in the TRU, the trauma team connects the initial preclinical emergency stabilization with the subsequent sophisticated treatment. Thus, the trauma team depends on concise information from the emergency personnel at the scene to provide its leader with further information as well as an accurate alarm including all departments necessary to stabilize the patient in the TRU. Aiming at an accurate and most efficient trauma team alarm, this study was designed to provide and analyze an alarm system which mobilizes the trauma team in a stepwise fashion depending on the pattern of injuries and the threat to life. The trauma team alarm system was analyzed in a prospective data acquisition at a level I trauma center over a period of 12 months. Evaluation followed the acquisition phase and provided comparison to the status prior to the establishment of the alarm system. All items underwent statistical testing using t‑tests (p < 0.05). The data of 775 TRU patients showed a significant reduction of false information on the patients status prior to arrival. It also showed an increase in punctual arrival in the TRU of the emergency teams. False alarms were significantly reduced (from 11.9% to 2.7%, p > 0.01). The duration from arrival of the patient in the TRU to the initial multislice computed tomography (CT) scan was reduced by 6 min while the total period of treatment in the TRU was reduced by 17 min. After the alarm system to gradually mobilize the trauma team was put into action, team members left the TRU if unneeded prior to finishing the initial treatment in only 4% of the cases. The patient fatality rate was 8.8% (injury severity score, ISS = 23 points) after establishment of the alarm system compared to 12.9% (ISS = 25 points) before. The implementation of an accurate and patient status-based alarm system to mobilize the trauma team can improve the quality of treatment while the duration of treatment of the severely injured patients in the TRU can be decreased. It also provides a most efficient mobilization of personnel resources while sustaining patient safety.

[Orthopedic and trauma surgery in the German DRG system 2008].

PubMed

Franz, D; Kaufmann, M; Siebert, C H; Windolf, J; Roeder, N

2008-04-01

The German DRG (diagnosis-related groups) system has been modified and updated into version 2008. For orthopedic and trauma surgery significant changes concerning coding of diagnoses, medical procedures and the DRG structure were made. The modified version has been analyzed in order to ascertain whether the DRG system is suitably qualified to fulfill the demands of the reimbursement system or whether further improvements are necessary. Analysis of the severity of relevant side-effect diagnoses, medical procedures and G-DRGs in the versions 2007 and 2008 was carried out based on the publications of the German DRG institute (InEK) and the German Institute of Medical Documentation and Information (DIMDI). Changes for 2008 focused on the development of DRG structure, DRG validation and codes for medical procedures. The outcome of these changes for German hospitals may vary depending on the range of activities. G-DRG system has become even more complex and the new regulations have also resulted in new problems associated with complications.. High demands are made on correct and complete coding of complex orthopedic and trauma surgery cases. Quality of case allocation within the G-DRG system has been improved. Nevertheless, further improvements of the G-DRG system are necessary, especially for cases with severe injuries.

Economic evaluations of comprehensive geriatric assessment in surgical patients: a systematic review.

PubMed

Eamer, Gilgamesh; Saravana-Bawan, Bianka; van der Westhuizen, Brenden; Chambers, Thane; Ohinmaa, Arto; Khadaroo, Rachel G

2017-10-01

Seniors presenting with surgical disease face increased risk of postoperative morbidity and mortality and have increased treatment costs. Comprehensive Geriatric Assessment (CGA) is proposed to reduce morbidity, mortality, and the cost after surgery. A systematic review of CGA in emergency surgical patients was conducted. The primary outcome was cost-effectiveness; secondary outcomes were length of stay, return of function, and mortality. Inclusion and exclusion criteria were predefined. Systematic searches of MEDLINE, Embase, Cochrane, and National Health Service Economic Evaluation Database were performed. Text screening, bias assessment, and data extraction were performed by two authors. There were 560 articles identified; abstract review excluded 499 articles and full-text review excluded 53 articles. Eight studies were included; one nonorthopedic trauma and seven orthopedic trauma studies. Bias assessment revealed moderate to high risk of bias for all studies. Economic evaluation assessment identified two high-quality studies and six moderate or low quality studies. Pooled analysis from four studies assessed loss of function; loss of function decreased in the experimental arm (odds ratio 0.92, 95% confidence interval [CI]: 0.88-0.97). Pooled results for length of stay from five studies found a significant decrease (mean difference: -1.17, 95% CI: -1.63 to -0.71) after excluding the nonorthopedic trauma study. Pooled mortality was significantly decreased in seven studies (risk ratio: 0.78, 95% CI: 0.67-0.90). All studies decreased cost and improved health outcomes in a cost-effective manner. CGA improved return of function and mortality with reduced cost or improved utility. Our review suggests that CGA is economically dominant and the most cost-effective care model for orthogeriatric patients. Further research should examine other surgical fields. Copyright © 2017 Elsevier Inc. All rights reserved.

The Trauma Time-Out: Evaluating the Effectiveness of Protocol-Based Information Dissemination in the Traumatically Injured Patient.

PubMed

Nolan, Heather R; Fitzgerald, Michael; Howard, Brett; Jarrard, Joey; Vaughn, Danny

Procedural time-outs are widely accepted safety standards that are protocolized in nearly all hospital systems. The trauma time-out, however, has been largely unstudied in the existing literature and does not have a standard protocol outlined by any of the major trauma surgery organizations. The goal of this study was to evaluate our institution's use of the trauma time-out and assess how trauma team members viewed its effectiveness. A multiple-answer survey was sent to trauma team members at a Level I trauma center. Questions included items directed at background, experience, opinions, and write-in responses. Most responders were experienced trauma team members who regularly participated in trauma codes. All respondents noted the total time required to complete the time-out was less than 5 min, with the majority saying it took less than 1 min. Seventy-five percent agreed that trauma time-outs should continue, with 92% noting that it improved understanding of patient presentation and prehospital evaluation. Seventy-seven percent said it improved understanding of other team member's roles, and 75% stated it improved patient care. Subgroups of physicians and nurses were statistically similar; yet, physicians did note that it improved their understanding of the team member's function more frequently than nurses. The trauma time-out can be an excellent tool to improve patient care and team understanding of the incoming trauma patient. Although used widely at multiple levels of trauma institutions, development of a documented protocol can be the next step in creating a unified safety standard.

A multicenter, randomized controlled trial of immediate total-body CT scanning in trauma patients (REACT-2)

PubMed Central

2012-01-01

Background Computed tomography (CT) scanning has become essential in the early diagnostic phase of trauma care because of its high diagnostic accuracy. The introduction of multi-slice CT scanners and infrastructural improvements made total-body CT scanning technically feasible and its usage is currently becoming common practice in several trauma centers. However, literature provides limited evidence whether immediate total-body CT leads to better clinical outcome then conventional radiographic imaging supplemented with selective CT scanning in trauma patients. The aim of the REACT-2 trial is to determine the value of immediate total-body CT scanning in trauma patients. Methods/design The REACT-2 trial is an international, multicenter randomized clinical trial. All participating trauma centers have a multi-slice CT scanner located in the trauma room or at the Emergency Department (ED). All adult, non-pregnant, severely injured trauma patients according to predefined criteria will be included. Patients in whom direct scanning will hamper necessary cardiopulmonary resuscitation or who require an immediate operation because of imminent death (both as judged by the trauma team leader) are excluded. Randomization will be computer assisted. The intervention group will receive a contrast-enhanced total-body CT scan (head to pelvis) during the primary survey. The control group will be evaluated according to local conventional trauma imaging protocols (based on ATLS guidelines) supplemented with selective CT scanning. Primary outcome will be in-hospital mortality. Secondary outcomes are differences in mortality and morbidity during the first year post trauma, several trauma work-up time intervals, radiation exposure, general health and quality of life at 6 and 12 months post trauma and cost-effectiveness. Discussion The REACT-2 trial is a multicenter randomized clinical trial that will provide evidence on the value of immediate total-body CT scanning during the primary survey of severely injured trauma patients. If immediate total-body CT scanning is found to be the best imaging strategy in severely injured trauma patients it could replace conventional imaging supplemented with CT in this specific group. Trial Registration ClinicalTrials.gov: (NCT01523626). PMID:22458247

The mortality risk from motor vehicle injuries in California has increased during the last decade.

PubMed

Waxman, Kenneth; Izfar, Seema; Grotts, Jonathan

2012-09-01

Organized trauma systems and trauma centers are thought to improve trauma outcomes. It is clear that injured patients who receive care in trauma centers have survival advantages. However, large regions of California still do not have access to trauma centers. Many injured patients in California continue to receive their care in nontrauma center hospitals. The purpose of this study was to compare outcomes in California counties with and without trauma centers. In addition, we wished to query the efficacy of the current statewide trauma system by asking whether mortality after motor vehicle trauma in California has improved during the last decade. We performed a retrospective outcome study. The California highway patrol provided data from all motor vehicle crashes (MVCs) and mortality during the years 1999 to 2008 for the 58 counties in California. Percent fatality was calculated as the number of motor vehicle fatalities divided by the number of injuries. Data were analyzed to compare outcomes in counties with and without trauma centers. Furthermore, demographic data were studied to analyze the relationship of population and hospital density on mortality. Mortality was significantly lower in counties with trauma centers. Low population and hospital density independently correlated with increased mortality. Injury mortality rates after MVCs increased during the decade both in counties with and without trauma centers. Overall, the presence of a trauma center improved the chances of survival after an MVC in California counties. However, mortality rates after injuries increased during the decade both in counties with and without trauma centers. Future efforts to improve outcomes for injured patients in California will require new approaches, which must include improving both access to trauma centers and the care provided in nontrauma center hospitals. Epidemiologic study, level III.

Uptake of the World Health Organization’s trauma care guidelines: a systematic review

PubMed Central

Riggle, Kevin; Joshipura, Manjul; Quansah, Robert; Reynolds, Teri; Sherr, Kenneth; Mock, Charles

2016-01-01

Abstract Objective To understand the degree to which the trauma care guidelines released by the World Health Organization (WHO) between 2004 and 2009 have been used, and to identify priorities for the future implementation and dissemination of such guidelines. Methods We conducted a systematic review, across 19 databases, in which the titles of the three sets of guidelines – Guidelines for essential trauma care, Prehospital trauma care systems and Guidelines for trauma quality improvement programmes – were used as the search terms. Results were validated via citation analysis and expert consultation. Two authors independently reviewed each record of the guidelines’ implementation. Findings We identified 578 records that provided evidence of dissemination of WHO trauma care guidelines and 101 information sources that together described 140 implementation events. Implementation evidence could be found for 51 countries – 14 (40%) of the 35 low-income countries, 15 (32%) of the 47 lower-middle income, 15 (28%) of the 53 upper-middle-income and 7 (12%) of the 59 high-income. Of the 140 implementations, 63 (45%) could be categorized as needs assessments, 38 (27%) as endorsements by stakeholders, 20 (14%) as incorporations into policy and 19 (14%) as educational interventions. Conclusion Although WHO’s trauma care guidelines have been widely implemented, no evidence was identified of their implementation in 143 countries. More serial needs assessments for the ongoing monitoring of capacity for trauma care in health systems and more incorporation of the guidelines into both the formal education of health-care providers and health policy are needed. PMID:27516636

Validation of ICDPIC software injury severity scores using a large regional trauma registry.

PubMed

Greene, Nathaniel H; Kernic, Mary A; Vavilala, Monica S; Rivara, Frederick P

2015-10-01

Administrative or quality improvement registries may or may not contain the elements needed for investigations by trauma researchers. International Classification of Diseases Program for Injury Categorisation (ICDPIC), a statistical program available through Stata, is a powerful tool that can extract injury severity scores from ICD-9-CM codes. We conducted a validation study for use of the ICDPIC in trauma research. We conducted a retrospective cohort validation study of 40,418 patients with injury using a large regional trauma registry. ICDPIC-generated AIS scores for each body region were compared with trauma registry AIS scores (gold standard) in adult and paediatric populations. A separate analysis was conducted among patients with traumatic brain injury (TBI) comparing the ICDPIC tool with ICD-9-CM embedded severity codes. Performance in characterising overall injury severity, by the ISS, was also assessed. The ICDPIC tool generated substantial correlations in thoracic and abdominal trauma (weighted κ 0.87-0.92), and in head and neck trauma (weighted κ 0.76-0.83). The ICDPIC tool captured TBI severity better than ICD-9-CM code embedded severity and offered the advantage of generating a severity value for every patient (rather than having missing data). Its ability to produce an accurate severity score was consistent within each body region as well as overall. The ICDPIC tool performs well in classifying injury severity and is superior to ICD-9-CM embedded severity for TBI. Use of ICDPIC demonstrates substantial efficiency and may be a preferred tool in determining injury severity for large trauma datasets, provided researchers understand its limitations and take caution when examining smaller trauma datasets. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Probiotics for Trauma Patients: Should We Be Taking a Precautionary Approach?

PubMed

Vitko, Heather A; Sekula, L Kathleen; Schreiber, Martin A

The use of probiotics in the hospital setting is largely understudied and highly controversial. Probiotics are living organisms that, when taken internally, can produce an immunomodulating effect and improve the gastrointestinal (GI) mucosal barrier. Although used for centuries by healthy individuals for GI health, their use in the hospital setting is now gaining wide attention for the prevention of infectious complications such as antibiotic-associated diarrhea, Clostridium difficile infections, multiple-organ dysfunction syndrome, and ventilator-associated pneumonia. However, current understanding of the efficacy of probiotics in the acute care setting is confounded by the inconsistencies in the literature with regard to the strain of probiotic being studied, optimal dosage, and timing and duration of dosing, which make the formulation of clinical practice guidelines difficult. Although the safety of probiotics has been confirmed when used for the prevention and treatment of certain diseases, practitioners remain hesitant to administer them to their patients, citing the lack of high-quality studies clearly demonstrating efficacy and safety. Infection is a cause of late death in trauma patients, but only recently has research been conducted on the use of probiotics specifically for the prevention of hospital-acquired infections in trauma patients. In the face of such limited but promising research, is it reasonable to use probiotics for the prevention of infection in hospitalized trauma patients and improve outcomes? Use of the "precautionary principle" may be useful in this instance.

Route of delivery and neonatal birth trauma.

PubMed

Moczygemba, Charmaine K; Paramsothy, Pangaja; Meikle, Susan; Kourtis, Athena P; Barfield, Wanda D; Kuklina, Elena; Posner, Samuel F; Whiteman, Maura K; Jamieson, Denise J

2010-04-01

We sought to examine rates of birth trauma in 2 groupings (all International Classification of Diseases, Ninth Revision codes for birth trauma, and as defined by the Agency for Healthcare Research and Quality Patient Safety Indicator [PSI]) among infants born by vaginal and cesarean delivery. Data on singleton infants were obtained from the 2004-2005 Healthcare Cost and Utilization Project Nationwide Inpatient Sample. The rates of Agency for Healthcare Research and Quality PSI and all birth trauma were 2.45 and 25.85 per 1000 births, respectively. Compared with vaginal, cesarean delivery was associated with increased odds of PSI birth trauma (odds ratio [OR], 1.71), primarily due to an increased risk for "other specified birth trauma" (OR, 2.61). Conversely, cesarean delivery was associated with decreased odds of all birth trauma (OR, 0.55), due to decreased odds of clavicle fractures (OR, 0.07), brachial plexus (OR, 0.10), and scalp injuries (OR, 0.55). Infants delivered by cesarean are at risk for different types of birth trauma from infants delivered vaginally. Copyright 2010 Mosby, Inc. All rights reserved.

Predicting the post-operative length of stay for the orthopaedic trauma patient.

PubMed

Chona, Deepak; Lakomkin, Nikita; Bulka, Catherine; Mousavi, Idine; Kothari, Parth; Dodd, Ashley C; Shen, Michelle S; Obremskey, William T; Sethi, Manish K

2017-05-01

Length of stay (LOS) is a major driver of cost and quality of care. A bundled payment system makes it essential for orthopaedic surgeons to understand factors that increase a patient's LOS. Yet, minimal data regarding predictors of LOS currently exist. Using the ACS-NSQIP database, this is the first study to identify risk factors for increased LOS for orthopaedic trauma patients and create a personalized LOS calculator. All orthopaedic trauma surgery between 2006 and 2013 were identified from the ACS-NSQIP database using CPT codes. Patient demographics, pre-operative comorbidities, anatomic location of injury, and post-operative in-hospital complications were collected. To control for individual patient comorbidities, a negative binomial regression model evaluated hospital LOS after surgery. Betas (β), were determined for each pre-operative patient characteristic. We selected significant predictors of LOS (p < 0.05) using backwards stepwise elimination. 49,778 orthopaedic trauma patients were included in the analysis. Deep incisional surgical site infections and superficial surgical site infections were associated with the greatest percent change in predicted LOS (β = 1.2760 and 1.2473, respectively; p < 0.0001 for both). A post-operative LOS risk calculator was developed based on the formula: [Formula: see text]. Utilizing a large prospective cohort of orthopaedic trauma patients, we created the first personalized LOS calculator based on pre-operative comorbidities, post-operative complications and location of surgery. Future work may assess the use of this calculator and attempt to validate its utility as an accurate model. To improve the quality measures of hospitals, orthopaedists must employ such predictive tools to optimize care and better manage resources.

Organizational and provider level factors in implementation of trauma-informed care after a city-wide training: an explanatory mixed methods assessment.

PubMed

Damian, April Joy; Gallo, Joseph; Leaf, Philip; Mendelson, Tamar

2017-11-21

While there is increasing support for training youth-serving providers in trauma-informed care (TIC) as a means of addressing high prevalence of U.S. childhood trauma, we know little about the effects of TIC training on organizational culture and providers' professional quality of life. This mixed-methods study evaluated changes in organizational- and provider-level factors following participation in a citywide TIC training. Government workers and nonprofit professionals (N = 90) who participated in a nine-month citywide TIC training completed a survey before and after the training to assess organizational culture and professional quality of life. Survey data were analyzed using multiple regression analyses. A subset of participants (n = 16) was interviewed using a semi-structured format, and themes related to organizational and provider factors were identified using qualitative methods. Analysis of survey data indicated significant improvements in participants' organizational culture and professional satisfaction at training completion. Participants' perceptions of their own burnout and secondary traumatic stress also increased. Four themes emerged from analysis of the interview data, including "Implementation of more flexible, less-punitive policies towards clients," "Adoption of trauma-informed workplace design," "Heightened awareness of own traumatic stress and need for self-care," and "Greater sense of camaraderie and empathy for colleagues." Use of a mixed-methods approach provided a nuanced understanding of the impact of TIC training and suggested potential benefits of the training on organizational and provider-level factors associated with implementation of trauma-informed policies and practices. Future trainings should explicitly address organizational factors such as safety climate and morale, managerial support, teamwork climate and collaboration, and individual factors including providers' compassion satisfaction, burnout, and secondary traumatic stress, to better support TIC implementation.

National Trainers’ Perspectives on Challenges to Implementation of an Empirically-Supported Mental Health Treatment

PubMed Central

Hanson, Rochelle F.; Gros, Kirstin Stauffacher; Davidson, Tatiana M.; Barr, Simone; Cohen, Judith; Deblinger, Esther; Mannarino, Anthony P.; Ruggiero, Kenneth J.

2013-01-01

This study examined perceived challenges to implementation of an empirically supported mental health treatment for youth (Trauma-Focused Cognitive Behavioral Therapy; TF-CBT) and explored the potential use of technology-based resources in treatment delivery. Thematic interviews were conducted with 19 approved national TF-CBT trainers to assess their perspectives about challenges to implementation of TF-CBT and to explore their perceptions about the potential value of innovative, technology-based solutions to enhance provider fidelity and improve quality of care. These data offer some important insights and implications for training in evidence-based treatments, provider fidelity and competence, and patient engagement, particularly for those interventions targeting trauma-related symptoms among youth. PMID:23605292

Errors in imaging of traumatic injuries.

PubMed

Scaglione, Mariano; Iaselli, Francesco; Sica, Giacomo; Feragalli, Beatrice; Nicola, Refky

2015-10-01

The advent of multi-detector computed tomography (MDCT) has drastically improved the outcomes of patients with multiple traumatic injuries. However, there are still diagnostic challenges to be considered. A missed or the delay of a diagnosis in trauma patients can sometimes be related to perception or other non-visual cues, while other errors are due to poor technique or poor image quality. In order to avoid any serious complications, it is important for the practicing radiologist to be cognizant of some of the most common types of errors. The objective of this article is to review the various types of errors in the evaluation of patients with multiple trauma injuries or polytrauma with MDCT.

Cervical Spine Collar Removal by Emergency Room Nurses: A Quality Improvement Project.

PubMed

Fontaine, Guillaume; Forgione, Massimo; Lusignan, Francis; Lanoue, Marc-André; Drouin, Simon

2018-05-01

The Canadian C-Spine Rule (CCR) is a clinical decision aid to facilitate the safe removal of cervical collars in the alert, orientated, low-risk adult trauma patient. Few health care settings have assessed initiatives to train charge nurses to use the CCR. This practice improvement project conducted in a secondary trauma center in Canada aimed to (1) train charge nurses of the emergency room to use the CCR, (2) monitor its use throughout the project period, and (3) compare the assessments of the charge nurses with those of emergency physicians. The project began with the creation of an interdisciplinary team. Clinical guidelines were established by the interdisciplinary project team. Nine charge nurses of the emergency room were then trained to use the CCR (3 on each 8-hour shift). The use of the CCR was monitored throughout the project period, from June 1 to October 5, 2016. The 3 aims of this practice improvement project were attained successfully. Over a 5-month period, 114 patients were assessed with the CCR. Charge nurses removed the cervical collars for 54 of 114 patients (47%). A perfect agreement rate (114 of 114 patients, 100%) was attained between the assessments of the nurses and those of physicians. This project shows that the charge nurses of a secondary trauma center can use the CCR safely on alert, orientated, and low-risk adult trauma patients as demonstrated by the agreement in the assessments of emergency room nurses and physicians. Crown Copyright © 2017. Published by Elsevier Inc. All rights reserved.

[Appropriateness of ketorolac use in a trauma hospital].

PubMed

Angeles González-Fernández, M

2009-06-01

To evaluate the suitability of ketorolac and non-steroidal anti-inflamatory drugs (NSAIDs) and other analgesic drugs currently used in the hospital. We have followed the steps to develop a PDCA cycle (plan, do, check, act) or quality improvement cycle. The quality problem was analysed using an Ishikawa diagram. We defined both qualitative quality indicators, those that measure prescription quality, and quantitative ones (defined daily dose, DDD/100BDs), which measure drug consumption, being the objectives to achieve. The study was conducted in all patients admitted to the hospital and who were admitted to orthopaedic and trauma surgery and plastic surgery departments with unit-dose dispensing systems. The strategy used was to give information to physicians through meetings and documentation. Finally, the results were analysed and compared with the initial objectives. The study was performed on 260 patients in the first study period and 292 in the second. Qualitative indicators: intravenous ketorolac use < or =2 days, increased in 25.5% (p<0.001); in patients > or =65 years old at dose < or =60 mg/day it increased 27.7% (p<0.05). Quantitative indicators: in the second study period, ketorolac use decreased (plastic surgery department: 61.8 DDD/100BDs to 14.8), whereas tramadol, ibuprofen and metamizole increased (plastic surgery department: 0 to 14.1 in tramadol, 8.7 to 48.6 in ibuprofen and 50.1 to 71 in metamizole). Appropriateness of ketorolac, NSAIDs and tramadol use has been achieved, thus improving patient safety. Strategies have been effective.

Trauma-related symptoms in neglected preschoolers and affective quality of mother-child communication.

PubMed

Milot, Tristan; St-Laurent, Diane; Ethier, Louise S; Provost, Marc A

2010-11-01

This study (a) assessed whether child neglect is associated with posttraumatic stress disorder (PTSD) and dissociative symptoms in the preschool period and (b) examined the role of quality of mother-child affective communication in the development of trauma-related symptoms among neglected children. Participants were 33 neglected and 72 non-neglected preschoolers (mean age = 60 months). Neglected children were recruited from the Child Protection Agencies. Neglected and non-neglected children victims of other form of abuse were excluded from the study. Trauma symptoms were evaluated through mother and preschool teacher reports. Quality of mother-child affective communication was assessed in a lab visit during an unstructured task. According to teachers, neglected children displayed more PTSD and dissociative symptoms than non-neglected children. Quality of mother-child communication was lower in neglected dyads. Mother-child affective communication predicted teacher-reported child trauma symptomatology, over and above child neglect. Discussion focuses on the traumatic nature of child neglect and the underlying parent-child relational processes.

A survey of the quality of nursing services for brain trauma patients in the emergency wards of hospitals in Guilan Province, Iran (2012).

PubMed

Majidi, Seyed Ali; Ayoubian, Ali; Mardani, Sheida; Hashemidehaghi, Zahra

2014-01-01

Head trauma is the main cause of disabilities and death among young people, and the side effects of head trauma pose some of the greatest medical challenges. Rapid diagnosis and the use of proper treatments can prevent more severe brain damage. The purpose of this research was to determine the quality of nursing services provided to brain trauma patients in hospitals in Guilan Province, Iran. The study was conducted as a descriptive, cross-sectional study in the emergency wards of selected hospitals in Guilan in 2012. The research population was comprised of all the brain trauma patients in these hospitals. We developed a two-section questionnaire, ascertained its validity, and determined that it had a reliability of 88% (Cronbach's alpha). Subsequently, we used the questionnaire for gathering data. The data were analyzed using SPSS statistical software, and descriptive analysis tests (frequency rate and average) and deductive analyses tests (chi-squared) also were used. The results showed that the quality of health services provided to brain-trauma patients in the emergency ward was at the moderate level of 58.8% of the cases and at a low level in 41.2% of the cases. Based on the results that showed that the services were of moderate quality, the staff members in the emergency ward were required to update their knowledge and use the required measures to minimize or prevent side effects in brain-trauma patients; clearly, mastery of such measures was a real need among the emergency ward's staff.

The role of anxiety sensitivity in the relationship between posttraumatic stress symptoms and negative outcomes in trauma-exposed adults.

PubMed

Kugler, Brittany B; Phares, Vicky; Salloum, Alison; Storch, Eric A

2016-01-01

The development of posttraumatic stress symptoms (PTSs) following a trauma is related to impairment, diminished quality of life, and physical health issues. Yet it is not clear why some trauma-exposed individuals experience negative outcomes while others do not. The purpose of this study was to determine the role of several influential factors related to PTS severity and negative outcomes. One hundred and twenty-two trauma-exposed adults were administered the following self-report measures: the Posttraumatic Stress Disorder Checklist-Civilian, the Trauma History Questionnaire-Short, the Anxiety Sensitivity Index-3, Depression and Anxiety Stress Scale 21, Sheehan Disability Scale, World Health Organization Quality of Life-BREF, and an abbreviated Patient Health Questionnaire. PTS severity was positively correlated with depressive symptom severity (r = 0.54, p < 0.001), chronicity of the most distressing trauma (r = 0.21, p = 0.017), and number of traumas (r = 0.22, p = 0.012). Main effects were found for PTS severity (β = -0.38, p < 0.01) and anxiety sensitivity (AS; β = -0.39, p < 0.01) on quality of life. No interaction was found between PTS severity and AS with any negative outcome. PTS severity mediated the relationship between AS and physical health issues (0.05; 95% CI: 0.02-0.08). This study helps clarify the role of various factors in the relationship between trauma and negative outcomes. Clinical and research implications are discussed.

The relationship between patient volume and mortality in American trauma centres: a systematic review of the evidence.

PubMed

Caputo, Lisa M; Salottolo, Kristin M; Slone, Denetta Sue; Mains, Charles W; Bar-Or, David

2014-03-01

To synthesise published and unpublished findings examining the relationship between institutional trauma centre volume or trauma patient volume per surgeon and mortality. Evidence on the relationship between patient volume and survival in trauma patients is inconclusive in the literature and remains controversial. A literature search was performed to identify studies published between 1976 and 2013 via MEDLINE (Pubmed) and the Cumulative Index to Nursing and Allied Health Literature (EbscoHost) as well as footnote chasing. Abstracts from appropriate conferences and ProQuest Dissertations and Theses were also searched. Inclusion criteria required studies to be original research published in English that examined the relationship between mortality and either institutional or per surgeon volume in American trauma centres. We employed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement checklist and flowchart. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was employed to rate the quality of the evidence. Of 1392 studies reviewed, 19 studies met defined inclusion criteria; all studies were retrospective. The definition of volume was heterogeneous across the studies. Patient population and analysis methods also varied across the studies. Sixteen studies (84%) examined the relationship between institutional trauma centre volume and mortality. Of the 16 studies, 12 examined the volume of severely injured patients and eight examined overall trauma patient volume. High institutional volume was associated with at least somewhat improved mortality in ten of 16 studies (63%); however, nearly half of these studies found only some subpopulations experienced benefits. In the remaining six studies, volume was not associated with any benefits. Four studies (25%) analysed the impact of surgeon volume on mortality. High volume per surgeon was associated with improved mortality in only one of four studies (25%). The studies were extremely heterogeneous, thus definitive conclusions cannot be drawn regarding optimal volume before a clear advantage in survival is observed. A prospective study defining volume as a continuous variable is warranted to support current admission criteria for American trauma patients. Copyright © 2013 Elsevier Ltd. All rights reserved.

Understanding the burden and outcome of trauma care drives a new trauma systems model.

PubMed

Laing, G L; Skinner, D L; Bruce, J L; Aldous, C; Oosthuizen, G V; Clarke, D L

2014-07-01

The Pietermaritzburg Metropolitan Trauma Service (PMTS) attempts to provide care for a whole city and hence is referred to as a service rather than a center. As part of a multifaceted quality improvement program, the PMTS has developed and implemented a robust electronic surgical registry (ESR). This review of the first year's data from the ESR forms part of a situational analysis to assess the burden of trauma managed by the service and the quality of care delivered within the constraints of the available resources. Formal ethical approval was obtained prior to design and development of this study, and appropriate commercial software was sourced. The exercise of data capture was integrated into the process of service delivery and was accomplished at the endpoint of patient care. 12 months after implementation of the registry, the data were extracted and audited. A total of 2,733 patients were admitted over the 12 month study period. The average patient age was 28.3 years. There were 2,255 (82.5 %) male patients and 478 (17.5 %) female patients. The average monthly admission rate was 228 patients, with a peak of 354 admissions over the December period. The mean injury severity score (ISS) was 12 [interquartile range (IQR) 6.7-23.2]. A quarter (24.8 %) of all new emergency admissions had an ISS > 15. The average duration of stay for patients was 5.12 days (IQR 2.3-13.2 days). Some 2,432 (92.1 %) patients survived, and 208 (7.9 %) died. A total of 333 (13 %) patients required admission to either the intensive care unit (ICU) or the high dependency unit. From the city mortuary data a further 362 deaths were identified. These included 290 deaths that occurred on scene and 72 that occurred within Pietermaritzburg hospitals other than Greys and Edendale. The total trauma-related mortality for the entire city in 2012 was 570 (51 % on-scene deaths and 49 % in-hospital deaths). Blunt trauma accounted for 62 % of deaths. The PMTS treats a significant volume and spectrum of trauma. Despite significant resource limitations, we have managed to implement a functional and sustainable trauma service across multiple hospitals. We believe the major resource deficits limiting our service could be ameliorated by the development of an additional trauma facility, adequately equipped with dedicated trauma operating slates and trauma ICU beds. The adoption of our current model of trauma care came out of a need to work within our resource constraints, and it differs from the traditional model. Within the aforementioned limits, our data suggest that this model of delivering care is feasible, practical, and successful. Considering the universal burden of trauma and the all-too-common imbalance between resource demand and supply among many health-care institutions, it is our hope that this report will contribute to the ongoing academic debate around the topic of optimal systems of providing global trauma care.

The Adam Williams initiative: collaborating with community resources to improve care for traumatic brain injury.

PubMed

Bader, Mary Kay; Stutzman, Sonja E; Palmer, Sylvain; Nwagwu, Chiedozie I; Goodman, Gary; Whittaker, Margie; Olson, Daiwai M

2014-12-01

The Brain Trauma Foundation has developed treatment guidelines for the care of patients with acute traumatic brain injury. However, a method to provide broad acceptance and application of these guidelines has not been published. To describe methods for the development, funding, and continued educational efforts of the Adam Williams Initiative; the experiences from the first 10 years may serve as a template for hospitals and nurses that seek to engage in long-term quality improvement collaborations with foundations and/or industry. In 2004, the nonprofit Adam Williams Initiative was established with the goal of providing education and resources that would encourage hospitals across the United States to incorporate the Brain Trauma Foundation's guidelines into practice. Between 2004 and 2014, 37 hospitals have been funded by the Adam Williams Initiative and have had staff members participate in an immersion experience at Mission Hospital (Mission Viejo, California) during which team members received both didactic and hands-on education in the care of traumatic brain injury. Carefully cultivated relationships and relentless teamwork have contributed to successful implementation of the Brain Trauma Foundation's guidelines in US hospitals. ©2014 American Association of Critical-Care Nurses.

Surgery and trauma care providers' perception of the impact of dual-practice employment on quality of care provided in an Andean country.

PubMed

LaGrone, L N; Isquith-Dicker, L N; Huaman Egoavil, E; Herrera-Matta, J J; Fuhs, A K; Ortega Checa, D; Revoredo, F; Rodriguez Castro, M J A; Mock, C N

2017-05-01

Dual-practice, simultaneous employment by healthcare workers in the public and private sectors is pervasive worldwide. Although an estimated 30 per cent of the global burden of disease is surgical, the implications of dual practice on surgical care are not well understood. Anonymous in-depth individual interviews on trauma quality improvement practices were conducted with healthcare providers who participate in the care of the injured at ten large hospitals in Peru's capital city, Lima. A grounded theory approach to qualitative data analysis was employed to identify salient themes. Fifty interviews were conducted. A group of themes that emerged related to the perceived negative and positive impacts of dual practice on the quality of surgical care. Participants asserted that the majority of physicians in Lima working in the public sector also worked in the private sector. Dual practice has negative impacts on physicians' time, quality of care in the public sector, and surgical education. Dual practice positively affects patient care by allowing physicians to acquire management and quality improvement skills, and providing incentives for research and academic productivity. In addition, dual practice provides opportunities for clinical innovations and raises the economic status of the physician. Surgeons in Peru report that dual practice influences patient care negatively by creating time and human resource conflicts. Participants assert that these conflicts widen the gap in quality of care between rich and poor. This practice warrants redirection through national-level regulation of physician schedules and reorganization of public investment in health via physician remuneration. © 2017 BJS Society Ltd Published by John Wiley & Sons Ltd.

[Routine episiotomy in modern obstetrics. Is it necessary?].

PubMed

Korczyński, Jerzy

2002-01-01

The study presents a literature review on the benefits and risk of the routine episiotomy during the second stage of labour. Perineal trauma complications as well as perinatal outcomes are discussed. The risk of stress incontinence and sexual dysfunction are described. New techniques for improve of perinatal outcomes and prevention of post partum incontinence are described. Routine episiotomy gives poor effects in many cases. Perineal massage during pregnancy, waterbirth, are most interesting methods to avoid routine episiotomy and improve the quality of life in post partum women.

The Canadian Forces trauma care system

PubMed Central

Tien, Homer

2011-01-01

According to the Trauma Association of Canada, a trauma system is a preplanned, organized and coordinated injury-control effort in a defined geographic area. An effective trauma system engages in comprehensive injury surveillance and prevention programs; delivers trauma care from the time of injury to recovery; engages in research, training and performance improvement; and establishes linkages with an all-hazards emergency preparedness program. To support Canada’s combat mission in Afghanistan, the Canadian Forces (CF) developed a comprehensive trauma system based around its trauma hospital — the Role 3 Multinational Medical Unit (R3MMU) at Kandahar Airfield. This article reviews the essential components of a modern trauma system, outlines the evidence that trauma systems improve care to injury victims and describes how the current CF trauma system was developed. PMID:22099323

A comparative approach to deep vein thrombosis risk assessment.

PubMed

Hums, Wendy; Blostein, Paul

2006-01-01

Trauma patients are at risk for developing DVT/PE. The Bronson Trauma Model incorporates a DVT scoring system into the daily routine for all injured patients admitted to the Trauma Care Unit. Dr Paul Blostein added the DVT Risk Assessment spreadsheet to his personal digital assistant and made it available to other members of the team to allow calculation of a patient's DVT risk percentage during daily multidisciplinary rounds in the Trauma Care Unit. The Trauma Program has found the incorporation of the scoring systems into the trauma registry to be a value-added component of our performance improvement process. Bronson's unique model of trauma care, where patients are admitted and discharged from the same room, combined with today's technology of wireless laptops and personal digital assistants, promotes a progressive approach to DVT/PE prophylaxis and performance improvement. Our trauma follow-up program has proven to be effective in reintegrating patients back into the trauma system to optimize their functional status and improve their outcome.

Quality of life after major trauma with multiple rib fractures.

PubMed

Marasco, Silvana; Lee, Geraldine; Summerhayes, Robyn; Fitzgerald, Mark; Bailey, Michael

2015-01-01

Rib fractures are a common injury presenting to major trauma centres and community hospitals. Aside from the acute impact of rib fracture injury, longer-term morbidity of pain, disability and deformity have been described. Despite this, the mainstay of management for the vast majority of rib fracture injuries remains supportive only with analgesia and where required respiratory support. This study aimed to document the long-term quality of life in a cohort of major trauma patients with rib fracture injury over 24 months. Retrospective review (July 2006-July 2011) of 397 major trauma patients admitted to The Alfred Hospital with rib fractures and not treated with operative rib fixation. The main outcome measures were quality of life over 24 months post injury assessed using the Glasgow Outcome Scale Extended and SF12 health assessment forms and a pain questionnaire. Assessment over 24 months of major trauma patients with multiple rib fractures demonstrated significantly lower quality of life compared with published Australian norms at all time points measured. Return to work rates were poor with only 71% of those who were working prior to their accident, returning to any work. This study demonstrates a significant reduction in quality of life for rib fracture patients requiring admission to hospital, which does not return to the level of Australian norms for at least two years. Crown Copyright © 2014. Published by Elsevier Ltd. All rights reserved.

Physical Trauma and Infection as Precipitating Factors in Patients with Fibromyalgia.

PubMed

Jiao, Juan; Vincent, Ann; Cha, Stephen S; Luedtke, Connie A; Kim, Chul H; Oh, Terry H

2015-12-01

The objective of this study was to evaluate both precipitating factors in patients with fibromyalgia and any differences in clinical presentation, symptom severity, and quality-of-life between those with and without precipitating physical trauma or infection. In a retrospective cross-sectional study, the authors compared patient characteristics and fibromyalgia symptom severity and quality-of-life with the Fibromyalgia Impact Questionnaire and the Short Form-36 Health Survey in patients seen in a fibromyalgia treatment program. Of 939 patients, 27% reported precipitating factors (trauma, n = 203; infection, n = 53), with the rest having idiopathic fibromyalgia (n = 683). Patients with precipitating trauma were more likely to have worse Fibromyalgia Impact Questionnaire physical function than patients with idiopathic onset (P = 0.03). Compared with patients with idiopathic onset and precipitating trauma, patients with precipitating infection were more likely to have worse Short Form-36 Health Survey physical component summary (P = 0.01 and P = 0.003) but better role emotional (P = 0.04 and P = 0.005), mental health index (P = 0.02 and P = 0.007), and mental component summary (P = 0.03 and P = 0.004), respectively. One-fourth of this study's patients with fibromyalgia had precipitating physical trauma or infection. Patients with precipitating infection had different sociodemographic characteristics, clinical presentation, and quality-of-life from the idiopathic and trauma groups. Further studies are needed to look into the relationships between precipitating events and fibromyalgia.

Automatically-computed prehospital severity scores are equivalent to scores based on medic documentation.

PubMed

Reisner, Andrew T; Chen, Liangyou; McKenna, Thomas M; Reifman, Jaques

2008-10-01

Prehospital severity scores can be used in routine prehospital care, mass casualty care, and military triage. If computers could reliably calculate clinical scores, new clinical and research methodologies would be possible. One obstacle is that vital signs measured automatically can be unreliable. We hypothesized that Signal Quality Indices (SQI's), computer algorithms that differentiate between reliable and unreliable monitored physiologic data, could improve the predictive power of computer-calculated scores. In a retrospective analysis of trauma casualties transported by air ambulance, we computed the Triage Revised Trauma Score (RTS) from archived travel monitor data. We compared the areas-under-the-curve (AUC's) of receiver operating characteristic curves for prediction of mortality and red blood cell transfusion for 187 subjects with comparable quantities of good-quality and poor-quality data. Vital signs deemed reliable by SQI's led to significantly more discriminatory severity scores than vital signs deemed unreliable. We also compared automatically-computed RTS (using the SQI's) versus RTS computed from vital signs documented by medics. For the subjects in whom the SQI algorithms identified 15 consecutive seconds of reliable vital signs data (n = 350), the automatically-computed scores' AUC's were the same as the medic-based scores' AUC's. Using the Prehospital Index in place of RTS led to very similar results, corroborating our findings. SQI algorithms improve automatically-computed severity scores, and automatically-computed scores using SQI's are equivalent to medic-based scores.

Surfing the Net for medical information about psychological trauma: An empirical study of the quality and accuracy of trauma-related websites

PubMed Central

BREMNER, J. DOUGLAS; QUINN, JOHN; QUINN, WILLIAM; VELEDAR, EMIR

2011-01-01

Psychological trauma is a major public-health problem, and trauma victims frequently turn to the Internet for medical information related to trauma. The Internet has many advantages for trauma victims, including low cost, privacy, use of access, and reduced direct social interactions. However, there are no regulations on what is posted on the Internet, or by whom, and little is known about the quality of information currently available related to the topic of psychological trauma. The purpose of this study was to evaluate the quality of Internet sites related to the topic of psychological trauma. The top 20 hits for searches on Google, AllTheWeb, and Yahoo were tabulated, using search words of ‘psychological trauma’, ‘stress’, ‘PTSD’, and ‘trauma’. From these searches, a list of 94 unique unsponsored hits that represented accessible websites was generated. Fourteen sites were unrelated or only peripherally related, and eight were related but were not comprehensively evaluated because they represented brochures, online book sales, etc. Seventy-two websites underwent evaluation of the content, design, disclosure, ease of use, and other factors based on published guidelines for medical information sites. Forty-two per cent of sites had inaccurate information, 82% did not provide a source of their information, and 41% did not use a mental-health professional in the development of the content. Ratings of content (e.g. accuracy, reliability, etc.) were 4 (2 SD) on a scale of 1 – 10, with 10 being the best. There were similar ratings for the other variables assessed. These findings suggest that although abundant, websites providing information about psychological trauma are often not useful, and can sometimes provide inaccurate and potentially harmful information to consumers of medical information. PMID:16954059

Reno Orthopaedic Trauma Fellowship business curriculum.

PubMed

Althausen, Peter L; Bray, Timothy J; Hill, Austin D

2014-07-01

The Reno Orthopaedic Center (ROC) Trauma Fellowship business curriculum is designed to provide the fellow with a graduate level business practicum and research experience. The time commitments in a typical 12-month trauma fellowship are significant, rendering a traditional didactic master's in business administration difficult to complete during this short time. An organized, structured, practical business education can provide the trauma leaders of tomorrow with the knowledge and experience required to effectively navigate the convoluted and constantly changing healthcare system. The underlying principle throughout the curriculum is to provide the fellow with the practical knowledge to participate in cost-efficient improvements in healthcare delivery. Through the ROC Trauma Fellowship business curriculum, the fellow will learn that delivering healthcare in a manner that provides better outcomes for equal or lower costs is not only possible but a professional and ethical responsibility. However, instilling these values without providing actionable knowledge and programs would be insufficient and ineffective. For this reason, the core of the curriculum is based on individual teaching sessions with a wide array of hospital and private practice administrators. In addition, each section is equipped with a suggested reading list to maximize the learning experience. Upon completion of the curriculum, the fellow should be able to: (1) Participate in strategic planning at both the hospital and practice level based on analysis of financial and clinical data, (2) Understand the function of healthcare systems at both a macro and micro level, (3) Possess the knowledge and skills to be strong leaders and effective communicators in the business lexicon of healthcare, (4) Be a partner and innovator in the improvement of the delivery of orthopaedic services, (5) Combine scientific and strategic viewpoints to provide an evidence-based strategy for improving quality of care in a cost-efficient manner, (6) Understand the political, economic, and strategic basics of private practice orthopaedics.

TraumaNetzwerk DGU(®): optimizing patient flow and management.

PubMed

Ruchholtz, Steffen; Lewan, Ulrike; Debus, Florian; Mand, Carsten; Siebert, Hartmut; Kühne, Christian A

2014-10-01

Caring for severely injured trauma patients is challenging for all medical professionals involved both in the preclinical and in the clinical course of treatment. While the overall quality of care in Germany is high there still are significant regional differences remaining. Reasons are geographical and infrastructural differences as well as variations in personnel and equipment of the hospitals. To improve state-wide trauma care the German Trauma Society (DGU) initiated the TraumaNetzwerk DGU(®) (TNW) project. The TNW is based on five major components: (a) Whitebook for the treatment of severely injured patients; (b) evidence-based guidelines for the medical care of severe injury; (c) local auditing of participating hospitals; (d) contract of interhospital cooperation; (d) TraumaRegister DGU(®) documentation. By the end of 2013, 644 German Trauma Centres (TC) had successfully passed the audit. To that date 44 regional TNWs with a mean of 13.5 TCs had been established and certified. The TNWs cover approximately 90% of the country's surface. Of those hospitals, 2.3 were acknowledged as Supraregional TC, 5.4 as Regional TC and 6.7 as Lokal TC. Moreover, cross border TNW in cooperation with hospitals in The Netherlands, Luxembourg, Switzerland and Austria have been established. Preparing for the audit 66% of the hospitals implemented organizational changes (e.g. TraumaRegister DGU(®) documentation and interdisciplinary guidelines), while 60% introduced personnel and 21% structural (e.g. X-ray in the ER) changes. The TraumaNetzwerk DGU(®) project combines the control of common defined standards of care for all participating hospitals (top down) and the possibility of integrating regional cooperation by forming a regional TNW (bottom up). Based on the joint approach of healthcare professionals, it is possible to structure and influence the care of severely injured patients within a nationwide trauma system. Copyright © 2014 Elsevier Ltd. All rights reserved.

Skull base trauma: diagnosis and management.

PubMed

Samii, Madjid; Tatagiba, Marcos

2002-03-01

The singular anatomical relationship of the base of the skull is responsible for the particular problems that may arise after injury. Extensive dural laceration and severe neurovascular damage may accompany skull base injuries. Trauma to the anterior skull base is frequently related to the paranasal sinuses, and trauma to the middle and the posterior skull base usually affects the petrous bone. Injury to the anterior fossa including the paranasal sinuses may produce CSF leakage, damage the olfactory nerves, optic nerves, and orbita contents. Fractures may affect the carotid canal, injure the internal carotid artery and result in carotid-cavernous fistula. Trauma to the petrous bone may cause facial palsy and deafness, and CSF leakage with otorrhoea or paradoxal rhinoliquorrhoea. Trauma to the posterior fossa may lacerate the major venous sinuses, and affect the cranio-cervical stability. Each one of these injuries will need a particular strategy. Decision making for management as a whole must consider all aspects, including the fact that these injuries frequently involve polytraumatized patients. Decisions regarding the timing of surgery and the sequence of the surgical procedures must be made with great care. Modern surgical techniques and recent technologies including functional preservation of the olfactory nerves in frontobasal trauma, visual evoked potentials, assisted optic nerve decompression, facial nerve reconstruction, interventional technique for intravascular repair of vascular injuries, and recent developments in cochlea implants and brain stem implants, all contributed significantly to improve outcome and enhance the quality of life of patients. This article reviews basic principles of management of skull base trauma stressing the role of these advanced techniques.

Development and validation of a new pediatric resuscitation and trauma outcome (PRESTO) model using the U.S. National Trauma Data Bank.

PubMed

St-Louis, Etienne; Bracco, David; Hanley, James; Razek, Tarek; Baird, Robert

2017-10-12

There is a need for a pediatric trauma outcomes benchmarking model that is adapted for Low-and-Middle-Income Countries (LMICs). We used the National-Trauma-Data-Bank (NTDB) and applied constraints specific to resource-poor environments to develop and validate an LMIC-specific pediatric trauma score. We selected a sample of pediatric trauma patients aged 0-14years in the NTDB from 2007 to 2012. Primary outcome was in-hospital death. Logistic regression was used to create the Pediatric Resuscitation and Trauma Outcome (PRESTO) score, which includes only low-tech predictor variables - those easily obtainable at point-of-care. Internal validation was performed using 10-fold cross-validation. External validation compared PRESTO to TRISS using ROC analyses. Among 651,030 patients, there were 64% males. Median age was 7. In-hospital mortality-rate was 1.2%. Mean TRISS predicted mortality was 0.04% (range 0%-43%). Independent predictors included in PRESTO (p<0.01) were age, blood pressure, neurologic status, need for supplemental oxygen, pulse, and oxygen saturation. The sensitivity and specificity of PRESTO were 95.7% and 94.0%. The resulting model had an AUC of 0.98 compared to 0.89 for TRISS. PRESTO satisfies the requirements of low-resource settings and is inherently adapted to children, allowing for benchmarking and eventual quality improvement initiatives. Further research is necessary for in-situ validation using prospectively collected LMIC data. Level III - Case-Control (Prognostic) Study. Copyright © 2017 Elsevier Inc. All rights reserved.

Pain management for blunt thoracic trauma: A joint practice management guideline from the Eastern Association for the Surgery of Trauma and Trauma Anesthesiology Society.

PubMed

Galvagno, Samuel Michael; Smith, Charles E; Varon, Albert J; Hasenboehler, Erik A; Sultan, Shahnaz; Shaefer, Gregory; To, Kathleen B; Fox, Adam D; Alley, Darrell E R; Ditillo, Michael; Joseph, Bellal A; Robinson, Bryce R H; Haut, Elliot R

2016-11-01

Thoracic trauma is the second most prevalent nonintentional injury in the United States and is associated with significant morbidity. Analgesia for blunt thoracic trauma was first addressed by the Eastern Association for the Surgery of Trauma (EAST) with a practice management guideline published in 2005. Since that time, it was hypothesized that there have been advances in the analgesic management for blunt thoracic trauma. As a result, updated guidelines for this topic using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) framework recently adopted by EAST are presented. Five systematic reviews were conducted using multiple databases. The search retrieved articles regarding analgesia for blunt thoracic trauma from January1967 to August 2015. Critical outcomes of interest were analgesia, postoperative pulmonary complications, changes in pulmonary function tests, need for endotracheal intubation, and mortality. Important outcomes of interest examined included hospital and intensive care unit length of stay. Seventy articles were identified. Of these, 28 articles were selected to construct the guidelines. The overall risk of bias for all studies was high. The majority of included studies examined epidural analgesia. Epidural analgesia was associated with lower short-term pain scores in most studies, but the quality and quantity of evidence were very low, and no firm evidence of benefit or harm was found when this modality was compared with other analgesic interventions. The quality of evidence for paravertebral block, intrapleural analgesia, multimodal analgesia, and intercostal nerve blocks was very low as assessed by GRADE. The limitations with the available literature precluded the formulation of strong recommendations by our panel. We propose two evidence-based recommendations regarding analgesia for patients with blunt thoracic trauma. The overall risk of bias for all studies was high. The limitations with the available literature precluded the formulation of strong recommendations by our panel. We conditionally recommend epidural analgesia and multimodal analgesia as options for patients with blunt thoracic trauma, but the overall quality of evidence supporting these modalities is low in trauma patients. These recommendations are based on very low-quality evidence but place a high value on patient preferences for analgesia. These recommendations are in contradistinction to the previously published Practice Management Guideline published by EAST.

Development and pilot testing of an informed consent video for patients with limb trauma prior to debridement surgery using a modified Delphi technique.

PubMed

Lin, Yen-Ko; Chen, Chao-Wen; Lee, Wei-Che; Lin, Tsung-Ying; Kuo, Liang-Chi; Lin, Chia-Ju; Shi, Leiyu; Tien, Yin-Chun; Cheng, Yuan-Chia

2017-11-29

Ensuring adequate informed consent for surgery in a trauma setting is challenging. We developed and pilot tested an educational video containing information regarding the informed consent process for surgery in trauma patients and a knowledge measure instrument and evaluated whether the audiovisual presentation improved the patients' knowledge regarding their procedure and aftercare and their satisfaction with the informed consent process. A modified Delphi technique in which a panel of experts participated in successive rounds of shared scoring of items to forecast outcomes was applied to reach a consensus among the experts. The resulting consensus was used to develop the video content and questions for measuring the understanding of the informed consent for debridement surgery in limb trauma patients. The expert panel included experienced patients. The participants in this pilot study were enrolled as a convenience sample of adult trauma patients scheduled to receive surgery. The modified Delphi technique comprised three rounds over a 4-month period. The items given higher scores by the experts in several categories were chosen for the subsequent rounds until consensus was reached. The experts reached a consensus on each item after the three-round process. The final knowledge measure comprising 10 questions was developed and validated. Thirty eligible trauma patients presenting to the Emergency Department (ED) were approached and completed the questionnaires in this pilot study. The participants exhibited significantly higher mean knowledge and satisfaction scores after watching the educational video than before watching the video. Our process is promising for developing procedure-specific informed consent and audiovisual aids in medical and surgical specialties. The educational video was developed using a scientific method that integrated the opinions of different stakeholders, particularly patients. This video is a useful tool for improving the knowledge and satisfaction of trauma patients in the ED. The modified Delphi technique is an effective method for collecting experts' opinions and reaching a consensus on the content of educational materials for informed consent. Institutions should prioritize patient-centered health care and develop a structured informed consent process to improve the quality of care. The ClinicalTrials.gov Identifier is NCT01338480 . The date of registration was April 18, 2011 (retrospectively registered).

Childhood trauma, depression, and sleep quality and their association with psychotic symptoms and suicidality in schizophrenia.

PubMed

Kilicaslan, Esin Evren; Esen, Asli Tugba; Kasal, Meltem Izci; Ozelci, Erdal; Boysan, Murat; Gulec, Mustafa

2017-12-01

This study involved the examination of the relationship between childhood trauma and both psychotic symptoms and suicidality in patients with schizophrenia after controlling for the possible confounding factors, such as clinical features, depression, and sleep quality. The Childhood Trauma Questionnaire-Short Form, Positive and Negative Syndrome Scale (PANSS), Calgary Depression Scale for Schizophrenia (CDSS), Pittsburgh Sleep Quality Index (PSQI), and the suicidality subscale of Mini-International Neuropsychiatric Interview (MINI) were administered to 199 patients with schizophrenia. We used sequential multiple stepwise regression analyses in which positive symptoms, negative symptoms, overall psychopathology, total symptoms of schizophrenia, and suicidality were dependent variables. Depressive symptomatology and childhood physical abuse significantly contributed to positive, negative, general psychopathology, and global schizophrenia symptomatology. Interestingly, general psychopathology scores were negatively associated with childhood physical neglect. Also, subjective sleep quality significantly contributed to positive schizophrenia symptoms. Although prior suicide attempts and depression were significant antecedents of suicidal ideation, no association between suicidality and both childhood trauma and sleep was found. Childhood physical abuse could have an impact on psychopathology in schizophrenia. In addition to childhood trauma, depression, sleep disturbances, and clinical features should be considered and inquired about in the course of clinical care of schizophrenia patients. Copyright © 2017 Elsevier B.V. All rights reserved.

How to Measure Physical Motion and the Impact of Individualized Feedback in the Field of Rehabilitation of Geriatric Trauma Patients.

PubMed

Altenbuchner, Amelie; Haug, Sonja; Kretschmer, Rainer; Weber, Karsten

2018-01-01

This preparatory study accelerates an implementation of individualized monitoring and feedback of physical motion using conventional motion trackers in the rehabilitation process of geriatric trauma patients. Regaining mobility is accompanied with improved quality of life in persons of very advanced age recovering from fragility fractures. Quantitative survey of regaining physical mobility provides recommendations for action on how to use motion trackers effectively in a clinical geriatric setting. Method mix of quantitative and qualitative interdisciplinary and mutual complementary research approaches (sociology, health research, philosophy/ethics, medical informatics, nursing science, gerontology and physical therapy). While validating motion tracker use in geriatric traumatology preliminary data are used to develop a target group oriented motion feedback. In addition measurement accuracy of a questionnaire about quality of life of multimorbid geriatric patients (FLQM) is tested. Implementing a new technology in a complex clinical setting needs to be based on a strong theoretical background but will not succeed without careful field testing.

Impact of the version of the abbreviated injury scale on injury severity characterization and quality assessment of trauma care.

PubMed

Tohira, Hideo; Jacobs, Ian; Matsuoka, Tetsuya; Ishikawa, Kazuo

2011-07-01

The Abbreviated Injury Scale (AIS) was updated in 2008 (AIS 2008). We aimed to investigate the impact of AIS 2008 on the characterization of injury severity and quality assessment of trauma care. We identified all blunt trauma patients in the Japan Trauma Data Bank. First, we converted AIS 98 codes to AIS 2008 codes using a mapping table. Next, we compared Injury Severity Scores (ISSs) and New ISSs (NISSs) based on AIS 98 and AIS 2008. We compared the proportion of major trauma (ISS >15) between the two AISs. We derived risk-adjusted models using the two AISs and separately ranked hospitals according to the observed-to-expected death (OE) ratio. We counted the number of performance outliers for the two rankings. We analyzed the association between the percent change in OE ratios and the proportion of NISS outliers (change in NISS of <-12). There were 19,899 subjects. The ISSs and NISSs based on AIS 2008 were significantly less than those based on AIS 98. The proportion of major trauma was 46.3% and 38.9% for AIS 98 and AIS 2008, respectively (p < 0.001). The numbers of performance outliers were different between the two rankings. There was a significant positive linear relationship between the percent change in the OE ratio and the proportion of NISS outliers. The use of different AIS versions influenced the selection of major trauma patients and affected the quality assessment of the trauma care. Researchers should be aware of these findings when selecting the version of the AIS.

Mentalization of complex emotions in borderline personality disorder: The impact of parenting and exposure to trauma on the performance in a novel cartoon-based task.

PubMed

Brüne, Martin; Walden, Sarah; Edel, Marc-Andreas; Dimaggio, Giancarlo

2016-01-01

Borderline personality disorder (BPD) is characterized by a range of interpersonal difficulties, which are, in part, related to adverse experiences during childhood. Unresponsive parenting and traumatization may cause functional impairment of mentalization, i.e. the ability to reflect upon own and others' mental states. However, the relationship of poor parenting, trauma and mentalization in BPD has not exhaustively been studied. Thirty patients diagnosed with BPD and 30 matched control subjects were asked to sequence a novel cartoon-based mentalization task involving complex emotions such as jealousy, shame, guilt etc. In addition, they were required to reason about cognitive and affective mental states of the cartoon characters. The quality of parental care was assessed using a self-report measure for recalled parental rearing style, and childhood trauma was measured in retrospect using the Childhood Trauma Questionnaire. Patients with BPD performed more poorly in all aspects of the cartoon task. Mentalizing skills, particularly relating to affective mental states, were uniquely associated with the quality of recalled parental care and childhood trauma. Together, the quality of parental care and the experience of childhood trauma negatively impact on mentalization in BPD, even in an experimental "offline" task. Copyright © 2015 Elsevier Inc. All rights reserved.

Effect of Somatic Experiencing Resiliency-Based Trauma Treatment Training on Quality of Life and Psychological Health as Potential Markers of Resilience in Treating Professionals

PubMed Central

Winblad, Neal E.; Changaris, Michael; Stein, Phyllis K.

2018-01-01

Background: Individuals who treat trauma are at significant risk of vicarious traumatization and burnout. Somatic Experiencing® (SE®) is a resiliency-focused trauma treatment modality designed to address autonomic nervous system (ANS) dysregulation and its impacted physical health and mental health symptoms e.g., anxiety, depression, post-traumatic stress disorder, migraines, fibromyalgia, and chronic fatigue, etc. The SE® training supports the development of clinical skills to reduce physical health/mental health symptoms as well as increase clinician resilience. Individuals who display resilience often have increased experiences of well-being (quality of life) and decreased levels of self-reported psychological symptoms. Greater resilience could mitigate the risks to providers and the clients they treat. Materials and Methods: This within-groups, longitudinal study assessed students (N = 18) over the course of a 3-year SE® practitioner training. This training focuses on increased ANS, physical, and emotional regulation skills. The convenience of a web-based survey allowed for: measures of a general quality of life (WHOQOL-BREF), psychological symptoms, somatic, anxiety, and depressive symptoms (PHQ-SADS), as well as a measure of early life exposure to adversity (CDC/Kaiser Permanente ACE Score Calculator Questionnaire). The clinician survey was conducted yearly for 3 years. Future studies would do well to also include laboratory-based objective measures of ANS functioning. Results: ANOVA with repeated measures showed that there were significant reductions in anxiety symptoms (GAD7, p < 0.001) and somatization symptoms (PHQ15, p < 0.001). Health-related quality of life (a measure of physical well-being) and social quality of life (a measure of interpersonal well-being) both increased significantly (Health QoL p = 0.028; Social QoL p = 0.046). Conclusions: Results suggest that professionals attending the 3-year SE® training course experience a significant improvement in self-reported measures associated with resiliency including: quality of life (well-being) and psychological symptoms (anxiety and somatization). Our results support the importance of future research in a larger sample and support the exploration, cross-sectionally and prospectively, of the relationship of clinician resiliency and changes in clinician resiliency with SE® training and clinical outcomes. These data have implications for other professions at risk of exposure to vicarious trauma (VT) including nurses, medical providers, and paramedics. PMID:29503607

An audit of the complications of intercostal chest drain insertion in a high volume trauma service in South Africa

PubMed Central

Oosthuizen, GV; Sartorius, B; Keene, C; Clarke, DL

2014-01-01

Introduction Intercostal chest drain (ICD) insertion is a commonly performed procedure in trauma and may be associated with significant morbidity. Methods This was a retrospective review of ICD complications in a major trauma service in South Africa over a four-year period from January 2010 to December 2013. Results A total of 1,050 ICDs were inserted in 1,006 patients, of which 91% were male. The median patient age was 24 years (interquartile range [IQR]: 20–29 years). There were 962 patients with unilateral ICDs and 44 with bilateral ICDs. Seventy-five per cent (758/1,006) sustained penetrating trauma and the remaining 25% (248/1006) sustained blunt trauma. Indications for ICD insertion were: haemopneumothorax (n=338), haemothorax (n=314), simple pneumothorax (n=265), tension pneumothorax (n=79) and open pneumothorax (n=54). Overall, 203 ICDs (19%) were associated with complications: 18% (36/203) were kinked, 18% (36/203) were inserted subcutaneously, 13% (27/203) were too shallow and in 7% (14/203) there was inadequate fixation resulting in dislodgement. Four patients (2%) sustained visceral injuries and two sustained vascular injuries. Forty-one per cent (83/203) were inserted outside the ‘triangle of safety’ but without visceral or vascular injuries. One patient had the ICD inserted on the wrong side. Junior doctors inserted 798 ICDs (76%) while senior doctors inserted 252 (24%). Junior doctors had a significantly higher complication rate (24%) compared with senior doctors (5%) (p<0.001). There was no mortality as a direct result of ICD insertion. Conclusions ICD insertion is associated with a high rate of complications. These complications are significantly higher when junior doctors perform the procedure. A multifaceted quality improvement programme is needed to improve the situation. PMID:25350185

An audit of the complications of intercostal chest drain insertion in a high volume trauma service in South Africa.

PubMed

Kong, V Y; Oosthuizen, G V; Sartorius, B; Keene, C; Clarke, D L

2014-11-01

Intercostal chest drain (ICD) insertion is a commonly performed procedure in trauma and may be associated with significant morbidity. This was a retrospective review of ICD complications in a major trauma service in South Africa over a four-year period from January 2010 to December 2013. A total of 1,050 ICDs were inserted in 1,006 patients, of which 91% were male. The median patient age was 24 years (interquartile range [IQR]: 20-29 years). There were 962 patients with unilateral ICDs and 44 with bilateral ICDs. Seventy-five per cent (758/1,006) sustained penetrating trauma and the remaining 25% (248/1006) sustained blunt trauma. Indications for ICD insertion were: haemopneumothorax (n=338), haemothorax (n=314), simple pneumothorax (n=265), tension pneumothorax (n=79) and open pneumothorax (n=54). Overall, 203 ICDs (19%) were associated with complications: 18% (36/203) were kinked, 18% (36/203) were inserted subcutaneously, 13% (27/203) were too shallow and in 7% (14/203) there was inadequate fixation resulting in dislodgement. Four patients (2%) sustained visceral injuries and two sustained vascular injuries. Forty-one per cent (83/203) were inserted outside the 'triangle of safety' but without visceral or vascular injuries. One patient had the ICD inserted on the wrong side. Junior doctors inserted 798 ICDs (76%) while senior doctors inserted 252 (24%). Junior doctors had a significantly higher complication rate (24%) compared with senior doctors (5%) (p<0.001). There was no mortality as a direct result of ICD insertion. Conclusions ICD insertion is associated with a high rate of complications. These complications are significantly higher when junior doctors perform the procedure. A multifaceted quality improvement programme is needed to improve the situation.

Protocol for rapid sequence intubation in pediatric patients -- a four-year study.

PubMed

Marvez-Valls, Eduardo; Houry, Debra; Ernst, Amy A; Weiss, Steven J; Killeen, James

2002-04-01

To evaluate a protocol for rapid sequence intubation (RSI) for pediatric patients in a Level 1 trauma center. Retrospective review of prospectively gathered Continuing Quality Improvement (CQI) data at an inner city Level 1 trauma center with an emergency medicine residency program. Protocols for RSI were established prior to initiating the study. All pediatric intubations at the center from February 1996 to February 2000 were included. Statistical analysis included descriptive statistics for categorical data and Chi-square for comparisons between groups. Over the 4-year study period there were 83 pediatric intubations ranging in age from 18 months to 17 years; mean age 8.6. All had data collected at the time of intubation. There were 20 (24%) females and 62 (76%) males (p<0.001). Reasons for intubation were related to trauma in 71 (86%) and medical reasons in 12 (14%) (p<0.001). Of the trauma intubations 7 (10%) were for gunshot wounds, 39 (55%) were secondary to MVCs, and the remainder (25; 35%) were from assaults, falls, and closed head injuries. The non-trauma intubations were for smoke inhalation, overdose, seizure, HIV related complications, eclampsia, and near drowning. Intubations were successful with one attempt in 65 (78%) cases. No surgical airways were necessary. Rocuronium was used in 4 cases. Protocol deviations did not lead to complications. This protocol based pediatric rapid sequence intubation method worked well in an EM residency program. More intubations were in males and more were necessary due to trauma in this group.

Stress management versus cognitive restructuring in trauma-affected refugees-A pragmatic randomised study.

PubMed

Carlsson, Jessica; Sonne, Charlotte; Vindbjerg, Erik; Mortensen, Erik Lykke

2018-05-24

The aim of this randomised trial was to compare the effectiveness of stress management (SM) versus cognitive restructuring (CR) in trauma-affected refugees. The intention-to-treat sample comprised 126 refugees with PTSD (SM = 62, CR = 64). The treatment consisted of 16 sessions of psychotherapy with manualised SM or CR in addition to 10 sessions with a medical doctor (psychoeducation and pharmacological treatment). The primary outcome was PTSD symptom severity (Harvard Trauma Questionnaire). Secondary outcomes were symptoms of depression and anxiety (Hopkins Symptom Checklist-25, Hamilton Depression and Anxiety Ratings), quality of life (WHO-5), functioning (Global Assessment of Functioning, Sheehan Disability Scale), pain (Visual Analogue Scale) and somatisation (Symptom Checklist). There was no difference in the primary outcome between groups. A significant group difference was found on the Hamilton Anxiety Rating with the SM group improving more than the CR group (effect size 0.46) indicating that methods in SM could potentially be helpful in this population. Copyright © 2018 Elsevier B.V. All rights reserved.

Impact of a TeamSTEPPS Trauma Nurse Academy at a Level 1 Trauma Center.

PubMed

Peters, V Kristen; Harvey, Ellen M; Wright, Andi; Bath, Jennifer; Freeman, Dan; Collier, Bryan

2018-01-01

Nurses are crucial members of the team caring for the acutely injured trauma patient. Until recently, nurses and physicians gained an understanding of leadership and supportive roles separately. With the advent of a multidisciplinary team approach to trauma care, formal team training and simulation has transpired. Since 2007, our Level I trauma system has integrated TeamSTEPPS (Team Strategies & Tools to Enhance Performance & Patient Safety; Agency for Healthcare Research and Quality, Rockville, MD) into our clinical care, joint training of nurses and physicians, using simulations with participation of all health care providers. With the increased expectations of a well-orchestrated team and larger number of emergency nurses, our program created the Trauma Nurse Academy. This academy provides a core of experienced nurses with an advanced level of training while decreasing the variability of personnel in the trauma bay. Components of the academy include multidisciplinary didactic education, the Essentials of TeamSTEPPS, and interactive trauma bay learning, to include both equipment and drug use. Once completed, academy graduates participate in the orientation and training of General Surgery and Emergency Medicine residents' trauma bay experience and injury prevention activities. Internal and published data have demonstrated growing evidence linking trauma teamwork training to knowledge and self-confidence in clinical judgment to team performance, patient outcomes, and quality of care. Although trauma resuscitations are stressful, high risk, dynamic, and a prime environment for error, new methods of teamwork training and collaboration among trauma team members have become essential. Copyright © 2017 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved.

A Preliminary Analysis of Compassion Fatigue in a Surgeon Population: Are Female Surgeons at Heightened Risk?

PubMed

Wu, Daniel; Gross, Brian; Rittenhouse, Katelyn; Harnish, Carissa; Mooney, Claire; Rogers, Frederick B

2017-11-01

Compassion fatigue (CF), a state of physical/emotional distress caused by repeatedly caring for those experiencing traumatic episodes, is a prevalent issue for today's healthcare provider. We sought to characterize levels of CF within a surgeon population, particularly comparing trauma surgery with other surgical specialties. A survey containing the Professional Quality of Life Scale (ProQOL), a validated tool assessing compassion satisfaction (CS), CF, and burnout (BO) was distributed via electronic newsletter to members of the American College of Surgeons. Demographic data and Professional Quality of Life Scale scores for CS, BO, and CF were collected and compared within specialty and gender subgroups. A total of 178 surgeons completed surveys. Respondents were predominantly male, general surgeons, >55 years old. Trauma surgeons composed the second largest subgroup. Levels of CS were significantly lower in the trauma surgeon subgroup compared to other surgical specialties (trauma: 37.1 ± 5.28, other: 39.5 ± 6.30; P = 0.044). Female surgeons from all specialties exhibited significantly higher levels of BO (female: 26.7 ± 6.10, male: 24.6 ± 6.79; P = 0.035) and CF (female: 24.2 ± 6.29, male: 21.9 ± 6.11; P = 0.021) compared with male surgeons. Subanalyses comparing female trauma surgeons to female surgeons in other specialties found female trauma surgeons exhibited significantly lower levels of CS (trauma: 34.8 ± 4.63, other: 38.8 ± 5.99; P = 0.038) and higher levels of BO (trauma: 29.1 ± 3.14, other: 25.3 ± 6.41; P = 0.049). Trauma surgeons, particularly female trauma surgeons, may be at a heightened risk for developing a poorer overall professional quality of life compared with surgeons of other specialties. In addition, female surgeons may be at greater risk for developing CF compared with male counterparts.

Immersion team training in a realistic environment improves team performance in trauma resuscitation.

PubMed

Siriratsivawong, Kris; Kang, Jeff; Riffenburgh, Robert; Hoang, Tuan N

2016-09-01

In the US military, it is common for health care teams to be formed ad hoc and expected to function cohesively as a unit. Poor team dynamics decreases the effectiveness of trauma care delivery. The US Navy Fleet Surgical Team Three has developed a simulation-based trauma initiative-the Shipboard Surgical Trauma Training (S2T2) Course-that emphasizes team dynamics to improve the delivery of trauma care to the severely injured patient. The S2T2 Course combines classroom didactics with hands-on simulation over a period of 6 days, culminating in a daylong, mass casualty scenario. Each resuscitation team was initially evaluated with a simulated trauma resuscitation scenario then retested on the same scenario after completing the course. A written exam was also administered individually both before and after the course. A survey was administered to assess the participants' perceived effectiveness of the course on overall team training. From the evaluation of 20 resuscitation teams made up of 123 medical personnel, there was a decrease in the mean time needed to perform the simulated trauma resuscitation, from a mean of 24.4 minutes to 13.5 minutes (P < .01), a decrease in the mean number of critical events missed, from 5.15 to 1.00 (P < .01), and a mean improvement of 41% in written test scores. More than 90% of participants rated the course as highly effective for improving team dynamics. A team-based trauma course with immersion in a realistic environment is an effective tool for improving team performance in trauma training. This approach has high potential to improve trauma care and patient outcomes. The benefits of this team-based course can be adapted to the civilian rural sector, where gaps have been identified in trauma care. Published by Elsevier Inc.

Positive and negative volume-outcome relationships in the geriatric trauma population.

PubMed

Matsushima, Kazuhide; Schaefer, Eric W; Won, Eugene J; Armen, Scott B; Indeck, Matthew C; Soybel, David I

2014-04-01

In trauma populations, improvements in outcome are documented in institutions with higher case volumes. However, it is not known whether improved outcomes are attributable to the case volume within specific higher-risk groups, such as the elderly, or to the case volume among all trauma patients treated by an institution. To test the hypothesis that outcomes of trauma care for geriatric patients are affected differently by the volume of geriatric cases and nongeriatric cases of an institution. This retrospective cohort study using a statewide trauma registry was set in state-designated levels 1 and 2 trauma centers in Pennsylvania. It included 39 431 eligible geriatric trauma patients (aged >65 years) in the Pennsylvania Trauma Outcomes Study. In-hospital mortality, major complications, and mortality after major complications (failure to rescue). Between 2001 and 2010, 39 431 geriatric trauma patients and 105 046 nongeriatric patients were captured in a review of outcomes in 20 state-designated levels 1 and 2 trauma centers. Larger volumes of geriatric trauma patients were significantly associated with lower odds of in-hospital mortality, major complications, and failure to rescue. In contrast, larger nongeriatric trauma volumes were significantly associated with higher odds of major complications in geriatric patients. Higher rates of in-hospital mortality, major complications, and failure to rescue were associated with lower volumes of geriatric trauma care and paradoxically with higher volumes of trauma care for younger patients. These findings offer the possibility that outcomes might be improved with differentiated pathways of care for geriatric trauma patients.

Preventing nipple trauma in lactating women in the University Hospital of the University of Sao Paulo: a best practice implementation project.

PubMed

Shimoda, Gilcéria Tochika; Soares, Alda Valeria Neves; Aragaki, Ilva Marico Mizumoto; McArthur, Alexa

2015-03-12

Nipple trauma in lactating women is an important issue in facilitating successful breastfeeding. Evidence suggests that early postnatal education on the positioning and attachment technique, early observation of mothers and correcting breastfeeding techniques at an early stage may reduce nipple trauma. The aim of this project was to improve breastfeeding practice and thereby reduce nipple trauma in lactating women in a public hospital in Sao Paulo. More specifically the objectives of this project were: firstly, to assess the current practice in nurses' assistance concerning the prevention of nipple trauma; secondly, to adapt and trial a Breastfeeding Assessment Form to observe and educate the lactating mother during the early post-natal period; and thirdly, to assess the impact of introducing the assessment strategy on breastfeeding and nipple trauma rates. The Joanna Briggs Institute Practical Application of Clinical Evidence System online tool was utilized for this project. A clinical audit was conducted to assess compliance with best practice in nursing assistance concerning the prevention of nipple trauma. The project concluded with a second audit, which assessed the change in practice following the implementation of strategies to improve practice. The project was successful in that there was an improvement across all of the audit criteria following the introduction of the strategy to promote best practice. Criterion 1, concerning nursing staff knowledge, improved in compliance by 73%. Criterion 2 and 4, concerning women's knowledge about prevention and management of nipple trauma, improved by 53% and 55% respectively. Breastfeeding assessment improved by 26% from baseline to follow-up audit. Moreover, an improvement in women's satisfaction and exclusive breastfeeding rates was observed; however, nipple trauma rates did not decrease. This implementation project had great impact on both nursing staff as well as lactating women's knowledge of preventing and managing nipple trauma. It also enhanced women's satisfaction with breastfeeding and exclusive breastfeeding rates. Further research is required into other aspects involved with the onset of nipple trauma. The Joanna Briggs Institute.

Cost Effectiveness of Field Trauma Triage among Injured Adults Served by Emergency Medical Services

PubMed Central

Newgard, Craig D; Yang, Zhuo; Nishijima, Daniel; McConnell, K John; Trent, Stacy; Holmes, James F; Daya, Mohamud; Mann, N Clay; Hsia, Renee Y; Rea, Tom; Wang, N Ewen; Staudenmayer, Kristan; Delgado, M Kit

2016-01-01

Background The American College of Surgeons Committee on Trauma sets national targets for the accuracy of field trauma triage at ≥ 95% sensitivity and ≥ 65% specificity, yet the cost-effectiveness of realizing these goals is unknown. We evaluated the cost-effectiveness of current field trauma triage practices compared to triage strategies consistent with the national targets. Study Design This was a cost-effectiveness analysis using data from 79,937 injured adults transported by 48 emergency medical services (EMS) agencies to 105 trauma and non-trauma hospitals in 6 regions of the Western U.S. from 2006 through 2008. Incremental differences in survival, quality adjusted life years (QALYs), costs, and the incremental cost-effectiveness ratio (ICER; costs per QALY gained) were estimated for each triage strategy over a 1-year and lifetime horizon using a decision analytic Markov model. We considered an ICER threshold of less than $100,000 to be cost-effective. Results For these 6 regions, a high sensitivity triage strategy consistent with national trauma policy (sensitivity 98.6%, specificity 17.1%) would cost $1,317,333 per QALY gained, while current triage practices (sensitivity 87.2%, specificity 64.0%) cost $88,000 per QALY gained compared to a moderate sensitivity strategy (sensitivity 71.2%, specificity 66.5%). Refining EMS transport patterns by triage status improved cost-effectiveness. At the trauma system level, a high-sensitivity triage strategy would save 3.7 additional lives per year at a 1-year cost of $8.78 million, while a moderate sensitivity approach would cost 5.2 additional lives and save $781,616 each year. Conclusions A high-sensitivity approach to field triage consistent with national trauma policy is not cost effective. The most cost effective approach to field triage appears closely tied to triage specificity and adherence to triage-based EMS transport practices. PMID:27178369

Assessment of Surgical and Trauma Capacity in Potosí, Bolivia.

PubMed

Blair, Kevin J; Boeck, Marissa A; Gallardo Barrientos, José Luis; Hidalgo López, José Luis; Helenowski, Irene B; Nwomeh, Benedict C; Shapiro, Michael B; Swaroop, Mamta

Scaling up surgical and trauma care in low- and middle-income countries could prevent nearly 2 million annual deaths. Various survey instruments exist to measure surgical and trauma capacity, including Personnel, Infrastructure, Procedures, Equipment, and Supplies (PIPES) and International Assessment of Capacity for Trauma (INTACT). We sought to evaluate surgical and trauma capacity in the Bolivian department of Potosí using a combined PIPES and INTACT tool, with additional questions to further inform intervention targets. In June and July 2014 a combined PIPES and INTACT survey was administered to 20 government facilities in Potosí with a minimum of 1 operating room: 2 third-level, 10 second-level, and 8 first-level facilities. A surgeon, head physician, director, or obstetrician-gynecologist completed the survey. Additional personnel responded to 4 short-answer questions. Survey items were divided into subsections, and PIPES and INTACT indices calculated. Medians were compared via Wilcoxon rank sum and Kruskal-Wallis tests. Six of 20 facilities were located in the capital city and designated urban. Urban establishments had higher median PIPES (8.5 vs 6.7, P = .11) and INTACT (8.5 vs 6.9, P = .16) indices compared with rural. More than half of surgeons and anesthesiologists worked in urban hospitals. Urban facilities had higher median infrastructure and procedure scores compared with rural. Fifty-three individuals completed short-answer questions. Training was most desired in laparoscopic surgery and trauma management; less than half of establishments reported staff with trauma training. Surgical and trauma capacity in Potosí was most limited in personnel, infrastructure, and procedures at rural facilities, with greater personnel deficiencies than previously reported. Interventions should focus on increasing the number of surgical and anesthesia personnel in rural areas, with a particular focus on the reported desire for trauma management training. Results have been made available to key stakeholders in Potosí to inform targeted quality improvement interventions. Copyright © 2017 Icahn School of Medicine at Mount Sinai. Published by Elsevier Inc. All rights reserved.

Defining and Measuring Decision-Making for the Management of Trauma Patients.

PubMed

Madani, Amin; Gips, Amanda; Razek, Tarek; Deckelbaum, Dan L; Mulder, David S; Grushka, Jeremy R

Effective management of trauma patients is heavily dependent on sound judgment and decision-making. Yet, current methods for training and assessing these advanced cognitive skills are subjective, lack standardization, and are prone to error. This qualitative study aims to define and characterize the cognitive and interpersonal competencies required to optimally manage injured patients. Cognitive and hierarchical task analyses for managing unstable trauma patients were performed using qualitative methods to map the thoughts, behaviors, and practices that characterize expert performance. Trauma team leaders and board-certified trauma surgeons participated in semistructured interviews that were transcribed verbatim. Data were supplemented with content from published literature and prospectively collected field notes from observations of the trauma team during trauma activations. The data were coded and analyzed using grounded theory by 2 independent reviewers. A framework was created based on 14 interviews with experts (lasting 1-2 hours each), 35 field observations (20 [57%] blunt; 15 [43%] penetrating; median Injury Severity Score 20 [13-25]), and 15 literary sources. Experts included 11 trauma surgeons and 3 emergency physicians from 7 Level 1 academic institutions in North America (median years in practice: 12 [8-17]). Twenty-nine competencies were identified, including 17 (59%) related to situation awareness, 6 (21%) involving decision-making, and 6 (21%) requiring interpersonal skills. Of 40 potential errors that were identified, root causes were mapped to errors in situation awareness (20 [50%]), decision-making (10 [25%]), or interpersonal skills (10 [25%]). This study defines cognitive and interpersonal competencies that are essential for the management of trauma patients. This framework may serve as the basis for novel curricula to train and assess decision-making skills, and to develop quality-control metrics to improve team and individual performance. Copyright © 2017 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Nontechnical skills performance and care processes in the management of the acute trauma patient.

PubMed

Pucher, Philip H; Aggarwal, Rajesh; Batrick, Nicola; Jenkins, Michael; Darzi, Ara

2014-05-01

Acute trauma management is a complex process, with the effective cooperation among multiple clinicians critical to success. Despite this, the effect of nontechnical skills on performance on outcomes has not been investigated previously in trauma. Trauma calls in an urban, level 1 trauma center were observed directly. Nontechnical performance was measured using T-NOTECHS. Times to disposition and completion of assessment care processes were recorded, as well as any delays or errors. Statistical analysis assessed the effect of T-NOTECHS on performance and outcomes, accounting for Injury Severity Scores (ISS) and time of day as potential confounding factors. Meta-analysis was performed for incidence of delays. Fifty trauma calls were observed, with an ISS of 13 (interquartile range [IQR], 5-25); duration of stay 1 (IQR, 1-8) days; T-NOTECHS, 20.5 (IQR, 18-23); time to disposition, 24 minutes (IQR, 18-42). Trauma calls with low T-NOTECHS scores had a greater time to disposition: 35 minutes (IQR, 23-53) versus 20 (IQR, 16-25; P = .046). ISS showed a significant correlation to duration of stay (r = 0.736; P < .001), but not to T-NOTECHS (r = 0.201; P = .219) or time to disposition (r = 0.113; P = .494). There was no difference between "in-hours" and "out-of-hours" trauma calls for T-NOTECHS scores (21 [IQR, 18-22] vs 20 [IQR, 20-23]; P = .361), or time to disposition (34 minutes [IQR, 24-52] vs 17 [IQR, 15-27]; P = .419). Regression analysis revealed T-NOTECHS as the only factor associated with delays (odds ratio [OR], 0.24; 95% confidence interval [CI], 0.06-0.95). Better teamwork and nontechnical performance are associated with significant decreases in disposition time, an important marker of quality in acute trauma care. Addressing team and nontechnical skills has the potential to improve patient assessment, treatment, and outcomes. Copyright © 2014 Mosby, Inc. All rights reserved.

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

PubMed

Hirshon, Jon Mark; Galvagno, Samuel M; Comer, Angela; Millin, Michael G; Floccare, Douglas J; Alcorta, Richard L; Lawner, Benjamin J; Margolis, Asa M; Nable, Jose V; Bass, Robert R

2016-03-01

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. Copyright © 2015 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

We need to include bystander first aid in trauma research.

PubMed

Bakke, Håkon Kvåle; Wisborg, Torben

2017-03-23

The chain of trauma survival is a concept that originated in the area of out-of-hospital cardiac arrest (OHCA) and was adapted to the treatment of trauma. In out-of-hospital cardiac arrest research into bystander first aid has resulted in improved outcome. Whereas, in trauma research the first link of the chain of survival is almost ignored. In OHCA, cardiopulmonary resuscitation (CPR) from bystanders has been subject of a vast amount of research, as well as measures and programs to raise the rate of bystander CPR to cardiac arrest victims. These efforts have resulted in improved survival. The research effort has been well grounded in the research community, as demonstrated by its natural inclusion in the uniform reporting template (Utstein) for the treatment of OHCA. In trauma the bystander may contribute by providing an open airway, staunch bleedings, or prevent hypothermia. In trauma however, while the chain of survival has been adopted along with it distinct links, including bystander first aid, the consensus-based uniform reporting template for trauma (the Utstein template) does not include the bystander first aid efforts. There is extremely little research on what first aid measures bystanders provide to trauma victims, and on what impact such measures have on outcome. An important step to improve research on bystander first aid in trauma would be to include this as part of the uniform reporting template for trauma CONCLUSION: The lack of research on bystander first aid makes the first link in the trauma chain of survival the weakest link. We, the trauma research community, should either improve our research and knowledge in this area, or remove the link from the chain of survival.

Cost-effectiveness of the PECARN rules in children with minor head trauma.

PubMed

Nishijima, Daniel K; Yang, Zhuo; Urbich, Michael; Holmes, James F; Zwienenberg-Lee, Marike; Melnikow, Joy; Kuppermann, Nathan

2015-01-01

To improve the efficiency and appropriateness of computed tomography (CT) use in children with minor head trauma, clinical prediction rules were derived and validated by the Pediatric Emergency Care Applied Research Network (PECARN). The objective of this study was to conduct a cost-effectiveness analysis comparing the PECARN traumatic brain injury prediction rules to usual care for selective CT use. We used decision analytic modeling to project the outcomes, costs, and cost-effectiveness of applying the PECARN rules compared with usual care in a hypothetical cohort of 1,000 children with minor blunt head trauma. Clinical management was directed by level of risk as specified by the presence or absence of variables in the PECARN traumatic brain injury prediction rules. Immediate costs of care (diagnostic testing, treatment [not including clinician time], and hospital stay) were derived on single-center data. Quality-adjusted life-year losses related to the sequelae of clinically important traumatic brain injuries and to radiation-induced cancers, number of CT scans, number of radiation-induced cancers, number of missed clinically important traumatic brain injury, and total costs were evaluated. Compared with the usual care strategy, the PECARN strategy was projected to miss slightly more children with clinically important traumatic brain injuries (0.26 versus 0.02 per 1,000 children) but used fewer cranial CT scans (274 versus 353), resulted in fewer radiation-induced cancers (0.34 versus 0.45), cost less ($904,940 versus $954,420), and had lower net quality-adjusted life-year loss (-4.64 versus -5.79). Because the PECARN strategy was more effective (less quality-adjusted life-year loss) and less costly, it dominated the usual care strategy. Results were robust under sensitivity analyses. Application of the PECARN traumatic brain injury prediction rules for children with minor head trauma would lead to beneficial outcomes and more cost-effective care. Copyright © 2014 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Providing effective trauma care: the potential for service provider views to enhance the quality of care (qualitative study nested within a multicentre longitudinal quantitative study)

PubMed Central

Beckett, Kate; Earthy, Sarah; Sleney, Jude; Barnes, Jo; Kellezi, Blerina; Barker, Marcus; Clarkson, Julie; Coffey, Frank; Elder, Georgina; Kendrick, Denise

2014-01-01

Objective To explore views of service providers caring for injured people on: the extent to which services meet patients’ needs and their perspectives on factors contributing to any identified gaps in service provision. Design Qualitative study nested within a quantitative multicentre longitudinal study assessing longer term impact of unintentional injuries in working age adults. Sampling frame for service providers was based on patient-reported service use in the quantitative study, patient interviews and advice of previously injured lay research advisers. Service providers’ views were elicited through semistructured interviews. Data were analysed using thematic analysis. Setting Participants were recruited from a range of settings and services in acute hospital trusts in four study centres (Bristol, Leicester, Nottingham and Surrey) and surrounding areas. Participants 40 service providers from a range of disciplines. Results Service providers described two distinct models of trauma care: an ‘ideal’ model, informed by professional knowledge of the impact of injury and awareness of best models of care, and a ‘real’ model based on the realities of National Health Service (NHS) practice. Participants’ ‘ideal’ model was consistent with standards of high-quality effective trauma care and while there were examples of services meeting the ideal model, ‘real’ care could also be fragmented and inequitable with major gaps in provision. Service provider accounts provide evidence of comprehensive understanding of patients’ needs, awareness of best practice, compassion and research but reveal significant organisational and resource barriers limiting implementation of knowledge in practice. Conclusions Service providers envisage an ‘ideal’ model of trauma care which is timely, equitable, effective and holistic, but this can differ from the care currently provided. Their experiences provide many suggestions for service improvements to bridge the gap between ‘real’ and ‘ideal’ care. Using service provider views to inform service design and delivery could enhance the quality, patient experience and outcomes of care. PMID:25005598

Teamwork education improves trauma team performance in undergraduate health professional students.

PubMed

Baker, Valerie O'Toole; Cuzzola, Ronald; Knox, Carolyn; Liotta, Cynthia; Cornfield, Charles S; Tarkowski, Robert D; Masters, Carolynn; McCarthy, Michael; Sturdivant, Suzanne; Carlson, Jestin N

2015-01-01

Effective trauma resuscitation requires efficient and coordinated care from a team of providers; however, providers are rarely instructed on how to be effective members of trauma teams. Team-based learning using Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) has been shown to improve team dynamics among practicing professionals, including physicians and nurses. The impact of TeamSTEPPS on students being trained in trauma management in an undergraduate health professional program is currently unknown. We sought to determine the impact of TeamSTEPPS on team dynamics among undergraduate students being trained in trauma resuscitation. We enrolled teams of undergraduate health professional students from four programs: nursing, physician assistant, radiologic science, and respiratory care. After completing an online training on trauma resuscitation principles, the participants completed a trauma resuscitation scenario. The participants then received teamwork training using TeamSTEPPS and completed a second trauma resuscitation scenario identical to the first. All resuscitations were recorded and scored offline by two blinded research assistants using both the Team Emergency Assessment Measure (TEAM) and Trauma Team Performance Observation Tool (TPOT) scoring systems. Pre-test and post-test TEAM and TPOT scores were compared. We enrolled a total of 48 students in 12 teams. Team leadership, situational monitoring, and overall communication improved with TeamSTEPPS training (P=0.04, P=0.02, and P=0.03, respectively), as assessed by the TPOT scoring system. TeamSTEPPS also improved the team's ability to prioritize tasks and work together to complete tasks in a rapid manner (P<0.01 and P=0.02, respectively) as measured by TEAM. Incorporating TeamSTEPPS into trauma team education leads to improved TEAM and TPOT scores among undergraduate health professionals.

Treating childhood traumatic grief: a pilot study.

PubMed

Cohen, Judith A; Mannarino, Anthony P; Knudsen, Kraig

2004-10-01

To examine the potential efficacy and specific timing of treatment response of individual child and parent trauma-focused cognitive-behavioral therapy for childhood traumatic grief (CTG), a condition in which trauma symptoms impinge on the child's ability to successfully address the normal tasks of grieving. Twenty-two children and their primary caretakers received a manual-based 16-week treatment with sequential trauma- and grief-focused interventions. Children experienced significant improvements in CTG, posttraumatic stress disorder (PTSD), depressive, anxiety, and behavioral problems, with PTSD symptoms improving only during the trauma-focused treatment components and CTG improving during both trauma- and grief-focused components. Participating parents also experienced significant improvement in PTSD and depressive symptoms. The timing of improvements in CTG and PTSD symptoms lends support to providing sequential trauma- and grief-focused interventions and to the concept that CTG is related to but distinct from PTSD. The results also suggest the benefit of individual treatment for CTG and for including parents in the treatment of CTG. Randomized, controlled trials are needed to further test the efficacy of this treatment model.

Prior trauma exposure and serious illness at end of life: A national study of children in the US foster care system from 2005 to 2015.

PubMed

Lindley, Lisa C; Slayter, Elspeth M

2018-06-08

Children in foster care suffer with serious illness at end of life. However, the relationship between prior trauma exposure and serious illness has received little empirical attention. The objectives were to examine the prevalence and type of trauma exposure, and investigate the relationship between prior trauma and serious illness among foster children at end of life. We used national longitudinal foster care data. We included children who were less than 18 years with residence in the United States. Serious illness (i.e., physical health, mental/behavioral health, developmental disabilities) was measured via the foster care files. Three measures of prior trauma exposure (i.e., maltreatment, drug/alcohol exposure, psychosocial stressors) were created. Using multivariate logistic regressions, we evaluated the influence of prior trauma on serious illness at end of life, while controlling for demographic, geographic, and foster care support characteristics. Sixty-eight percent of children experienced maltreatment, 28% exposure to parental drug/alcohol misuse, and 39% psychosocial stressors prior to entering foster care. Maltreatment was positively associated with physical health and developmental disabilities, while parental drug/alcohol exposure was inversely related to developmental disabilities. Psychosocial stressors contributed to the prediction of poor physical, mental, and developmental health. These findings suggest that trauma-informed end-of-life care may be a critical need among children in foster care with serious illness. Future directions are discussed, including collaboration between end-of-life clinicians and social service workers and the importance of future research to understand and improve the quality of health at end of life for this underserved population. Copyright © 2018. Published by Elsevier Inc.

Trauma surgeon becomes consultant: evaluation of a protocol for management of intermediate-level trauma patients.

PubMed

Fallon, Sara C; Delemos, David; Christopher, Daniel; Frost, Mary; Wesson, David E; Naik-Mathuria, Bindi

2014-01-01

At our level 1 pediatric trauma center, 9-54 intermediate-level ("level 2") trauma activations are received per month. Previously, the surgery team was required to respond to and assume responsibility for all patients who had "level 2" trauma activations. In 8/2011, we implemented a protocol where the emergency room (ER) physician primarily manages these patients with trauma consultation for surgical evaluation or admission. The purpose of this study was to prospectively evaluate the effects of the new protocol to ensure that patient safety and quality of care were maintained. We compared outcomes of patients treated PRE-implementation (10/2010-7/2011) and POST-implementation (9/2011-5/2012), including surgeon consultation rate, utilization of imaging and laboratory testing, ER length of stay, admission rate, and missed injuries or readmissions. Statistical analysis included chi-square and Student's t-test. We identified 472 patients: 179 in the PRE and 293 in the POST period. The populations had similar baseline clinical characteristics. The surgical consultation rate in the POST period was only 42%, with no missed injuries or readmissions. The ER length of stay did not change. However, in the POST period there were significant decreases in the admission rate (73% to 44%) and the mean number of CT scans (1.4 to 1), radiographs (2.4 to 1.7), and laboratory tests (5.1 to 3.3) ordered in the emergency room (all p<0.001). Intermediate-level pediatric trauma patients can be efficiently and safely managed by pediatric emergency room physicians, with surgical consultation only as needed. The protocol change improved resource utilization by decreasing testing and admissions and streamlining resident utilization in an era of reduced duty hours. © 2014.

In view of standardization: comparison and analysis of initial management of severely burned patients in Germany, Austria and Switzerland.

PubMed

Münzberg, Matthias; Ziegler, Benjamin; Fischer, Sebastian; Wölfl, Christoph Georg; Grützner, Paul Alfred; Kremer, Thomas; Kneser, Ulrich; Hirche, Christoph

2015-02-01

Initial treatment of severely injured patients in German speaking trauma centers follows precise sequences. Several guidelines and training courses ensure a constant quality in providing evidence-based treatment for these patients. Similar standards, algorithms and guidelines for the treatment of severely burned patients are lacking. This raises the question about the current standard of care for burn victims in German speaking burn centers. In order to achieve standardization, as a first step this study surveys principles of burn room organization and management in these burn centers. A questionnaire including 40 questions regarding burn room organization, personnel structure and qualification, infrastructural conditions and quality management was developed and sent to 21 level one burn centers in Germany, Austria and Switzerland. The rate of returned questionnaires was 81%. The analysis revealed varying personnel and infrastructural conditions in participating burn centers. Indications for admission to the burn room and admission procedures itself are different throughout surveyed hospitals. Individual standard operating procedure (SOP) for burn trauma admissions was available in most burn centers and nearly all participants register their burn trauma cases using an in-house burn register. The survey suggests a lack of standardization in personnel structure, infrastructure and treatment approach for the initial clinical care of severely burned patients in burn centers across the German speaking countries. Further evaluation of existing protocols and international standards in burn care is inevitable to develop standardized guidelines for burn care and to improve quality of care. Copyright © 2014 Elsevier Ltd and ISBI. All rights reserved.

Hospital fundamentals.

PubMed

Althausen, Peter L; Hill, Austin D; Mead, Lisa

2014-07-01

Under the current system, orthopaedic trauma surgeons must work in some form of hospital setting as our primary service involves treatment of the trauma patient. We must not forget that just as a trauma center cannot exist without our services, we cannot function without their support. As a result, a clear understanding of the balance between physicians and hospitals is paramount. Historical perspective enables physicians and hospital personnel alike to understand the evolution of hospital-physician relationship. This process should be understood upon completion of this chapter. The relationship between physicians and hospitals is becoming increasingly complex and multiple forms of integration exist such as joint ventures, gain sharing, and co-management agreements. For the surgeon to negotiate well, an understanding of hospital governance and the role of the orthopaedic traumatologist is vital to success. An understanding of the value provided by the traumatologist includes all aspects of care including efficiency, availability, cost effectiveness, and research activities. To create effective and sustainable healthcare institutions, physicians and hospitals must be aligned over a sustained period of time. Unfortunately, external forces have eroded the historical basis for the working relationship between physicians and hospitals. Increased competition and reimbursement cuts, coupled with the increasing demands for quality, efficiency, and coordination and the payment changes outlined in healthcare reform, have left many organizations wondering how to best rebuild the relationship. The principal goal for the physician when partnering with a hospital or healthcare entity is to establish a sustainable model of service line management that protects or advances the physician's ability to make impactful improvements in quality of patient care, decreases in healthcare costs, and improvements in process efficiency through evidence-based practices and protocols.

Cardiac Trauma.

PubMed

Gosavi, Sucheta; Tyroch, Alan H; Mukherjee, Debabrata

2016-11-01

Cardiac trauma is a leading cause of death in the United States and occurs mostly due to motor vehicle accidents. Blunt cardiac trauma and penetrating chest injuries are most common, and both can lead to aortic injuries. Timely diagnosis and early management are the key to improve mortality. Cardiac computed tomography and cardiac ultrasound are the 2 most important diagnostic modalities. Mortality related to cardiac trauma remains high despite improvement in diagnosis and management.

Predictors of mental health and quality of life in male tortured refugees.

PubMed

Carlsson, Jessica M; Mortensen, Erik L; Kastrup, Marianne

2006-01-01

Some of the most frequently reported mental health problems in traumatized refugees are depression, anxiety and post-traumatic stress disorder (PTSD). The aim of this paper is to describe a group of tortured refugees referred to the Rehabilitation and Research Centre for Torture Victims (RCT) and to study the importance of past trauma/torture and post-migratory factors for the present symptoms of PTSD, depression, anxiety and for health-related quality of life. The sample comprises 63 male tortured refugees admitted to a pre-treatment assessment at RCT. Data on personal background, trauma, present situation in Denmark, symptoms of depression, anxiety (Hopkins Symptom Checklist-25, HSCL-25, and Hamilton Depression Scale, HDS), PTSD (Harvard Trauma Questionnaire, HTQ), and on health-related quality of life (WHO Quality of life-Bref, WHOQOL-Bref) were collected through self-administered questionnaires and structured and semi-structured interviews. The scores in the questionnaires measuring emotional distress were high. Previous torture and trauma, lower education, fewer social contacts, no occupation and pain were identified as significant predictors of emotional distress. Few social contacts was a significant predictor of a lower health-related quality of life. Even after many years, past torture is significantly associated with emotional distress. Post-migratory factors are also significantly associated with emotional distress and health-related quality of life, and potentially modifiable factors, such as social relations and occupation, are of special interest.

Imagery rescripting and eye movement desensitisation and reprocessing for treatment of adults with childhood trauma-related post-traumatic stress disorder: IREM study design.

PubMed

Boterhoven de Haan, Katrina L; Lee, Christopher W; Fassbinder, Eva; Voncken, Marisol J; Meewisse, Mariel; Van Es, Saskia M; Menninga, Simone; Kousemaker, Margriet; Arntz, Arnoud

2017-05-04

Post-traumatic stress disorder (PTSD) that originates from childhood trauma experiences can develop into a chronic condition that has lasting effects on an individual's functioning and quality of life. While there are evidence-based guidelines for treating adult onset PTSD, treatments for adults with childhood trauma-related PTSD (Ch-PTSD) are varied and subject to ongoing debate. This study will test the effectiveness of two trauma-focused treatments, imagery rescripting (ImRs) and eye movement desensitisation and reprocessing (EMDR) in participants with Ch-PTSD. Both have been found effective in treatment of adult PTSD or mixed onset PTSD and previous research indicates they are well-tolerated treatments. However, we know less about their effectiveness for treating Ch-PTSD or their underlying working mechanisms. IREM is an international multicentre randomised controlled trial involving seven sites across Australia, Germany and the Netherlands. We aim to recruit 142 participants (minimum of n = 20 per site), who will be randomly assigned to treatment condition. Assessments will be conducted before treatment until 1-year follow-up. Assessments before and after the waitlist will assess change in time only. The primary outcome measure is change in PTSD symptom severity from pre-treatment to 8-weeks post-treatment. Secondary outcome measures include change in severity of depression, anger, trauma-related cognitions, guilt, shame, dissociation and quality of life. Underlying mechanisms of treatment will be assessed on changes in vividness, valence and encapsulated belief of a worst trauma memory. Additional sub-studies will include qualitative investigation of treatment experiences from the participant and therapists' perspective, changes in memory and the impact of treatment fidelity on outcome measures. The primary aims of this study are to compare the effectiveness of EMDR and ImRs in treating Ch-PTSD and to investigate the underlying working mechanisms of the two treatments. The large-scale international design will make a significant contribution to our understanding of how these treatments address the needs of individuals with Ch-PTSD and therefore, potentially improve their effectiveness. Australian New Zealand Clinical Trials Registry ACTRN12614000750684 . Registered 16 July 2014.

[The efficiency of emergency therapy in patients with head-brain, multiple injury. Quality assurance in emergency medicine].

PubMed

Schüttler, J; Schmitz, B; Bartsch, A C; Fischer, M

1995-12-01

For cardio-pulmonary resuscitation there are standardized treatment concepts, but there have been few prospective investigations examining the efficacy of prehospital advanced trauma life support and its effect on the outcome in patients with severe head injury and multiple trauma treated within the German emergency system. The results of this study underline the importance of intensive prehospital treatment and highlight some problems that should be taken into account in future in the training of emergency physicians. METHODS. A total of 179 patients with cerebral trauma were investigated. Data obtained included demographic and logistic data of the patients and the emergency physicians, diagnoses and treatment at the scene of the accident and state of the patient on admission in each case. Having divided the patients into three groups by severity of the trauma, we distinguished between sufficient and insufficient treatment and assessed infusion therapy, ventilatory support, positioning and immobilization, and analgesic and sedative therapy. For statistical analysis of the data we used chi 2-test and Fisher's exact test. P < 0.05 was considered significant. RESULTS. There were 102 patients who had sustained a cerebral trauma without other life-threatening lesions (score 1), 40 with multiple trauma (score 2) and 37 with multiple trauma (score 3). On average 2.4 IV lines were established and the patients received 1186 +/- 765 cc of crystalloid in addition to 801 +/- 411 cc of colloid fluids. In all groups, patients who received adequate infusion therapy had a better outcome; even in the group with score 1 significantly fewer had a fatal outcome. In all, 167 (93%) patients had endotracheal tubes placed, and in 150 cases (84%) ventilatory therapy was considered sufficient. The proportion of score 1 patients with sufficient ventilatory support who had a fatal outcome was significantly lower than that in the group with insufficient treatment. In patients with multiple trauma we could not separate the benefits of sufficient respiratory therapy and infusion therapy. In only 54% of the cases a vacuum mattress was used and in only 41% the patients were positioned with the upper part of the body elevated by 30 degrees. These were 28 patients (16%) who received neither analgesics nor sedatives. Regardless of the quality of prehospital treatment of isolated head injury, a Glasgow Coma Scale (GCS) score lower than 5 involved a very high mortality and all patients with a GCS score of 9 or more survived. In the group with GCS scores between 5 and 8, however, significantly more of the patients who received adequate treatment survived (82.5% vs 40%). CONCLUSIONS. The present study confirms that sufficient advanced trauma life support can improve the outcome of trauma victims with cerebral trauma. Adequate infusion and respiratory therapy reduce the mortality among such patients significantly. In patients with multiple trauma a clear positive effect of generous infusion therapy also is evident. The clearest effect of sufficient prehospital treatment is seen in patients with isolated cerebral trauma and a GCS score between 5 and 8. These results demonstrate the importance of advanced trauma life support and show emphatically that the so-called scoop-and-run strategy should be abandoned when resources are available for extended preclinical emergency treatment. On the other hand, we detected some problem areas in the prehospital treatment of trauma victims, such as positioning, immobilization and drug therapy with analgesics and sedatives. These findings allow us to pinpoint specific points that should be stressed in the training of emergency physicians and paramedics.

Which future for traumatology in Europe?

PubMed

Rommens, P M

2014-01-01

The last decades have been characterized by rapid changes in society, medicine and surgery. There is a distinct evolution towards specialization and super-specialization. Trauma surgery also evolves towards a specialty, focused on the care of the injured. To optimize the quality of care and meet the needs of patients and care providers, a well-structured trauma surgery training program as well as the regionalization of trauma care with the implementation of Level I trauma centers are needed. The core competence of the European trauma surgeon is the coordination of the early management of the severely injured and the treatment of muskuloskeletal trauma, which represent the most common pathologies in our countries.

The experience of linking Victorian emergency medical service trauma data

PubMed Central

Boyle, Malcolm J

2008-01-01

Background The linking of a large Emergency Medical Service (EMS) dataset with the Victorian Department of Human Services (DHS) hospital datasets and Victorian State Trauma Outcome Registry and Monitoring (VSTORM) dataset to determine patient outcomes has not previously been undertaken in Victoria. The objective of this study was to identify the linkage rate of a large EMS trauma dataset with the Department of Human Services hospital datasets and VSTORM dataset. Methods The linking of an EMS trauma dataset to the hospital datasets utilised deterministic and probabilistic matching. The linking of three EMS trauma datasets to the VSTORM dataset utilised deterministic, probabilistic and manual matching. Results There were 66.7% of patients from the EMS dataset located in the VEMD. There were 96% of patients located in the VAED who were defined in the VEMD as being admitted to hospital. 3.7% of patients located in the VAED could not be found in the VEMD due to hospitals not reporting to the VEMD. For the EMS datasets, there was a 146% increase in successful links with the trauma profile dataset, a 221% increase in successful links with the mechanism of injury only dataset, and a 46% increase with sudden deterioration dataset, to VSTORM when using manual compared to deterministic matching. Conclusion This study has demonstrated that EMS data can be successfully linked to other health related datasets using deterministic and probabilistic matching with varying levels of success. The quality of EMS data needs to be improved to ensure better linkage success rates with other health related datasets. PMID:19014622

Trauma memory characteristics and the development of acute stress disorder and post-traumatic stress disorder in youth.

PubMed

McKinnon, A; Brewer, N; Meiser-Stedman, R; Nixon, R D V

2017-03-01

The present study addresses gaps in knowledge regarding the association between trauma memory processes and posttraumatic stress responses in youth. Our primary goal was to explore the relative contribution of perceptions of trauma memory quality versus narrative trauma memory characteristics to explain overall adjustment. Children (N = 67) were interviewed within four weeks (T1) of an injury leading to hospital treatment and then again eight weeks later (T2). In each interview, the child told a trauma narrative (which were later coded), and answered the Trauma Memory Quality Questionnaire (Meiser-Stedman, Smith, Yule, & Dalgleish, 2007a), a self-report measure indexing the sensory, fragmented, and disorganised characteristics of trauma memory. They then completed measures of Acute Stress Disorder (ASD) symptoms and associated psychopathology at T1 and measures of Posttraumatic Stress (PTS) symptoms and associated psychopathology at T2. Self-reported trauma memory characteristics predicted ASD symptoms cross-sectionally at T1 and PTS symptoms prospectively over time. At both time points, self-reported trauma memory characteristics accounted for all of the unique variance in symptoms initially explained by narrative characteristics. A reduction in self-report ratings, but not the hypothesised narrative features (e.g., disorganised or lexical elements of the narrative), significantly predicted a reduction in PTS symptoms over time. The small sample size and the absence of a within-subjects narrative control were the main limitations of the study. These findings underscore the importance of self-reported trauma memory characteristics to the aetiology of PTSD. Copyright © 2016 Elsevier Ltd. All rights reserved.

Trauma Sequelae are Uniquely Associated with Components of Self-Reported Sleep Dysfunction in OEF/OIF/OND Veterans.

PubMed

DeGutis, Joseph; Chiu, Christopher; Thai, Michelle; Esterman, Michael; Milberg, William; McGlinchey, Regina

2018-01-01

While the associations between psychological distress (e.g., posttraumatic stress disorder [PTSD], depression) and sleep dysfunction have been demonstrated in trauma-exposed populations, studies have not fully explored the associations between sleep dysfunction and the wide range of common physical and physiological changes that can occur after trauma exposure (e.g., pain, cardiometabolic risk factors). We aimed to clarify the unique associations of psychological and physical trauma sequelae with different aspects of self-reported sleep dysfunction. A comprehensive psychological and physical examination was administered to 283 combat-deployed trauma-exposed Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) veterans. The Pittsburgh Sleep Quality Index (PSQI) and PSQI Addendum for PSTD (PSQI-A) were administered along with measures of PTSD, depression, anxiety, pain, traumatic brain injury, alcohol use, nicotine dependence, and cardiometabolic symptoms. We first performed a confirmatory factor analysis of the PSQI and then conducted regressions with the separate PSQI factors as well as the PSQI-A to identify unique associations between trauma-related measures and the separate aspects of sleep. We found that the PSQI global score was composed of three factors: Sleep Efficiency (sleep efficiency/sleep duration), Perceived Sleep Quality (sleep quality/sleep latency/sleep medication) and Daily Disturbances (sleep disturbances/daytime dysfunction). Linear regressions demonstrated that PTSD symptoms were uniquely associated with the PSQI global score and all three factors, as well as the PSQI-A. For the other psychological distress variables, anxiety was independently associated with PSQI global as well as Sleep Efficiency, Perceived Sleep Quality, and PSQI-A, whereas depression was uniquely associated with Daily Disturbances and PSQI-A. Notably, cardiometabolic symptoms explained independent variance in PSQI global and Sleep Efficiency. These findings help lay the groundwork for further investigations of the mechanisms of sleep dysfunction in trauma-exposed individuals and may help in the development of more effective, individualized treatments.

Effects of advanced life support versus basic life support on the mortality rates of patients with trauma in prehospital settings: a study protocol for a systematic review and meta-analysis

PubMed Central

Kondo, Yutaka; Fukuda, Tatsuma; Uchimido, Ryo; Hifumi, Toru; Hayashida, Kei

2017-01-01

Introduction Advanced life support (ALS) is thought to be associated with improved survival in prehospital trauma care when compared with basic life support (BLS). However, evidence on the benefits of prehospital ALS for patients with trauma is controversial. Therefore, we aim to clarify if ALS improves mortality in patients with trauma when compared with BLS by conducting a systematic review and meta-analysis of the recent literature. Methods and analysis We will perform searches in PubMed, Embase and the Cochrane Central Register of Controlled Trials for published observational studies, controlled before-and-after studies, randomised controlled trials and other controlled trials conducted in humans and published until March 2017. We will screen search results, assess study selection, extract data and assess the risk of bias in duplicate; disagreements will be resolved through discussions. Data from clinically homogeneous studies will be pooled using a random-effects meta-analysis, heterogeneity of effects will be assessed using the χ2 test of homogeneity, and any observed heterogeneity will be quantified using the I2 statistic. Last, the Grading of Recommendations Assessment, Development and Evaluation approach will be used to rate the quality of the evidence. Ethics and dissemination Our study does not require ethical approval as it is based on findings of previously published articles. Results will be disseminated through publication in a peer-reviewed journal, presentations at relevant conferences and publications for patient information. Trial registration number PROSPERO (International Prospective Register of Systematic Reviews) registration number CRD42017054389. PMID:29061611

Factors Influencing the Relationship between Sexual Trauma and Risky Sexual Behavior in College Students

ERIC Educational Resources Information Center

Johnson, Nicole L.; Johnson, Dawn M.

2013-01-01

While the relationship between sexual trauma and risky sexual behavior (RSB) has received much attention, only a handful of studies have investigated the factors that protect victims of sexual trauma from developing this maladaptive pattern of behavior. The current study investigated the protective role of social support, quality and quantity, in…

The Effects of Traumatic Stressors and HIV-Related Trauma Symptoms on Health and Health Related Quality of Life

PubMed Central

Sher, Tamara G.; Mattson, Melissa; Thilges, Sarah; Hansen, Nathan B.

2012-01-01

The study identified relations among traumatic stressors, HIV-related trauma symptoms, comorbid medical conditions, and health related quality of life (HRQL) in individuals with HIV. Participants (N = 118) completed a structured clinical interview on HIV as a traumatic stressor and other severe traumatic stressors and completed the Impact of Event Scale to assess HIV-related trauma symptoms and the Medical Outcomes Study 36-item Short Form (SF-36) to assess HRQL. Medical chart reviews determined comorbid conditions. Path analysis findings indicated participants with prior severe traumatic stressors experienced their HIV diagnosis as traumatic and in turn were more likely to have current HIV-related trauma symptoms which were negatively related to HRQL. HIV as a traumatic stressor was related to coronary artery diseases and HRQL. Traumatic stressors and HIV-related trauma symptoms impact health in individuals with HIV and highlight the need for psychological interventions prior to diagnosis and throughout treatment. PMID:21667297

Dose reduction in whole-body computed tomography of multiple injuries (DoReMI): protocol for a prospective cohort study

PubMed Central

2014-01-01

Background Single-pass, contrast-enhanced whole body multidetector computed tomography (MDCT) emerged as the diagnostic standard for evaluating patients with major trauma. Modern iterative image algorithms showed high image quality at a much lower radiation dose in the non-trauma setting. This study aims at investigating whether the radiation dose can safely be reduced in trauma patients without compromising the diagnostic accuracy and image quality. Methods/Design Prospective observational study with two consecutive cohorts of patients. Setting: A high-volume, academic, supra-regional trauma centre in Germany. Study population: Consecutive male and female patients who 1. had been exposed to a high-velocity trauma mechanism, 2. present with clinical evidence or high suspicion of multiple trauma (predicted Injury Severity Score [ISS] ≥16) and 3. are scheduled for primary MDCT based on the decision of the trauma leader on call. Imaging protocols: In a before/after design, a consecutive series of 500 patients will undergo single-pass, whole-body 128-row multi-detector computed tomography (MDCT) with a standard, as low as possible radiation dose. This will be followed by a consecutive series of 500 patients undergoing an approved ultra-low dose MDCT protocol using an image processing algorithm. Data: Routine administrative data and electronic patient records, as well as digital images stored in a picture archiving and communications system will serve as the primary data source. The protocol was approved by the institutional review board. Main outcomes: (1) incidence of delayed diagnoses, (2) diagnostic accuracy, as correlated to the reference standard of a synopsis of all subsequent clinical, imaging, surgical and autopsy findings, (3) patients’ safety, (4) radiation exposure (e.g. effective dose), (5) subjective image quality (assessed independently radiologists and trauma surgeons on a 100-mm visual analogue scale), (6) objective image quality (e.g., contrast-to-noise ratio). Analysis: Multivariate regression will be employed to adjust and correct the findings for time and cohort effects. An exploratory interim analysis halfway after introduction of low-dose MDCT will be conducted to assess whether this protocol is clearly inferior or superior to the current standard. Discussion Although non-experimental, this study will generate first large-scale data on the utility of imaging-enhancing algorithms in whole-body MDCT for major blunt trauma. Trial registration Current Controlled Trials ISRCTN74557102. PMID:24589310

Comparing traditional and novel injury scoring systems in a US level-I trauma center: an opportunity for improved injury surveillance in low- and middle-income countries.

PubMed

Laytin, Adam D; Dicker, Rochelle A; Gerdin, Martin; Roy, Nobhojit; Sarang, Bhakti; Kumar, Vineet; Juillard, Catherine

2017-07-01

In most low- and middle-income countries (LMICs), the resources to accurately quantify injury severity using traditional injury scoring systems are limited. Novel injury scoring systems appear to have adequate discrimination for mortality in LMIC contexts, but they have not been rigorously compared where traditional injury scores can be accurately calculated. To determine whether novel injury scoring systems perform as well as traditional ones in a HIC with complete and comprehensive data collection. Data from an American level-I trauma registry collected 2008-2013 were used to compare three traditional injury scoring systems: Injury Severity Score (ISS); Revised Trauma Score (RTS); and Trauma Injury Severity Score (TRISS); and three novel injury scoring systems: Kampala Trauma Score (KTS); Mechanism, GCS, Age and Pressure (MGAP) score; and GCS, Age and Pressure (GAP) score. Logistic regression was used to assess the association between each scoring system and mortality. Standardized regression coefficients (β 2 ), Akaike information criteria, area under the receiver operating characteristics curve, and the calibration line intercept and slope were used to evaluate the discrimination and calibration of each model. Among 18,746 patients, all six scores were associated with hospital mortality. GAP had the highest effect size, and KTS had the lowest median Akaike information criteria. Although TRISS discriminated best, the discrimination of KTS approached that of TRISS and outperformed GAP, MGAP, RTS, and ISS. MGAP was best calibrated, and KTS was better calibrated than RTS, GAP, ISS, or TRISS. The novel injury scoring systems (KTS, MGAP, and GAP), which are more feasible to calculate in low-resource settings, discriminated hospital mortality as well as traditional injury scoring systems (ISS and RTS) and approached the discrimination of a sophisticated, data-intensive injury scoring system (TRISS) in a high-resource setting. Two novel injury scoring systems (KTS and MGAP) surpassed the calibration of TRISS. These novel injury scoring systems should be considered when clinicians and researchers wish to accurately account for injury severity. Implementation of these resource-appropriate tools in LMICs can improve injury surveillance, guiding quality improvement efforts, and supporting advocacy for resource allocation commensurate with the volume and severity of trauma. Copyright © 2017 Elsevier Inc. All rights reserved.

RADIOLOGY EDUCATION: A PILOT STUDY TO ASSESS KNOWLEDGE OF MEDICAL STUDENTS REGARDING IMAGING IN TRAUMA.

PubMed

Siddiqui, Saad; Saeed, Muhammad Anwar; Shah, Noreen; Nadeem, Naila

2015-01-01

Trauma remains one of the most frequent presentations in emergency departments. Imaging has established role in setting of acute trauma with ability to identify potentially fatal conditions. Adequate knowledge of health professionals regarding trauma imaging is vital for improved healthcare. In this work we try to assess knowledge of medical students regarding imaging in trauma as well as identify most effective way of imparting radiology education. This cross-sectional pilot study was conducted at Aga Khan University Medical College & Khyber Girls Medical College, to assess knowledge of medical students regarding imaging protocols practiced in initial management of trauma patients. Only 40 & 20% respectively were able to identify radiographs included in trauma series. Very few had knowledge of correct indication for Focused abdominal sonography in trauma. Clinical radiology rotation was reported as best way of learning radiology. Change in curricula & restructuring of clinical radiology rotation structure is needed to improve knowledge regarding Trauma imaging.

Psychosocial rehabilitation after war trauma with adaptive disclosure: Design and rationale of a comparative efficacy trial.

PubMed

Yeterian, Julie D; Berke, Danielle S; Litz, Brett T

2017-10-01

Posttraumatic stress disorder (PTSD) from warzone exposure is associated with chronic and disabling social and occupational problems. However, functional impairment is rarely assessed or targeted directly in PTSD treatments, which instead focus on symptom reduction. Trauma-related contributors to diminished functioning, including guilt, shame, and anger resulting from morally compromising or loss-based war experiences, are also underemphasized. The goal of this clinical trial is to fill a substantial gap in the treatment of military-related PTSD by testing a modified Adaptive Disclosure (AD) therapy for war-related PTSD stemming from moral injury and traumatic loss focused on improving psychosocial functioning AD. This paper describes the rationale and design of a multi-site randomized controlled trial comparing AD to Present-Centered Therapy (PCT). We will recruit 186 veterans with PTSD, who will be assessed at baseline, post-treatment, and 3- and 6-months post-treatment. Primary outcomes are functional changes (i.e., functioning/disability and quality of life). Secondary outcomes are mental health variables (i.e., PTSD, depression, guilt, shame). We hypothesize that veterans treated with AD will experience greater improvements in all outcomes compared to those treated with PCT. This trial will advance knowledge in rehabilitation research by testing the first therapy specifically designed to address psychosocial functioning among veterans with war-related PTSD. The results may improve the quality of mental health care for veterans by offering an ecologically sound treatment for experiences that are uniquely impactful for war veterans. Published by Elsevier Inc.

Advanced Practitioners Are Peers in Trauma Performance Improvement Peer Review.

PubMed

Collins, Tara Ann; Sicoutris, Corinna P; McNicholas, Amanda; Krumrie, Nicole; Eddinger, Abby; Fernandez, Forrest B; Schwab, C William; Reilly, Patrick M; Kim, Patrick K

2016-01-01

Advanced practitioners (APs) have been successfully integrated into the clinical care of injured patients. Given the expanding role of APs in trauma care, we hypothesized that APs can perform Performance Improvement and Patient Safety (PIPS) peer review at a level comparable with trauma surgeons. For Phase 1, cases previously reviewed by a trauma surgeon were randomly selected by the PIPS coordinator and peer reviewed by an AP. The trauma surgeons' and APs' reviews were compared. For Phase 2, cases requiring concurrent review were peer reviewed by both an AP and an MD, who were blinded to each other's review. Both the APs' and trauma surgeons' reviews of the same medical record were presented at a bimonthly performance improvement (PI) meeting. In Phase 1, 46 PI cases were reviewed including 22 deaths. Trauma surgeons and APs had high concordance (96.0%) regarding appropriateness or inappropriateness of care (κ = 0.774). Among disagreements, APs were 3 times more likely than trauma surgeons to determine care to be inappropriate. Trauma surgeons and APs had similarly high concordance (95.5%) regarding preventability of mortality (κ = 0.861). In Phase 2, 38 PI cases were reviewed, including 31 deaths. Trauma surgeons and APs had high concordance (89.0%) regarding appropriateness or inappropriateness of care (κ = 0.585). Among disagreements, trauma surgeons and APs had similarly high concordance (86.2%) regarding preventability of mortality (κ = 0.266). We found that APs had high concordance with trauma surgeons regarding medical record reviews and are thus able to effectively review medical records for the purposes of PIPS.

Surgical treatment of multiple rib fractures and flail chest in trauma: a one-year follow-up study.

PubMed

Caragounis, Eva-Corina; Fagevik Olsén, Monika; Pazooki, David; Granhed, Hans

2016-01-01

Multiple rib fractures and unstable thoracic cage injuries are common in blunt trauma. Surgical management of rib fractures has received increasing attention in recent years and the aim of this 1-year, prospective study was to assess the long-term effects of surgery. Fifty-four trauma patients with median Injury Severity Score 20 (9-66) and median New Injury Severity Score 34 (16-66) who presented with multiple rib fractures and flail chest, and underwent surgical stabilization with plate fixation were recruited. Patients responded to a standardized questionnaire concerning pain, local discomfort, breathlessness and use of analgesics and health-related quality of life (EQ-5D-3 L) questionnaire at 6 weeks, 3 months, 6 months and 1 year. Lung function, breathing movements, range of motion and physical function were measured at 3 months, 6 months and 1 year. Symptoms associated with pain, breathlessness and use of analgesics significantly decreased from 6 weeks to 1 year following surgery. After 1 year, 13 % of patients complained of pain at rest, 47 % had local discomfort and 9 % used analgesics. The EQ-5D-3 L index increased from 0.78 to 0.93 and perceived overall health state increased from 60 to 90 % (p < 0.0001) after 6 weeks to 1 year. Lung function improved significantly with predicted Forced vital capacity and Peak expiratory flow increasing from 86 to 106 % (p = 0.0002) and 81 to 110 % (p < 0.0001), respectively, from 3 months to 1 year after surgery. Breathing movements and range of motion tended to improve over time. Physical function improved significantly over time and the median Disability rating index was 0 after 1 year. Patients with multiple rib fractures and flail chest show a gradual improvement in symptoms associated with pain, quality of life, mobility, disability and lung function over 1 year post surgery. Therefore, the final outcome of surgery cannot be assessed before 1 year post-operatively.

Surgical plate fixation of multiple rib fractures: a case report.

PubMed

Mitev, Konstantin; Neziri, Dashurie; Stoicovski, Emil; Mitrev, Zan

2018-05-29

The healthcare system in developing countries is limited; particularly, medical specialties such as emergency and trauma medicine are underdeveloped. Consequently, trauma injuries sustained in traffic accidents result in chronic morbidity more often than similar cases in developed countries. Multiple rib fractures induce significant patient morbidity. Current international guidelines recommend a multidisciplinary, surgery-based treatment approach to achieve optimal clinical benefit. We admitted a 41-year-old Albanian man to our emergency department following a pedestrian-vehicle accident 5 days earlier. He presented with severe upper thoracic pain, chest deformity, dyspnea, tachycardia, subcutaneous emphysema, and hematoma. Chest radiography pointed to hypoventilated lung fields and a minor pleural effusion. Computed tomographic scans indicated displaced fractures of right lateral ribs 5 -11, hyperdensity regions from bone fragments, and pulmonary contusion. The treatment consisted of surgical fixation of ribs 7-10 using titanium reconstruction plates and cortical locking screws. The patient's clinical condition rapidly improved postoperatively. Follow-up at 6 weeks confirmed a full return to preoperative daily activities and a high quality of life. In this case report, we present a novel and promising development in the field of trauma medicine in the Republic of Macedonia. Trauma injuries can be treated via advanced multidisciplinary medical care according to international standards, allowing optimal health recovery.

Abdominal trauma in infants and children: prompt identification and early management of serious and life-threatening injuries. Part II: Specific injuries and ED management.

PubMed

Rothrock, S G; Green, S M; Morgan, R

2000-06-01

Evaluation of children with suspected abdominal trauma could be a difficult task. Unique anatomic and physiologic features render vital sign assessment and the physical examination less useful than in the adult population. Awareness of injury patterns and associations will improve the early diagnosis of abdominal trauma. Clinicians must have a complete understanding of common and atypical presentations of children with significant abdominal injuries. Knowledge of the utility and limitations of available laboratory and radiologic adjuncts will assist in accurately identifying abdominal injury. While other obvious injuries (eg, facial, cranial, and extremity trauma) can distract physicians from less obvious abdominal trauma, an algorithmic approach to evaluating and managing children with multisystem trauma will improve overall care and help to identify and treat abdominal injuries in a timely fashion. Finally, physicians must be aware of the capabilities of their own facility to handle pediatric trauma. Protocols must be in place for expediting the transfer of children who require a higher level of care. Knowledge of each of these areas will help to improve the overall care and outcome of children with abdominal trauma.

Evaluating the long-term impact of the Trauma Team Training course in Guyana: an explanatory mixed-methods approach.

PubMed

Pemberton, Julia; Rambaran, Madan; Cameron, Brian H

2013-02-01

We evaluated the retention of trauma knowledge and skills after an interprofessional Trauma Team Training (TTT) course in Guyana and explored the course impact on participants. A mixed-methods design evaluated knowledge using a multiple-choice quiz test, skills and trauma moulage simulation with checklists, and course impact with qualitative interviews. Participants were evaluated at 3 time points; before, after, and 4 months after TTT. Forty-seven course participants included 20 physicians, 17 nurses, and 10 paramedical providers. All participants had improved multiple-choice quiz test scores after the course and retained knowledge after 4 months, with nonphysicians showing the most improved scores. Trauma skill and moulage scores declined slightly after 4 months, with the greatest decline observed in complex skills. Qualitatively, course participants self-reported impact of the TTT course included improved empowerment, knowledge, teamwork, and patient care. Interprofessional team-based training led to the retention of trauma knowledge and skills as well as the empowerment of nonphysicians. The decline in performance of some trauma skills indicates the need for a regular trauma update course. Copyright © 2013 Elsevier Inc. All rights reserved.

The impact of major trauma network triage systems on patients with major burns.

PubMed

Nizamoglu, Metin; O'Connor, Edmund Fitzgerald; Bache, Sarah; Theodorakopoulou, Evgenia; Sen, Sankhya; Sherren, Peter; Barnes, David; Dziewulski, Peter

2016-12-01

Trauma is a leading cause of death and disability worldwide. Patients presenting with severe trauma and burns benefit from specifically trained multidisciplinary teams. Regional trauma systems have shown improved outcomes for trauma patients. The aim of this study is to determine whether the development of major trauma systems have improved the management of patients with major burns. A retrospective study was performed over a four-year period reviewing all major burns in adults and children received at a regional burns centre in the UK before and after the implementation of the regional trauma systems and major trauma centres (MTC). Comparisons were drawn between three areas: (1) Patients presenting before the introduction of MTC and after the introduction of MTC. (2) Patients referred from MTC and non-MTC within the region, following the introduction of MTC. (3) Patients referred using the urban trauma protocol and the rural trauma protocol. Following the introduction of regional trauma systems and major trauma centres (MTC), isolated burn patients seen at our regional burns centre did not show any significant improvement in transfer times, admission resuscitation parameters, organ dysfunction or survival when referred from a MTC compared to a non-MTC emergency department. There was also no significant difference in survival when comparing referrals from all hospitals pre and post establishment of the major trauma network. No significant outcome benefit was demonstrated for burns patients referred via MTCs compared to non-MTCs. We suggest further research is needed to ascertain whether burns patients benefit from prolonged transfer times to a MTC compared to those seen at their local hospitals prior to transfer to a regional burns unit for further specialist care. Copyright © 2016 Elsevier Ltd and ISBI. All rights reserved.

PubMed

Aléx, Jonas; Gyllencreutz, Lina

2018-02-05

Trauma care at an accident site is of great importance for patient survival. The purpose of the study was to observe the compliance of ambulance nurses with the Prehospital Trauma Life Support (PHTLS) concept of trauma care in a simulation situation. The material consisted of video recordings in trauma simulation and an observation protocol was designed to analyze the video material. The result showed weaknesses in systematic exam and an ineffective use of time at the scene of injury. Development of observation protocols in trauma simulation can ensure the quality of ambulance nurses' compliance with established concepts. Our pilot study shows that insufficiencies in systematic care lead to an ineffective treatment for trauma patients which in turn may increase the risk of complications and mortality.

Improvement of research quality in the fields of orthopaedics and trauma: a global perspective.

PubMed

Fayaz, Hangama C; Haas, Norbert; Kellam, James; Bavonratanavech, Suthorn; Parvizi, Javad; Dyer, George; Pohlemann, Tim; Jerosch, Jörg; Prommersberger, Karl-Josef; Pape, Hans Christoph; Smith, Malcolm; Vrahas, Marc; Perka, Carsten; Siebenrock, Klaus; Elhassan, Bassem; Moran, Christopher; Jupiter, Jesse B

2013-07-01

The international orthopaedic community aims to achieve the best possible outcome for patient care by constantly modifying surgical techniques and expanding the surgeon's knowledge. These efforts require proper reflection within a setting that necessitates a higher quality standard for global orthopaedic publication. Furthermore, these techniques demand that surgeons acquire information at a rapid rate while enforcing higher standards in research performance. An international consensus exists on how to perform research and what rules should be considered when publishing a scientific paper. Despite this global agreement, in today's "Cross Check Era", too many authors do not give attention to the current standards of systematic research. Thus, the purpose of this paper is to describe these performance standards, the available choices for orthopaedic surgeons and the current learning curve for seasoned teams of researchers and orthopaedic surgeons with more than three decades of experience. These lead to provide an accessible overview of all important aspects of the topics that will significantly influence the research development as we arrive at an important globalisation era in orthopaedics and trauma-related research.

Trauma health literacy: In need of remediation.

PubMed

Shahan, Charles P; Weinberg, Jordan A; Magnotti, Louis J; Fabian, Timothy C; Croce, Martin A

2016-12-01

Little is known regarding health literacy among trauma patients. Anecdotal experience at our institution has suggested that a profound lack of understanding of basic health care information exists at some level in our patients after hospital discharge. The purpose of this study was to report the results of a pilot quality improvement project to determine trauma patient injury comprehension and how this affects their overall satisfaction with care received. Trauma patients were surveyed for knowledge of their injuries, operations, and satisfaction with their care at the first outpatient visit following hospital discharge from a Level 1 trauma center. One hundred seventy-five surveys were distributed and 35 were returned complete and eligible for analysis. Average time from discharge to survey completion was 16 days. Seventy-five percent of patients were male, and the mean age was 37. Fifty-six percent of the injuries were from a blunt mechanism. Seventy-one percent reported household income of less than $25,000 per annum, and 61% had an education level of high school diploma or less. Forty percent of patients were unable to correctly recall their injuries, and 54% were unable to correctly recall operations performed. Seventy-two percent were unable to recall the name of any physician that provided care during their hospital stay. Nonetheless, 90% of patients were at least somewhat satisfied with their injury understanding, and only 3% felt that their level of understanding had a negative impact on their overall satisfaction with care received. There was no correlation between education or income level and ability to correctly recall injuries or operations. In addition, there was no correlation between ability to recall injuries or operations and patients' satisfaction. The observed deficiency in postdischarge health literacy among our patients is alarming and demonstrates that current hospital discharge education is lacking. Although this deficit did not affect satisfaction with care, we feel a responsibility to improve the health literacy of our patients. The next step at our institution will be to implement a revised discharge education program followed by surveillance to evaluate for improvement. Therapeutic/care management study, level IV.

Effect of early trauma on the sleep quality of euthymic bipolar patients.

PubMed

Aubert, E; Jaussent, I; Olié, E; Ducasse, D; Azorin, J M; Bellivier, F; Belzeaux, R; Bougerol, T; Etain, B; Gard, S; Henry, C; Kahn, J P; Leboyer, M; Loftus, J; Passerieux, C; Lopez-Castroman, J; Courtet, Ph

2016-12-01

Poor quality of sleep is frequent in euthymic bipolar patients and conveys worse clinical outcomes. We investigated the features of euthymic bipolar patients associated with poor sleep quality, with a focus on the effect of childhood trauma. 493 euthymic patients with DSM-IV-defined bipolar disorders were recruited in FondaMental Advanced Centers of Expertize for Bipolar Disorders (FACE-BD) between 2009 and 2014. Clinical variables were recorded. Subjective sleep quality and history of childhood trauma were respectively measured by the Pittsburgh Sleep Quality Index (PSQI) and the Childhood Trauma Questionnaire (CTQ). Poor sleepers were older, less professionally active, had significantly higher anxiety levels, took more anxiolytic drugs and did endorse more suicide attempts and suicidal ideas than good sleepers after adjusting for anxiety levels and age. Emotional abuse was associated with poor sleep quality after adjustment for BMI, age, professional activity, and bipolar disorders (BD) type (OR=1.83; 95% CI [1.30; 3.10]; p=0.02). However, this association was lost after adjustment for anxiety levels, anxiolytic treatment and suicide ideation/attempts. The main limitation was the type of sleep assessment, which only measured the subjective part of sleep complaints. A history of emotional abuse might underlie sleep problems in many bipolar patients but anxiety seems to act as a confounding factor in this relationship. New studies are needed to elucidate the role of childhood maltreatment on poor sleep among bipolar patients. Copyright © 2016 Elsevier B.V. All rights reserved.

Initial evaluation of the "Trauma surgery course"

PubMed Central

Tugnoli, Gregorio; Ribaldi, Sergio; Casali, Marco; Calderale, Stefano M; Coletti, Massimo; Alifano, Marco; Parri, Sergio N Forti; Villani, Silvia; Biscardi, Andrea; Giordano, M Chiara; Baldoni, Franco

2006-01-01

Background The consequence of the low rate of penetrating injuries in Europe and the increase in non-operative management of blunt trauma is a decrease in surgeons' confidence in managing traumatic injuries has led to the need for new didactic tools. The aim of this retrospective study was to present the Corso di Chirurgia del Politrauma (Trauma Surgery Course), developed as a model for teaching operative trauma techniques, and assess its efficacy. Method the two-day course consisted of theoretical lectures and practical experience on large-sized swine. Data of the first 126 participants were collected and analyzed. Results All of the 126 general surgeons who had participated in the course judged it to be an efficient model to improve knowledge about the surgical treatment of trauma. Conclusion A two-day course, focusing on trauma surgery, with lectures and life-like operation situations, represents a model for simulated training and can be useful to improve surgeons' confidence in managing trauma patients. Cooperation between organizers of similar initiatives would be beneficial and could lead to standardizing and improving such courses. PMID:16759403

Thoracic wall trauma—misdiagnosed lesions on radiographs and usefulness of ultrasound, multidetector computed tomography and magnetic resonance imaging

PubMed Central

Facenda, Catherine; Vaz, Nuno; Castañeda, Edgar Augusto; del Amo, Montserrat; Garcia-Diez, Ana Isabel; Pomes, Jaime

2017-01-01

Blunt injuries to the chest wall are an important chapter on emergency room (ER) departments, being the third most common injuries in trauma patients which ominous complications could appear. This article describes different types of traumatic events affecting the chest wall, which maybe misdiagnosed with conventional X-ray. Special emphasis has been done in computed tomography (CT) and multidetector CT (MDCT) imaging. This technique is considered the “gold-standard” for those traumatic patients, due to its fast acquisition covering the whole area of interest in axial plane, reconstructing multiplanar (2D, 3D) volume-rendered images with a superb quality and angiographic CT capabilities for evaluating vascular damage. Complementary techniques such as ultrasonography (US) and magnetic resonance imaging (MRI) may improve the diagnostic accuracy due to its great capacity in visualising soft-tissue trauma (muscle-tendinous tears) and subtle fractures. All these imaging methods have an important role in quantifying the severity of chest wall trauma. The findings of this study have been exposed with cases of our archives in a didactic way. PMID:28932697

Trauma care in Oman: A call for action.

PubMed

Mehmood, Amber; Allen, Katharine A; Al-Maniri, Abdullah; Al-Kashmiri, Ammar; Al-Yazidi, Mohamed; Hyder, Adnan A

2017-12-01

Many Arab countries have undergone the epidemiologic transition of diseases with increasing economic development and a proportionately decreasing prevalence of communicable diseases. With this transition, injuries have emerged as a major cause of mortality and morbidity in the Gulf Cooperation Council countries in addition to diseases of affluence. Injuries are the number one cause of years of life lost and disability-adjusted life-years in the Sultanate of Oman. The burden of injuries, which affects mostly young Omani males, has a unique geographic distribution that is in contrast to the trauma care capabilities of the country. The concentration of health care resources in the northern part of the country makes it difficult for the majority of Omanis who live elsewhere to access high-quality and time-sensitive care. A broader multisectorial national injury prevention strategy should be evidence based and must strengthen human resources, service delivery, and information systems to improve care of the injured and loss of life. This paper provides a unique overview of the Omani health system with the goal of examining its trauma care capabilities and injury control policies. Copyright © 2017 Elsevier Inc. All rights reserved.

A Population-Based Survival Assessment of Categorizing Level III and IV Rural Hospitals as Trauma Centers

ERIC Educational Resources Information Center

Arthur, Melanie; Newgard, Craig D.; Mullins, Richard J.; Diggs, Brian S.; Stone, Judith V.; Adams, Annette L.; Hedges, Jerris R.

2009-01-01

Context: Patients injured in rural areas are hypothesized to have improved outcomes if statewide trauma systems categorize rural hospitals as Level III and IV trauma centers, though evidence to support this belief is sparse. Purpose: To determine if there is improved survival among injured patients hospitalized in states that categorize rural…

Whole-body multislice computed tomography (MSCT) improves trauma care in patients requiring surgery after multiple trauma.

PubMed

Wurmb, T E; Quaisser, C; Balling, H; Kredel, M; Muellenbach, R; Kenn, W; Roewer, N; Brederlau, J

2011-04-01

Whole-body multislice helical CT becomes increasingly important as a diagnostic tool in patients with multiple injuries. Time gain in multiple-trauma patients who require emergency surgery might improve outcome. The authors hypothesised that whole-body multislice computed tomography (MSCT) (MSCT trauma protocol) as the initial diagnostic tool reduces the interval to start emergency surgery (tOR) if compared to conventional radiography, combined with abdominal ultrasound and organ-focused CT (conventional trauma protocol). The second goal of the study was to investigate whether the diagnostic approach chosen has an impact on outcome. The authors' level 1 trauma centre uses whole-body MSCT for initial radiological diagnostic work-up for patients with suspected multiple trauma. Before the introduction of MSCT in 2004, a conventional approach was used. Group I: data of trauma patients treated with conventional trauma protocol from 2001 to 2003. Group II: data from trauma patients treated with whole-body MSCT trauma protocol from 2004 to 2006. tOR in group I (n=155) was 120 (90-150) min (median and IQR) and 105 (85-133) min (median and IQR) in group II (n=163), respectively (p<0.05). Patients of group II had significantly more serious injuries. No difference in outcome data was found. 14 patients died in both groups within the first 30 days; five of these died within the first 24 h. A whole-body MSCT-based diagnostic approach to multiple trauma shortens the time interval to start emergency surgery in patients with multiple injuries. Mortality remained unchanged in both groups. Patients of group II were more seriously injured; an improvement of outcome might be assumed.

Social capital in a regional inter-hospital network among trauma centers (trauma network): results of a qualitative study in Germany.

PubMed

Loss, Julika; Weigl, Johannes; Ernstberger, Antonio; Nerlich, Michael; Koller, Michael; Curbach, Janina

2018-02-26

As inter-hospital alliances have become increasingly popular in the healthcare sector, it is important to understand the challenges and benefits that the interaction between representatives of different hospitals entail. A prominent example of inter-hospital alliances are certified 'trauma networks', which consist of 5-30 trauma departments in a given region. Trauma networks are designed to improve trauma care by providing a coordinated response to injury, and have developed across the USA and multiple European countries since the 1960s. Their members need to interact regularly, e.g. develop joint protocols for patient transfer, or discuss patient safety. Social capital is a concept focusing on the development and benefits of relations and interactions within a network. The aim of our study was to explore how social capital is generated and used in a regional German trauma network. In this qualitative study, we performed semi-standardized face-to-face interviews with 23 senior trauma surgeons (2013-14). They were the official representatives of 23 out of 26 member hospitals of the Trauma Network Eastern Bavaria. The interviews covered the structure and functioning of the network, climate and reciprocity within the network, the development of social identity, and different resources and benefits derived from the network (e.g. facilitation of interactions, advocacy, work satisfaction). Transcripts were coded using thematic content analysis. According to the interviews, the studied trauma network became a group of surgeons with substantial bonding social capital. The surgeons perceived that the network's culture of interaction was flat, and they identified with the network due to a climate of mutual respect. They felt that the inclusive leadership helped establish a norm of reciprocity. Among the interviewed surgeons, the gain of technical information was seen as less important than the exchange of information on political aspects. The perceived resources derived from this social capital were smoother interactions, a higher medical credibility, and joint advocacy securing certain privileges. Apart from addressing quality of care, a trauma network may, by way of strengthening social capital among its members, serve as a valuable resource for the participating surgeons. Some member hospitals could exploit the social capital for strategic benefits.

Comparison of outcomes in severely injured patients between a South Korean trauma center and matched patients treated in the United States.

PubMed

Jung, Kyoungwon; Matsumoto, Shokei; Smith, Alan; Hwang, Kyungjin; Lee, John Cook-Jong; Coimbra, Raul

2018-06-05

The South Korean government recently developed a master plan for establishing a national trauma system based on the implementation of regional trauma centers. We aimed to compare outcomes between severely injured patients treated at a recently established South Korean trauma center and matched patients treated in American level-1 trauma centers. Two cohorts were selected from an institutional trauma database at Ajou University Medical Center (AUMC) and the American National Trauma Data Bank. Adult patients with an Injury Severity Score of ≥9 were included. Patients were matched based on covariates that affect mortality, using 1:1 propensity score matching. We compared outcomes between the two datasets and performed survival analyses. We created 1,451 and 2,103 matched pairs for the pre-trauma center and post-trauma center periods, respectively. The in-hospital mortality rate was higher in the institutional trauma database pre-trauma center period compared with the American National Trauma Data Bank (11.6% versus 8.1%, P<.001). However, the mortality rate decreased in the institutional trauma database post-trauma center period and was similar to that in the American National Trauma Data Bank (6.9% versus 6.8%, P=.903). Being treated at Ajou University Medical Center Trauma Center was significantly associated with higher mortality during the pre-trauma center period (OR: 1.842, 95% CI: 1.336-2.540; P<.001), although no significant association was observed during the post-trauma center period (OR: 1.102, 95% CI: 0.827-1.468; P=.509). The mortality rate improved after a trauma center was established in a South Korean hospital and is similar to that from matched cases treated at American level-1 trauma centers. Thus, creating trauma centers and a regional trauma system may improve outcomes in major trauma cases. Copyright © 2018 Elsevier Inc. All rights reserved.

Serum amyloid A (SAA) as a biomarker of chronic infection due to boat strike trauma in a free-ranging Florida manatee (Trichechus manatus latirostris) with incidental polycystic kidneys

USGS Publications Warehouse

Harr, Kendal E.; Rember, Renee; Ginn, Pamela E.; Lightsey, Jessica; Keller, Martha; Reid, James; Bonde, Robert K.

2011-01-01

Watercraft-related trauma is the predominant cause of human-induced mortality in manatees (Trichechus manatus latirostris), a federal- and state-listed endangered species. Pyothorax (documented in this case report) and other secondary infections are common sequelae of inhalation of water and the open wounds caused by boat propellers. These secondary infections can lead to the demise of the animal weeks to months after the traumatic incident when external wounds have healed. Diagnosis of underlying disease on physical examination during capture and restraint can be difficult. Acute phase proteins, including serum amyloid A, fibrinogen, and albumin can be used to diagnose inflammatory disease in manatees and improve quality of medical care and husbandry. We also provide the first report of polycystic kidneys in Sirenians.

Serum amyloid A (SAA) as a biomarker of chronic infection due to boat strike trauma in a free-ranging Florida manatee (Trichechus manatus latirostris) with incidental polycystic kidneys.

PubMed

Harr, Kendal E; Rember, Renee; Ginn, Pamela E; Lightsey, Jessica; Keller, Martha; Reid, James; Bonde, Robert K

2011-10-01

Watercraft-related trauma is the predominant cause of human-induced mortality in manatees (Trichechus manatus latirostris), a federal- and state-listed endangered species. Pyothorax (documented in this case report) and other secondary infections are common sequelae of inhalation of water and the open wounds caused by boat propellers. These secondary infections can lead to the demise of the animal weeks to months after the traumatic incident when external wounds have healed. Diagnosis of underlying disease on physical examination during capture and restraint can be difficult. Acute phase proteins, including serum amyloid A, fibrinogen, and albumin can be used to diagnose inflammatory disease in manatees and improve quality of medical care and husbandry. We also provide the first report of polycystic kidneys in Sirenians.

Pathogen inactivation treatment of plasma and platelet concentrates and their predicted functionality in massive transfusion protocols.

PubMed

Arbaeen, Ahmad F; Schubert, Peter; Serrano, Katherine; Carter, Cedric J; Culibrk, Brankica; Devine, Dana V

2017-05-01

Trauma transfusion packages for hemorrhage control consist of red blood cells, plasma, and platelets at a set ratio. Although pathogen reduction improves the transfusion safety of platelet and plasma units, there is an associated reduction in quality. This study aimed to investigate the impact of riboflavin/ultraviolet light-treated plasma or platelets in transfusion trauma packages composed of red blood cell, plasma, and platelet units in a ratio of 1:1:1 in vitro by modeling transfusion scenarios for trauma patients and assessing function by rotational thromboelastometry. Pathogen-reduced or untreated plasma and buffy coat platelet concentrate units produced in plasma were used in different combinations with red blood cells in trauma transfusion packages. After reconstitution of these packages with hemodiluted blood, the hemostatic functionality was analyzed by rotational thromboelastometry. Hemostatic profiles of pathogen-inactivated buffy coat platelet concentrate and plasma indicated decreased activity compared with their respective controls. Reconstitution of hemodiluted blood (hematocrit = 20%) with packages that contained treated or nontreated components resulted in increased alpha and maximum clot firmness and enhanced clot-formation time. Simulating transfusion scenarios based on 30% blood replacement with a transfusion trauma package resulted in a nonsignificant difference in rotational thromboelastometry parameters between packages containing treated and nontreated blood components (p ≥ 0.05). Effects of pathogen inactivation treatment were evident when the trauma package percentage was 50% or greater and contained both pathogen inactivation-treated plasma and buffy coat platelet concentrate. Rotational thromboelastometry investigations suggest that there is relatively little impact of pathogen inactivation treatment on whole blood clot formation unless large amounts of treated components are used. © 2017 AABB.

"Recommendations for uniform reporting of data following major trauma--the Utstein style" (as of July 17, 1999). An International Trauma Anaesthesia and Critical Care Society (ITACCS).

PubMed

Dick, W F; Baskett, P J; Grande, C; Delooz, H; Kloeck, W; Lackner, C; Lipp, M; Mauritz, W; Nerlich, M; Nicholl, J; Nolan, J; Oakley, P; Parr, M; Seekamp, A; Soreide, E; Steen, P A; van Camp, L; Wolcke, B; Yates, D

2000-01-01

Basic and advanced care of trauma patients has always been an important aspect of prehospital and immediate in-hospital emergency medicine, involving a broad spectrum of disciplines, specialties and skills delivered through Emergency Medical Services Systems which, however, may differ significantly in structure, resources and operation. This complex background has, at least in part, hindered the development of a uniform pattern or set of criteria and definitions. This in turn has hitherto rendered data incompatible, with the consequence that such differing systems or protocols of care cannot be readily evaluated or compared with acceptable validity. Guided by previous consensus processes evolved by the ERC, the AHA and other International Organizations--represented in ILCOR--on 'Uniform reporting of data following out-of-hospital and in-hospital cardiac arrest--the Utstein style' an international working group of ITACCS has drafted a document, 'Recommendations for uniform reporting of data following major trauma--the Utstein style'. The reporting system is based on the following considerations: A structured reporting system based on an "Utstein style template" which would permit the compilation of data and statistics on major trauma care, facilitating and validating independent or comparative audit of performance and quality of care (and enable groups to challenge performance statistics which did not take account of all relevant information). The recommendations and template should encompass both out-of-hospital and in-hospital trauma care. The recommendations and template should further permit intra- and inter-system evaluation to improve the quality of delivered care and identification of the relative benefits of different systems and innovative initiatives. The template should facilitate studies setting out to improve epidemiological understanding of trauma; for example such studies might focus on the factors that determine survival. The document is structured along the lines of the original Utstein Style Guidelines publication on 'prehospital cardiac arrest'. It includes a glossary of terms used in the prehospital and early hospital phase and definitions, time points and intervals. The document uses an almost identical scheme for illustrating the different process time clocks--one for the patient, one for the dispatch centre, one for the ambulance and, finally, one for the hospital. For clarity, data should be reported as core data (i.e. always obtained) and optional data (obtained under specific circumstances). In contrast to the graphic approach used for the Utstein template for pre- or in-hospital cardiac arrest, respectively, the present template introduces, for the time being, at least, a number of terms and definitions and a semantic rather than a graphic report form. The document includes the following sections: The Section Introduction and background The Section on Trauma Data Structure Development: presents a general outline of the development of structured data using object-orientated modelling (which will be discussed in due course) and includes a set of explanatory illustrations. The Section on Terms and Definitions: outlines terms and definitions in trauma care, describing different types of trauma (blunt, penetrating, long bone, major/combined, multiple/polytrauma and predominant trauma). The Section on Factors relating to the circumstances of the injury describes the following items: cause of injury (e.g. type of injury (blunt or penetrating), burns, cold, crush, laceration, amputation, radiation, multiple, etc. Severity of Injury e.g. prehospital basic abbreviated injury score developed by the working group. The score contains anatomical and physiological disability data, with the anatomical scale ranging ordinally from 1. Head to 9. External; the physiological disability scale ranging ordinally from 0--unsurvivable. Mechanism of injury recording for transportation incidents etc. e.g. the type of impact, po

Key performance indicators in British military trauma.

PubMed

Stannard, Adam; Tai, Nigel R; Bowley, Douglas M; Midwinter, Mark; Hodgetts, Tim J

2008-08-01

Key performance indicators (KPI) are tools for assessing process and outcome in systems of health care provision and are an essential component in performance improvement. Although KPI have been used in British military trauma for 10 years, they remain poorly defined and are derived from civilian metrics that do not adjust for the realities of field trauma care. Our aim was to modify current trauma KPI to ensure they more faithfully reflect both the military setting and contemporary evidence in order to both aid accurate calibration of the performance of the British Defence Medical Services and act as a driver for performance improvement. A workshop was convened that was attended by senior, experienced doctors and nurses from all disciplines of trauma care in the British military. "Speciality-specific" KPI were developed by interest groups using evidence-based data where available and collective experience where this was lacking. In a final discussion these were streamlined into 60 KPI covering each phase of trauma management. The introduction of these KPI sets a number of important benchmarks by which British military trauma can be measured. As part of a performance improvement programme, these will allow closer monitoring of our performance and assist efforts to develop, train, and resource British military trauma providers.

Trauma Resuscitation Evaluation Times and Correlating Human Patient Simulation Training Differences-What is the Standard?

PubMed

Bonjour, Timothy J; Charny, Grigory; Thaxton, Robert E

2016-11-01

Rapid effective trauma resuscitations (TRs) decrease patient morbidity and mortality. Few studies have evaluated TR care times. Effective time goals and superior human patient simulator (HPS) training can improve patient survivability. The purpose of this study was to compare live TR to HPS resuscitation times to determine mean incremental resuscitation times and ascertain if simulation was educationally equivalent. The study was conducted at San Antonio Military Medical Center, Department of Defense Level I trauma center. This was a prospective observational study measuring incremental step times by trauma teams during trauma and simulation patient resuscitations. Trauma and simulation patient arms had 60 patients for statistical significance. Participants included Emergency Medicine residents and Physician Assistant residents as the trauma team leader. The trauma patient arm revealed a mean evaluation time of 10:33 and simulation arm 10:23. Comparable time characteristics in the airway, intravenous access, blood sample collection, and blood pressure data subsets were seen. TR mean times were similar to the HPS arm subsets demonstrating simulation as an effective educational tool. Effective stepwise approaches, incremental time goals, and superior HPS training can improve patient survivability and improved departmental productivity using TR teams. Reprint & Copyright © 2016 Association of Military Surgeons of the U.S.

Psychological Distress After Orthopedic Trauma: Prevalence in Patients and Implications for Rehabilitation.

PubMed

Vincent, Heather K; Horodyski, MaryBeth; Vincent, Kevin R; Brisbane, Sonya T; Sadasivan, Kalia K

2015-09-01

Orthopedic trauma is an unforeseen life-changing event. Serious injuries include multiple fractures and amputation. Physical rehabilitation has traditionally focused on addressing functional deficits after traumatic injury, but important psychological factors also can dramatically affect acute and long-term recovery. This review presents the effects of orthopedic trauma on psychological distress, potential interventions for distress reduction after trauma, and implications for participation in rehabilitation. Survivors commonly experience post-traumatic stress syndrome, depression, and anxiety, all of which interfere with functional gains and quality of life. More than 50% of survivors have psychological distress that can last decades after the physical injury has been treated. Early identification of patients with distress can help care teams provide the resources and support to offset the distress. Several options that help trauma patients navigate their short-term recovery include holistic approaches, pastoral care, coping skills, mindfulness, peer visitation, and educational resources. The long-term physical and mental health of the trauma survivor can be enhanced by strategies that connect the survivor to a network of people with similar experiences or injuries, facilitate support groups, and social support networking (The Trauma Survivors Network). Rehabilitation specialists can help optimize patient outcomes and quality of life by participating in and advocating these strategies. Copyright © 2015 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.

Implementation and Evaluation of a Wiki Involving Multiple Stakeholders Including Patients in the Promotion of Best Practices in Trauma Care: The WikiTrauma Interrupted Time Series Protocol

PubMed Central

Turgeon, Alexis F; Witteman, Holly O; Lauzier, François; Moore, Lynne; Lamontagne, François; Horsley, Tanya; Gagnon, Marie-Pierre; Droit, Arnaud; Weiss, Matthew; Tremblay, Sébastien; Lachaine, Jean; Le Sage, Natalie; Émond, Marcel; Berthelot, Simon; Plaisance, Ariane; Lapointe, Jean; Razek, Tarek; van de Belt, Tom H; Brand, Kevin; Bérubé, Mélanie; Clément, Julien; Grajales III, Francisco Jose; Eysenbach, Gunther; Kuziemsky, Craig; Friedman, Debbie; Lang, Eddy; Muscedere, John; Rizoli, Sandro; Roberts, Derek J; Scales, Damon C; Sinuff, Tasnim; Stelfox, Henry T; Gagnon, Isabelle; Chabot, Christian; Grenier, Richard; Légaré, France

2015-01-01

Background Trauma is the most common cause of mortality among people between the ages of 1 and 45 years, costing Canadians 19.8 billion dollars a year (2004 data), yet half of all patients with major traumatic injuries do not receive evidence-based care, and significant regional variation in the quality of care across Canada exists. Accordingly, our goal is to lead a research project in which stakeholders themselves will adapt evidence-based trauma care knowledge tools to their own varied institutional contexts and cultures. We will do this by developing and assessing the combined impact of WikiTrauma, a free collaborative database of clinical decision support tools, and Wiki101, a training course teaching participants how to use WikiTrauma. WikiTrauma has the potential to ensure that all stakeholders (eg, patients, clinicians, and decision makers) can all contribute to, and benefit from, evidence-based clinical knowledge about trauma care that is tailored to their own needs and clinical setting. Objective Our main objective will be to study the combined effect of WikiTrauma and Wiki101 on the quality of care in four trauma centers in Quebec. Methods First, we will pilot-test the wiki with potential users to create a version ready to test in practice. A rapid, iterative prototyping process with 15 health professionals from nonparticipating centers will allow us to identify and resolve usability issues prior to finalizing the definitive version for the interrupted time series. Second, we will conduct an interrupted time series to measure the impact of our combined intervention on the quality of care in four trauma centers that will be selected—one level I, one level II, and two level III centers. Participants will be health care professionals working in the selected trauma centers. Also, five patient representatives will be recruited to participate in the creation of knowledge tools destined for their use (eg, handouts). All participants will be invited to complete the Wiki101 training and then use, and contribute to, WikiTrauma for 12 months. The primary outcome will be the change over time of a validated, composite, performance indicator score based on 15 process performance indicators found in the Quebec Trauma Registry. Results This project was funded in November 2014 by the Canadian Medical Protective Association. We expect to start this trial in early 2015 and preliminary results should be available in June 2016. Two trauma centers have already agreed to participate and two more will be recruited in the next months. Conclusions We expect that this study will add important and unique evidence about the effectiveness, safety, and cost savings of using collaborative platforms to adapt knowledge implementation tools across jurisdictions. PMID:25699546

Effects of advanced life support versus basic life support on the mortality rates of patients with trauma in prehospital settings: a study protocol for a systematic review and meta-analysis.

PubMed

Kondo, Yutaka; Fukuda, Tatsuma; Uchimido, Ryo; Hifumi, Toru; Hayashida, Kei

2017-10-22

Advanced life support (ALS) is thought to be associated with improved survival in prehospital trauma care when compared with basic life support (BLS). However, evidence on the benefits of prehospital ALS for patients with trauma is controversial. Therefore, we aim to clarify if ALS improves mortality in patients with trauma when compared with BLS by conducting a systematic review and meta-analysis of the recent literature. We will perform searches in PubMed, Embase and the Cochrane Central Register of Controlled Trials for published observational studies, controlled before-and-after studies, randomised controlled trials and other controlled trials conducted in humans and published until March 2017. We will screen search results, assess study selection, extract data and assess the risk of bias in duplicate; disagreements will be resolved through discussions. Data from clinically homogeneous studies will be pooled using a random-effects meta-analysis, heterogeneity of effects will be assessed using the χ 2 test of homogeneity, and any observed heterogeneity will be quantified using the I 2 statistic. Last, the Grading of Recommendations Assessment, Development and Evaluation approach will be used to rate the quality of the evidence. Our study does not require ethical approval as it is based on findings of previously published articles. Results will be disseminated through publication in a peer-reviewed journal, presentations at relevant conferences and publications for patient information. PROSPERO (International Prospective Register of Systematic Reviews) registration number CRD42017054389. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Assessment of quality of life and functional outcome in patients sustaining moderate and major trauma: a multicentre, prospective cohort study.

PubMed

Rainer, T H; Yeung, J H H; Cheung, S K C; Yuen, Y K Y; Poon, W S; Ho, H F; Kam, C W; Cattermole, G N; Chang, A; So, F L; Graham, C A

2014-05-01

Trauma care systems aim to reduce both death and disability, yet there is little data on post-trauma health status and functional outcome. To evaluate baseline, discharge, six month and 12 month post-trauma quality of life, functional outcome and predictors of quality of life in Hong Kong. Multicentre, prospective cohort study using data from the trauma registries of three regional trauma centres in Hong Kong. Trauma patients with an ISS≥9 and aged≥18 years were included. The main outcome measures were the physical component summary (PCS) score and mental component summary (MCS) scores of the Short-Form 36 (SF36) for health status, and the extended Glasgow Outcome Scale (GOSE) for functional outcome. Between 1 January 2010 and 31 September 2010, 400 patients (mean age 53.3 years; range 18-106; 69.5% male) were recruited to the study. There were no statistically significant differences in baseline characteristics between responders (N=177) and surviving non-responders (N=163). However, there were significant differences between these groups and the group of patients who died (N=60). Only 16/400 (4%) cases reported a GOSE≥7. 62/400 (15.5%) responders reached the HK population norm for PCS. 125/400 (31%) responders reached the HK population norm for MCS. If non-responders had similar outcomes to responders, then the percentages for GOSE≥7 would rise from 4% to 8%, for PCS from 15.5% to 30%, and for MCS from 31% to 60%. Univariate analysis showed that 12-month poor quality of life was significantly associated with age>65 years (OR 4.77), male gender (OR 0.44), pre-injury health problems (OR 2.30), admission to ICU (OR 2.15), ISS score 26-40 (OR 3.72), baseline PCS (OR 0.89), one-month PCS (OR 0.89), one-month MCS (OR 0.97), 6-month PCS (OR 0.76) and 6-month MCS (OR 0.97). For patients sustaining moderate or major trauma in Hong Kong at 12 months after injury<1 in 10 patients had an excellent recovery, ≤3 in 10 reached a physical health status score≥Hong Kong norm, although as many as 6 in 10 patients had a mental health status score which is≥Hong Kong norm. Copyright © 2013 Elsevier Ltd. All rights reserved.

Trauma in adolescents causes long-term marked deficits in quality of life: adolescent children do not recover preinjury quality of life or function up to two years postinjury compared to national norms.

PubMed

Holbrook, Troy Lisa; Hoyt, David B; Coimbra, Raul; Potenza, Bruce; Sise, Michael J; Sack, Dan I; Anderson, John P

2007-03-01

Injury is a leading cause of death and preventable morbidity in adolescents. Little is known about long-term quality of life (QoL) outcomes in injured adolescents. The objectives of the present report are to describe long-term QoL outcomes and compare posttrauma QoL to national norms for QoL in uninjured adolescents from the National Health Interview Survey (NHIS). In all, 401 trauma patients aged 12 to 19 years were enrolled in the study. Enrollment criteria excluded spinal cord injury. QoL after trauma was measured using the Quality of Well-being (QWB) scale, a sensitive and well-validated functional index (range: 0 = death to 1.000 = optimum functioning). Patient outcomes were assessed at discharge, and 3, 6, 12, 18, and 24 months after discharge. NHIS data were based on 3 survey years and represent a population-based U.S. national random sample of uninjured adolescents. Major trauma in adolescents was associated with significant and marked deficits in QoL throughout the 24-month follow-up period, compared with NHIS norms for this age group. Compared with NHIS norms for QoL in uninjured adolescents aged 12 to 19 years (N = 81,216,835; QWB mean = 0.876), injured adolescents after major trauma had striking and significant QoL deficits beginning at 3-month follow-up (QWB mean = 0.694, p < 0.0001), that continued throughout the long-term follow-up 24 months after discharge (6-month follow-up QWB mean = 0.726, p < 0.0001; 12-month follow-up QWB mean = 0.747, p < 0.0001; 18-month follow-up QWB mean = 0.758, p < 0.0001; 24-month follow-up QWB mean = 0.766, p < 0.0001). QoL deficits were also strongly associated with age (>or=15 years) and female sex. Other significant risk factors for poor QoL outcomes were perceived threat to life, pedestrian struck mechanism, and Injury Severity Scores >16. Major trauma in adolescents is associated with significant and marked deficits in long-term QoL outcomes, compared with U.S. norms for healthy adolescents. Early identification and treatment of risk factors for poor long-term QoL outcomes must become an integral component of trauma care in mature trauma care systems.

Abdominal injuries in a low trauma volume hospital - a descriptive study from northern Sweden

PubMed Central

2014-01-01

Background Abdominal injuries occur relatively infrequently during trauma, and they rarely require surgical intervention. In this era of non-operative management of abdominal injuries, surgeons are seldom exposed to these patients. Consequently, surgeons may misinterpret the mechanism of injury, underestimate symptoms and radiologic findings, and delay definite treatment. Here, we determined the incidence, diagnosis, and treatment of traumatic abdominal injuries at our hospital to provide a basis for identifying potential hazards in non-operative management of patients with these injuries in a low trauma volume hospital. Methods This retrospective study included prehospital and in-hospital assessments of 110 patients that received 147 abdominal injuries from an isolated abdominal trauma (n = 70 patients) or during multiple trauma (n = 40 patients). Patients were primarily treated at the University Hospital of Umeå from January 2000 to December 2009. Results The median New Injury Severity Score was 9 (range: 1–57) for 147 abdominal injuries. Most patients (94%) received computed tomography (CT), but only 38% of patients with multiple trauma were diagnosed with CT < 60 min after emergency room arrival. Penetrating trauma caused injuries in seven patients. Solid organ injuries constituted 78% of abdominal injuries. Non-operative management succeeded in 82 patients. Surgery was performed for 28 patients, either immediately (n = 17) as result of operative management or later (n = 11), due to non-operative management failure; the latter mainly occurred with hollow viscus injuries. Patients with multiple abdominal injuries, whether associated with multiple trauma or an isolated abdominal trauma, had significantly more non-operative failures than patients with a single abdominal injury. One death occurred within 30 days. Conclusions Non-operative management of patients with abdominal injuries, except for hollow viscus injuries, was highly successful in our low trauma volume hospital, even though surgeons receive low exposure to these patients. However, a growing proportion of surgeons lack experience in decision-making and performing trauma laparotomies. Quality assurance programmes must be emphasized to ensure future competence and quality of trauma care at low trauma volume hospitals. PMID:25124882

The management of corneal trauma: advances in the past twenty-five years.

PubMed

Macsai, M S

2000-09-01

Over the past quarter century, advances in our understanding of corneal anatomy, physiology, and wound healing have all played an integral role in the management of corneal trauma. As the etiologies of corneal trauma have changed, so has our understanding of the impact of injury on corneal function as it relates to visual rehabilitation. Numerous new classes of antibiotics, antiinflammatory agents, and tissue adhesives have emerged. Occlusive therapy has advanced from simple pressure patching bandage soft contact lenses and collagen shields. Surgical instrumentation, operating microscopes, viscoelastic substances, and suture materials have all improved the outcomes of corneal trauma repair. Improved understanding of the refractive properties of the cornea through topography and alternative suture techniques has helped us restore the natural corneal curvature and visual outcomes. Consequently, in the last quarter of this century our therapeutic approaches to cornea trauma, both medical and surgical, have improved.

Providing effective trauma care: the potential for service provider views to enhance the quality of care (qualitative study nested within a multicentre longitudinal quantitative study).

PubMed

Beckett, Kate; Earthy, Sarah; Sleney, Jude; Barnes, Jo; Kellezi, Blerina; Barker, Marcus; Clarkson, Julie; Coffey, Frank; Elder, Georgina; Kendrick, Denise

2014-07-08

To explore views of service providers caring for injured people on: the extent to which services meet patients' needs and their perspectives on factors contributing to any identified gaps in service provision. Qualitative study nested within a quantitative multicentre longitudinal study assessing longer term impact of unintentional injuries in working age adults. Sampling frame for service providers was based on patient-reported service use in the quantitative study, patient interviews and advice of previously injured lay research advisers. Service providers' views were elicited through semistructured interviews. Data were analysed using thematic analysis. Participants were recruited from a range of settings and services in acute hospital trusts in four study centres (Bristol, Leicester, Nottingham and Surrey) and surrounding areas. 40 service providers from a range of disciplines. Service providers described two distinct models of trauma care: an 'ideal' model, informed by professional knowledge of the impact of injury and awareness of best models of care, and a 'real' model based on the realities of National Health Service (NHS) practice. Participants' 'ideal' model was consistent with standards of high-quality effective trauma care and while there were examples of services meeting the ideal model, 'real' care could also be fragmented and inequitable with major gaps in provision. Service provider accounts provide evidence of comprehensive understanding of patients' needs, awareness of best practice, compassion and research but reveal significant organisational and resource barriers limiting implementation of knowledge in practice. Service providers envisage an 'ideal' model of trauma care which is timely, equitable, effective and holistic, but this can differ from the care currently provided. Their experiences provide many suggestions for service improvements to bridge the gap between 'real' and 'ideal' care. Using service provider views to inform service design and delivery could enhance the quality, patient experience and outcomes of care. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Father-involvement in a refugee sample: relations between posttraumatic stress and caregiving.

PubMed

van Ee, Elisa; Sleijpen, Marieke; Kleber, Rolf J; Jongmans, Marian J

2013-12-01

Despite increased attention to the role of fathers within families, there is still a dearth of studies on the impact of trauma on father-involvement. This study investigates the quantity of father-involvement and the influence of posttraumatic stress on the quality of involvement in a refugee and asylum seeker population. Eighty refugees and asylum seekers and their young children (aged 18-42 months) were recruited. Measures included assessment of parental trauma (Harvard Trauma Questionnaire), quantity and quality of involvement (quantity of caregiving and Emotional Availability Scales), and perception of the father-child relationship (interview). The results show that fathers were less involved in caregiving tasks and play activities than mothers. No parental gender differences were found on each of the Emotional Availability Scales. Traumatic stress symptoms negatively affected the perception and the actual quality of parent-child interaction (sensitivity, structuring, nonhostility). Nevertheless, almost all fathers described their relationship with their child as good and their child as very important to them. As the quality of father-involvement is of importance to the development of the child, traumatized fathers are as much in need of clinical intervention as mothers. Despite the impact of posttraumatic stress, refugee fathers clearly are involved in the lives of their children. Mechanisms such as a deliberate withdrawal when stressed and compensation might enable affected fathers to step into the interaction when needed, raise the quality of involvement with their child, and diminish the negative impact of stress resulting from trauma and migration. © FPI, Inc.

Sexual problems and post-traumatic stress disorder following sexual trauma: A meta-analytic review.

PubMed

O'Driscoll, Ciarán; Flanagan, Esther

2016-09-01

Difficulties with sex often develop following sexual trauma, yet are rarely targeted within treatment of post-traumatic stress disorder (PTSD). Where outcomes of sexual function are included, they are secondary to other measures. This review aimed to assess whether psychological treatment for PTSD (from sexual trauma) has an effect on sexual functioning. Systematic searches of MEDLINE, PsycINFO, EMBASE, and trial registers were performed. Five studies met inclusion criteria. Pre-post treatment effect sizes were also calculated. Data from four good-quality RCTs were included in the meta-analyses. These examined females (n = 799) who had experienced adult sexual trauma or child sexual abuse. Studies compared psychological treatment to control conditions, but no effect on outcomes of sexual concerns, standardized mean difference (SMD) = 0.03 and dysfunctional sexual behaviour, SMD = 0.02, was found. Pre-post treatment effect sizes were small to medium (SMD = 0.36 and 0.47, respectively). While firm conclusions cannot be drawn, the available evidence suggests that psychological treatment for PTSD has no effect on sexual problems. Pre-post effects indicate some improvement over the course of treatment, which may be strengthened if treatment actively targeted sexual problems. The paucity of evidence in this area suggests that there is substantial need for further research in order to establish a set of evidence-based guidelines for practitioners implementing treatment in this area. The measurement of sexual problems is overlooked in psychological treatment RCTs for sexual trauma. Current treatments for post-traumatic stress disorder (PTSD) from sexual trauma do not appear to be addressing sexual problems. Integrated treatments for comorbid sexual problems and PTSD treatment may be warranted. It is imperative that in future, RCTs that examine people with PTSD from sexual trauma use outcomes of sexual problems. © 2015 The British Psychological Society.

Utilizing a Trauma Systems Approach to Benchmark and Improve Combat Casualty Care

DTIC Science & Technology

2010-07-01

modern battlefield utilizing evidence - based medicine . The development of injury care benchmarks enhanced the evolution of the combat casualty care performance improvement process within the trauma system.

Significant improvement of the quality of bystander first aid using an expert system with a mobile multimedia device.

PubMed

Ertl, Lorenz; Christ, Frank

2007-08-01

Better quality bystander first-aid could improve outcome rates for emergency victims significantly. In this case-control study, we hypothesised that expert knowledge presented step-by-step to untrained helpers using a personal digital assistant (PDA), would improve the quality of bystanders basic life support. We confronted 101 lay-helpers with two standard emergency situations. (1) An unconscious trauma victim with severe bleeding. (2) Cardiopulmonary resuscitation (CPR). Performance was assessed using an Objective Structured Clinical Examination (OSCE). One group was supported by a PDA providing visual and audio instructions, whereas the control group acted only with their current knowledge. The expert system was programmed in HTML-code and displayed on the PDA's Internet browser. The maximum score obtainable was 24 points corresponding to optimal treatment. The control group without the PDA reached 14.8+/-3.5 (mean value+/-standard deviation), whereas the PDA supported group scored significantly higher (21.9+/-2.7, p<0.01). The difference in performance was measurable in all criteria tested and particularly notable in the items: placing in recovery position, airway management and quality of CPR. The PDA based expert system increased the performance of untrained helpers supplying emergency care significantly. Since Internet compatible mobile devices have become widely available, a significant quality improvement in bystander first-aid seems possible.

Assessment of traumatic deaths in a level one trauma center in Ankara, Turkey.

PubMed

Arslan, E D; Kaya, E; Sonmez, M; Kavalci, C; Solakoglu, A; Yilmaz, F; Durdu, T; Karakilic, E

2015-06-01

Trauma management shows significant progress in last decades. Determining the time and place of deaths indicate where to focus to improve our knowledge about trauma. We conducted this retrospective study from data of trauma victims who were brought to a major tertiary hospital which is a level one trauma center in Ankara, Turkey, and died even if during transport or in the hospital between 1 March 2010 and 1 March 2013. The patients' demographic characteristics, trauma mechanisms, time frames and causes of deaths determined by physicians were recorded. Traumas were grouped as "high energy trauma" (HET) and "low energy trauma" (LET). Falls from ground level were defined as LET. 209 traumatic deaths due to trauma or trauma-related conditions were found in the study period. 161 of 209 (78 %) patients suffered from HET. Motor vehicle collisions (MVC) (56 %) were the most common mechanism of trauma followed by burns (16 %), falls (11 %), gunshots (9 %) and stabs (6 %) in this group and traumatic brain injuries (TBI) (41 %) were the most common cause of death followed by circulatory collapse (22 %) and multi-organ failure (20 %). 36 % of deaths occurred before arrival at hospital, 25 % in the first 24 h of admission, 18 % between 2nd and 7th day and 21 % after first week. Trimodal distribution of traumatic deaths was not valid for all types of injuries and the most important factor to decrease traumatic deaths is still prevention. Also we have to keep on searching to improve our knowledge about trauma management.

Mobile in Situ Simulation as a Tool for Evaluation and Improvement of Trauma Treatment in the Emergency Department.

PubMed

Amiel, Imri; Simon, Daniel; Merin, Ofer; Ziv, Amitai

2016-01-01

Medical simulation is an increasingly recognized tool for teaching, coaching, training, and examining practitioners in the medical field. For many years, simulation has been used to improve trauma care and teamwork. Despite technological advances in trauma simulators, including better means of mobilization and control, most reported simulation-based trauma training has been conducted inside simulation centers, and the practice of mobile simulation in hospitals' trauma rooms has not been investigated fully. The emergency department personnel from a second-level trauma center in Israel were evaluated. Divided into randomly formed trauma teams, they were reviewed twice using in situ mobile simulation training at the hospital's trauma bay. In all, 4 simulations were held before and 4 simulations were held after a structured learning intervention. The intervention included a 1-day simulation-based training conducted at the Israel Center for Medical Simulation (MSR), which included video-based debriefing facilitated by the hospital's 4 trauma team leaders who completed a 2-day simulation-based instructors' course before the start of the study. The instructors were also trained on performance rating and thus were responsible for the assessment of their respective teams in real time as well as through reviewing of the recorded videos; thus enabling a comparison of the performances in the mobile simulation exercise before and after the educational intervention. The internal reliability of the experts' evaluation calculated in the Cronbach α model was found to be 0.786. Statistically significant improvement was observed in 4 of 10 parameters, among which were teamwork (29.64%) and communication (24.48%) (p = 0.00005). The mobile in situ simulation-based training demonstrated efficacy both as an assessment tool for trauma teams' function and an educational intervention when coupled with in vitro simulation-based training, resulting in a significant improvement of the teams' function in various aspects of treatment. Copyright © 2015 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Has TRISS become an anachronism? A comparison of mortality between the National Trauma Data Bank and Major Trauma Outcome Study databases.

PubMed

Rogers, Frederick B; Osler, Turner; Krasne, Margaret; Rogers, Amelia; Bradburn, Eric H; Lee, John C; Wu, Daniel; McWilliams, Nathan; Horst, Michael A

2012-08-01

The Trauma and Injury Severity Score (TRISS) has been the approach to trauma outcome prediction during the past 20 years and has been adopted by many commercial registries. Unfortunately, its survival predictions are based upon coefficients that were derived from a data set collected in the 1980s and updated only once using a data set collected in the early 1990s. We hypothesized that the improvements in trauma care during the past 20 years would lead to improved survival in a large database, thus making the TRISS biased. The TRISSs from the Pennsylvania statewide trauma registry (Collector, Digital Innovations) for the years 1990 to 2010. Observed-to-expected mortality ratios for each year of the study were calculated by taking the ratio of actual deaths (observed deaths, O) to the summation of the probability of mortality predicted by the TRISS taken over all patients (expected deaths, E). For reference, O/E ratio should approach 1 if the TRISS is well calibrated (i.e., has predictive accuracy). There were 408,489 patients with complete data sufficient to calculate the TRISSs. There was a significant trend toward improved outcome (i.e., decreasing O/E ratio; nonparametric test of trend, p < 0.001) over time in both the total population and the blunt trauma subpopulation. In the penetrating trauma population, there was a trend toward improved outcome (decreasing O/E ratio), but it did not quite reach significance (nonparametric test of trend p = 0.073). There is a steady trend toward improved O/E survival in the Pennsylvania database with each passing year, suggesting that the TRISS is drifting out of calibration. It is likely that improvements in care account for these changes. For the TRISS to remain an accurate outcome prediction model, new coefficients would need to be calculated periodically to keep up with trends in trauma care. This requirement for occasional updating is likely to be a requirement of any trauma prediction model, but because many other deficiencies in the TRISS have been reported, we think that rather than updating the TRISS, it would be more productive to replace the TRISS with a modern statistical model.

Analysis of the causes of surgery-related medical disputes in Taiwan: Need for acute care surgeons to improve quality of care.

PubMed

Hu, Yi-Hsuan; Wang, Chien-Ying; Huang, Mu-Shun; Lee, Chen-Hsen; Wen, Yi-Szu

2016-11-01

This study investigated surgery-related medical disputes and analyzed disease etiologies and the main causes of disputes in order to identify key points for the purpose of improving the quality of surgical patient care in Taiwan. Reports on all surgery-related cases appraised by the Taiwan Witness Examiner Committee of the Department of Health between 2004 and 2008 were reviewed retrospectively by three senior physicians from the emergency department who specialize in both trauma and emergency general surgery. The causes of the various medical disputes were categorized under the following descriptions: operation- or procedure-related complication, anesthesia complication, inappropriate management or decision, delayed diagnosis or misdiagnosis, and unsatisfactory result. A total of 154 cases were reviewed, of which 39 were trauma-related and 115 were disease-related. The two leading causes of disputes in this review were found to be operation- or procedure-related complications (35.7%) and unsatisfactory results (31.8%), followed by delayed diagnoses or misdiagnoses, inappropriate management, and anesthesia complications. Among these, 74 cases (48.1%) required the care of an acute care surgeon and 40 cases (26.0%) required emergency general surgery intervention. Surgery- or procedure-related complications and unsatisfactory treatment results constituted the major causes of medical disputes in Taiwan. The majority of these cases involved acute care surgery; thus, the establishment of an acute care surgery system should be considered to improve patient care. The management of hemorrhagic shock and incarcerated hernia should be reinforced in future medical training. Copyright © 2016. Published by Elsevier Taiwan LLC.

The Perception of Trauma Patients from Social Support in Adjustment to Lower-Limb Amputation: A Qualitative Study

PubMed Central

Valizadeh, Sousan; Dadkhah, Behrouz; Mohammadi, Eissa; Hassankhani, Hadi

2014-01-01

Introduction: The effect of amputation on an individual's psychological condition as well as family and social relationships is undeniable because physical disability not just affects the psycho-social adjustment, but also the mental health. When compared to normal people, such people are mostly experiencing social isolation. On the other hand, social support is known as the most powerful force to cope with stressful situations and it allows patients to withstand problems. The present study aims to explain understanding the trauma of patients and the experience of support sources during the process of adaptation to a lower limb amputation. Materials and Methods: The present study was conducted using qualitative content analysis. Participants included 20 patients with lower limb amputation due to trauma. Sampling was purposive initially and continued until data saturation. Unstructured interviews were used as the main method of data collection. Collected data were analyzed using qualitative content analysis and constant comparison methods. Results: The main theme extracted from the data was support sources. The classes include “supportive family”, “gaining friends’ support”, “gaining morale from peers”, and “assurance and satisfaction with the workplace.” Conclusion: Given the high number of physical, mental and social problems in trauma patients, identifying and strengthening support sources can be effective in their adaptation with the disease and improvement of the quality of their life. PMID:25191013

Direct oral anticoagulants compared with warfarin in patients with severe blunt trauma.

PubMed

Feeney, James M; Neulander, Matthew; DiFiori, Monica; Kis, Lilla; Shapiro, David S; Jayaraman, Vijay; Marshall, William T; Montgomery, Stephanie C

2017-01-01

We queried our Trauma Quality Improvement Program registry for patients who presented between 6/1/2011 and 9/1/2015 with severe (injury severity score (ISS)>15) blunt traumatic injury during anticoagulant use. Patients were then grouped into those prescribed warfarin and patients prescribed any of the available novel Direct Oral Anticoagulants (DOAC) medications. We excluded severe (AIS≧4) head injuries. There were no differences between DOAC and warfarin groups in terms of age, gender mean ISS, median hospital or intensive care unit lengths of stay, complication proportions, numbers of complications per patient, or the proportion of patients requiring transfusion. Finally, excluding patients who died, the observed proportion of discharge to skilled nursing facility was similar. In our sample of trauma patients, DOAC use was associated with significantly lower mortality (DOAC group 8.3% vs. warfarin group 29.5%, p<0.015). The ratio of units transfused per patient was also lower in the DOAC group (2.8±1.8 units/patient in the DOAC group vs. 6.7±6.4 units per patient in the warfarin group; p=0.001). In conclusion, we report an association with decrease in mortality and a decrease in transfused blood products in severely injured trauma patients with likely minimal or no head injury taking novel DOACs over those anticoagulated with warfarin for outpatient anticoagulation. Copyright © 2016 Elsevier Ltd. All rights reserved.

The American College of Surgeons Children's Surgery Verification and Quality Improvement Program: implications for anesthesiologists.

PubMed

Houck, Constance S; Deshpande, Jayant K; Flick, Randall P

2017-06-01

The Task Force for Children's Surgical Care, an ad-hoc multidisciplinary group of invited leaders in pediatric perioperative medicine, was assembled in May 2012 to consider approaches to optimize delivery of children's surgical care in today's competitive national healthcare environment. Over the subsequent 3 years, with support from the American College of Surgeons (ACS) and Children's Hospital Association (CHA), the group established principles regarding perioperative resource standards, quality improvement and safety processes, data collection, and verification that were used to develop an ACS-sponsored Children's Surgery Verification and Quality Improvement Program (ACS CSV). The voluntary ACS CSV was officially launched in January 2017 and more than 125 pediatric surgical programs have expressed interest in verification. ACS CSV-verified programs have specific requirements for pediatric anesthesia leadership, resources, and the availability of pediatric anesthesiologists or anesthesiologists with pediatric expertise to care for infants and young children. The present review outlines the history of the ACS CSV, key elements of the program, and the standards specific to pediatric anesthesiology. As with the pediatric trauma programs initiated more than 40 years ago, this program has the potential to significantly improve surgical care for infants and children in the United States and Canada.

Current status and future options for trauma and emergency surgery in Turkey.

PubMed

Taviloğlu, Korhan; Ertekin, Cemalettin

2008-01-01

The number of trauma victims in Turkey is expected to increase as a consequence of the increasing vehicular traffic, potential for earthquakes, and risk of terrorist attacks. The Turkish Association for Trauma and Emergency Surgery monitors trauma cases, publishes a quarterly journal, organizes trauma courses and seminars for various health personnel nationwide. It is also extending efforts to improve in-hospital care by establishing trauma and emergency surgery fellowships and trauma and emergency surgery centers nationwide, which is run by General Surgeons currently. Turkey faces the same dilemma as the rest of the developed world regarding the future of trauma surgeons in the current era of nonoperative trauma management. We suggest that the field of trauma and emergency surgery be redefined to include emergency general surgery and cavitary trauma.

Strategic proposal for a national trauma system in France.

PubMed

Gauss, Tobias; Balandraud, Paul; Frandon, Julien; Abba, Julio; Ageron, Francois Xavier; Albaladejo, Pierre; Arvieux, Catherine; Barbois, Sandrine; Bijok, Benjamin; Bobbia, Xavier; Charbit, Jonathan; Cook, Fabrice; David, Jean-Stephane; Maurice, Guillaume De Saint; Duranteau, Jacques; Garrigue, Delphine; Gay, Emmanuel; Geeraerts, Thomas; Ghelfi, Julien; Hamada, Sophie; Harrois, Anatole; Kobeiter, Hicham; Leone, Marc; Levrat, Albrice; Mirek, Sebastien; Nadji, Abdel; Paugam-Burtz, Catherine; Payen, Jean Francois; Perbet, Sebastien; Pirracchio, Romain; Plenier, Isabelle; Pottecher, Julien; Rigal, Sylvain; Riou, Bruno; Savary, Dominique; Secheresse, Thierry; Tazarourte, Karim; Thony, Frederic; Tonetti, Jerome; Tresallet, Christophe; Wey, Pierre-Francois; Picard, Julien; Bouzat, Pierre

2018-05-29

In this road map for trauma in France, we focus on the main challenges for system implementation, surgical and radiology training, and upon innovative training techniques. Regarding system organisation: procedures for triage, designation and certification of trauma centres are mandatory to implement trauma networks on a national scale. Data collection with registries must be created, with a core dataset defined and applied through all registries. Regarding surgical and radiology training, diagnostic-imaging processes should be standardised and the role of the interventional radiologist within the trauma team and the trauma network should be clearly defined. Education in surgery for trauma is crucial and recent changes in medical training in France will promote trauma surgery as a specific sub-specialty. Innovative training techniques should be implemented and be based on common objectives, scenarios and evaluation, so as to improve individual and team performances. The group formulated 14 proposals that should help to structure and improve major trauma management in France over the next 10 years. Copyright © 2018 Société française d'anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.

Improving teamwork and communication in trauma care through in situ simulations.

PubMed

Miller, Daniel; Crandall, Cameron; Washington, Charles; McLaughlin, Steven

2012-05-01

Teamwork and communication often play a role in adverse clinical events. Due to the multidisciplinary and time-sensitive nature of trauma care, the effects of teamwork and communication can be especially pronounced in the treatment of the acutely injured patient. Our hypothesis was that an in situ trauma simulation (ISTS) program (simulating traumas in the trauma bay with all members of the trauma team) could be implemented in an emergency department (ED) and that this would improve teamwork and communication measured in the clinical setting. This was an observational study of the effect of an ISTS program on teamwork and communication during trauma care. The authors observed a convenience sample of 39 trauma activations. Cases were selected by their presenting to the resuscitation bay of a Level I trauma center between 09:00 and 16:00, Monday through Thursday, during the study period. Teamwork and communication were measured using the previously validated Clinical Teamwork Scale (CTS). The observers were three Trauma Nursing Core Course certified RNs trained on the CTS by observing simulated and actual trauma cases and following each of these cases with a discussion of appropriate CTS scores with two certified Advanced Trauma Life Support instructors/emergency physicians. Cases observed for measurement were scored in four phases: 1) preintervention phase (baseline); 2) didactic-only intervention, the phase following a lecture series on teamwork and communication in trauma care; 3) ISTS phase, real trauma cases scored during period when weekly ISTSs were performed; and 4) potential decay phase, observations following the discontinuation of the ISTSs. Multirater agreement was assessed with Krippendorf's alpha coefficient; agreement was excellent (mean agreement = 0.92). Nonparametric procedures (Kruskal-Wallis) were used to test the hypothesis that the scores observed during the various phases were different and to compare each individual phase to baseline scores. The ISTS program was implemented and achieved regular participation of all components of our trauma team. Data were collected on 39 cases. The scores for 11 of 14 measures improved from the baseline to the didactic phase, and the mean and median scores of all CTS component measures were greatest during the ISTS phase. When each phase was compared to baseline scores, using the baseline as a control, there were no significant differences seen during the didactic or the decay phases, but 12 of the 14 measures showed significant improvements from the baseline to the simulation phase. However, when the Kruskal-Wallis test was used to test for differences across all phases, only overall communication showed a significant difference. During the potential decay phase, the scores for every measure returned to baseline phase values. This study shows that an ISTS program can be implemented with participation from all members of a multidisciplinary trauma team in the ED of a Level I trauma center. While teamwork and communication in the clinical setting were improved during the ISTS program, this effect was not sustained after ISTS were stopped. © 2012 by the Society for Academic Emergency Medicine.

1029: Tranexamic Acid for Pediatric Trauma

DTIC Science & Technology

2014-12-01

DEC 2014 2. REPORT TYPE N/A 3. DATES COVERED - 4. TITLE AND SUBTITLE 1029: TRANEXAMIC ACID FOR PEDIATRIC TRAUMA 5a. CONTRACT NUMBER 5b...and has a higher mortality rate. Improving trauma systems and staff education may help bridge this gap. 1029 TRANEXAMIC ACID FOR PEDIATRIC TRAUMA...San Antonio, TX Learning Objectives: Tranexamic Acid (TXA) has been shown to decrease mortality in adult trauma. Although TXA has not been reported or

Physiological, anatomical, and behavioral changes after acoustic trauma in Drosophila melanogaster

PubMed Central

Christie, Kevin W.; Sivan-Loukianova, Elena; Smith, Wesley C.; Aldrich, Benjamin T.; Schon, Michael A.; Roy, Madhuparna; Lear, Bridget C.; Eberl, Daniel F.

2013-01-01

Noise-induced hearing loss (NIHL) is a growing health issue, with costly treatment and lost quality of life. Here we establish Drosophila melanogaster as an inexpensive, flexible, and powerful genetic model system for NIHL. We exposed flies to acoustic trauma and quantified physiological and anatomical effects. Trauma significantly reduced sound-evoked potential (SEP) amplitudes and increased SEP latencies in control genotypes. SEP amplitude but not latency effects recovered after 7 d. Although trauma produced no gross morphological changes in the auditory organ (Johnston’s organ), mitochondrial cross-sectional area was reduced 7 d after exposure. In nervana 3 heterozygous flies, which slightly compromise ion homeostasis, trauma had exaggerated effects on SEP amplitude and mitochondrial morphology, suggesting a key role for ion homeostasis in resistance to acoustic trauma. Thus, Drosophila exhibit acoustic trauma effects resembling those found in vertebrates, including inducing metabolic stress in sensory cells. This report of noise trauma in Drosophila is a foundation for studying molecular and genetic sequelae of NIHL. PMID:24003166

A major haemorrhage protocol improves the delivery of blood component therapy and reduces waste in trauma massive transfusion.

PubMed

Khan, Sirat; Allard, Shubha; Weaver, Anne; Barber, Colin; Davenport, Ross; Brohi, Karim

2013-05-01

Major haemorrhage protocols (MHP) are required as part of damage control resuscitation regimens in modern trauma care. The primary objectives of this study were to ascertain whether a MHP improved blood product administration and reduced waste compared to traditional massive transfusion protocols (MTP). Datasets on adult trauma admissions 1 year prior and 1 year post implementation of a MHP at a Level 1 trauma centre were obtained from the trauma registry. Demographic and clinical data were collected prospectively including mechanism of injury, physiological observations, ICU admission and length of stay. The volume of blood components (packed red blood cells, platelets, cryoprecipitate and fresh frozen plasma) issued, transfused, returned to stock and wasted within the first 24h was gathered retrospectively. Over the 2-year study period 2986 patient records were available for analysis. 40 patients required a 10+ Units of packed red blood ells transfusion in the MTP group vs. 56 patients post MHP implementation. The administration of blood component therapy improved significantly post MHP implementation. FFP:PRBC transfusion improved from 1:3 to 1:2 (p<0.01) and CRYO:PRBC improved from 1:10 to 1:7 (p<0.05). We reported a significant reduction in the waste of platelets from 14% to 2% (p<0.01). Outcomes had improved: Median hospital length of stay was reduced from 54 days to 26 days (p<0.05). Implementation of a MHP results in improved delivery of blood components and a reduction in the waste of blood products compared to the older model of MTP. In combination with educational programmes MHP can significantly improve blood product administration and patient outcomes in trauma haemorrhage. Level III diagnostic test study. Crown Copyright © 2012. Published by Elsevier Ltd. All rights reserved.

Blunt carotid and vertebral artery injuries.

PubMed

Arthurs, Zachary M; Starnes, Benjamin W

2008-11-01

The recognition and treatment of blunt cerebrovascular injuries has dramatically evolved over the past two decades. As imaging technology has improved both with respect to the image quality and acquisition times, its use has become a fundamental diagnostic tool in blunt trauma evaluation. The single greatest radiological advance in the past quarter century has been the refinement and increasing use of computed tomographic imaging for the diagnosis of surgical disease. Paralleling advances in noninvasive imaging, a heightened awareness of blunt cerebrovascular injuries has emerged, and the first screening protocols were developed at high volume trauma centres. Through aggressive screening, these injuries have increasingly been recognised before devastating neurological ischaemia and adverse neurocognitive outcomes. The mainstay of treatment for these injuries is antithrombotic therapy. However, all blunt cerebrovascular injuries require short and long-term follow-up. While the majority of injuries will resolve with medical management, a proportion will require further intervention in order to reduce the risk of subsequent stroke.

The effect of the quality of vital sign recording on clinical decision making in a regional acute care trauma ward.

PubMed

Keene, Claire M; Kong, Victor Y; Clarke, Damian L; Brysiewicz, Petra

2017-10-01

Recording vital signs is important in the hospital setting and the quality of this documentation influences clinical decision making. The Modified Early Warning Score (MEWS) uses vital signs to categorise the severity of a patient's physiological derangement and illustrates the clinical impact of vital signs in detecting patient deterioration and making management decisions. This descriptive study measured the quality of vital sign recordings in an acute care trauma setting, and used the MEWS to determine the impact the documentation quality had on the detection of physiological derangements and thus, clinical decision making. Vital signs recorded by the nursing staff of all trauma patients in the acute care trauma wards at a regional hospital in South Africa were collected from January 2013 to February 2013. Investigator-measured values taken within 2 hours of the routine observations and baseline patient information were also recorded. A MEWS for each patient was calculated from the routine and investigator-measured observations. Basic descriptive statistics were performed using EXCEL. The details of 181 newly admitted patients were collected. Completion of recordings was 81% for heart rate, 88% for respiratory rate, 98% for blood pressure, 92% for temperature and 41% for GCS. The recorded heart rate was positively correlated with the investigator's measurement (Pearson's correlation coefficient of 0.76); while the respiratory rate did not correlate (Pearson's correlation coefficient of 0.02). In 59% of patients the recorded respiratory rate (RR) was exactly 20 breaths per minute and 27% had a recorded RR of exactly 15. Seven percent of patients had aberrant Glasgow Coma Scale readings above the maximum value of 15. The average MEWS was 2 for both the recorded (MEWS(R)) and investigator (MEWS(I)) vitals, with the range of MEWS(R) 0-7 and MEWS(I) 0-9. Analysis showed 59% of the MEWS(R) underestimated the physiological derangement (scores were lower than the MEWS(I)); 80% of patients had a MEWS(R) requiring 4 hourly checks which was only completed in 2%; 86% of patients had a MEWS(R) of less than three (i.e. not necessitating escalation of care), but 33% of these showed a MEWS(I) greater than three (i.e. actually necessitating escalation of care). Documentation of vital signs aids management decisions, indicating the physiological derangement of a patient and dictating treatment. This study showed that there was a poor quality of vital sign recording in this acute care trauma setting, which led to underestimation of patients' physiological derangement and an inability to detect deteriorating patients. The MEWS could be a powerful tool to empower nurses to become involved in the diagnosis and detection of deteriorating patients, as well as providing a framework to communicate the severity of derangement between health workers. However, it requires a number of strategies to improve the quality of vital sign recording, including continuing education, increasing the numbers of competent staff and administrative changes in vital sign charts. Copyright © 2017. Production and hosting by Elsevier B.V.

The identification of criteria to evaluate prehospital trauma care using the Delphi technique.

PubMed

Rosengart, Matthew R; Nathens, Avery B; Schiff, Melissa A

2007-03-01

Current trauma system performance improvement emphasizes hospital- and patient-based outcome measures such as mortality and morbidity, with little focus upon the processes of prehospital trauma care. Little data exist to suggest which prehospital criteria should serve as potential filters. This study identifies the most important filters for auditing prehospital trauma care using a Delphi technique to achieve consensus of expert opinion. Experts in trauma care from the United States (n = 81) were asked to generate filters of potential utility in monitoring the prehospital aspect of the trauma system, and were then required to rank these questions in order of importance to identify those of greatest importance. Twenty-eight filters ranking in the highest tertile are proposed. The majority (54%) pertains to aspects of emergency medical services, which comprise 7 of the top 10 (70%) filters. Triage filters follow in priority ranking, comprising 29% of the final list. Filters concerning interfacility transfers and transportation ranked lowest. This study identifies audit filters representing the most important aspects of prehospital trauma care that merit continued evaluation and monitoring. A subsequent trial addressing the utility of these filters could potentially enhance the sensitivity of identifying deviations in prehospital care, standardize the performance improvement process, and translate into an improvement in patient care and outcome.

Evaluation of chest and abdominal injuries in trauma patients hospitalized in the surgery ward of poursina teaching hospital, guilan, iran.

PubMed

Hemmati, Hossein; Kazemnezhad-Leili, Ehsan; Mohtasham-Amiri, Zahra; Darzi, Ali Asghar; Davoudi-Kiakalayeh, Ali; Dehnadi-Moghaddam, Anoush; Kouchakinejad-Eramsadati, Leila

2013-01-01

Trauma, especially chest and abdominal trauma are increasing due to the growing number of vehicles on the roads, which leads to an increased incidence of road accidents. Urbanization, industrialization and additional problems are the other associated factors which accelerate this phenomenon. A better understanding of the etiology and pattern of such injuries can help to improve the management and ultimate the outcomes of these patients. This study aimed to evaluate the patients with chest and abdominal trauma hospitalized in the surgery ward of Poursina teaching hospital, Guilan, Iran. In this cross-sectional study, the data of all chest and abdominal trauma patients hospitalized in the surgery ward of Poursina teaching hospital were collected from March 2011 to March 2012. Information about age, gender, injured areas, type of injury (penetrating or blunt), etiology of the injury, accident location (urban or rural) and patients' discharge outcomes were collected by a questionnaire. In total, 211 patients with a mean age of 34.1 ± 1.68 years was entered into the study. The most common cause of trauma was traffic accidents (51.7%). Among patients with chest trauma, 45 cases (35.4%) had penetrating injuries and 82 cases (64.6%) blunt lesions. The prevalence of chest injuries was 35.5% and rib fractures 26.5%. In chest injuries, the prevalence of hemothorax was 65.3%, pneumothorax 2.7%, lung contusion 4% and emphysema 1.3%, respectively. There were 24 cases (27.9%) with abdominal trauma which had penetrating lesions and 62 cases (72.1%) with blunt lesions. The most common lesions in patients with penetrating abdominal injuries were spleen (24.2%) and liver (12.1%) lesions. The outcomes of the patients were as follow: 95.7% recovery and 4.3% death. The majority of deaths were observed among road traffic victims (77.7%). Considering the fact that road-related accidents are quite predictable and controllable; therefore, the quality promotion of traumatic patients' care, and the road safety should be noted as problems associated with public health.

Evaluation of Chest and Abdominal Injuries in Trauma Patients Hospitalized in the Surgery Ward of Poursina Teaching Hospital, Guilan, Iran

PubMed Central

Hemmati, Hossein; Kazemnezhad-Leili, Ehsan; Mohtasham-Amiri, Zahra; Darzi, Ali Asghar; Davoudi-Kiakalayeh, Ali; Dehnadi-Moghaddam, Anoush; Kouchakinejad-Eramsadati, Leila

2013-01-01

Background Trauma, especially chest and abdominal trauma are increasing due to the growing number of vehicles on the roads, which leads to an increased incidence of road accidents. Urbanization, industrialization and additional problems are the other associated factors which accelerate this phenomenon. A better understanding of the etiology and pattern of such injuries can help to improve the management and ultimate the outcomes of these patients. Objectives This study aimed to evaluate the patients with chest and abdominal trauma hospitalized in the surgery ward of Poursina teaching hospital, Guilan, Iran. Patients and Methods In this cross-sectional study, the data of all chest and abdominal trauma patients hospitalized in the surgery ward of Poursina teaching hospital were collected from March 2011 to March 2012. Information about age, gender, injured areas, type of injury (penetrating or blunt), etiology of the injury, accident location (urban or rural) and patients' discharge outcomes were collected by a questionnaire. Results In total, 211 patients with a mean age of 34.1 ± 1.68 years was entered into the study. The most common cause of trauma was traffic accidents (51.7%). Among patients with chest trauma, 45 cases (35.4%) had penetrating injuries and 82 cases (64.6%) blunt lesions. The prevalence of chest injuries was 35.5% and rib fractures 26.5%. In chest injuries, the prevalence of hemothorax was 65.3%, pneumothorax 2.7%, lung contusion 4% and emphysema 1.3%, respectively. There were 24 cases (27.9%) with abdominal trauma which had penetrating lesions and 62 cases (72.1%) with blunt lesions. The most common lesions in patients with penetrating abdominal injuries were spleen (24.2%) and liver (12.1%) lesions. The outcomes of the patients were as follow: 95.7% recovery and 4.3% death. The majority of deaths were observed among road traffic victims (77.7%). Conclusions Considering the fact that road-related accidents are quite predictable and controllable; therefore, the quality promotion of traumatic patients' care, and the road safety should be noted as problems associated with public health. PMID:24396771

Ventilator-Associated Pneumonia in Trauma Patients: Different Criteria, Different Rates.

PubMed

Leonard, Kenji L; Borst, Gregory M; Davies, Stephen W; Coogan, Michael; Waibel, Brett H; Poulin, Nathaniel R; Bard, Michael R; Goettler, Claudia E; Rinehart, Shane M; Toschlog, Eric A

2016-06-01

No consensus exists regarding the definition of ventilator-associated pneumonia (VAP). Even within a single institution, inconsistent diagnostic criteria result in conflicting rates of VAP. As a Level 1 trauma center participating in the Trauma Quality Improvement Project (TQIP) and the National Healthcare Safety Network (NHSN), our institution showed inconsistencies in VAP rates depending on which criteria was applied. The purpose of this study was to compare VAP definitions, defined by culture-based criteria, National Trauma Data Bank (NTDB) and NHSN, using incidence in trauma patients. A retrospective chart review of consecutive trauma patients who were diagnosed with VAP and met pre-determined inclusion and exclusion criteria admitted to our rural, 861-bed, Level 1 trauma and tertiary care center between January 2008 and December 2011 was performed. These patients were identified from the National Trauma Registry of the American College of Surgeons (NTRACS) database and an in-house infection control database. Ventilator-associated pneumonia diagnosis criteria defined by the U.S. Center for Disease Control and Prevention (used by the NHSN), the NTDB, and our institutional, culture-based criteria gold standard were compared among patients. Two hundred seventy-nine patients were diagnosed with VAP (25.4% met NHSN criteria, 88.2% met NTDB, and 76.3% met culture-based criteria). Only 58 (20.1%) patients met all three criteria. When NHSN criteria were compared with culture-based criteria, NHSN showed a high specificity (92.5%) and low sensitivity (28.2%). The positive predictive value (PPV) was 84.5%, but the negative predictive value (NPV) was 47.1%. The agreement between the NHSN and the culture-based criteria was poor (κ = 0.18). Conversely, the NTDB showed a lower specificity (57.8%), but greater sensitivity (86.4%) compared with culture-based criteria. The PPV and NPV were both 74% and the two criteria showed fair agreement (κ = 0.41). The lack of standard diagnostic criteria for VAP resulted in variable reporting to different agencies. Emphasis on establishing a consensus VAP definition should be undertaken.

Kinetic therapy in multiple trauma patients with severe thoracic trauma: a treatment option to reduce ventilator time and improve outcome.

PubMed

Wutzler, S; Sturm, K; Lustenberger, T; Wyen, H; Zacharowksi, K; Marzi, I; Bingold, T

2017-04-01

Continuous lateral rotational therapy (CLRT) has been described as a promising approach for prophylaxis and treatment of respiratory complications in critically ill patients over two decades ago. However, meta-analyses failed to demonstrate any significant benefit on outcome by CLRT, possibly due to the heterogeneity and low overall quality of available studies. Observational trial over a 3-year period on outcome in trauma patients (Injury Severity Score, ISS ≥16) with severe thoracic injury (Abbreviated Injury Scale, AIS Thorax ≥3) initially treated with CLRT as standard of care. Epidemiological data, injury severity, and pattern and physiological parameters were recorded. Outcome indicators were time on mechanical ventilation, length of stay, rates of pneumonia, sepsis and acute respiratory distress syndrome, hospital mortality, and rates of re-intubation. Additionally, data are compared with the results from the TraumaRegister ® of the German Trauma Society. Over the 3-year period 76 patients with ISS ≥16/AIS Thorax ≥3 received CLRT, equaling 24 % of all patients with ISS ≥16 between 18 and 80 years. Mean ISS was 35.3 (standard deviations, SD 12.2) [71.1 % male, 97.4 % blunt trauma, mean age 43.9 years (SD 18.7)]. Mean time on CLRT was 3.3 days (SD 2.2), time on mechanical ventilation 7.8 days (SD 7.1), and 9.2 % had to be re-intubated due to respiratory complications. CLRT-related complications occurred in 8.9 %. Overall 25 % of the patients developed pneumonia (VAP = 13.2 %). Despite a significantly higher ISS we observed shorter times on mechanical ventilation and intensive care unit in our collective in comparison to data published from the nationwide TraumaRegister ® . CLRT remains a therapeutic option to reduce pulmonary complications after severe chest trauma in our center. However, a RCT is needed to study the effects of other treatment options such as early extubation and non-invasive ventilation or prone/supine positioning.

Primary prevention of pediatric abusive head trauma: a cost audit and cost-utility analysis.

PubMed

Friedman, Joshua; Reed, Peter; Sharplin, Peter; Kelly, Patrick

2012-01-01

To obtain comprehensive, reliable data on the direct cost of pediatric abusive head trauma in New Zealand, and to use this data to evaluate the possible cost-benefit of a national primary prevention program. A 5 year cohort of infants with abusive head trauma admitted to hospital in Auckland, New Zealand was reviewed. We determined the direct costs of hospital care (from hospital and Ministry of Health financial records), community rehabilitation (from the Accident Compensation Corporation), special education (from the Ministry of Education), investigation and child protection (from the Police and Child Protective Services), criminal trials (from the Police, prosecution and defence), punishment of offenders (from the Department of Corrections) and life-time care for moderate or severe disability (from the Accident Compensation Corporation). Analysis of the possible cost-utility of a national primary prevention program was undertaken, using the costs established in our cohort, recent New Zealand national data on the incidence of pediatric abusive head trauma, international data on quality of life after head trauma, and published international literature on prevention programs. There were 52 cases of abusive head trauma in the sample. Hospital costs totaled $NZ2,433,340, child protection $NZ1,560,123, police investigation $NZ1,842,237, criminal trials $NZ3,214,020, punishment of offenders $NZ4,411,852 and community rehabilitation $NZ2,895,848. Projected education costs for disabled survivors were $NZ2,452,148, and the cost of projected lifetime care was $NZ33,624,297. Total costs were $NZ52,433,864, averaging $NZ1,008,344 per child. Cost-utility analysis resulted in a strongly positive economic argument for primary prevention, with expected case scenarios showing lowered net costs with improved health outcomes. Pediatric abusive head trauma is very expensive, and on a conservative estimate the costs of acute hospitalization represent no more than 4% of lifetime direct costs. If shaken baby prevention programs are effective, there is likely to be a strong economic argument for their implementation. This study also provides robust data for future cost-benefit analysis in the field of abusive head trauma prevention. Copyright © 2012 Elsevier Ltd. All rights reserved.

[Hypoacusia as a result of chronic traumatic acoustic lesion in workers with affiliation to the Mexican Social Security Institute, 1992-2002].

PubMed

Loera-González, Maria de los Angeles; Salinas-Tovar, Santiago; Aguilar-Madrid, Guadalupe; Borja-Aburto, Victor Hugo

2006-01-01

Hypoacusia by chronic acoustic trauma (HTAC) is one of the main work diseases. to analyze the distribution and frequency of hearing loss produced by chronic acoustic trauma (HLON) in workers who attend to Mexican Social Security Institute (IMSS). Also analyze the estimated cost of permanent work disabilities. We analyze all hearing loss cases of the workers who attend to IMSS in the period between 1992 to 2001, registered in the Subsystem of registration of work's risk in the IMSS. Measures of central tendency, odds ratio (OR) and direct costs by means were calculated. The HLON represents 41% (1867) of all work's disease, during the period it was observed an increase of number of cases, the average of permanent disabilities, the rate of incidence and the average of rating percentage. The cases solved through a demand showed an increase to 105% in four years. The estimate monthly cost for every worker was 277 pesos. The HLON represents an important problem for the IMSS causing social and economic impact. If they don't take some actions to improve the quality of chronic acoustic trauma diagnosis it will have more serious consequences.

Guideline validation in multiple trauma care through business process modeling.

PubMed

Stausberg, Jürgen; Bilir, Hüseyin; Waydhas, Christian; Ruchholtz, Steffen

2003-07-01

Clinical guidelines can improve the quality of care in multiple trauma. In our Department of Trauma Surgery a specific guideline is available paper-based as a set of flowcharts. This format is appropriate for the use by experienced physicians but insufficient for electronic support of learning, workflow and process optimization. A formal and logically consistent version represented with a standardized meta-model is necessary for automatic processing. In our project we transferred the paper-based into an electronic format and analyzed the structure with respect to formal errors. Several errors were detected in seven error categories. The errors were corrected to reach a formally and logically consistent process model. In a second step the clinical content of the guideline was revised interactively using a process-modeling tool. Our study reveals that guideline development should be assisted by process modeling tools, which check the content in comparison to a meta-model. The meta-model itself could support the domain experts in formulating their knowledge systematically. To assure sustainability of guideline development a representation independent of specific applications or specific provider is necessary. Then, clinical guidelines could be used for eLearning, process optimization and workflow management additionally.

76 FR 36135 - Agency Information Collection Activities; Proposed Collection; Comment Request

Federal Register 2010, 2011, 2012, 2013, 2014

2011-06-21

... serves multiple practical purposes: (1) To collect and analyze descriptive, outcome, and service... on access to high-quality, trauma-informed care; (3) to evaluate NCTSN centers' training and... below. Descriptive and Clinical Outcomes In order to describe the children served, their trauma...

Development of a novel Global Trauma System Evaluation Tool and initial results of implementation in the Republic of South Sudan.

PubMed

Remick, Kyle N; Wong, Evan G; Chuot Chep, Chep; Morton, Richard T; Monsour, Abdullah; Fisher, Dane; Oh, John S; Wilson, Ramey; Malone, Debra L; Branas, Charles; Elster, Eric; Gross, Kirby R; Kushner, Adam L

2014-11-01

Trauma remains a leading cause of death and disability in the world, and trauma systems decrease mortality from trauma. We developed the Global Trauma System Evaluation Tool (G-TSET) specifically for use in low- and middle-income countries (LMICs). The Sudan People's Liberation Army (SPLA) in the Republic of South Sudan (RSS) desires a military trauma system (MTS) which allowed us to pilot the G-TSET. The G-TSET was developed by modifying key components of a trauma system applicable to LMICs. We partnered with the SPLA Medical Corps using clinical collaboration, direct observation, and discussion groups. Benchmarks and indicators were scored with 5 indicating "full capability" and 1 meaning "not present" and were used to develop a SPLA MTS plan. The overall MTS score was 1.15 indicating an urgent need for system development. The assessment highlighted the need for SPLA Command support. Battlefield care, transport to a trauma facility, and inter-facility communication were identified for improvement. After essential battlefield care, consisting primarily of bandaging and splinting, transport times for injured SPLA soldiers were 12h to 3 days by truck. Based on our findings, we collaborated with SPLA medical leadership to develop a plan to develop a formal MTS. We piloted a novel trauma system assessment tool for the MTS in the RSS. Qualitatively, we identified gaps in the MTS and provided the medical leadership with a plan for improvement. We anticipate a short-term follow-up to quantify improvement, and we seek to validate this tool for use in other countries. Published by Elsevier Ltd.

Development and Validation of Quality Criteria for Providing Patient- and Family-centered Injury Care.

PubMed

Boyd, Jamie M; Burton, Rachael; Butler, Barb L; Dyer, Dianne; Evans, David C; Felteau, Melissa; Gruen, Russell L; Jaffe, Kenneth M; Kortbeek, John; Lang, Eddy; Lougheed, Val; Moore, Lynne; Narciso, Michelle; Oxland, Peter; Rivara, Frederick P; Roberts, Derek; Sarakbi, Diana; Vine, Karen; Stelfox, Henry T

2017-08-01

The aim of this study was to develop and evaluate the content validity of quality criteria for providing patient- and family-centered injury care. Quality criteria have been developed for clinical injury care, but not patient- and family-centered injury care. Using a modified Research AND Development Corporation (RAND)/University of California, Los Angeles (UCLA) Appropriateness Methodology, a panel of 16 patients, family members, injury and quality of care experts serially rated and revised criteria for patient- and family-centered injury care identified from patient and family focus groups. The criteria were then sent to 384 verified trauma centers in the United States, Canada, Australia, and New Zealand for evaluation. A total of 46 criteria were rated and revised by the panel over 4 rounds of review producing 14 criteria related to clinical care (n = 4; transitions of care, pain management, patient safety, provider competence), communication (n = 3; information for patients/families; communication of discharge plans to patients/families, communication between hospital and community providers), holistic care (n = 4; patient hygiene, kindness and respect, family access to patient, social and spiritual support) and end-of-life care (n = 3; decision making, end-of-life care, family follow-up). Medical directors, managers, or coordinators representing 254 trauma centers (66% response rate) rated 12 criteria to be important (95% of responses) for patient- and family-centered injury care. Fewer centers rated family access to the patient (80%) and family follow-up after patient death (65%) to be important criteria. Fourteen-candidate quality criteria for patient- and family-centered injury care were developed and shown to have content validity. These may be used to guide quality improvement practices.

[Systematic development of a scale for determination of health-related quality of life in multiple trauma patients. The Polytrauma Outcome (POLO) Chart].

PubMed

Pirente, N; Bouillon, B; Schäfer, B; Raum, M; Helling, H J; Berger, E; Neugebauer, E

2002-05-01

Even years after having sustained multiple injuries patients often suffer from its sequelae. These comprise restrictions in physical function, but also pain, social and psychological impairments. Although the Meran Consensus Conference in 1990 defined the contents of "quality of life" (QoL) measures in surgery, still no instrument is available for the valid assessment of all relevant QoL domains in multiple injured patients. This paper describes the systematic development of a modular instrument for the assessment of health related QoL. Within three phases (phase I: generation of items, phase II: item reduction, phase III: pre-testing in 70 multiple injured and control patients) a questionnaire of 57 items was developed, which measures all relevant trauma-related aspects of QoL after acute hospital care. In combination with the Glascow Outcome Scale (GOS), the EUROQOL and the SF-36, the newly developed instrument builds the Polytrauma Outcome Chart (POLO-Chart) which will also be used as "Part E" for outcome assessment within the "Trauma registry" of the German Society for Trauma Surgery. In phase IV, the POLO-Chart will finally be validated in five trauma centres (Celle, Essen, Hanover, Cologne und Munich).

Trauma-Informed HIV Prevention and Treatment.

PubMed

Sales, Jessica M; Swartzendruber, Andrea; Phillips, Ashley L

2016-12-01

The high prevalence of trauma and its negative impact on health and health-promoting behaviors underscore the need for multi-level interventions to address trauma and its associated sequelae to improve physical and mental well-being in both HIV-infected and HIV-uninfected populations. Growing global awareness of the intersection of trauma and HIV has resulted in development and testing of interventions to address trauma in the context of HIV treatment and HIV prevention in the USA and globally. Despite increasing recognition of the widespread nature of trauma and the importance of trauma to HIV transmission around the globe, several gaps remain. Through a survey of the literature, we identified eight studies (published in the past 5 years) describing interventions to address the effects of trauma on HIV-related outcomes. In particular, this study focused on the levels of intervention, populations the interventions were designed to benefit, and types of trauma addressed in the interventions in the context of both HIV prevention and treatment. Remarkably absent from the HIV prevention, interventions reviewed were interventions designed to address violence experienced by men or transgender individuals, in the USA or globally. Given the pervasive nature of trauma experienced generally, but especially among individuals at heightened risk for HIV, future HIV prevention interventions universally should consider becoming trauma-informed. Widespread acknowledgement of the pervasive impact of gender-based violence on HIV outcomes among women has led to multiple calls for trauma-informed care (TIC) approaches to improve the effectiveness of HIV services for HIV-infected women. TIC approaches may be relevant for and should also be tested among men and all groups with high co-occurring epidemics of HIV and trauma (e.g., men who have sex with men (MSM), transgendered populations, injection drug users, sex workers), regardless of type of trauma experience.

Trauma-Informed HIV Prevention and Treatment

PubMed Central

Sales, Jessica M.; Swartzendruber, Andrea; Phillips, Ashley L.

2016-01-01

The high prevalence of trauma and its negative impact on health and health-promoting behaviors underscore the need for multi-level interventions to address trauma and its associated sequelae to improve physical and mental well-being in both HIV-infected and HIV-uninfected populations. Growing global awareness of the intersection of trauma and HIV has resulted in development and testing of interventions to address trauma in the context of HIV treatment and HIV prevention in the U.S. and globally. Despite increasing recognition of the widespread nature of trauma and the importance of trauma to HIV transmission around the globe, several gaps remain. Through a survey of the literature, we identified 8 studies (published in the past 5 years) describing interventions to address the effects of trauma on HIV-related outcomes. In particular, this study focused on the levels of intervention, populations the interventions were designed to benefit, and types of trauma addressed in the interventions in the context of both HIV prevention and treatment. Remarkably absent from the HIV prevention interventions reviewed were interventions designed to address violence experienced by men or transgender individuals, in the U.S. or globally. Given the pervasive nature of trauma experienced generally, but especially among individuals at heightened risk for HIV, future HIV prevention interventions universally should consider becoming trauma-informed. Widespread acknowledgement of the pervasive impact of gender-based violence on HIV outcomes among women has led to multiple calls for trauma-informed care (TIC) approaches to improve the effectiveness of HIV services for HIV infected women. TIC approaches may be relevant for and should also be tested among men and all groups with high co-occurring epidemics of HIV and trauma (e.g., men who have sex with men (MSM), transgendered populations, injection drug users, sex workers), regardless of type of trauma experience. PMID:27704251

Benchmarking of trauma care worldwide: the potential value of an International Trauma Data Bank (ITDB).

PubMed

Haider, Adil H; Hashmi, Zain G; Gupta, Sonia; Zafar, Syed Nabeel; David, Jean-Stephane; Efron, David T; Stevens, Kent A; Zafar, Hasnain; Schneider, Eric B; Voiglio, Eric; Coimbra, Raul; Haut, Elliott R

2014-08-01

National trauma registries have helped improve patient outcomes across the world. Recently, the idea of an International Trauma Data Bank (ITDB) has been suggested to establish global comparative assessments of trauma outcomes. The objective of this study was to determine whether global trauma data could be combined to perform international outcomes benchmarking. We used observed/expected (O/E) mortality ratios to compare two trauma centers [European high-income country (HIC) and Asian lower-middle income country (LMIC)] with centers in the North American National Trauma Data Bank (NTDB). Patients (≥16 years) with blunt/penetrating injuries were included. Multivariable logistic regression, adjusting for known predictors of trauma mortality, was performed. Estimates were used to predict the expected deaths at each center and to calculate O/E mortality ratios for benchmarking. A total of 375,433 patients from 301 centers were included from the NTDB (2002-2010). The LMIC trauma center had 806 patients (2002-2010), whereas the HIC reported 1,003 patients (2002-2004). The most important known predictors of trauma mortality were adequately recorded in all datasets. Mortality benchmarking revealed that the HIC center performed similarly to the NTDB centers [O/E = 1.11 (95% confidence interval (CI) 0.92-1.35)], whereas the LMIC center showed significantly worse survival [O/E = 1.52 (1.23-1.88)]. Subset analyses of patients with blunt or penetrating injury showed similar results. Using only a few key covariates, aggregated global trauma data can be used to adequately perform international trauma center benchmarking. The creation of the ITDB is feasible and recommended as it may be a pivotal step towards improving global trauma outcomes.

Clinical Holistic Medicine (Mindful, Short-Term Psychodynamic Psychotherapy Complemented with Bodywork) in the Treatment of Experienced Physical Illness and Chronic Pain

PubMed Central

Ventegodt, Søren; Thegler, Suzette; Andreasen, Tove; Struve, Flemming; Enevoldsen, Lars; Bassaine, Laila; Torp, Margrethe; Merrick, Joav

2007-01-01

We investigated the treatment effect of psychodynamic short-term therapy complemented with bodywork on patients who presented with physical illness at the Research Clinic for Holistic Medicine in Copenhagen. Psychodynamic short-term therapy was complemented with bodywork (Marion Rosen) to help patients confront old emotional pain from childhood trauma(s). Patients were measured with a five-item quality of life and health questionnaire (QOL5), a one-item questionnaire of self-assessed quality of life (QOL1), and four questions on self-rated ability to love and to function sexually, socially, and at work (ability to sustain a full-time job). Most of the patients had chronic pain that could not be alleviated with drugs. Results showed that 31 patients with the experience of being severely physically ill (mostly from chronic pain), in spite of having consulted their own general practitioner, entered the study. The holistic approach and body therapy accelerated the therapy dramatically and no significant side effects were detected. After the intervention, 38.7% did not feel ill (1.73 < NNT < 4.58) (p = 0.05). Psychodynamic short-term therapy complemented with bodywork can help patients. When the patients responded to the therapy, the self-assessed mental health, relationship with partner, ability to work, self-assessed quality of life, relationships in general, measured QOL (with the validated questionnaire QOL5), and life's total state (mean of health, QOL and ability) were significantly improved, statistically and clinically. Most importantly, all aspects of life were improved simultaneously, due to induction of Antonovsky-salutogenesis. The patients received in average 20 sessions over 14 months at a cost of 1600 EURO. For the treatment responders, the treatment seemingly provided lasting benefits. PMID:17334622

Effectiveness of educational poster on knowledge of emergency management of dental trauma--part 2: cluster randomised controlled trial for secondary school students.

PubMed

Young, Cecilia; Wong, Kin Yau; Cheung, Lim K

2014-01-01

To investigate the effectiveness of educational poster on improving secondary school students' knowledge of emergency management of dental trauma. A cluster randomised controlled trial was conducted. 16 schools with total 671 secondary students who can read Chinese or English were randomised into intervention (poster, 8 schools, 364 students) and control groups (8 schools, 305 students) at the school level. Baseline knowledge of dental trauma was obtained by a questionnaire. Poster containing information of dental trauma management was displayed in a classroom for 2 weeks in each school in the intervention group whereas in the control group there was no display of such posters. Students of both groups completed the same questionnaire after 2 weeks. Two-week display of posters improved the knowledge score by 1.25 (p-value = 0.0407) on average. Educational poster on dental trauma management significantly improved the level of knowledge of secondary school students in Hong Kong. HKClinicalTrial.com HKCTR-1343 ClinicalTrials.gov NCT01809457.

Mortality factors in geriatric blunt trauma patients.

PubMed

Knudson, M M; Lieberman, J; Morris, J A; Cushing, B M; Stubbs, H A

1994-04-01

To examine various clinical factors for their ability to predict mortality in geriatric patients following blunt trauma. In this retrospective study, trauma registries and medical records from three trauma centers were reviewed for patients 65 years and older who had sustained blunt trauma. The following variables were extracted and examined independently and in combination for their ability to predict death: age, gender, mechanism of injury, admission blood pressure, and Glasgow Coma Scale score, respiratory status, Trauma Score, Revised Trauma Score, and Injury Severity Score. Three urban trauma centers. Geriatric trauma patients entering three trauma centers (Stanford [Calif] University Hospital, Vanderbilt University Medical Center, Nashville, Tenn, and Maryland Institute for Emergency Medical Services Systems, Baltimore) following blunt trauma during a 7-year period (1982 to 1989). The Injury Severity Score was the single variable that correlated most significantly with mortality. Mortality rates were higher for men than for women and were significantly higher in patients 75 years and older. Admission variables associated with the highest relative risks of death included a Trauma Score less than 7; hypotension (systolic blood pressure, < 90 mm Hg); hypoventilation (respiratory rate, < 10 breaths per minute); or a Glasgow Coma Scale score equal to 3. Admission variables in geriatric trauma patients can be used to predict outcome and may also be useful in making decisions about triage, quality assurance, and use of intensive care unit beds.

Open pneumothorax resulting from blunt thoracic trauma: a case report.

PubMed

McClintick, Colleen M

2008-01-01

Cases of open pneumothorax have been documented as early as 326 BC. Until the last 50 years, understanding of the epidemiology and treatment of penetrating chest trauma has arisen from military surgery. A better understanding of cardiopulmonary dynamics, advances in ventilatory support, and improvement in surgical technique have drastically improved treatment and increased the survival rate of patients with penetrating thoracic trauma. Open pneumothorax is rare in blunt chest trauma, but can occur when injury results in a substantial loss of the chest wall. This case study presents an adolescent who sustained a large open pneumothorax as a result of being run over by a car. Early and appropriate surgical intervention coupled with coordinated efforts by all members of the trauma team resulted in a positive outcome for this patient.

Simulated Trauma and Resuscitation Team Training course-evolution of a multidisciplinary trauma crisis resource management simulation course.

PubMed

Gillman, Lawrence M; Brindley, Peter; Paton-Gay, John Damian; Engels, Paul T; Park, Jason; Vergis, Ashley; Widder, Sandy

2016-07-01

We previously reported on a pilot trauma multidisciplinary crisis resource course titled S.T.A.R.T.T. (Simulated Trauma and Resuscitative Team Training). Here, we study the course's evolution. Satisfaction was evaluated by postcourse survey. Trauma teams were evaluated using the Ottawa global rating scale and an Advanced Trauma Life Support primary survey checklist. Eleven "trauma teams," consisting of physicians, nurses, and respiratory therapists, each completed 4 crisis simulations over 3 courses. Satisfaction remained high among participants with overall mean satisfaction being 4.39 on a 5-point Likert scale. As participants progressed through scenarios, improvements in global rating scale scores were seen between the 1st and 4th (29.8 vs 36.1 of 42, P = .022), 2nd and 3rd (28.2 vs 34.6, P = .017), and 2nd and 4th (28.2 vs 36.1, P = .003) scenarios. There were no differences in Advanced Trauma Life Support checklist with mean scores for each scenario ranging 11.3 to 13.2 of 17. The evolved Simulated Trauma and Resuscitative Team Training curriculum has maintained high participant satisfaction and is associated with improvement in team crisis resource management skills over the duration of the course. Copyright © 2015 Elsevier Inc. All rights reserved.

Digital health technology and trauma: development of an app to standardize care.

PubMed

Hsu, Jeremy M

2015-04-01

Standardized practice results in less variation, therefore reducing errors and improving outcome. Optimal trauma care is achieved through standardization, as is evidenced by the widespread adoption of the Advanced Trauma Life Support approach. The challenge for an individual institution is how does one educate and promulgate these standardized processes widely and efficiently? In today's world, digital health technology must be considered in the process. The aim of this study was to describe the process of developing an app, which includes standardized trauma algorithms. The objective of the app was to allow easy, real-time access to trauma algorithms, and therefore reduce omissions/errors. A set of trauma algorithms, relevant to the local setting, was derived from the best available evidence. After obtaining grant funding, a collaborative endeavour was undertaken with an external specialist app developing company. The process required 6 months to translate the existing trauma algorithms into an app. The app contains 32 separate trauma algorithms, formatted as a single-page flow diagram. It utilizes specific smartphone features such as 'pinch to zoom', jump-words and pop-ups to allow rapid access to the desired information. Improvements in trauma care outcomes result from reducing variation. By incorporating digital health technology, a trauma app has been developed, allowing easy and intuitive access to evidenced-based algorithms. © 2015 Royal Australasian College of Surgeons.

Outcome of severely injured trauma patients at a designated trauma centre in the Hong Kong Special Administrative Region.

PubMed

Leung, Ka Kit Gilberto; Ho, Wendy; Tong, King Hung Daniel; Yuen, Wai Key

2010-05-20

The Hong Kong Special Administrative Region (HKSAR) of the People's Republic of China (PRC) has seen significant changes in its trauma service over the last ten years including the implementation of a regional trauma system. The author's institution is one of the five trauma centres designated in 2003. This article reports our initial clinical experience. A prospective single-centre trauma registry from January 2004 to December 2008 was reviewed. The primary clinical outcome measure was hospital mortality. The Trauma and Injury Severity Score (TRISS) methodology was used for bench-marking with the North America Major Trauma Outcome Study (MTOS) database. There were 1451 patients. The majority (83.9%) suffered from blunt injury. The overall mortality rate was 7.8%. Severe injury, defined as the Injury Severity Score > 15, occurred in 22.5% of patients, and was associated with a mortality rate of 31.6%. A trend of progressive improvement was noted. The M-statistic was 0.99, indicating comparable case-mix with the MTOS. The Z- and W-statistics of each individual year revealed fewer, but not significantly so, number of survivors than expected. Trauma centre designation was feasible in the HKSAR and was associated with a gradual improvement in patient care. Trauma system implementation may be considered in regions equipped with the necessary socio-economic and organizational set-up.

The outcomes of 1120 severe multiple trauma patients with hemorrhagic shock in an emergency department: a retrospective study.

PubMed

Wen, Yin; Yang, Huang; Wei, Wang; Shan-shou, Liu

2013-01-01

Uncontrolled hemorrhagic shock is a significant factor in death of severe multiple trauma patients. The acute management of injured bleeding in emergency department (ED) may improve patient outcomes. The medical records of severe multiple trauma patients with hemorrhagic shock in our ED were reviewed to summarize an evidence-based approach to the management of critically injured bleeding trauma patients. A retrospective study was carried out from January 2002 to December 2011 in a Chinese tertiary hospital. Clinical data from major trauma patients with hemorrhagic shock admitted to ED were evaluated. The patients were stratified based on the characteristics of traumatic condition and resuscitation strategies. The medical treatments and the outcomes of these severe multiple trauma patients were described. A total of 1120 major trauma patients, consisting of 832 males and 288 females, were enrolled. 906 of the patients (80.9%) were injured in traffic accidents, 104 (9.3%) from falling, and 100 from other reasons. The number of injured sites varied from 2 to 6, 616(55.0%) more than 3. 902 (80.5%) trauma patients have recovered and been discharged from hospital. Uncontrolled hemorrhagic shock is a main reason of trauma patients' death. The resuscitation strategy should center upon permissive hypotension and early hemostatic resuscitation combined identified and corrects coagulopathy. The current approach to the management of critically injured bleeding trauma patients is able to improve patient outcomes.

“Do You Expect Me to Receive PTSD Care in a Setting Where Most of the Other Patients Remind Me of the Perpetrator?”: Home-Based Telemedicine to Address Barriers to Care Unique to Military Sexual Trauma and Veterans Affairs Hospitals

PubMed Central

Gilmore, Amanda K.; Davis, Margaret T.; Grubaugh, Anouk; Resnick, Heidi; Birks, Anna; Denier, Carol; Muzzy, Wendy; Tuerk, Peter; Acierno, Ron

2016-01-01

Home-based telemedicine (HBT) is a validated method of evidence-based treatment delivery for posttraumatic stress disorder (PTSD), and justification for its use has centered on closing gaps related to provider availability and distance to treatment centers. However, another potential use of HBT may be to overcome barriers to care that are inherent to the treatment environment, such as with female veterans who have experienced military sexual trauma (MST) and who must present to VA Medical Centers where the majority of patients share features with perpetrator (e.g. gender, clothing) and may function as reminders of the trauma. Delivering evidence-based therapies to female veterans with MST-related PTSD via HBT can provide needed treatment to this population. This manuscript describes an ongoing federally funded randomized controlled trial comparing Prolonged Exposure (PE) delivered in-person to PE delivered via HBT. Outcomes include session attendance, satisfaction with services, and clinical and quality of life indices. It is hypothesized that based on intent-to-treat analyses, HBT delivery of PE will be more effective than SD at improving both clinical and quality of life outcomes at post, 3-, and 6-month follow-up. This is because ‘dose received’, that is fewer sessions missed, and lower attrition, will be observed in the HBT group. Although the current manuscript focuses on female veterans with MST-related PTSD, implications for other populations facing systemic barriers are discussed. PMID:26992740

"Do you expect me to receive PTSD care in a setting where most of the other patients remind me of the perpetrator?": Home-based telemedicine to address barriers to care unique to military sexual trauma and veterans affairs hospitals.

PubMed

Gilmore, Amanda K; Davis, Margaret T; Grubaugh, Anouk; Resnick, Heidi; Birks, Anna; Denier, Carol; Muzzy, Wendy; Tuerk, Peter; Acierno, Ron

2016-05-01

Home-based telemedicine (HBT) is a validated method of evidence-based treatment delivery for posttraumatic stress disorder (PTSD), and justification for its use has centered on closing gaps related to provider availability and distance to treatment centers. However, another potential use of HBT may be to overcome barriers to care that are inherent to the treatment environment, such as with female veterans who have experienced military sexual trauma (MST) and who must present to VA Medical Centers where the majority of patients share features with perpetrator (e.g. gender, clothing) and may function as reminders of the trauma. Delivering evidence-based therapies to female veterans with MST-related PTSD via HBT can provide needed treatment to this population. This manuscript describes an ongoing federally funded randomized controlled trial comparing Prolonged Exposure (PE) delivered in-person to PE delivered via HBT. Outcomes include session attendance, satisfaction with services, and clinical and quality of life indices. It is hypothesized that based on intent-to-treat analyses, HBT delivery of PE will be more effective than SD at improving both clinical and quality of life outcomes at post, 3-, and 6-month follow-up. This is because 'dose received', that is fewer sessions missed, and lower attrition, will be observed in the HBT group. Although the current manuscript focuses on female veterans with MST-related PTSD, implications for other populations facing systemic barriers are discussed. Copyright © 2016 Elsevier Inc. All rights reserved.

Trauma Collaborative Care Intervention: Effect on Surgeon Confidence in Managing Psychosocial Complications After Orthopaedic Trauma.

PubMed

Wegener, Stephen T; Carroll, Eben A; Gary, Joshua L; McKinley, Todd O; OʼToole, Robert V; Sietsema, Debra L; Castillo, Renan C; Frey, Katherine P; Scharfstein, Daniel O; Huang, Yanjie; Collins, Susan C J; MacKenzie, Ellen J

2017-08-01

The impact of the Trauma Collaborative Care (TCC) program on surgeon confidence in managing the psychosocial sequelae of orthopaedic trauma was evaluated as part of a larger prospective, multisite, cluster clinical trial. We compared confidence and perceived resource availability among surgeons practicing in trauma centers that implemented the TCC program with orthopaedic trauma surgeons in similar trauma centers that did not implement the TCC. Prospective cohort design. Level-I trauma centers. Attending surgeons and fellows (N = 95 Pre and N = 82 Post). Self-report 10-item measure of surgeon confidence in managing psychosocial issues associated with trauma and perceived availability of support resources. Analyses, performed on the entire sample and repeated on the subset of 52 surgeons who responded to the survey at both times points, found surgeons at intervention sites experienced a significantly greater positive improvement (P < 0.05) in their (1) belief that they have strategies to help orthopaedic trauma patients change their psychosocial situation; (2) confidence in making appropriate referrals for orthopaedic trauma patients with psychosocial problems; and (3) belief that they have access to information to guide the management of psychosocial issues related to recovery. Initial data suggest that the establishment of the TCC program can improve surgeons' perceived availability of resources and their confidence in managing the psychosocial sequelae after injury. Further studies will be required to determine if this translates into beneficial patient effects. Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Disaster preparedness of Canadian trauma centres: the perspective of medical directors of trauma

PubMed Central

Gomez, David; Haas, Barbara; Ahmed, Najma; Tien, Homer; Nathens, Avery

2011-01-01

Background Owing to their constant readiness to treat injured patients, trauma centres are essential to regional responses to mass casualty incidents (MCIs). Reviews of recent MCIs suggest that trauma centre preparedness has frequently been limited. We set out to evaluate Canadian trauma centre preparedness and the extent of their integration into a regional response to MCIs. Methods We conducted a survey of Canadian level-1 trauma centres (n = 29) to characterize their existing disaster-response plans and to identify areas where pre-paredness could be improved. The survey was directed to the medical director of trauma at each centre. Descriptive statistics were used to analyze responses. Results Twenty-three (79%) trauma centres in 5 provinces responded. Whereas most (83%) reported the presence of a committee dedicated to disaster preparedness, only half of the medical directors of trauma were members of these committees. Almost half (43%) the institutions had not run any disaster drill in the previous 2 years. Only 70% of trauma centres used communications assets designed to function during MCIs. Additionally, more than half of the trauma directors (59%) did not know if their institutions had the ability to sustain operations for at least 72 hours during MCIs. Conclusion The results of this study suggest important opportunities to better prepare Canadian trauma centers to respond to an MCI. The main areas identified for potential improvement include the need for the standardization of MCI planning and response at a regional level and the implementation of strategies such as stockpiling of resources and novel communication strategies to avoid functional collapse during an MCI. PMID:21251427

The impact of patient protection and Affordable Care Act on trauma care: A step in the right direction.

PubMed

Joseph, Bellal; Haider, Ansab A; Azim, Asad; Kulvatunyou, Narong; Tang, Andrew; OʼKeeffe, Terence; Latifi, Rifat; Green, Donald J; Friese, Randall S; Rhee, Peter

2016-09-01

The Patient Protection and Affordable Care Act (ACA) was implemented to guarantee financial coverage for health care for all Americans. The implementation of ACA is likely to influence the insurance status of Americans and reimbursement rates of trauma centers. The aim of this study was to assess the impact of ACA on the patient insurance status, hospital reimbursements, and clinical outcomes at a Level I trauma center. We hypothesized that there would be a significant decrease in the proportion of uninsured trauma patients visiting our Level I trauma center following the ACA, and this is associated with improved reimbursement. We performed a retrospective analysis of the trauma registry and financial database at our Level I trauma center for a 27-month (July 2012 to September 2014) period by quarters. Our outcome measures were change in insurance status, hospital reimbursement rates (total payments/expected payments), and clinical outcomes before and after ACA (March 31, 2014). Trend analysis was performed to assess trends in outcomes over each quarter (3 months). A total of 9,892 patients were included in the study. The overall uninsured rate during the study period was 20.3%. Post-ACA period was associated with significantly lower uninsured rate (p < 0.001). During the same time, there was as a significant increase in the Medicaid patients (p = 0.009). This was associated with significantly improved hospital reimbursements (p < 0.001).On assessing clinical outcomes, there was no change in hospitalization (p = 0.07), operating room procedures (p = 0.99), mortality (p = 0.88), or complications (p = 0.20). Post-ACA period was also not associated with any change in the hospital (p = 0.28) or length of stay at intensive care unit (p = 0.66). The implementation of ACA has led to a decrease in the number of uninsured trauma patients. There was a significant increase in Medicaid trauma patients. This was associated with an increase in hospital reimbursements that substantially improved the financial revenues. Despite the controversies, implementation of ACA has the potential to substantially improve the financial outcomes of trauma centers through Medicaid expansion. Economic and value-based evaluation, level III.

Serial Assessment of Trauma Care Capacity in Ghana in 2004 and 2014.

PubMed

Stewart, Barclay T; Quansah, Robert; Gyedu, Adam; Boakye, Godfred; Abantanga, Francis; Ankomah, James; Donkor, Peter; Mock, Charles

2016-02-01

Trauma care capacity assessments in developing countries have generated evidence to support advocacy, detailed baseline capabilities, and informed targeted interventions. However, serial assessments to determine the effect of capacity improvements or changes over time have rarely been performed. To compare the availability of trauma care resources in Ghana between 2004 and 2014 to assess the effects of a decade of change in the trauma care landscape and derive recommendations for improvements. Capacity assessments were performed using direct inspection and structured interviews derived from the World Health Organization's Guidelines for Essential Trauma Care. In Ghana, 10 hospitals in 2004 and 32 hospitals in 2014 were purposively sampled to represent those most likely to care for injuries. Clinical staff, administrators, logistic/procurement officers, and technicians/biomedical engineers who interacted, directly or indirectly, with trauma care resources were interviewed at each hospital. Availability of items for trauma care was rated from 0 (complete absence) to 3 (fully available). Factors contributing to deficiency in 2014 were determined for items rated lower than 3. Each item rated lower than 3 at a specific hospital was defined as a hospital-item deficiency. Scores for total number of hospital-item deficiencies were derived for each contributing factor. There were significant improvements in mean ratings for trauma care resources: district-level (smaller) hospitals had a mean rating of 0.8 for all items in 2004 vs 1.3 in 2014 (P = .002); regional (larger) hospitals had a mean rating of 1.1 in 2004 vs 1.4 in 2014 (P = .01). However, a number of critical deficiencies remain (eg, chest tubes, diagnostics, and orthopedic and neurosurgical care; mean ratings ≤ 2). Leading contributing factors were item absence (503 hospital-item deficiencies), lack of training (335 hospital-item deficiencies), and stockout of consumables (137 hospital-item deficiencies). There has been significant improvement in trauma care capacity during the past decade in Ghana; however, critical deficiencies remain and require urgent redress to avert preventable death and disability. Serial capacity assessment is a valuable tool for monitoring efforts to strengthen trauma care systems, identifying what has been successful, and highlighting needs.

[Modern concepts of trauma care and multiple trauma management in oral and maxillofacial region].

PubMed

Tan, Yinghui

2015-06-01

Multiple trauma management requires the application of modem trauma care theories. Optimal treatment results can be achieved by reinforcing cooperation and stipulating a treatment plan together with other disciplines. Based on modem theories in trauma care and our understanding of the theoretical points, this paper analyzes the injury assessment strategies and methods in oral and maxillofacial multiple trauma management. Moreover, this paper discusses operating time and other influencing factors as well as proposed definitive surgical timing and indications in comprehensive management of oral and maxillofacial multiple trauma patients associated with injuries in other body parts. We hope that this paper can help stomatological physicians deepen their understanding of modem trauma care theories and improve their capacity and results in the treatment of oral and maxillofacial multiple trauma.

The impact of a statewide trauma-informed child welfare initiative on children's permanency and maltreatment outcomes.

PubMed

Barto, Beth; Bartlett, Jessica Dym; Von Ende, Adam; Bodian, Ruth; Noroña, Carmen Rosa; Griffin, Jessica; Fraser, Jenifer Goldman; Kinniburgh, Kristine; Spinazzola, Joseph; Montagna, Crystaltina; Todd, Marybeth

2018-05-05

This article presents findings of a state-wide trauma informed child-welfare initiative with the goal of improving well-being, permanency and maltreatment outcomes for traumatized children. The Massachuetts Child Trauma Project (MCTP), funded by the Administration of Children and Families, Children's Bureau was a multi-year project implementing trauma-informed care into child welfare service delivery. The project's implementation design included training and consultation for mental health providers in three evidence-based treatments and training of the child-welfare workforce in trauma-informed case work practice. The learning was integrated between child-welfare and mental health with Trauma Informed Leadership Teams which included leaders from both systems and the greater community. These teams developed incremental steps toward trauma-informed system improvement. This study evaluated whether MCTP was associated with reductions in child abuse and neglect, improvements in placement stability, and higher rates of permanency during the first year of implementation. Children in the intervention group had fewer total substantiated reports of maltreatment, including less physical abuse and neglect than the comparison group by the end of the intervention year. However, children in the intervention group had more maltreatment reports (substantiated or not) and total out-of-home placements than did their counterparts in the comparison group. Assignment to MCTP, however, was not associated with an increase in kinship care or adoption. Overall, the results are promising in reinforcing the importance of mobilizing communities toward improvements in child-welfare service delivery. Copyright © 2018 Elsevier Ltd. All rights reserved.

Evaluation of Resources Necessary for Provision of Trauma Care in Botswana: An Initiative for a Local System.

PubMed

Mwandri, Michael B; Hardcastle, Timothy C

2018-06-01

Developing countries face the highest incidence of trauma, and on the other hand, they do not have resources for mitigating the scourge of these injuries. The World Health Organization through the Essential Trauma Care (ETC) project provides recommendations for improving management of the injured and building up of systems that are effective in low-middle-income countries (LMICs). This study uses ETC project recommendations and other trauma-care guidelines to evaluate the current status of the resources and organizational structures necessary for optimal trauma care in Botswana; an African country with relatively good health facilities network, subsidized public hospital care and a functioning Motor Vehicle Accident fund covering road traffic collision victims. A cross-sectional descriptive design employed convenience sampling for recruiting high-volume trauma hospitals and selecting candidates. A questionnaire, checklist, and physical verification of resources were utilized to evaluate resources, staff knowledge, and organization-of-care and hospital capabilities. Results are provided in plain descriptive language to demonstrate the findings. Necessary consumables, good infrastructure, adequate numbers of personnel and rehabilitation services were identified all meeting or exceeding ETC recommendations. Deficiencies were noted in staff knowledge of initial trauma care, district hospital capability to provide essential surgery, and the organization of trauma care. The good level of resources available in Botswana may be used to improve trauma care: To further this process, more empowering of high-volume trauma hospitals by adopting trauma-care recommendations and inclusive trauma-system approaches are desirable. The use of successful examples on enhanced surgical skills and capabilities, effective trauma-care resource management, and leadership should be encouraged.

Risk factors for adverse outcomes in older adults with blunt chest trauma: A systematic review.

PubMed

Sawa, Jake; Green, Robert S; Thoma, Brent; Erdogan, Mete; Davis, Philip J

2017-08-11

The objective of this study was to systematically review the published literature for risk factors associated with adverse outcomes in older adults sustaining blunt chest trauma. EMBASE and MEDLINE were searched from inception until March 2017 for prognostic factors associated with adverse outcomes in older adults sustaining blunt chest trauma using a pre-specified search strategy. References were independently screened for inclusion by two reviewers. Study quality was assessed using the Quality in Prognostic Studies tool. Where appropriate, descriptive statistics were used to evaluate study characteristics and predictors of adverse outcomes. Thirteen cohort studies representing 79,313 patients satisfied our selection criteria. Overall, 26 prognostic factors were examined across studies and were reported for morbidity (8 studies), length of stay (7 studies), mortality (6 studies), and loss of independence (1 study). No studies examined patient quality of life or emergency department recidivism. Prognostic factors associated with morbidity and mortality included age, number of rib fractures, and injury severity score. Although age and rib fractures were found to be associated with adverse outcomes in more than 3 studies, meta-analysis was not performed due to heterogeneity amongst included studies in how these variables were measured. While blunt chest wall trauma in older adults is relatively common, the literature on prognostic factors for adverse outcomes in this patient population remains inadequate due to a paucity of high quality studies and lack of consistent reporting standards.

Developing Orthopaedic Trauma Capacity in Uganda: Considerations From the Uganda Sustainable Trauma Orthopaedic Program.

PubMed

OʼHara, Nathan N; OʼBrien, Peter J; Blachut, Piotr A

2015-10-01

Uganda, like many low-income countries, has a tremendous volume of orthopaedic trauma injuries. The Uganda Sustainable Trauma Orthopaedic Program (USTOP) is a partnership between the University of British Columbia and Makerere University that was initiated in 2007 to reduce the consequences of neglected orthopaedic trauma in Uganda. USTOP works with local collaborators to build orthopaedic trauma capacity through clinical training, skills workshops, system support, technology development, and research. USTOP has maintained a multidisciplinary approach to training, involving colleagues in anaesthesia, nursing, rehabilitation, and sterile reprocessing. Since the program's inception, the number of trained orthopaedic surgeons practicing in Uganda has more than doubled. Many of these newly trained surgeons provide clinical care in the previously underserved regional hospitals. The program has also worked with collaborators to develop several technologies aimed at reducing the cost of providing orthopaedic care without compromising quality. As orthopaedic trauma capacity in Uganda advances, USTOP strives to continually evolve and provide relevant support to colleagues in Uganda.

76 FR 53138 - Agency Information Collection Activities: Submission for OMB Review; Comment Request

Federal Register 2010, 2011, 2012, 2013, 2014

2011-08-25

... serves multiple practical purposes: (1) To collect and analyze descriptive, outcome, and service... impact on access to high-quality, trauma-informed care; (3) to evaluate NCTSI centers' training and... below. Descriptive and Clinical Outcomes In order to describe the children served, their trauma...

Physiological Predictors of Response to Exposure, Relaxation, and Rescripting Therapy for Chronic Nightmares in a Randomized Clinical Trial

PubMed Central

Davis, Joanne L.; Rhudy, Jamie L.; Pruiksma, Kristi E.; Byrd, Patricia; Williams, Amy E.; McCabe, Klanci M.; Bartley, Emily J.

2011-01-01

Study Objectives: Evidence supports the use of cognitive behavioral therapies for nightmares in trauma-exposed individuals. This randomized clinical trial replicated a study of exposure, relaxation, and rescripting therapy(ERRT) and extended prior research by including broad measures of mental health difficulties, self-reported physical health problems, and quality of life. Additionally, physiological correlates of treatment-related change assessed from a script-driven imagery paradigm were examined. Methods: Forty-seven individuals were randomized to treatment or waitlist control. Results: The treatment group demonstrated improvements relative to the control group at the one-week post-treatment assessment. At the 6-month follow-up assessment, significant improvements were found for frequency and severity of nightmares, posttraumatic stress disorder symptoms, depression, sleep quality and quantity, physical health symptoms, anger, dissociation, and tension reduction behaviors. Participants also reported improved quality of life. Treatment-related decreases in heart rate to nightmare imagery were correlated with improvements in sleep quality and quantity; treatment-related decreases in skin conductance to nightmare imagery were correlated with improvements in nightmare severity, posttraumatic stress disorder symptom severity, sleep quality, and fear of sleep; and treatment-related decreases in corrugator activity to nightmare imagery were correlated with improved physical health. Conclusions: Findings provide additional support for the use of ERRT in treating nightmares and related difficulties and improving sleep. Citation: Davis JL; Rhudy JL; Pruiksma KE; Byrd P; Williams AE; McCabe KM; Bartley EJ. Physiological predictors of response to exposure, relaxation, and rescripting therapy for chronic nightmares in a randomized clinical trial. J Clin Sleep Med 2011;7(6):622-631. PMID:22171201

The effect of a nurse team leader on communication and leadership in major trauma resuscitations.

PubMed

Clements, Alana; Curtis, Kate; Horvat, Leanne; Shaban, Ramon Z

2015-01-01

Effective assessment and resuscitation of trauma patients requires an organised, multidisciplinary team. Literature evaluating leadership roles of nurses in trauma resuscitation and their effect on team performance is scarce. To assess the effect of allocating the most senior nurse as team leader of trauma patient assessment and resuscitation on communication, documentation and perceptions of leadership within an Australian emergency department. The study design was a pre-post-test survey of emergency nursing staff (working at resuscitation room level) perceptions of leadership, communication, and documentation before and after the implementation of a nurse leader role. Patient records were audited focussing on initial resuscitation assessment, treatment, and nursing clinical entry. Descriptive statistical analyses were performed. Communication trended towards improvement. All (100%) respondents post-test stated they had a good to excellent understanding of their role, compared to 93.2% pre-study. A decrease (58.1-12.5%) in 'intimidating personality' as a negative aspect of communication. Nursing leadership had a 6.7% increase in the proportion of those who reported nursing leadership to be good to excellent. Accuracy of clinical documentation improved (P = 0.025). Trauma nurse team leaders improve some aspects of communication and leadership. Development of trauma nurse leaders should be encouraged within trauma team training programmes. Crown Copyright © 2014. Published by Elsevier Ltd. All rights reserved.

[Effectiveness of Trauma Evaluation and Management course for Mexican senior medical students: When to implement it?].

PubMed

Delgado-Reyes, Luis; Gasca-González, Oscar Octavio; Delgado-Guerrero, Francisco; Reyes-Arellano, Wulfrano

2016-01-01

Trauma Evaluation and Management course was designed to develop trauma cognitive skills in senior medical students. Its effectiveness has been demonstrated in many regions, except in Latin America, where it has been poorly studied. The objective was to determine the Trauma Evaluation and Management course effectiveness, and whether greater effectiveness is achieved in basic- or clinic-cycle students, as well as student perception. Descriptive, observational, longitudinal and prospective study. Two tests were performed, pre- and post-course; the manual was read by the students prior to both tests. Students were divided into 2 groups: group A (consisting of 71 basic-cycle medical students) and group B (consisting of 44 clinical-cycle medical students). Group A achieved a 2.45 increase (p<0.01) in the post-course evaluation compared with pre-course test. Group B increased the mean score by 2.25 (p>0.05) from pre- to post-course tests. There was a significant difference between groups in both evaluations (pre-course test p<0.01 and post-course test p>0.05), with no difference in improvement (p>0.05). Using a questionnaire, 92.17% of the students totally agreed that the course improved their trauma knowledge, 76.52% that it increased their trauma clinical skills, with 94.78% being totally satisfied with the course, and 86.09% totally agreed that Trauma Evaluation and Management course should be in Medicine curriculum. Trauma Evaluation and Management course improves trauma cognitive skills, and undergraduate medical students in Mexico broadly accept it. Copyright © 2015 Academia Mexicana de Cirugía A.C. Published by Masson Doyma México S.A. All rights reserved.

Point-of-injury Use of Reconstituted Freeze Dried Plasma as a Resuscitative Fluid: A Special Report for Prehospital Trauma Care

DTIC Science & Technology

2013-01-01

Point-of-injury use of reconstituted freeze dried plasma as a resuscitative fluid: A special report for prehospital trauma care Elon Glassberg, MD...in- jury as part of the multidisciplinary efforts to improve trauma victims’ outcome. BACKGROUND Trauma is the leading cause of death among adults be...diabetes.1 Managing the burden of injuries from decades of wars has underscored the importance of trauma research aimed at reducing morbidity and

Therapeutic mentoring: reducing the impact of trauma for foster youth.

PubMed

Johnson, Sara B; Pryce, Julia M

2013-01-01

This study utilized secondary data analysis to examine therapeutic mentoring (TM) as a service intervention in helping to reduce trauma symptoms in foster youth. Outcomes were compared for mentored (n = 106) and non-mentored (n = 156) foster youth related to experience and symptoms of trauma. Results showed that mentored youth improved significantly in the reduction of trauma symptoms relative to non-mentored youth, suggesting that TM shows promise as an important treatment intervention for foster youth with trauma experiences.

Impact of trauma system structure on injury outcomes: a systematic review protocol.

PubMed

Moore, Lynne; Champion, Howard; O'Reilly, Gerard; Leppaniemi, Ari; Cameron, Peter; Palmer, Cameron; Abu-Zidan, Fikri M; Gabbe, Belinda; Gaarder, Christine; Yanchar, Natalie; Stelfox, Henry Thomas; Coimbra, Raul; Kortbeek, John; Noonan, Vanessa; Gunning, Amy; Leenan, Luke; Gordon, Malcolm; Khajanchi, Monty; Shemilt, Michèle; Porgo, Valérie; Turgeon, Alexis F

2017-01-21

Injury represents one of the greatest public health challenges of our time with over 5 million deaths and 100 million people temporarily or permanently disabled every year worldwide. The effectiveness of trauma systems in decreasing injury mortality and morbidity has been well demonstrated. However, the organisation of trauma care varies significantly across trauma systems and we know little about which components of trauma systems contribute to their effectiveness. The objective of the study described in this protocol is to systematically review evidence of the impact of trauma system components on clinically significant outcomes including mortality, function and disability, quality of life, and resource utilization. We will perform a systematic review of studies evaluating the association between at least one trauma system component (e.g. accreditation by a central agency, interfacility transfer agreements) and at least one injury outcome (e.g. mortality, disability, resource use). We will search MEDLINE, EMBASE, COCHRANE central, and BIOSIS/Web of Knowledge databases, thesis holdings, key injury organisation websites and conference proceedings for eligible studies. Pairs of independent reviewers will evaluate studies for eligibility and extract data from included articles. Methodological quality will be evaluated using elements of the ROBINS-I tool and the Cochrane risk of bias tool for non-randomized and randomized studies, respectively. Strength of evidence will be evaluated using the GRADE tool. We expect to advance knowledge on the components of trauma systems that contribute to their effectiveness. This may lead to recommendations on trauma system structure that will help policy-makers make informed decisions as to where resources should be focused. The review may also lead to specific recommendations for future research efforts. This protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 28-06-2016. PROSPERO 2016:CRD42016041336 Available from http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42016041336 .

The cumulative effect of multiple critical care protocols on length of stay in a geriatric trauma population.

PubMed

Frederickson, Tiffany A; Renner, Catherine Hackett; Swegle, James R; Sahr, Sheryl M

2013-01-01

The elderly individuals are the most rapidly growing cohort within the US population, and a corresponding increase is being seen in elderly trauma patients. Elderly patients are more likely to have a hospital length of stay (LOS) in excess of 10 days. They account for 60% of total ICU days. Length of stay is frequently used as a proxy measure for improvement in injury outcomes, changes in quality of care, and hospital outcomes. Patient care protocols are typically created from evidence-based guidelines that serve to reduce variation in care from patient to patient. Patient care protocols have been found to positively impact patient care with reduced duration of mechanical ventilation, shorter LOS in the ICU and shorter overall hospitalization time, reduced mortality, and reduced health care costs. The following study was designed to assess the impact of the implementation of 4 patient care protocols within an elderly trauma population. We hypothesized that the implementation of these protocols would have a beneficial impact on patient care that could be measured by a decrease in hospital LOS. An archival, retrospective pretest/posttest study was performed on elderly trauma patients. The new protocols helped guide practical changes in care that resulted in a 32% decrease in LOS for our elderly trauma patients which exceeds the 25% decrease found in other studies. Additionally, the "Other" category for each variable was less frequently used in the post-protocol phase than in the pre-protocol phase, suggesting a spillover effect on the level of detail recorded in the patient chart. With less variation in practices in the post-protocol phase, Injury Severity score, and admission systolic blood pressure emerged as significant predictors of LOS.

Failure mode and effects analysis as a performance improvement tool in trauma.

PubMed

Day, Suzanne; Dalto, Joseph; Fox, Jolene; Turpin, Melinda

2006-01-01

Performance improvement (PI) in the multiple systems injured patient frequently highlights areas for improvement in overall hospital care processes. Failure mode effects analysis (FMEA) is an effective tool to assess and prioritize areas of risk in clinical practice. Failure mode effects analysis is often initiated by a "near-miss" or concern for risk as opposed to a root cause analysis that is initiated solely after a sentinel event. In contrast to a root cause analysis, the FMEA looks more broadly at processes involved in the delivery of care. The purpose of this abstract was to demonstrate the usefulness of FMEA as a PI tool by describing an event and following the event through the healthcare delivery PI processes involved. During routine chart abstraction, a trauma registrar found that an elderly trauma patient admitted with a subdural hematoma inadvertently received heparin during the course of a dialysis treatment. Although heparin use was contraindicated in this patient, there were no sequelae as a result of the error. This case was reviewed by the trauma service PI committee and the quality improvement team, which initiated FMEA. An FMEA of inpatient dialysis process was conducted following this incident. The process included physician, nursing, and allied health representatives involved in dialysis. As part of the process, observations of dialysis treatments and staff interviews were conducted. Observation revealed that nurses generally left the patient's room and did not involve themselves in the dialysis process. A formal patient "pass-off" report was not done. Nurses did not review dialysis orders or reevaluate the treatment plan before treatment. We found that several areas of our current practice placed our patients at risk. 1. The nephrology consult/dialysis communication process was inconsistent. 2. Scheduling of treatments for chronic dialysis patients could occur without a formal consult or order. 3. RNs were not consistently involved in dialysis scheduling, setup, or treatment. 4. Dialysis technicians may exceed scope of practice (taking telephone orders) when scheduling of treatment occurred before consult and written orders. Near-miss events may be overlooked as opportunities for improvement in cases where no harm has come to the patient. As a result of our FMEA investigation, the following recommendations were made to improve hospital care delivery in those trauma patients who require inpatient dialysis: 1. Education of RNs about the dialysis process. 2. Implementation of a formal reporting process between the RN and the dialysis technician before the procedure is initiated. 3. RN supervision of dialysis treatments. 4. Use of a preprinted inpatient dialysis form. 5. Education of dialysis technicians regarding their scope of practice. 6. Improve notification process for scheduling dialysis procedures between units and dialysis coordinator (similar to x-ray scheduling). Our performance improvement focus has broadened to include all reported "near-miss" events in order to improve our healthcare delivery process before an event with sequelae occurs. We have found that using FMEA has greatly increased our ability to facilitate change across all services and departments within the hospital.

Point-of-Care Coagulation Monitoring in Trauma Patients.

PubMed

Stein, Philipp; Kaserer, Alexander; Spahn, Gabriela H; Spahn, Donat R

2017-06-01

Trauma remains one of the major causes of death and disability all over the world. Uncontrolled blood loss and trauma-induced coagulopathy represent preventable causes of trauma-related morbidity and mortality. Treatment may consist of allogeneic blood product transfusion at a fixed ratio or in an individualized goal-directed way based on point-of-care (POC) and routine laboratory measurements. Viscoelastic POC measurement of the developing clot in whole blood and POC platelet function testing allow rapid and tailored coagulation and transfusion treatment based on goal-directed, factor concentrate-based algorithms. The first studies have been published showing that this concept reduces the need for allogeneic blood transfusion and improves outcome. This review highlights the concept of goal-directed POC coagulation management in trauma patients, introduces a selection of POC devices, and presents algorithms which allow a reduction in allogeneic blood product transfusion and an improvement of trauma patient outcome. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Positive predictors of quality of life for postpartum mothers with a history of childhood maltreatment.

PubMed

Irwin, Jessica L; Beeghly, Marjorie; Rosenblum, Katherine L; Muzik, Maria

2016-12-01

The postpartum period brings a host of biopsychosocial, familial, and economic changes, which may be challenging for new mothers, especially those with trauma histories. Trauma-exposed women are at heightened risk for psychiatric symptomatology and reduced quality of life. The current study sought to evaluate whether a set of hypothesized promotive factors assessed during the first 18 months postpartum (positive parenting, family cohesion, and maternal resilience) are associated with life satisfaction in this population, after controlling for income and postpartum psychiatric symptoms. Analyses were based on data collected for 266 mother-infant dyads from a longitudinal cohort study, Maternal Anxiety during the Childbearing Years (MACY), of women oversampled for childhood maltreatment history. Hierarchical linear regression was used to evaluate the study hypotheses. Consistent with prior work, greater postpartum psychiatric symptoms and less income predicted poor perceptions of life quality. In hierarchical regressions controlling for income and psychiatric symptoms, positive parenting and family cohesion predicted unique variance in mothers' positive perceptions of life quality, and resilience was predictive beyond all other factors. Factors from multiple levels of analysis (maternal, dyadic, and familial) may serve as promotive factors predicting positive perceptions of life quality among women with childhood trauma histories, even those struggling with high levels of psychiatric or economic distress.

Retrospective analysis of spinal trauma in patients with ankylosing spondylitis: a descriptive study in Indian population.

PubMed

Mahajan, R; Chhabra, H S; Srivastava, A; Venkatesh, R; Kanagaraju, V; Kaul, R; Tandon, V; Nanda, A; Sangondimath, G; Patel, N

2015-05-01

This study aims to understand the demographics, mode of trauma, hospital stay, complications, neurological improvement, mortality and expenditure incurred by Indian patients with spinal trauma and ankylosing spondylitis (AS). Retrospective analysis of the patient data admitted to a tertiary referral hospital from 2008 to 2013 with the diagnosis of AS and spinal trauma was carried out. The variables studied were demographics, mode of trauma, neurological status, neurological improvement, involved vertebral level, duration of hospital stay, comorbid factors, expenditure and complications during the stay. Forty-six patients with diagnosis of AS with spine trauma were admitted over the last 5 years with a total of 52 fractures. All were male patients; 58.6% had injury because of trivial trauma and 78.2% patients presented with neurological injury. C5 C6, C6 C7, C7 D1 and D12 were the most common injured level. Fractures through intervertebral disc were most common in cervical spine. Of the patients, 52.7% had shown neurological improvement of at least grade 1(AIS). Mean expenditure of patient admitted with spinal cord injury (SCI) with AS is 7957 USD (United States dollar), which is around five times the per capita income in India (as per year 2013). Males with AS are much more prone to spinal fractures than females and its incidence may be higher than previously reported. Domestic falls are the most common mechanism of spinal trauma in this population. High velocity injuries are associated with complete SCI. The study reinforces the need for development of subsidized spinal care services for SCI management.

A major trauma course based on posters, audio-guides and simulation improves the management skills of medical students: Evaluation via medical simulator.

PubMed

Cuisinier, Adrien; Schilte, Clotilde; Declety, Philippe; Picard, Julien; Berger, Karine; Bouzat, Pierre; Falcon, Dominique; Bosson, Jean Luc; Payen, Jean-François; Albaladejo, Pierre

2015-12-01

Medical competence requires the acquisition of theoretical knowledge and technical skills. Severe trauma management teaching is poorly developed during internship. Nevertheless, the basics of major trauma management should be acquired by every future physician. For this reason, the major trauma course (MTC), an educational course in major traumatology, has been developed for medical students. Our objective was to evaluate, via a high fidelity medical simulator, the impact of the MTC on medical student skills concerning major trauma management. The MTC contains 3 teaching modalities: posters with associated audio-guides, a procedural workshop on airway management and a teaching session using a medical simulator. Skills evaluation was performed 1 month before (step 1) and 1 month after (step 3) the MTC (step 2). Nineteen students were individually evaluated on 2 different major trauma scenarios. The primary endpoint was the difference between steps 1 and 3, in a combined score evaluating: admission, equipment, monitoring and safety (skill set 1) and systematic clinical examinations (skill set 2). After the course, the combined primary outcome score improved by 47% (P<0.01). Scenario choice or the order of use had no significant influence on the skill set evaluations. This study shows improvement in student skills for major trauma management, which we attribute mainly to the major trauma course developed in our institution. Copyright © 2015 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.

Debriefing interventions for the prevention of psychological trauma in women following childbirth.

PubMed

Bastos, Maria Helena; Furuta, Marie; Small, Rhonda; McKenzie-McHarg, Kirstie; Bick, Debra

2015-04-10

Childbirth is a complex life event that can be associated with both positive and negative psychological responses. When giving birth is experienced as particularly traumatic this can have a negative impact on a woman's postnatal emotional well-being. There has been an increasing focus on women's psychological trauma symptoms following childbirth, including the relatively rare phenomenon of post-traumatic stress disorder (PTSD), and the benefit of debriefing interventions to prevent this. In this review we examined the evidence for debriefing as a preventative intervention for psychological trauma following childbirth. To assess the effects of debriefing interventions compared with standard postnatal care for the prevention of psychological trauma in women following childbirth. The trials registers of the Cochrane Depression, Anxiety and Neurosis Group (CCDANCTR-References and CCDANCTR-Studies) and the Cochrane Pregnancy and Childbirth Group were searched up to 4 March 2015. These registers include relevant randomised controlled trials from the following bibliographic databases: the Cochrane Library (all years to date), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date). Additional searches were conducted in CENTRAL, MEDLINE, EMBASE, PsycINFO, and Maternity and Infant Care. The reference lists of all included studies were checked for additional published reports and citations of unpublished research. Experts in the field were contacted. We included randomised controlled trials (RCTs) and quasi-randomised trials comparing postnatal debriefing interventions with standard postnatal care for the prevention of psychological trauma of women following childbirth. The intervention consisted of at least one debriefing intervention session, which had the purpose of allowing women to describe their experience and to normalise their emotional reaction to that experience. Three authors independently assessed trial quality and extracted data. Meta-analysis was conducted where there were more than two trials examining the same outcomes. We included seven trials (eight articles) from three countries (UK, Australia and Sweden) that fulfilled the inclusion criteria. The number of women contributing data to each outcome varied from 102 to 1745. Methodological quality was variable and most of the studies were of low quality. The quality of evidence for the prevalence of psychological trauma (primary outcome) and the prevalence of depression symptoms was rated low or very low, based on few studies (ranging from a single study to three studies) with high risk of bias in main domains such as performance bias, random sequence generation, allocation concealment and incomplete outcome data. The quality of evidence for the remaining outcomes (that is prevalence of anxiety, prevalence of fear of childbirth, prevalence of general psychological morbidity, health service utilization and attrition from treatment) was not assessed as data were not available.Among women who had a high level of obstetric intervention during labour and birth, we found no difference between standard postnatal care with debriefing and standard postnatal care without debriefing on psychological trauma symptoms within three months postpartum (RR 0.61; 95% CI 0.28 to 1.31; n = 425) or at three to six months postpartum (RR 0.62; 95% CI 0.27 to 1.42; n = 246). The results were based on two trials, respectively. Among women who experienced a distressing or traumatic birth, there was no evidence of an effect of psychological debriefing on the prevention of PTSD (measured by the MINI-PTSD) at four to six weeks postpartum (RR 1.15; 95% CI 0.66 to 2.01; n = 102) or at six months (RR 0.35; 95% CI 0.10 to 1.23; n = 103). The results were based on one small trial. One trial involving low-risk women who delivered healthy infants at or near term reported no significant difference between the intervention group and the control group in the proportion of women who met the diagnostic criteria for psychological trauma during the year following childbirth (RR 1.06; 95% CI 0.88 to 1.28; n = 1745). We did not find any information about attrition rates. We did not find any high quality evidence to inform practice, with substantial heterogeneity being found between the studies conducted to date. There is little or no evidence to support either a positive or adverse effect of psychological debriefing for the prevention of psychological trauma in women following childbirth. There is no evidence to support routine debriefing for women who perceive giving birth as psychologically traumatic.Future research should provide greater detail of the outcome measures used, and with scales for measuring psychological trauma validated against clinical diagnostic interviews. High rates of obstetric intervention in some birth settings may mean that women require improved emotional care from health professionals to reduce the risk of childbirth being experienced as traumatic. As all included trials excluded women unable to communicate in the native language of the study setting, there is no information on the response of these women to psychological debriefing. No included studies were conducted in low or middle-income countries.

Cognitive-behavioral conjoint therapy for PTSD improves various PTSD symptoms and trauma-related cognitions: Results from a randomized controlled trial.

PubMed

Macdonald, Alexandra; Pukay-Martin, Nicole D; Wagner, Anne C; Fredman, Steffany J; Monson, Candice M

2016-02-01

Numerous studies document an association between posttraumatic stress disorder (PTSD) and impairments in intimate relationship functioning, and there is evidence that PTSD symptoms and associated impairments are improved by cognitive-behavioral conjoint therapy for PTSD (CBCT for PTSD; Monson & Fredman, 2012). The present study investigated changes across treatment in clinician-rated PTSD symptom clusters and patient-rated trauma-related cognitions in a randomized controlled trial comparing CBCT for PTSD with waitlist in a sample of 40 individuals with PTSD and their partners (N = 40; Monson et al., 2012). Compared with waitlist, patients who received CBCT for PTSD immediately demonstrated greater improvements in all PTSD symptom clusters, trauma-related beliefs, and guilt cognitions (Hedge's gs -.33 to -1.51). Results suggest that CBCT for PTSD improves all PTSD symptom clusters and trauma-related cognitions among individuals with PTSD and further supports the value of utilizing a couple-based approach to the treatment of PTSD. (c) 2016 APA, all rights reserved).

Evaluation of a dedicated MDCT protocol using iterative image reconstruction after cervical spine trauma.

PubMed

Geyer, L L; Körner, M; Hempel, R; Deak, Z; Mueck, F G; Linsenmaier, U; Reiser, M F; Wirth, S

2013-07-01

To evaluate radiation exposure for 64-row computed tomography (CT) of the cervical spine comparing two optimized protocols using filtered back projection (FBP) and adaptive statistical iterative reconstruction (ASIR), respectively. Sixty-seven studies using FBP (scanner 1) were retrospectively compared with 80 studies using ASIR (scanner 2). The key scanning parameters were identical (120 kV dose modulation, 64 × 0.625 mm collimation, pitch 0.531:1). In protocol 2, the noise index (NI) was increased from 5 to 25, and ASIR and the high-definition (HD) mode were used. The scan length, CT dose index (CTDI), and dose-length product (DLP) were recorded. The image quality was analysed subjectively by using a three-point scale (0; 1; 2), and objectively by using a region of interest (ROI) analysis. Mann-Whitney U and Wilcoxon's test were used. In the FBP group, the mean CTDI was 21.43 mGy, mean scan length 186.3 mm, and mean DLP 441.15 mGy cm. In the ASIR group, the mean CTDI was 9.57 mGy, mean scan length 195.21 mm, and mean DLP 204.23 mGy cm. The differences were significant for CTDI and DLP (p < 0.001) and scan length (p = 0.01). There was no significant difference in the subjective image quality (p > 0.05). The estimated mean effective dose decreased from 2.38 mSv (FBP) to 1.10 mSv (ASIR). The radiation dose of 64-row MDCT can be reduced to a level comparable to plain radiography without loss of subjective image quality by implementation of ASIR in a dedicated cervical spine trauma protocol. These results might contribute to an improved relative risk-to-benefit ratio and support the justification of CT as a first-line imaging tool to evaluate cervical spine trauma. Copyright © 2013 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

Trauma-associated lung injury differs clinically and biologically from acute lung injury due to other clinical disorders*

PubMed Central

Calfee, Carolyn S.; Eisner, Mark D.; Ware, Lorraine B.; Thompson, B. Taylor; Parsons, Polly E.; Wheeler, Arthur P.; Korpak, Anna; Matthay, Michael A.

2009-01-01

Objective Patients with trauma-associated acute lung injury have better outcomes than patients with other clinical risks for lung injury, but the mechanisms behind these improved outcomes are unclear. We sought to compare the clinical and biological features of patients with trauma-associated lung injury with those of patients with other risks for lung injury and to determine whether the improved outcomes of trauma patients reflect their baseline health status or less severe lung injury, or both. Design, Setting, and Patients Analysis of clinical and biological data from 1,451 patients enrolled in two large randomized, controlled trials of ventilator management in acute lung injury. Measurements and Main Results Compared with patients with other clinical risks for lung injury, trauma patients were younger and generally less acutely and chronically ill. Even after adjusting for these baseline differences, trauma patients had significantly lower plasma levels of intercellular adhesion molecule-1, von Willebrand factor antigen, surfactant protein-D, and soluble tumor necrosis factor receptor-1, which are biomarkers of lung epithelial and endothelial injury previously found to be prognostic in acute lung injury. In contrast, markers of acute inflammation, except for interleukin-6, and disordered coagulation were similar in trauma and nontrauma patients. Trauma-associated lung injury patients had a significantly lower odds of death at 90 days, even after adjusting for baseline clinical factors including age, gender, ethnicity, comorbidities, and severity of illness (odds ratio, 0.44; 95% confidence interval, 0.24 – 0.82; p = .01). Conclusions Patients with trauma-associated lung injury are less acutely and chronically ill than other lung injury patients; however, these baseline clinical differences do not adequately explain their improved outcomes. Instead, the better outcomes of the trauma population may be explained, in part, by less severe lung epithelial and endothelial injury. PMID:17944012

A heuristic approach and heretic view on the technical issues and pitfalls in the management of penetrating abdominal injuries

PubMed Central

2010-01-01

There is a general decline in penetrating abdominal trauma throughout the western world. As a result of that, there is a significant loss of expertise in dealing with this type of injury particularly when the patient presents to theatre with physiological instability. A significant percentage of these patients will not be operated by a trauma surgeon but, by the "occasional trauma surgeon", who is usually trained as a general surgeon. Most general surgeons have a general knowledge of operating penetrating trauma, knowledge originating from their training years and possibly enhanced by reading operative surgery textbooks. Unfortunately, the details included in most of these books are not extensive enough to provide them with enough armamentaria to tackle the difficult case. In this scenario, their operative dexterity and knowledge cannot be compared to that of their trauma surgeon colleagues, something that is taken for granted in the trauma textbooks. Techniques that are considered basic and easy by the trauma surgeons can be unfamiliar and difficult to general surgeons. Knowing the danger points and pitfalls that will be encountered in penetrating trauma to the abdomen, will help the occasional trauma surgeons to avoid intraoperative errors and improve patient care. This manuscript provides a heuristic approach from surgeons working in a high volume penetrating trauma centers in South African. Some of the statements could be considered heretic by the "accepted" trauma literature. We believe that this heuristic ("rule of thumb" approach, that originating from "try and error" experience) can help surgical trainees or less experienced in penetrating trauma surgeons to improve their surgical decision making and technique, resulting in better patient outcome. PMID:20630100

The first 5 years since trauma center designation in the Hong Kong Special Administrative Region, People's Republic of China.

PubMed

Leung, Gilberto Ka Kit; Chang, Annice; Cheung, F C; Ho, H F; Ho, Wendy; Hui, S M; Kam, C W; Lai, Albert; Lam, K W; Leung, M; Liu, S H; Lo, C B; Mok, Francis; Rainer, Timothy H; Shen, W Y; So, F L; Wong, Gordon; Wu, Amy; Yeung, Janice; Yuen, W K

2011-05-01

In 1994, the Hong Kong Special Administrative Region (HKSAR) introduced plans to implement a trauma system based on the recommendations outlined by Professor Donald Trunkey in his report to the local Hospital Authority. Five government-subsidized public hospitals were subsequently designated as trauma centers in 2003. This article reviews the initial experience in these five centers. Prospective trauma registries from January 2004 to December 2008 were reviewed. Primary clinical outcome measures were hospital mortality. The Trauma and Injury Severity Score methodology was used for benchmarking with the Major Trauma Outcome Study (MTOS) database. The majority (83.3%) of the 10,462 patients suffered from blunt trauma. Severe injury, defined as Injury Severity Score>15, occurred in 29.7% of patients. The leading causes of trauma were motor vehicle collisions and falls, with crude hospital mortality rates of 6.9% and 10.7%, respectively. The M-statistic was 0.95, indicating comparable case-mix with the MTOS. The worst outcome occurred in the first year. Significant improvement was seen in patients with penetrating injuries. By 2008, these patients had significantly higher survival rates than expected (Z-statistic=0.85). Although the overall mortality rates for blunt trauma were higher than expected, the difference was no longer statistically significant from the second year onward. The case-mix of trauma patients in the HKSAR is comparable with that of the MTOS. A young trauma system relatively unburdened by dissimilar reimbursement and patient access issues may achieve significant improvement and satisfactory patient outcomes. Our findings may serve as a useful benchmark for HK and other Southeast Asian cities and trauma systems to establish local coefficients for future evaluations.

A heuristic approach and heretic view on the technical issues and pitfalls in the management of penetrating abdominal injuries.

PubMed

Yilmaz, Tugba H; Ndofor, Brown C; Smith, Martin D; Degiannis, Elias

2010-07-14

There is a general decline in penetrating abdominal trauma throughout the western world. As a result of that, there is a significant loss of expertise in dealing with this type of injury particularly when the patient presents to theatre with physiological instability. A significant percentage of these patients will not be operated by a trauma surgeon but, by the "occasional trauma surgeon", who is usually trained as a general surgeon. Most general surgeons have a general knowledge of operating penetrating trauma, knowledge originating from their training years and possibly enhanced by reading operative surgery textbooks. Unfortunately, the details included in most of these books are not extensive enough to provide them with enough armamentaria to tackle the difficult case. In this scenario, their operative dexterity and knowledge cannot be compared to that of their trauma surgeon colleagues, something that is taken for granted in the trauma textbooks. Techniques that are considered basic and easy by the trauma surgeons can be unfamiliar and difficult to general surgeons. Knowing the danger points and pitfalls that will be encountered in penetrating trauma to the abdomen, will help the occasional trauma surgeons to avoid intraoperative errors and improve patient care. This manuscript provides a heuristic approach from surgeons working in a high volume penetrating trauma centers in South African. Some of the statements could be considered heretic by the "accepted" trauma literature. We believe that this heuristic ("rule of thumb" approach, that originating from "try and error" experience) can help surgical trainees or less experienced in penetrating trauma surgeons to improve their surgical decision making and technique, resulting in better patient outcome.

The relationship between subjective sleep disturbance, sleep quality, and emotion regulation difficulties in a sample of college students reporting trauma exposure.

PubMed

Pickett, Scott M; Barbaro, Nicole; Mello, David

2016-01-01

Sleep disturbance and poor sleep quality has been associated with trauma exposure and posttraumatic stress disorder (PTSD) symptoms; however, the associated emotional consequences of sleep disturbance have not been examined within this context (i.e., emotional reactivity, emotion modulation). The current study examined the relationship between sleep disturbance, poor sleep quality, and emotion regulation difficulties. In a sample of college students reporting exposure to at least 1 traumatic event, online survey methodology was used to assess PTSD symptom severity (PTSS), sleep disturbances, including PTSD-specific sleep disturbances, and emotion regulation difficulties. After controlling for PTSS, sleep disturbance and poor sleep quality domains were related to both global and specific difficulties in emotion regulation domains. The findings suggest that sleep disturbance and emotion regulation difficulties associated with PTSD may not be a mere extension of the clinical picture of PTSD. Sleep disturbances following trauma exposure may contribute to emotion regulation difficulties and exacerbate negative consequences. Future research should examine the effects of treatments that simultaneously address sleep disturbances and PTSD symptoms on emotion regulation processes. (c) 2016 APA, all rights reserved).

Whole-body computed tomography in trauma patients: optimization of the patient scanning position significantly shortens examination time while maintaining diagnostic image quality.

PubMed

Hickethier, Tilman; Mammadov, Kamal; Baeßler, Bettina; Lichtenstein, Thorsten; Hinkelbein, Jochen; Smith, Lucy; Plum, Patrick Sven; Chon, Seung-Hun; Maintz, David; Chang, De-Hua

2018-01-01

The study was conducted to compare examination time and artifact vulnerability of whole-body computed tomographies (wbCTs) for trauma patients using conventional or optimized patient positioning. Examination time was measured in 100 patients scanned with conventional protocol (Group A: arms positioned alongside the body for head and neck imaging and over the head for trunk imaging) and 100 patients scanned with optimized protocol (Group B: arms flexed on a chest pillow without repositioning). Additionally, influence of two different scanning protocols on image quality in the most relevant body regions was assessed by two blinded readers. Total wbCT duration was about 35% or 3:46 min shorter in B than in A. Artifacts in aorta (27 vs 6%), liver (40 vs 8%) and spleen (27 vs 5%) occurred significantly more often in B than in A. No incident of non-diagnostic image quality was reported, and no significant differences for lungs and spine were found. An optimized wbCT positioning protocol for trauma patients allows a significant reduction of examination time while still maintaining diagnostic image quality.

Effectiveness of Educational Poster on Knowledge of Emergency Management of Dental Trauma - Part 2: Cluster Randomised Controlled Trial for Secondary School Students

PubMed Central

Young, Cecilia; Wong, Kin Yau; Cheung, Lim K.

2014-01-01

Objective To investigate the effectiveness of educational poster on improving secondary school students' knowledge of emergency management of dental trauma. Methods A cluster randomised controlled trial was conducted. 16 schools with total 671 secondary students who can read Chinese or English were randomised into intervention (poster, 8 schools, 364 students) and control groups (8 schools, 305 students) at the school level. Baseline knowledge of dental trauma was obtained by a questionnaire. Poster containing information of dental trauma management was displayed in a classroom for 2 weeks in each school in the intervention group whereas in the control group there was no display of such posters. Students of both groups completed the same questionnarie after 2 weeks. Results Two-week display of posters improved the knowledge score by 1.25 (p-value = 0.0407) on average. Conclusion Educational poster on dental trauma management significantly improved the level of knowledge of secondary school students in Hong Kong. Trial Registration HKClinicalTrial.com HKCTR-1343 ClinicalTrials.gov NCT01809457 PMID:25093728

Hypopituitarism after traumatic brain injury.

PubMed

Fernandez-Rodriguez, Eva; Bernabeu, Ignacio; Castro, Ana I; Casanueva, Felipe F

2015-03-01

The prevalence of hypopituitarism after traumatic brain (TBI) injury is widely variable in the literature; a meta-analysis determined a pooled prevalence of anterior hypopituitarism of 27.5%. Growth hormone deficiency is the most prevalent hormone insufficiency after TBI; however, the prevalence of each type of pituitary deficiency is influenced by the assays used for diagnosis, severity of head trauma, and time of evaluation. Recent studies have demonstrated improvement in cognitive function and cognitive quality of life with substitution therapy in GH-deficient patients after TBI. Copyright © 2015 Elsevier Inc. All rights reserved.

Revolutionizing Child Welfare with Outcomes Management

PubMed Central

Toche-Manley, Linda L.; Dietzen, Laura; Nankin, Jesse; Beigel, Astrid

2013-01-01

Outcomes management technology holds great promise for improving the quality of services provided to youth in the child welfare system. Advantages include better detection of behavioral health and trauma-related issues, early indicators of case progress or risk of failure and program- and system-level learning. Yet organizational barriers to implementation persist. Attention is spent in this paper on addressing these barriers so the use of outcomes management technology becomes a common practice. A model for predicting resiliency is presented, along with case examples demonstrating its potential use for treatment planning and monitoring progress. PMID:23460130

A Study Protocol for Tracking Quality of Life Among U.S. Service Members Wounded in Iraq and Afghanistan: The Wounded Warrior Recovery Project

DTIC Science & Technology

2014-03-01

Freedorn and Iraqi Freedotn combat injury to improve care and treatment, and prevent poor physical, psychological , and social outcomes. We describe the...and Iraqi Freedom (OEF/OIF) is the highest in tnodem history primarily because of advanced protective gear and rapid effective medical care.’^ To date...useful to assess the need for care and rehabilitation.’" ’ ’ A theoretical model of trauma and its effect on QOL, devel- oped by Sprangers and Schwartz

The medical communications officer. A resource for data collection, quality management and medical control.

PubMed

Gunderson, Michael; Barnard, Jeff; McPherson, John; Kearns, Conrad T

2002-08-01

Pinellas County EMS' Medical Communications Officers provide a wide variety of services to patients, field clinicians, managers and their medical director. The concurrent data collection processes used in the MCO program for performance measurement of resuscitation efforts, intubations, submersion incidents and aeromedical transports for trauma cases have been very effective in the integration of data from multiple computer databases and telephone follow-ups with field crews and receiving emergency department staffs. This has facilitated significant improvements in the performance of these and many other aspects of our EMS system.

Improve the Communication, Decrease the Distance: The Investigation into Problematic Communication and Delays in Inter-Hospital Transfer of Rural Trauma Patients

ERIC Educational Resources Information Center

Avtgis, Theodore A.; Polack, E. Phillips; Martin, Matthew M.; Rossi, Daniel

2010-01-01

Time delays in the treatment and transfer of trauma patients is a contributing factor responsible for many fatalities. Time delays are more characteristic of rural trauma systems due to factors such as greater distance, and delays in accident reporting. Efforts to reduce the trauma transfer process have resulted in many changes in protocol and use…

Did the DSM-5 Improve the Traumatic Stressor Criterion?: Association of DSM-IV and DSM-5 Criterion A with Posttraumatic Stress Disorder Symptoms.

PubMed

Larsen, Sadie E; Berenbaum, Howard

2017-01-01

A recent meta-analysis found that DSM-III- and DSM-IV-defined traumas were associated with only slightly higher posttraumatic stress disorder (PTSD) symptoms than nontraumatic stressors. The current study is the first to examine whether DSM-5-defined traumas were associated with higher levels of PTSD than DSM-IV-defined traumas. Further, we examined theoretically relevant event characteristics to determine whether characteristics other than those outlined in the DSM could predict PTSD symptoms. One hundred six women who had experienced a trauma or significant stressor completed questionnaires assessing PTSD, depression, impairment, and event characteristics. Events were rated for whether they qualified as DSM-IV and DSM-5 trauma. There were no significant differences between DSM-IV-defined traumas and stressors. For DSM-5, effect sizes were slightly larger but still nonsignificant (except for significantly higher hyperarousal following traumas vs. stressors). Self-reported fear for one's life significantly predicted PTSD symptoms. Our results indicate that the current DSM-5 definition of trauma, although a slight improvement from DSM-IV, is not highly predictive of who develops PTSD symptoms. Our study also indicates the importance of individual perception of life threat in the prediction of PTSD. © 2017 S. Karger AG, Basel.

How to quantify exposure to traumatic stress? Reliability and predictive validity of measures for cumulative trauma exposure in a post-conflict population.

PubMed

Wilker, Sarah; Pfeiffer, Anett; Kolassa, Stephan; Koslowski, Daniela; Elbert, Thomas; Kolassa, Iris-Tatjana

2015-01-01

While studies with survivors of single traumatic experiences highlight individual response variation following trauma, research from conflict regions shows that almost everyone develops posttraumatic stress disorder (PTSD) if trauma exposure reaches extreme levels. Therefore, evaluating the effects of cumulative trauma exposure is of utmost importance in studies investigating risk factors for PTSD. Yet, little research has been devoted to evaluate how this important environmental risk factor can be best quantified. We investigated the retest reliability and predictive validity of different trauma measures in a sample of 227 Ugandan rebel war survivors. Trauma exposure was modeled as the number of traumatic event types experienced or as a score considering traumatic event frequencies. In addition, we investigated whether age at trauma exposure can be reliably measured and improves PTSD risk prediction. All trauma measures showed good reliability. While prediction of lifetime PTSD was most accurate from the number of different traumatic event types experienced, inclusion of event frequencies slightly improved the prediction of current PTSD. As assessing the number of traumatic events experienced is the least stressful and time-consuming assessment and leads to the best prediction of lifetime PTSD, we recommend this measure for research on PTSD etiology.

Using Trauma and Injury Severity Score (TRISS)-based analysis in the development of regional risk adjustment tools to trend quality in a voluntary trauma system: the experience of the Trauma Foundation of Northeast Ohio.

PubMed

Mancuso, C; Barnoski, A; Tinnell, C; Fallon, W

2000-04-01

Presently, no trauma system exists in Ohio. Since 1993, all hospitals in Cuyahoga County (CUY), northeast Ohio (n = 22) provide data to a trauma registry. In return, each received hospital-specific data, comparison data by trauma care level and a county-wide aggregate summary. This report describes the results of this approach in our region. All cases were entered by paper abstract or electronic download. Interrater reliability audits and z score analysis was performed by using the Major Trauma Outcome Study and the CUY 1994 baseline groups. Risk adjustment of mortality data was performed using statistical modeling and logistic regression (Trauma and Injury Severity Score, Major Trauma Outcome Study, CUY). Trauma severity measures were defined. In 1995, 3,375 patients were entered. Two hundred ninety-one died (8.6%). Severity measures differed by level of trauma care, indicating differences in case mix. Probability of survival was lowest in the Level I centers, highest in the acute care hospitals. Outcomes z scores demonstrated survival differences for all levels. In a functioning trauma system, the most severely injured patients should be cared for at the trauma centers. A low volume at acute care hospitals is desirable. By using Trauma and Injury Severity Score with community-specific constants, NE Ohio is accomplishing these goals. The Level I performance data are an interesting finding compared with the data from the Level II centers in the region

Are the ACSCOT filters associated with outcome? Examining morbidity and mortality in a European setting.

PubMed

Di Bartolomeo, Stefano; Valent, Francesca; Sanson, Gianfranco; Nardi, Giuseppe; Gambale, Giorgio; Barbone, Fabio

2008-09-01

Quality indicators are widely needed for external assessment and comparison of trauma care. It is common to extend the use of the American College of Surgeons Committee on Trauma (ACSCOT) audit filters to this scope. This mandates that their actual link with outcome be demonstrated. Several studies attempted to do so, but with inconsistent risk-adjustment, conflicting results and never using long-term disability as outcome measure, despite its recognised importance. We tried to overcome these limitations. Risk-adjusted analysis of the association of filters 1, 3, 10 and 13 with 30-day mortality and 6-month disability measured with the EQ5D scale. Multivariate logistic and linear regression models were used respectively. The data came from a National Italian Trauma Registry comprising 838 patients with major trauma. Three (1, 3 and 10) of the filters analysed did not show any significant association with either outcome. Filter 13 was associated with decreased mortality and lower (worse) disability scores. Methodological difficulties, incomplete, obsolete or non-generalizable definitions of some filters can explain the generally poor correlation with outcomes. The conflicting association of filter 13 with the two types of outcomes raises some interesting questions about the targeted outcomes in trauma research. It is recommended that further studies develop better quality indicators and test their link with both survival and functional outcome in the same setting where they are applied for assessment and comparison of trauma care.

Professional Development for Elementary Educators: Creating a Trauma-Informed Classroom

ERIC Educational Resources Information Center

Bonk, Ivy Teresa

2016-01-01

In classrooms all across America, educators stand between the tension of providing quality instruction and meeting the need of all students. This difficulty reveals the need to equip educators to engage and educate those students with barriers and challenges that the negative impact of emotional and psychological trauma, that result from child…

Perineal techniques during the second stage of labour for reducing perineal trauma.

PubMed

Aasheim, Vigdis; Nilsen, Anne Britt Vika; Reinar, Liv Merete; Lukasse, Mirjam

2017-06-13

Most vaginal births are associated with trauma to the genital tract. The morbidity associated with perineal trauma can be significant, especially when it comes to third- and fourth-degree tears. Different interventions including perineal massage, warm or cold compresses, and perineal management techniques have been used to prevent trauma. This is an update of a Cochrane review that was first published in 2011. To assess the effect of perineal techniques during the second stage of labour on the incidence and morbidity associated with perineal trauma. We searched Cochrane Pregnancy and Childbirth's Trials Register (26 September 2016) and reference lists of retrieved studies. Published and unpublished randomised and quasi-randomised controlled trials evaluating perineal techniques during the second stage of labour. Cross-over trials were not eligible for inclusion. Three review authors independently assessed trials for inclusion, extracted data and evaluated methodological quality. We checked data for accuracy. Twenty-two trials were eligible for inclusion (with 20 trials involving 15,181 women providing data). Overall, trials were at moderate to high risk of bias; none had adequate blinding, and most were unclear for both allocation concealment and incomplete outcome data. Interventions compared included the use of perineal massage, warm and cold compresses, and other perineal management techniques.Most studies did not report data on our secondary outcomes. We downgraded evidence for risk of bias, inconsistency, and imprecision for all comparisons. Hands off (or poised) compared to hands onHands on or hands off the perineum made no clear difference in incidence of intact perineum (average risk ratio (RR) 1.03, 95% confidence interval (CI) 0.95 to 1.12, two studies, Tau² 0.00, I² 37%, 6547 women; moderate-quality evidence), first-degree perineal tears (average RR 1.32, 95% CI 0.99 to 1.77, two studies, 700 women; low-quality evidence), second-degree tears (average RR 0.77, 95% CI 0.47 to 1.28, two studies, 700 women; low-quality evidence), or third- or fourth-degree tears (average RR 0.68, 95% CI 0.21 to 2.26, five studies, Tau² 0.92, I² 72%, 7317 women; very low-quality evidence). Substantial heterogeneity for third- or fourth-degree tears means these data should be interpreted with caution. Episiotomy was more frequent in the hands-on group (average RR 0.58, 95% CI 0.43 to 0.79, Tau² 0.07, I² 74%, four studies, 7247 women; low-quality evidence), but there was considerable heterogeneity between the four included studies.There were no data for perineal trauma requiring suturing. Warm compresses versus control (hands off or no warm compress)A warm compress did not have any clear effect on the incidence of intact perineum (average RR 1.02, 95% CI 0.85 to 1.21; 1799 women; four studies; moderate-quality evidence), perineal trauma requiring suturing (average RR 1.14, 95% CI 0.79 to 1.66; 76 women; one study; very low-quality evidence), second-degree tears (average RR 0.95, 95% CI 0.58 to 1.56; 274 women; two studies; very low-quality evidence), or episiotomy (average RR 0.86, 95% CI 0.60 to 1.23; 1799 women; four studies; low-quality evidence). It is uncertain whether warm compress increases or reduces the incidence of first-degree tears (average RR 1.19, 95% CI 0.38 to 3.79; 274 women; two studies; I² 88%; very low-quality evidence).Fewer third- or fourth-degree perineal tears were reported in the warm-compress group (average RR 0.46, 95% CI 0.27 to 0.79; 1799 women; four studies; moderate-quality evidence). Massage versus control (hands off or routine care)The incidence of intact perineum was increased in the perineal-massage group (average RR 1.74, 95% CI 1.11 to 2.73, six studies, 2618 women; I² 83% low-quality evidence) but there was substantial heterogeneity between studies). This group experienced fewer third- or fourth-degree tears (average RR 0.49, 95% CI 0.25 to 0.94, five studies, 2477 women; moderate-quality evidence).There were no clear differences between groups for perineal trauma requiring suturing (average RR 1.10, 95% CI 0.75 to 1.61, one study, 76 women; very low-quality evidence), first-degree tears (average RR 1.55, 95% CI 0.79 to 3.05, five studies, Tau² 0.47, I² 85%, 537 women; very low-quality evidence), or second-degree tears (average RR 1.08, 95% CI 0.55 to 2.12, five studies, Tau² 0.32, I² 62%, 537 women; very low-quality evidence). Perineal massage may reduce episiotomy although there was considerable uncertainty around the effect estimate (average RR 0.55, 95% CI 0.29 to 1.03, seven studies, Tau² 0.43, I² 92%, 2684 women; very low-quality evidence). Heterogeneity was high for first-degree tear, second-degree tear and for episiotomy - these data should be interpreted with caution. Ritgen's manoeuvre versus standard careOne study (66 women) found that women receiving Ritgen's manoeuvre were less likely to have a first-degree tear (RR 0.32, 95% CI 0.14 to 0.69; very low-quality evidence), more likely to have a second-degree tear (RR 3.25, 95% CI 1.73 to 6.09; very low-quality evidence), and neither more nor less likely to have an intact perineum (RR 0.17, 95% CI 0.02 to 1.31; very low-quality evidence). One larger study reported that Ritgen's manoeuvre did not have an effect on incidence of third- or fourth-degree tears (RR 1.24, 95% CI 0.78 to 1.96,1423 women; low-quality evidence). Episiotomy was not clearly different between groups (RR 0.81, 95% CI 0.63 to 1.03, two studies, 1489 women; low-quality evidence). Other comparisonsThe delivery of posterior versus anterior shoulder first, use of a perineal protection device, different oils/wax, and cold compresses did not show any effects on perineal outcomes. Only one study contributed to each of these comparisons, so data were insufficient to draw conclusions. Moderate-quality evidence suggests that warm compresses, and massage, may reduce third- and fourth-degree tears but the impact of these techniques on other outcomes was unclear or inconsistent. Poor-quality evidence suggests hands-off techniques may reduce episiotomy, but this technique had no clear impact on other outcomes. There were insufficient data to show whether other perineal techniques result in improved outcomes.Further research could be performed evaluating perineal techniques, warm compresses and massage, and how different types of oil used during massage affect women and their babies. It is important for any future research to collect information on women's views.

Inclusion of Highest Glasgow Coma Scale Motor Component Score in Mortality Risk Adjustment for Benchmarking of Trauma Center Performance.

PubMed

Gomez, David; Byrne, James P; Alali, Aziz S; Xiong, Wei; Hoeft, Chris; Neal, Melanie; Subacius, Harris; Nathens, Avery B

2017-12-01

The Glasgow Coma Scale (GCS) is the most widely used measure of traumatic brain injury (TBI) severity. Currently, the arrival GCS motor component (mGCS) score is used in risk-adjustment models for external benchmarking of mortality. However, there is evidence that the highest mGCS score in the first 24 hours after injury might be a better predictor of death. Our objective was to evaluate the impact of including the highest mGCS score on the performance of risk-adjustment models and subsequent external benchmarking results. Data were derived from the Trauma Quality Improvement Program analytic dataset (January 2014 through March 2015) and were limited to the severe TBI cohort (16 years or older, isolated head injury, GCS ≤8). Risk-adjustment models were created that varied in the mGCS covariates only (initial score, highest score, or both initial and highest mGCS scores). Model performance and fit, as well as external benchmarking results, were compared. There were 6,553 patients with severe TBI across 231 trauma centers included. Initial and highest mGCS scores were different in 47% of patients (n = 3,097). Model performance and fit improved when both initial and highest mGCS scores were included, as evidenced by improved C-statistic, Akaike Information Criterion, and adjusted R-squared values. Three-quarters of centers changed their adjusted odds ratio decile, 2.6% of centers changed outlier status, and 45% of centers exhibited a ≥0.5-SD change in the odds ratio of death after including highest mGCS score in the model. This study supports the concept that additional clinical information has the potential to not only improve the performance of current risk-adjustment models, but can also have a meaningful impact on external benchmarking strategies. Highest mGCS score is a good potential candidate for inclusion in additional models. Copyright © 2017 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

A crew resource management program tailored to trauma resuscitation improves team behavior and communication.

PubMed

Hughes, K Michael; Benenson, Ronald S; Krichten, Amy E; Clancy, Keith D; Ryan, James Patrick; Hammond, Christopher

2014-09-01

Crew Resource Management (CRM) is a team-building communication process first implemented in the aviation industry to improve safety. It has been used in health care, particularly in surgical and intensive care settings, to improve team dynamics and reduce errors. We adapted a CRM process for implementation in the trauma resuscitation area. An interdisciplinary steering committee developed our CRM process to include a didactic classroom program based on a preimplementation survey of our trauma team members. Implementation with new cultural and process expectations followed. The Human Factors Attitude Survey and Communication and Teamwork Skills assessment tool were used to design, evaluate, and validate our CRM program. The initial trauma communication survey was completed by 160 team members (49% response). Twenty-five trauma resuscitations were observed and scored using Communication and Teamwork Skills. Areas of concern were identified and 324 staff completed our 3-hour CRM course during a 3-month period. After CRM training, 132 communication surveys and 38 Communication and Teamwork Skills observations were completed. In the post-CRM survey, respondents indicated improvement in accuracy of field to medical command information (p = 0.029); accuracy of emergency department medical command information to the resuscitation area (p = 0.002); and team leader identity, communication of plan, and role assignment (p = 0.001). After CRM training, staff were more likely to speak up when patient safety was a concern (p = 0.002). Crew Resource Management in the trauma resuscitation area enhances team dynamics, communication, and, ostensibly, patient safety. Philosophy and culture of CRM should be compulsory components of trauma programs and in resuscitation of injured patients. Copyright © 2014 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Neuron-specific caveolin-1 overexpression improves motor function and preserves memory in mice subjected to brain trauma.

PubMed

Egawa, Junji; Schilling, Jan M; Cui, Weihua; Posadas, Edmund; Sawada, Atsushi; Alas, Basheer; Zemljic-Harpf, Alice E; Fannon-Pavlich, McKenzie J; Mandyam, Chitra D; Roth, David M; Patel, Hemal H; Patel, Piyush M; Head, Brian P

2017-08-01

Studies in vitro and in vivo demonstrate that membrane/lipid rafts and caveolin (Cav) organize progrowth receptors, and, when overexpressed specifically in neurons, Cav-1 augments neuronal signaling and growth and improves cognitive function in adult and aged mice; however, whether neuronal Cav-1 overexpression can preserve motor and cognitive function in the brain trauma setting is unknown. Here, we generated a neuron-targeted Cav-1-overexpressing transgenic (Tg) mouse [synapsin-driven Cav-1 (SynCav1 Tg)] and subjected it to a controlled cortical impact model of brain trauma and measured biochemical, anatomic, and behavioral changes. SynCav1 Tg mice exhibited increased hippocampal expression of Cav-1 and membrane/lipid raft localization of postsynaptic density protein 95, NMDA receptor, and tropomyosin receptor kinase B. When subjected to a controlled cortical impact, SynCav1 Tg mice demonstrated preserved hippocampus-dependent fear learning and memory, improved motor function recovery, and decreased brain lesion volume compared with wild-type controls. Neuron-targeted overexpression of Cav-1 in the adult brain prevents hippocampus-dependent learning and memory deficits, restores motor function after brain trauma, and decreases brain lesion size induced by trauma. Our findings demonstrate that neuron-targeted Cav-1 can be used as a novel therapeutic strategy to restore brain function and prevent trauma-associated maladaptive plasticity.-Egawa, J., Schilling, J. M., Cui, W., Posadas, E., Sawada, A., Alas, B., Zemljic-Harpf, A. E., Fannon-Pavlich, M. J., Mandyam, C. D., Roth, D. M., Patel, H. H., Patel, P. M., Head, B. P. Neuron-specific caveolin-1 overexpression improves motor function and preserves memory in mice subjected to brain trauma. © FASEB.

Nonpathologizing trauma interventions in abnormal psychology courses.

PubMed

Hoover, Stephanie M; Luchner, Andrew F; Pickett, Rachel F

2016-01-01

Because abnormal psychology courses presuppose a focus on pathological human functioning, nonpathologizing interventions within these classes are particularly powerful and can reach survivors, bystanders, and perpetrators. Interventions are needed to improve the social response to trauma on college campuses. By applying psychodynamic and feminist multicultural theory, instructors can deliver nonpathologizing interventions about trauma and trauma response within these classes. We recommend class-based interventions with the following aims: (a) intentionally using nonpathologizing language, (b) normalizing trauma responses, (c) subjectively defining trauma, (d) challenging secondary victimization, and (e) questioning the delineation of abnormal and normal. The recommendations promote implications for instructor self-reflection, therapy interventions, and future research.

System care improves trauma outcome: patient care errors dominate reduced preventable death rate.

PubMed

Thoburn, E; Norris, P; Flores, R; Goode, S; Rodriguez, E; Adams, V; Campbell, S; Albrink, M; Rosemurgy, A

1993-01-01

A review of 452 trauma deaths in Hillsborough County, Florida, in 1984 documented that 23% of non-CNS trauma deaths were preventable and occurred because of inadequate resuscitation or delay in proper surgical care. In late 1988 Hillsborough County organized a County Trauma Agency (HCTA) to coordinate trauma care among prehospital providers and state-designated trauma centers. The purpose of this study was to review county trauma deaths after the inception of the HCTA to determine the frequency of preventable deaths. 504 trauma deaths occurring between October 1989 and April 1991 were reviewed. Through committee review, 10 deaths were deemed preventable; 2 occurred outside the trauma system. Of the 10 deaths, 5 preventable deaths occurred late in severely injured patients. The preventable death rate has decreased to 7.0% with system care. The causes of preventable deaths have changed from delayed or inadequate intervention to postoperative care errors.

Cervical spine collar clearance in the obtunded adult blunt trauma patient: a systematic review and practice management guideline from the Eastern Association for the Surgery of Trauma.

PubMed

Patel, Mayur B; Humble, Stephen S; Cullinane, Daniel C; Day, Matthew A; Jawa, Randeep S; Devin, Clinton J; Delozier, Margaret S; Smith, Lou M; Smith, Miya A; Capella, Jeannette M; Long, Andrea M; Cheng, Joseph S; Leath, Taylor C; Falck-Ytter, Yngve; Haut, Elliott R; Como, John J

2015-02-01

With the use of the framework advocated by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group, our aims were to perform a systematic review and to develop evidence-based recommendations that may be used to answer the following PICO [Population, Intervention, Comparator, Outcomes] question:In the obtunded adult blunt trauma patient, should cervical collar removal be performed after a negative high-quality cervical spine (C-spine) computed tomography (CT) result alone or after a negative high-quality C-spine CT result combined with adjunct imaging, to reduce peri-clearance events, such as new neurologic change, unstable C-spine injury, stable C-spine injury, need for post-clearance imaging, false-negative CT imaging result on re-review, pressure ulcers, and time to cervical collar clearance? Our protocol was registered with the PROSPERO international prospective register of systematic reviews on August 23, 2013 (REGISTRATION NUMBER: CRD42013005461). Eligibility criteria consisted of adult blunt trauma patients 16 years or older, who underwent C-spine CT with axial thickness of less than 3 mm and who were obtunded using any definition.Quantitative synthesis via meta-analysis was not possible because of pre-post, partial-cohort, quasi-experimental study design limitations and the consequential incomplete diagnostic accuracy data. Of five articles with a total follow-up of 1,017 included subjects, none reported new neurologic changes (paraplegia or quadriplegia) after cervical collar removal. There is a worst-case 9% (161 of 1,718 subjects in 11 studies) cumulative literature incidence of stable injuries and a 91% negative predictive value of no injury, after coupling a negative high-quality C-spine CT result with 1.5-T magnetic resonance imaging, upright x-rays, flexion-extension CT, and/or clinical follow-up. Similarly, there is a best-case 0% (0 of 1,718 subjects in 11 studies) cumulative literature incidence of unstable injuries after negative initial imaging result with a high-quality C-spine CT. In obtunded adult blunt trauma patients, we conditionally recommend cervical collar removal after a negative high-quality C-spine CT scan result alone. Systematic review, level III.

Impact of adaptive statistical iterative reconstruction on radiation dose in evaluation of trauma patients.

PubMed

Maxfield, Mark W; Schuster, Kevin M; McGillicuddy, Edward A; Young, Calvin J; Ghita, Monica; Bokhari, S A Jamal; Oliva, Isabel B; Brink, James A; Davis, Kimberly A

2012-12-01

A recent study showed that computed tomographic (CT) scans contributed 93% of radiation exposure of 177 patients admitted to our Level I trauma center. Adaptive statistical iterative reconstruction (ASIR) is an algorithm that reduces the noise level in reconstructed images and therefore allows the use of less ionizing radiation during CT scans without significantly affecting image quality. ASIR was instituted on all CT scans performed on trauma patients in June 2009. Our objective was to determine if implementation of ASIR reduced radiation dose without compromising patient outcomes. We identified 300 patients activating the trauma system before and after the implementation of ASIR imaging. After applying inclusion criteria, 245 charts were reviewed. Baseline demographics, presenting characteristics, number of delayed diagnoses, and missed injuries were recorded. The postexamination volume CT dose index (CTDIvol) and dose-length product (DLP) reported by the scanner for CT scans of the chest, abdomen, and pelvis and CT scans of the brain and cervical spine were recorded. Subjective image quality was compared between the two groups. For CT scans of the chest, abdomen, and pelvis, the mean CTDIvol (17.1 mGy vs. 14.2 mGy; p < 0.001) and DLP (1,165 mGy·cm vs. 1,004 mGy·cm; p < 0.001) was lower for studies performed with ASIR. For CT scans of the brain and cervical spine, the mean CTDIvol (61.7 mGy vs. 49.6 mGy; p < 0.001) and DLP (1,327 mGy·cm vs. 1,067 mGy·cm; p < 0.001) was lower for studies performed with ASIR. There was no subjective difference in image quality between ASIR and non-ASIR scans. All CT scans were deemed of good or excellent image quality. There were no delayed diagnoses or missed injuries related to CT scanning identified in either group. Implementation of ASIR imaging for CT scans performed on trauma patients led to a nearly 20% reduction in ionizing radiation without compromising outcomes or image quality. Therapeutic study, level IV.

Impact of adaptive statistical iterative reconstruction on radiation dose in evaluation of trauma patients

PubMed Central

Maxfield, Mark W.; Schuster, Kevin M.; McGillicuddy, Edward A.; Young, Calvin J.; Ghita, Monica; Bokhari, S.A. Jamal; Oliva, Isabel B.; Brink, James A.; Davis, Kimberly A.

2013-01-01

BACKGROUND A recent study showed that computed tomographic (CT) scans contributed 93% of radiation exposure of 177 patients admitted to our Level I trauma center. Adaptive statistical iterative reconstruction (ASIR) is an algorithm that reduces the noise level in reconstructed images and therefore allows the use of less ionizing radiation during CT scans without significantly affecting image quality. ASIR was instituted on all CT scans performed on trauma patients in June 2009. Our objective was to determine if implementation of ASIR reduced radiation dose without compromising patient outcomes. METHODS We identified 300 patients activating the trauma system before and after the implementation of ASIR imaging. After applying inclusion criteria, 245 charts were reviewed. Baseline demographics, presenting characteristics, number of delayed diagnoses, and missed injuries were recorded. The postexamination volume CT dose index (CTDIvol) and dose-length product (DLP)reported by the scanner for CT scans of the chest, abdomen, and pelvis and CT scans of the brain and cervical spine were recorded. Subjective image quality was compared between the two groups. RESULTS For CT scans of the chest, abdomen, and pelvis, the mean CTDIvol(17.1 mGy vs. 14.2 mGy; p < 0.001) and DLP (1,165 mGy·cm vs. 1,004 mGy·cm; p < 0.001) was lower for studies performed with ASIR. For CT scans of the brain and cervical spine, the mean CTDIvol(61.7 mGy vs. 49.6 mGy; p < 0.001) and DLP (1,327 mGy·cm vs. 1,067 mGy·cm; p < 0.001) was lower for studies performed with ASIR. There was no subjective difference in image quality between ASIR and non-ASIR scans. All CT scans were deemed of good or excellent image quality. There were no delayed diagnoses or missed injuries related to CT scanning identified in either group. CONCLUSION Implementation of ASIR imaging for CT scans performed on trauma patients led to a nearly 20% reduction in ionizing radiation without compromising outcomes or image quality. PMID:23147183

Trauma-Focused CBT for Youth who Experience Ongoing Traumas

PubMed Central

Cohen, Judith A.; Mannarino, Anthony P.; Murray, Laura A.

2011-01-01

Many youth experience ongoing trauma exposure, such as domestic or community violence. Clinicians often ask whether evidence-based treatments containing exposure components to reduce learned fear responses to historical trauma are appropriate for these youth. Essentially the question is, if youth are desensitized to their trauma experiences, will this in some way impair their responding to current or ongoing trauma? The paper addresses practical strategies for implementing one evidence-based treatment, Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) for youth with ongoing traumas. Collaboration with local therapists and families participating in TF-CBT community and international programs elucidated effective strategies for applying TF-CBT with these youth. These strategies included: 1) enhancing safety early in treatment; 2) effectively engaging parents who experience personal ongoing trauma; and 3) during the trauma narrative and processing component focusing on a) increasing parental awareness and acceptance of the extent of the youths’ ongoing trauma experiences; b) addressing youths’ maladaptive cognitions about ongoing traumas; and c) helping youth differentiate between real danger and generalized trauma reminders. Case examples illustrate how to use these strategies in diverse clinical situations. Through these strategies TF-CBT clinicians can effectively improve outcomes for youth experiencing ongoing traumas. PMID:21855140

A consensus exercise identifying priorities for research into clinical effectiveness among children's orthopaedic surgeons in the United Kingdom.

PubMed

Perry, D C; Wright, J G; Cooke, S; Roposch, A; Gaston, M S; Nicolaou, N; Theologis, T

2018-05-01

Aims High-quality clinical research in children's orthopaedic surgery has lagged behind other surgical subspecialties. This study used a consensus-based approach to identify research priorities for clinical trials in children's orthopaedics. Methods A modified Delphi technique was used, which involved an initial scoping survey, a two-round Delphi process and an expert panel formed of members of the British Society of Children's Orthopaedic Surgery. The survey was conducted amongst orthopaedic surgeons treating children in the United Kingdom and Ireland. Results A total of 86 clinicians contributed to both rounds of the Delphi process, scoring priorities from one (low priority) to five (high priority). Elective topics were ranked higher than those relating to trauma, with the top ten elective research questions scoring higher than the top question for trauma. Ten elective, and five trauma research priorities were identified, with the three highest ranked questions relating to the treatment of slipped capital femoral epiphysis (mean score 4.6/ 5), Perthes' disease (4.5) and bone infection (4.5). Conclusion This consensus-based research agenda will guide surgeons, academics and funders to improve the evidence in children's orthopaedic surgery and encourage the development of multicentre clinical trials. Cite this article: Bone Joint J 2018;100-B:680-4.

Comminuted Laryngeal Fracture Following Blunt Trauma: A Need for Strict Legislation on Roads!

PubMed

Jain, Shraddha; Singh, Pragya; Gupta, Minal; Kamble, Bhavna; Phatak, Suresh S

2017-01-01

Laryngeal fracture is a rare condition with potential life-long implications related to airway patency, voice quality, and swallowing. Rarity of the condition leads to lack of consensus on the most suitable way to manage this injury. The mode of injury can be prevented by strict legislation on the roads. We report a case of a 28-year-old Indian male who sustained a comminuted displaced fracture of the thyroid cartilage with disruption of anterior commissure due to blunt trauma caused by the metallic side rod of a ladder projecting from the rear of a vehicle in front of the bike on which he was riding. He presented with breathing difficulty, change in voice, surgical emphysema, and pneumomediastinum, but without any skin changes over the neck. His airway could be restored due to early tracheostomy and open reduction with internal fixation with sutures along with laryngeal stenting. He has no significant swallowing or breathing problem and reasonably good voice 6 months after surgery. This case highlights the need for strict legislation on roads in India and the importance of high level of suspicion for laryngeal fracture in acute trauma patient. Early identification and timely internal fixation not only restore the airway but also improve long-term voice and airway outcomes.

Video techniques and data compared with observation in emergency trauma care

PubMed Central

Mackenzie, C; Xiao, Y

2003-01-01

Video recording is underused in improving patient safety and understanding performance shaping factors in patient care. We report our experience of using video recording techniques in a trauma centre, including how to gain cooperation of clinicians for video recording of their workplace performance, identify strengths of video compared with observation, and suggest processes for consent and maintenance of confidentiality of video records. Video records are a rich source of data for documenting clinician performance which reveal safety and systems issues not identified by observation. Emergency procedures and video records of critical events identified patient safety, clinical, quality assurance, systems failures, and ergonomic issues. Video recording is a powerful feedback and training tool and provides a reusable record of events that can be repeatedly reviewed and used as research data. It allows expanded analyses of time critical events, trauma resuscitation, anaesthesia, and surgical tasks. To overcome some of the key obstacles in deploying video recording techniques, researchers should (1) develop trust with video recorded subjects, (2) obtain clinician participation for introduction of a new protocol or line of investigation, (3) report aggregated video recorded data and use clinician reviews for feedback on covert processes and cognitive analyses, and (4) involve multidisciplinary experts in medicine and nursing. PMID:14645896

Orthopaedic Trauma Care Capacity Assessment and Strategic Planning in Ghana: Mapping a Way Forward.

PubMed

Stewart, Barclay T; Gyedu, Adam; Tansley, Gavin; Yeboah, Dominic; Amponsah-Manu, Forster; Mock, Charles; Labi-Addo, Wilfred; Quansah, Robert

2016-12-07

Orthopaedic conditions incur more than 52 million disability-adjusted life years annually worldwide. This burden disproportionately affects low and middle-income countries, which are least equipped to provide orthopaedic care. We aimed to assess orthopaedic capacity in Ghana, describe spatial access to orthopaedic care, and identify hospitals that would most improve access to care if their capacity was improved. Seventeen perioperative and orthopaedic trauma care-related items were selected from the World Health Organization's Guidelines for Essential Trauma Care. Direct inspection and structured interviews with hospital staff were used to assess resource availability and factors contributing to deficiencies at 40 purposively sampled facilities. Cost-distance analyses described population-level spatial access to orthopaedic trauma care. Facilities for targeted capability improvement were identified through location-allocation modeling. Orthopaedic trauma care assessment demonstrated marked deficiencies. Some deficient resources were low cost (e.g., spinal immobilization, closed reduction capabilities, and prosthetics for amputees). Resource nonavailability resulted from several contributing factors (e.g., absence of equipment, technology breakage, lack of training). Implants were commonly prohibitively expensive. Building basic orthopaedic care capacity at 15 hospitals without such capacity would improve spatial access to basic care from 74.9% to 83.0% of the population (uncertainty interval [UI] of 81.2% to 83.6%), providing access for an additional 2,169,714 Ghanaians. The availability of several low-cost resources could be better supplied by improvements in organization and training for orthopaedic trauma care. There is a critical need to advocate and provide funding for orthopaedic resources. These initiatives might be particularly effective if aimed at hospitals that could provide care to a large proportion of the population.

Relationships among emotion regulation and symptoms during trauma-focused CBT for school-aged children.

PubMed

Thornback, Kristin; Muller, Robert T

2015-12-01

This study examined improvement in emotion regulation throughout Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) and the degree to which improvement in emotion regulation predicted improvement in symptoms. Traumatized children, 7-12 years (69.9% female), received TF-CBT. Data from 4 time periods were used: pre-assessment (n=107), pre-treatment (n=78), post-treatment (n=58), and 6-month follow-up (n=44). Questionnaires measured emotion regulation in the form of inhibition and dysregulation (Children's Emotion Management Scales) and lability/negativity and emotion regulation skill (Emotion Regulation Checklist), as well as child-reported (Trauma Symptom Checklist for Children) and parent-reported (Trauma Symptom Checklist for Young Children) posttraumatic stress, and internalizing and externalizing problems (Child Behaviuor Checklist). To the extent that children's dysregulation and lability/negativity improved, their parents reported fewer symptoms following therapy. Improvements in inhibition best predicted improvements in child-reported posttraumatic stress (PTS) during clinical services, but change in dysregulation and lability/negativity best predicted improvement in child-reported PTS symptoms at 6-month follow-up. Moreover, statistically significant improvements of small effect size were found following therapy, for inhibition, dysregulation, and lability/negativity, but not emotion regulation skill. These findings suggest that emotion regulation is a worthy target of intervention and that improvements in emotion regulation can be made. Suggestions for future research are discussed. Copyright © 2015 Elsevier Ltd. All rights reserved.

Lean methodology for performance improvement in the trauma discharge process.

PubMed

O'Mara, Michael Shaymus; Ramaniuk, Aliaksandr; Graymire, Vickie; Rozzell, Monica; Martin, Stacey

2014-07-01

High-volume, complex services such as trauma and acute care surgery are at risk for inefficiency. Lean process improvement can reduce health care waste. Lean allows a structured look at processes not easily amenable to analysis. We applied lean methodology to the current state of communication and discharge planning on an urban trauma service, citing areas for improvement. A lean process mapping event was held. The process map was used to identify areas for immediate analysis and intervention-defining metrics for the stakeholders. After intervention, new performance was assessed by direct data evaluation. The process was completed with an analysis of effect and plans made for addressing future focus areas. The primary area of concern identified was interservice communication. Changes centering on a standardized morning report structure reduced the number of consult questions unanswered from 67% to 34% (p = 0.0021). Physical therapy rework was reduced from 35% to 19% (p = 0.016). Patients admitted to units not designated to the trauma service had 1.6 times longer stays (p < 0.0001). The lean process lasted 8 months, and three areas for new improvement were identified: (1) the off-unit patients; (2) patients with length of stay more than 15 days contribute disproportionately to length of stay; and (3) miscommunication exists around patient education at discharge. Lean process improvement is a viable means of health care analysis. When applied to a trauma service with 4,000 admissions annually, lean identifies areas ripe for improvement. Our inefficiencies surrounded communication and patient localization. Strategies arising from the input of all stakeholders led to real solutions for communication through a face-to-face morning report and identified areas for ongoing improvement. This focuses resource use and identifies areas for improvement of throughput in care delivery.

Specific Trauma Subtypes Improve the Predictive Validity of the Harvard Trauma Questionnaire in Iraqi Refugees

PubMed Central

Arnetz, Bengt B.; Broadbridge, Carissa L.; Jamil, Hikmet; Lumley, Mark A.; Pole, Nnamdi; Barkho, Evone; Fakhouri, Monty; Talia, Yousif Rofa; Arnetz, Judith E.

2014-01-01

Background Trauma exposure contributes to poor mental health among refugees, and exposure often is measured using a cumulative index of items from the Harvard Trauma Questionnaire (HTQ). Few studies, however, have asked whether trauma subtypes derived from the HTQ could be superior to this cumulative index in predicting mental health outcomes. Methods A community sample of recently arrived Iraqi refugees (N = 298) completed the HTQ and measures of posttraumatic stress disorder (PTSD) and depression symptoms. Results Principal components analysis of HTQ items revealed a 5-component subtype model of trauma that accounted for more item variance than a 1-component solution. These trauma subtypes also accounted for more variance in PTSD and depression symptoms (12% and 10%, respectively) than did the cumulative trauma index (7% and 3%, respectively). Discussion Trauma subtypes provided more information than cumulative trauma in the prediction of negative mental health outcomes. Therefore, use of these subtypes may enhance the utility of the HTQ when assessing at-risk populations. PMID:24549491

Specific trauma subtypes improve the predictive validity of the Harvard Trauma Questionnaire in Iraqi refugees.

PubMed

Arnetz, Bengt B; Broadbridge, Carissa L; Jamil, Hikmet; Lumley, Mark A; Pole, Nnamdi; Barkho, Evone; Fakhouri, Monty; Talia, Yousif Rofa; Arnetz, Judith E

2014-12-01

Trauma exposure contributes to poor mental health among refugees, and exposure often is measured using a cumulative index of items from the Harvard Trauma Questionnaire (HTQ). Few studies, however, have asked whether trauma subtypes derived from the HTQ could be superior to this cumulative index in predicting mental health outcomes. A community sample of recently arrived Iraqi refugees (N = 298) completed the HTQ and measures of posttraumatic stress disorder (PTSD) and depression symptoms. Principal components analysis of HTQ items revealed a 5-component subtype model of trauma that accounted for more item variance than a 1-component solution. These trauma subtypes also accounted for more variance in PTSD and depression symptoms (12 and 10%, respectively) than did the cumulative trauma index (7 and 3%, respectively). Trauma subtypes provided more information than cumulative trauma in the prediction of negative mental health outcomes. Therefore, use of these subtypes may enhance the utility of the HTQ when assessing at-risk populations.

Visual grading characteristics and ordinal regression analysis during optimisation of CT head examinations.

PubMed

Zarb, Francis; McEntee, Mark F; Rainford, Louise

2015-06-01

To evaluate visual grading characteristics (VGC) and ordinal regression analysis during head CT optimisation as a potential alternative to visual grading assessment (VGA), traditionally employed to score anatomical visualisation. Patient images (n = 66) were obtained using current and optimised imaging protocols from two CT suites: a 16-slice scanner at the national Maltese centre for trauma and a 64-slice scanner in a private centre. Local resident radiologists (n = 6) performed VGA followed by VGC and ordinal regression analysis. VGC alone indicated that optimised protocols had similar image quality as current protocols. Ordinal logistic regression analysis provided an in-depth evaluation, criterion by criterion allowing the selective implementation of the protocols. The local radiology review panel supported the implementation of optimised protocols for brain CT examinations (including trauma) in one centre, achieving radiation dose reductions ranging from 24 % to 36 %. In the second centre a 29 % reduction in radiation dose was achieved for follow-up cases. The combined use of VGC and ordinal logistic regression analysis led to clinical decisions being taken on the implementation of the optimised protocols. This improved method of image quality analysis provided the evidence to support imaging protocol optimisation, resulting in significant radiation dose savings. • There is need for scientifically based image quality evaluation during CT optimisation. • VGC and ordinal regression analysis in combination led to better informed clinical decisions. • VGC and ordinal regression analysis led to dose reductions without compromising diagnostic efficacy.

Quality of life following trauma before and after implementation of a physician-staffed helicopter.

PubMed

Funder, K S; Rasmussen, L S; Hesselfeldt, R; Siersma, V; Lohse, N; Sonne, A; Wulffeld, S; Steinmetz, J

2017-01-01

Implementation of a physician-staffed helicopter emergency medical service (PS-HEMS) in Denmark was associated with lower 30-day mortality in severely injured trauma patients and less time on social subsidy. However, the reduced 30-day mortality in severely injured patients might be at the expense of a worse functional outcome and quality of life (QoL) in those who survive. The aim of this study was to investigate the effect of a physician-staffed helicopter on long-term QoL in trauma patients. Prospective, observational study including trauma patients who survived at least 3 years after injury. A 5-month period prior to PS-HEMS implementation was compared with the first 12 months after PS-HEMS implementation. QoL was assessed 4.5 years after trauma by the SF-36 questionnaire. Primary endpoint was the Physical Component Summary score. Of the 1994 patients assessed by a trauma team, 1521 were eligible for inclusion in the study. Of these, 566 (37%) gave consent to participate and received a questionnaire by mail, and 402 (71%) of them returned the questionnaire (n = 114 before PS-HEMS; n = 288 after PS-HEMS implementation). Older patients, women and patients with trauma in the after PS-HEMS period were more likely to return the questionnaire. No significant association between QoL and period (before vs. after PS-HEMS) was found; the Physical Component Summary scores were 50.0 and 50.9 in the before and after PS-HEMS periods, respectively (P = 0.47). We also found no difference on multivariable analysis with adjustment for sex, age and injury severity score. No significant difference in QoL among trauma patients was found after implementation of a PS-HEMS. © 2016 The Authors. Acta Anaesthesiologica Scandinavica published by John Wiley & Sons Ltd on behalf of Acta Anaesthesiologica Scandinavica Foundation.

[The radiologist physician in major trauma evaluation].

PubMed

Motta-Ramírez, Gaspar Alberto

2016-01-01

Trauma is the most common cause of death in young adults. A multidisciplinary trauma team consists of at least a surgical team, an anesthesiology team, radiologic team, and an emergency department team. Recognize the integration of multidisciplinary medical team in managing the trauma patient and which must include the radiologist physician responsible for the institutional approach to the systematization of the trauma patient regarding any radiological and imaging study with emphasis on the FAST (del inglés, Focused Assessment with Sonography in Trauma)/USTA, Whole body computed tomography. Ultrasound is a cross-sectional method available for use in patients with major trauma. Whole-body multidetector computed tomography became the imaging modality of choice in the late 1990s. In patients with major trauma, examination FAST often is the initial imaging examination, extended to extraabdominal regions. Patients who have multitrauma from blunt mechanisms often require multiple diagnostic examinations, including Computed Tomography imaging of the torso as well as abdominopelvic Computed Tomography angiography. Multiphasic Whole-body trauma imaging is feasible, helps detect clinically relevant vascular injuries, and results in diagnostic image quality in the majority of patients. Computed Tomography has gained importance in the early diagnostic phase of trauma care in the emergency room. With a single continuous acquisition, whole-body computed tomography angiography is able to demonstrate all potentially injured organs, as well as vascular and bone structures, from the circle of Willis to the symphysis pubis.

The Applicability of Two Strengths-Based Systemic Psychotherapy Models for Young People Following Type 1 Trauma

ERIC Educational Resources Information Center

Coulter, Stephen

2014-01-01

This paper will consider the inter-relationship of a number of overlapping disciplinary theoretical concepts relevant to a strengths-based orientation, including well-being, salutogenesis, sense of coherence, quality of life and resilience. Psychological trauma will be referenced and the current evidence base for interventions with children and…

Hypogonadism after traumatic brain injury.

PubMed

Hohl, Alexandre; Mazzuco, Tânia Longo; Coral, Marisa Helena César; Schwarzbold, Marcelo; Walz, Roger

2009-11-01

Traumatic brain injury (TBI) is the most common cause of death and disability in young adults. Post-TBI neuroendocrine disorders have been increasingly acknowledged in recent years due to their potential contribution to morbidity and, probably, to mortality after trauma. Marked alterations of the hypothalamic-pituitary axis during the post-TBI acute and chronic phases have been reported. Prospective and longitudinal studies have shown that some abnormalities are transitory. On the other hand, there is a high frequency (15% to 68%) of pituitary hormone deficiency among TBI survivors in a long term setting. Post-TBI hypogonadism is a common finding after cranial trauma, and it is predicted to develop in 16% of the survivors in the long term. Post-TBI hypogonadism has been associated with adverse results in the acute and chronic phases after injury. These data reinforce the need for identification of hormonal deficiencies and their proper treatment, in order to optimize patient recovery, improve their life quality, and avoid the negative consequences of non-treated hypogonadism in the long term.

The general surgery model: a more appealing and sustainable alternative for the care of trauma patients.

PubMed

Roettger, Richard H; Taylor, Spence M; Youkey, Jerry R; Blackhurst, Dawn W

2005-08-01

The contemporary model of trauma care where dedicated trauma/critical care surgeons exclusively manage trauma patients has become progressively unsustainable. Little objective data, however, is available documenting that a better model exists. From September 2002 through August 2003, the trauma model at a 735-bed level I trauma teaching hospital was changed from the contemporary model to a new one where selected general surgeons with Advanced Trauma Life Support (ATLS) certification covered in-house trauma and emergency surgery call on a rotational basis. As well, each pursued elective practices, admitting all inpatients (trauma, emergent, elective) to a single teaching service (formerly the trauma service). Critical care was managed by a separate group of intensivists. The purpose of this study was to objectively compare the two models. Quantitative, financial, and qualitative data were derived from August 2001 to January 2002 (trauma/critical care model) and compared to August 2003 to January 2004 (general surgery model). During the two periods (trauma/critical care vs general surgery), the mean Revised Trauma Score (7.1 vs 7.2; P = 0.029), the mean Injury Severity Score (ISS) (10.9 vs 10.8; P = 0.84), and the percentage of penetrating trauma (12.5% vs 13.2%; P = 0.79) were similar. Differences (trauma/critical care vs general surgery, % increase/P value) included average daily census (24 vs 54, 225%), cases/attending (262 vs 543, 207%), cases/resident (54 vs 262, 485%), charges/attending (353,811 dollars vs 471,725 dollars, 133%), collections/attending (106,143 dollars vs 165,103 dollars, 156%), number of trauma patients (643 vs 748, 116%), trauma mortality (7.3% vs 4.0%; P = 0.007), trauma mortality with ISS >15 (21.7% vs 12.0%; P = 0.035), trauma complications (33.1% vs 17%; P < 0.001), and ICU morbidity (66.8% vs 43.9%; P < .001). The new general surgery model produced superior financial results and better quantitative surgical experience while exceeding trauma and ICU quality outcomes compared to the former trauma/critical care model. These data objectively support a model such as ours--one that is financially sustainable and more professionally attractive.

The changing nature of death on the trauma service.

PubMed

Kahl, Jessica E; Calvo, Richard Y; Sise, Michael J; Sise, C Beth; Thorndike, Jonathan F; Shackford, Steven R

2013-08-01

Recent innovations in care have improved survival following injury. Coincidentally, the population of elderly injured patients with preexisting comorbidities has increased. We hypothesized that this increase in elderly injured patients may have combined with recent care innovations to alter the causes of death after trauma. We reviewed demographics, injury characteristics, and cause of death of in-hospital deaths of patients admitted to our Level I trauma service from 2000 through 2011. Cause of death was classified as acute hemorrhagic shock; severe traumatic brain injury or high spinal cord injury; complications of preexisting medical condition only (PM); survivable trauma combined with complications of preexisting medical condition (TCoM); multiple-organ failure, sepsis, or adult respiratory distress syndrome (MOF/S/ARDS), or trauma not otherwise categorized (e.g., asphyxiation). Major trauma care advances implemented on our service during the period were identified, and trends in the causes of death were analyzed. Of the 27,276 admissions, 819 (3%) eligible nonsurvivors were identified for the cause-of-death analyses. Causes of death were severe traumatic brain injury or high spinal cord injury at 44%, acute hemorrhagic shock at 28%, PM at 11%, TCoM at 10%, MOF/S/ARDS at 2%, and trauma not otherwise categorized at 5%. Mean age at death increased across the study interval (range, 47-57 years), while mean Injury Severity Score (ISS) decreased (range, 28-35). There was a significant increase in deaths because of TCoM (3.3-20.9%) and PM (6.7-16.4%), while deaths caused by MOF/S/ARDS decreased from 5% to 0% by 2007. Compared with year 2000, the annual adjusted mortality rate decreased consistently starting in 2009, after the 2002 to 2007 adoption of four major trauma practice guidelines. Mortality caused by preexisting medical conditions has increased, while markedly fewer deaths resulted from the complications of injury. Future improvements in outcomes will require improvement in the management of elderly trauma patients with comorbid conditions.

How formative courses about damage control surgery and non-operative management improved outcome and survival in unstable politrauma patients in a Mountain Trauma Center.

PubMed

Bellanova, Giovanni; Buccelletti, Francesco; Berletti, Riccardo; Cavana, Marco; Folgheraiter, Giorgio; Groppo, Francesca; Marchetti, Chiara; Marzano, Amelia; Massè, Alessandro; Musetti, Antonio; Pelanda, Tina; Ricci, Nicola; Tugnoli, Gregorio; Papadia, Damiano; Ramponi, Claudio

2016-01-01

Aim of this study is to analyze how the starting of Course of Trauma in our hospital improved survival and organization in management of polytraumatized patients. We analysed all major trauma patients (Injury Severity Score (Injury Severity Score (ISS)> 15) treated at Emergency Department of the Santa Chiara Hospital between January 2011 and December 2014. The training courses (TC) were named "management of polytrauma" (MP) and "clinical cases discussion" (CCD), and started in November 2013. We divided the patients between two groups: before November 2013 (pre-TC group) and after November 2013 (post-TC group). MTG's courses (EMC accredited), CCD and MP courses started in November 2013. The target of these courses was the multidisciplinary management of polytrauma patient; the courses were addressed to general surgeons, anaesthesiologists, radiologists, orthopaedics and emergency physicians. Respectively 110 and 78 doctors were formed in CCD's and MP's courses. Patients directly transported to our trauma centre rose from 67.5% to 83% (p<0,005), and E-FAST grew from 15.6% in the pre-TC group to 51.3% in the post-TC group. Time of access in operatory theatre decreased from 62 to 44 minutes. Early Mortality (within 48 hours from the hospital arrival) was 9% in the pre-TC group and 4.5% in the post-tc group (p<0.005). Be needed to complete our goal. Further analysis and possible comparison with other trauma centers be needed to complete our goal Our results show that in our experience the multidisciplinary approach to polytrauma patients increased early survival and improved outcome with an evidence of worker's satisfaction. However, the best practice would ask to start with the approval of procedures and guidelines by the hospital governance, followed by clinical practice changes, in order to create a dedicated emergency and trauma surgery group. Damage Control Surgery, Non Operative Management, Trauma Course, Trauma Team, Trauma Center.

[Effects of combined action of radon baths and transcranial magnetotherapy on cerebral circulation in patients in an intermediate period of a mild craniocerebral trauma].

PubMed

Moliavchikova, O V; Cherevashchenko, L A; Grinzaĭd, Iu M; Aĭvazov, V N; Zhuravlev, M E

2007-01-01

The authors propose combined therapy improving cerebral circulation in patients in an intermediate period of a mild craniocerebral trauma. The combination consists of radon baths and transcranial magnetotherapy which raise blood volume filling, relieve vascular resistance, improve venous outflow.

Long-term treatment effect of trauma-affected refugees with flexible cognitive behavioural therapy and antidepressants.

PubMed

Buhmann, Caecilie Böck; Nordentoft, Merete; Ekstroem, Morten; Carlsson, Jessica; Mortensen, Erik Lykke

2018-04-04

Few studies exist on the long-term effect of treatment of trauma-affected refugees. The purpose of this study was to estimate the long-term treatment effects of cognitive behavioural therapy and antidepressants (sertraline and mianserin) in trauma-affected refugees. Follow-ups were conducted 6 and 18 months after a randomised controlled clinical trial. The included patients were refugees with war-related traumatic experiences, PTSD and without psychotic disorders. We found a small improvement over time in PTSD, depression and anxiety symptoms and level of functioning, but the improvement was not associated with any specific treatment. Personality change after catastrophic experiences and life events influenced the symptom level at all follow-ups while depression at completion of treatment was associated with a steeper decline in symptom load at the follow-ups. In spite of the limited decline in symptom scores and treatment effects immediately after treatment, the condition of the treated trauma-affected refugees was significantly improved 6 and 18 months after treatment although the improvement was small. Copyright © 2018 Elsevier B.V. All rights reserved.

Physical activity and quality of life of amputees in southern Brazil.

PubMed

da Silva, Rudney; Rizzo, Julia Ghazel; Gutierres Filho, Paulo José Barbosa; Ramos, Valmor; Deans, Sarah

2011-12-01

Physical activity is a positive component of human health. Its effects are associated with improvement in physical, psychological and social aspects of quality of life. Physical activity is therefore an important factor in the rehabilitation of amputees. To analyse the relationship between physical activity and quality of life for amputees in southern Brazil. Descriptive, cross-sectional design with nonrandomized sample. A total of 40 questionnaire instruments were distributed to subjects who met the inclusion criteria, with a response rate of 55% (22 individuals, n = 15 males, n = 7 females). Outcome measurements were obtained through the International Physical Activity Questionnaire and World Health Organization Quality of Life-Bref. The sample was characterized by physically active adult male prosthetic users with positive quality of life, and amputation below the right knee caused by mechanical trauma related to traffic accidents with motorcycles. Significant correlations were identified between all domains of quality of life and between level of physical activity and psychological quality of life. No correlation was identified between gender and quality of life variables or physical activity levels. This study showed that in very active amputees of both genders, level of physical activity is not associated with quality of life except for the psychological domain.

A Randomized Implementation Study of Trauma-Focused Cognitive Behavioral Therapy for Adjudicated Teens in Residential Treatment Facilities.

PubMed

Cohen, Judith A; Mannarino, Anthony P; Jankowski, Kay; Rosenberg, Stanley; Kodya, Suzanne; Wolford, George L

2016-05-01

Adjudicated youth in residential treatment facilities (RTFs) have high rates of trauma exposure and post-traumatic stress disorder (PTSD). This study evaluated strategies for implementing trauma-focused cognitive behavioral therapy (TF-CBT) in RTF. Therapists (N = 129) treating adjudicated youth were randomized by RTF program (N = 18) to receive one of the two TF-CBT implementation strategies: (1) web-based TF-CBT training + consultation (W) or (2) W + 2 day live TF-CBT workshop + twice monthly phone consultation (W + L). Youth trauma screening and PTSD symptoms were assessed via online dashboard data entry using the University of California at Los Angeles PTSD Reaction Index. Youth depressive symptoms were assessed with the Mood and Feelings Questionnaire-Short Version. Outcomes were therapist screening; TF-CBT engagement, completion, and fidelity; and youth improvement in PTSD and depressive symptoms. The W + L condition resulted in significantly more therapists conducting trauma screening (p = .0005), completing treatment (p = .03), and completing TF-CBT with fidelity (p = .001) than the W condition. Therapist licensure significantly impacted several outcomes. Adjudicated RTF youth receiving TF-CBT across conditions experienced statistically and clinically significant improvement in PTSD (p = .001) and depressive (p = .018) symptoms. W + L is generally superior to W for implementing TF-CBT in RTF. TF-CBT is effective for improving trauma-related symptoms in adjudicated RTF youth. Implementation barriers are discussed. © The Author(s) 2016.

Thermal ablation for partial splenectomy hemostasis, spleen trauma, splenic metastasis and hypersplenism.

PubMed

Duan, Ya-Qi; Liang, Ping

2013-05-01

Many studies have been conducted on splenic thermal ablation for partial splenectomy hemostasis, spleen trauma, splenic metastasis and hypersplenism. In this article, we review the evolution and current status of radiofrequency and microwave ablation in the treatment of spleen diseases. All publications from 1990 to 2011 on radiofrequency and microwave ablation for partial splenectomy hemostasis, spleen trauma, splenic metastasis and hypersplenism were retrieved by searching PubMed. Thermal ablation in the spleen for partial splenectomy hemostasis, spleen trauma, splenic metastasis and hypersplenism can preserve part of the spleen and maintain splenic immunologic function. Thermal ablation for assisting hemostasis in partial splenectomy minimizes blood loss during operation. Thermal ablation for spleen trauma reduces the number of splenectomy and the amount of blood transfusion. Thermal ablation for splenic metastasis is minimally invasive and can be done under the guidance of an ultrasound, which helps shorten the recovery time. Thermal ablation for hypersplenism increases platelet (PLT) and white blood cell (WBC) counts and improves liver function. It also helps to maintain splenic immunologic function and even improves splenic immunologic function in the short-term. In conclusion, thermal ablative approaches are promising for partial splenectomy hemostasis, spleen trauma, splenic metastasis and hypersplenism. In order to improve therapeutic effects, directions for future studies may include standardized therapeutic indications, prolonged observation periods and enlarged sample sizes.

Do trauma courses change practice? A qualitative review of 20 courses in East, Central and Southern Africa.

PubMed

Ologunde, Rele; Le, Grace; Turner, Jim; Pandit, Hemant; Peter, Noel; Maurer, David; Hodgson, Sam; Larvin, Joseph; Lavy, Chris

2017-09-01

Trauma courses have been shown to improve clinical knowledge and patient outcomes. However, little is known about the individual drivers of change in practice amongst course participants in their home clinic environment. Front-line healthcare workers participated in a two-day Primary Trauma Care (PTC) course. Immediately after the course participants completed an evaluation survey on intended change in the management of trauma patients. Six months after the course, participants completed a survey on actual changes that had occurred. A total of 451 participants were sampled, with 321 responding at 6 months, from 40 courses across East, Central and Southern Africa. The most commonly reported intended change was the adoption of an ABCDE/systematic approach (53%). Six months after the course, 92.7% of respondents reported that they had made changes in their management, with adoption of an ABCDE/systematic approach (50.0%) remaining most common. 77% of participants reported an improvement in departmental trauma management, 26% reported an increase in staffing, 29% an increase in equipment and 68% of participants had gone on to train other healthcare workers in PTC. The findings suggest that PTC courses not only improve individual management of trauma patients but also but is also associated with beneficial effects for participants' host institutions with regards to staffing, equipment and training. Copyright © 2017 Elsevier Ltd. All rights reserved.

A Randomized Implementation Study of Trauma-Focused Cognitive Behavioral Therapy for Adjudicated Teens in Residential Treatment Facilities

PubMed Central

Cohen, Judith A.; Mannarino, Anthony P.; Jankowski, Kay; Rosenberg, Stanley; Kodya, Suzanne; Wolford, George L.

2016-01-01

Adjudicated youth in residential treatment facilities (RTFs) have high rates of trauma exposure and post-traumatic stress disorder (PTSD). This study evaluated strategies for implementing trauma-focused cognitive behavioral therapy (TF-CBT) in RTF. Therapists (N = 129) treating adjudicated youth were randomized by RTF program (N = 18) to receive one of the two TF-CBT implementation strategies: (1) web-based TF-CBT training + consultation (W) or (2) W + 2 day live TF-CBT workshop + twice monthly phone consultation (W + L). Youth trauma screening and PTSD symptoms were assessed via online dashboard data entry using the University of California at Los Angeles PTSD Reaction Index. Youth depressive symptoms were assessed with the Mood and Feelings Questionnaire–Short Version. Outcomes were therapist screening; TF-CBT engagement, completion, and fidelity; and youth improvement in PTSD and depressive symptoms. The W + L condition resulted in significantly more therapists conducting trauma screening (p = .0005), completing treatment (p = .03), and completing TF-CBT with fidelity (p = .001) than the W condition. Therapist licensure significantly impacted several outcomes. Adjudicated RTF youth receiving TF-CBT across conditions experienced statistically and clinically significant improvement in PTSD (p = .001) and depressive (p = .018) symptoms. W + L is generally superior to W for implementing TF-CBT in RTF. TF-CBT is effective for improving trauma-related symptoms in adjudicated RTF youth. Implementation barriers are discussed. PMID:26747845

Benchmarking Outcomes in the Critically Injured Trauma Patient and the Effect of Implementing Standard Operating Procedures

PubMed Central

Cuschieri, Joseph; Johnson, Jeffrey L.; Sperry, Jason; West, Michael A.; Moore, Ernest E.; Minei, Joseph P.; Bankey, Paul E.; Nathens, Avery B.; Cuenca, Alex G.; Efron, Philip A.; Hennessy, Laura; Xiao, Wenzhong; Mindrinos, Michael N.; McDonald-Smith, Grace P.; Mason, Philip H.; Billiar, Timothy R.; Schoenfeld, David A.; Warren, H. Shaw; Cobb, J. Perren; Moldawer, Lyle L.; Davis, Ronald W.; Maier, Ronald V.; Tompkins, Ronald G.

2012-01-01

Objective To determine and compare outcomes with accepted benchmarks in trauma care at seven academic Level I trauma centers in which patients were treated based on a series of standard operating procedures (SOPs). Background Injury remains the leading cause of death for those under 45 years of age. We describe the baseline patient characteristics and well-defined outcomes of persons hospitalized in the United States for severe blunt trauma. Methods We followed 1,637 trauma patients from 2003–2009 up to 28 hospital days using SOPs developed at the onset of the study. An extensive database on patient and injury characteristics, clinical treatment, and outcomes was created. These data were compared with existing trauma benchmarks. Results The study patients were critically injured and in shock. SOP compliance improved 10–40% during the study period. Multiple organ failure and mortality rates were 34.8% and 16.7% respectively. Time to recovery, defined as the time until the patient was free of organ failure for at least two consecutive days, was developed as a new outcome measure. There was a reduction in mortality rate in the cohort during the study that cannot be explained by changes in the patient population. Conclusions This study provides the current benchmark and the overall positive effect of implementing SOPs for severely injured patients. Over the course of the study, there were improvements in morbidity and mortality and increasing compliance with SOPs. Mortality was surprisingly low, given the degree of injury, and improved over the duration of the study, which correlated with improved SOP compliance. PMID:22470077

Trauma team utilization of universal precautions: if you see something, say something.

PubMed

Peponis, T; Cropano, M C; Larentzakis, A; van der Wilden, M G; Mejaddam, Y A; Sideris, C A; Michailidou, M; Fikry, K; Bramos, A; Janjua, S; Chang, Y; King, D R

2017-02-01

The risks deriving from the lack of compliance with universal safety precautions (USPs) are unequivocal. However, the adoption of these prophylactic precautions by healthcare providers remains unacceptably low. We hypothesized that trauma teams are not routinely adhering to USPs and that a brief educational intervention, followed by real-time peer feedback, would substantially improve compliance rates. This before-and-after interventional study took place in the resuscitation bay of a Level I Trauma Center during trauma team activations. Six USPs were examined: hand washing (before and after patient contact), use of gloves, gowns, eye protection, and masks. Surgery and Emergency Medicine attending physicians, residents, and nurses, who had direct patient contact, were included. Following 162 baseline observations, an educational intervention in the form of brief lectures was conducted, emphasizing the danger to self from dereliction of USPs. Subsequently, 167 post-intervention observations were made after a one-month period of knowledge decay. Finally, real-time feedback was provided by trauma team leaders and study staff. Adherence to prophylactic measures was recorded again. Baseline compliance rates were dismal. Only hand washing prior to patient interaction, the use of eye protection, and the use of masks improved significantly (p < 0.05) after the educational initiative. However, compliance rates remained suboptimal. No difference was noted regarding the three other USPs. Impressively, following real-time behavioral corrections, compliance improved to nearly 90 % for all USPs (p < 0.05). Compliance with OSHA-required USPs during trauma team activations is unacceptably low, but can be dramatically improved through simple educational interventions, combined with real-time peer feedback.

Benchmarking outcomes in the critically injured trauma patient and the effect of implementing standard operating procedures.

PubMed

Cuschieri, Joseph; Johnson, Jeffrey L; Sperry, Jason; West, Michael A; Moore, Ernest E; Minei, Joseph P; Bankey, Paul E; Nathens, Avery B; Cuenca, Alex G; Efron, Philip A; Hennessy, Laura; Xiao, Wenzhong; Mindrinos, Michael N; McDonald-Smith, Grace P; Mason, Philip H; Billiar, Timothy R; Schoenfeld, David A; Warren, H Shaw; Cobb, J Perren; Moldawer, Lyle L; Davis, Ronald W; Maier, Ronald V; Tompkins, Ronald G

2012-05-01

To determine and compare outcomes with accepted benchmarks in trauma care at 7 academic level I trauma centers in which patients were treated on the basis of a series of standard operating procedures (SOPs). Injury remains the leading cause of death for those younger than 45 years. This study describes the baseline patient characteristics and well-defined outcomes of persons hospitalized in the United States for severe blunt trauma. We followed 1637 trauma patients from 2003 to 2009 up to 28 hospital days using SOPs developed at the onset of the study. An extensive database on patient and injury characteristics, clinical treatment, and outcomes was created. These data were compared with existing trauma benchmarks. The study patients were critically injured and were in shock. SOP compliance improved 10% to 40% during the study period. Multiple organ failure and mortality rates were 34.8% and 16.7%, respectively. Time to recovery, defined as the time until the patient was free of organ failure for at least 2 consecutive days, was developed as a new outcome measure. There was a reduction in mortality rate in the cohort during the study that cannot be explained by changes in the patient population. This study provides the current benchmark and the overall positive effect of implementing SOPs for severely injured patients. Over the course of the study, there were improvements in morbidity and mortality rates and increasing compliance with SOPs. Mortality was surprisingly low, given the degree of injury, and improved over the duration of the study, which correlated with improved SOP compliance.

Improving outcome of trauma patients by implementing patient blood management.

PubMed

Füllenbach, Christoph; Zacharowski, Kai; Meybohm, Patrick

2017-04-01

Patient blood management aims to improve patient outcome and safety by reducing the number of unnecessary red blood cell transfusions and vitalizing patient-specific anemia reserves. While this is increasingly recognized as best clinical practice in elective surgery, the implementation in the setting of trauma is restrained because of typically nonelective (emergency) surgery and, in specific circumstances, allogeneic blood transfusions as life-saving therapy. Viscoelastic diagnostics allow a precise identification of trauma-induced coagulopathy. A coagulation factor concentrate-based therapy is increasingly recognized as a fast and effective concept to correct coagulopathy and minimize blood loss. Using smaller tubes has a great potential to reduce the severity of phlebotomy-induced anemia. Washed cell salvage may reduce the number of allogeneic blood transfusions. Intravenous iron (with or without erythropoietin) may result in an increase of hemoglobin levels and reduced red blood cell transfusion requirements. Although a restrictive transfusion strategy is recommended in general, a target hemoglobin level of 7-9 g/dl is recommended in acute bleeding patients. In the setting of trauma, options to avoid unnecessary blood loss and reduce blood transfusion are manifold. These are likely to improve safety and outcome of trauma patients while potentially reducing therapeutic costs.

Trajectories of women's homelessness in Canada's 3 northern territories

PubMed Central

Schmidt, Rose; Hrenchuk, Charlotte; Bopp, Judie; Poole, Nancy

2015-01-01

Background Repairing the Holes in the Net was a 2-year, multilevel action research project designed to inform the development of culturally appropriate and gender-specific services for northern women who are homeless or marginally housed and who face mental health and substance use concerns. The study was designed to learn about the barriers and supports experienced by homeless women in the North when accessing mental health care, shelter, housing and other services; and to inform the work of northern service providers and policy advocates in a position to implement adjustments in their praxis. Methods This article describes the trajectories of women's service access and their ideas for service improvement from 61 qualitative, semi-structured interviews conducted with homeless women in Whitehorse, Yukon (YT), Yellowknife, Northwest Territories (NT), and Iqualit, Nunavut (NU). Results Unresolved trauma, poverty and social exclusion, inability to find and maintain housing and ineffective services emerged as interconnected and multifaceted challenges related to women's service engagement. In the face of these challenges, women displayed significant resilience and resistance, and offered important ideas for service improvement. Conclusions The 4 interconnected systemic challenges identified in the research, coupled with specific ideas for change cited by the resilient homeless women interviewed, offer points of entry to improve service policy and delivery. Implementing trauma-informed approaches emerged as a key example of how access to, and quality of, services could be improved for homeless women in the North. PMID:26700413

Effects of psychotherapies for posttraumatic stress disorder on sleep disturbances: Results from a randomized clinical trial.

PubMed

Woodward, Elizabeth; Hackmann, Ann; Wild, Jennifer; Grey, Nick; Clark, David M; Ehlers, Anke

2017-10-01

The effectiveness and mechanisms of psychotherapies for posttraumatic stress disorder (PTSD) in treating sleep problems is of interest. This study compared the effects of a trauma-focused and a non-trauma-focused psychotherapy on sleep, to investigate whether 1) sleep improves with psychotherapy for PTSD; 2) the degree of sleep improvement depends on whether the intervention is trauma or nontrauma-focused; 3) the memory-updating procedure in cognitive therapy for PTSD (CT-PTSD) is associated with sleep improvements; 4) initial sleep duration affects PTSD treatment outcome; and 5) which symptom changes are associated with sleep duration improvements. Self-reported sleep was assessed during a randomized controlled trial (Ehlers et al., 2014) comparing CT-PTSD (delivered weekly or intensively over 7-days) with emotion-focused supportive therapy, and a waitlist. Sleep duration was reported daily in sleep diaries during intensive CT-PTSD. CT-PTSD led to greater increases in sleep duration (55.2 min) and reductions in insomnia symptoms and nightmares than supportive therapy and the waitlist. In intensive CT-PTSD, sleep duration improved within 7 days, and sleep diaries indicated a 40-min sleep duration increase after updating trauma memories. Initial sleep duration was not related to CT-PTSD treatment outcome when initial PTSD symptom severity was controlled. The results suggest that trauma-focused psychotherapy for PTSD is more effective than nontrauma-focused therapy in improving self-reported sleep, and that CT-PTSD can still be effective in the presence of reduced sleep duration. Copyright © 2017 The Authors. Published by Elsevier Ltd.. All rights reserved.

Ventilator-associated pneumonia rates at major trauma centers compared with a national benchmark: a multi-institutional study of the AAST.

PubMed

Michetti, Christopher P; Fakhry, Samir M; Ferguson, Pamela L; Cook, Alan; Moore, Forrest O; Gross, Ronald

2012-05-01

Ventilator-associated pneumonia (VAP) rates reported by the National Healthcare Safety Network (NHSN) are used as a benchmark and quality measure, yet different rates are reported from many trauma centers. This multi-institutional study was undertaken to elucidate VAP rates at major trauma centers. VAP rate/1,000 ventilator days, diagnostic methods, institutional, and aggregate patient data were collected retrospectively from a convenience sample of trauma centers for 2008 and 2009 and analyzed with descriptive statistics. At 47 participating Level I and II centers, the pooled mean VAP rate was 17.2 versus 8.1 for NHSN (2006-2008). Hospitals' rates were highly variable (range, 1.8-57.6), with 72.3% being above NHSN's mean. Rates differed based on who determined the rate (trauma service, 27.5; infection control or quality or epidemiology, 11.9; or collaborative effort, 19.9) and the frequency with which VAP was excluded based on aspiration or diagnosis before hospital day 5. In 2008 and 2009, blunt trauma patients had higher VAP rates (17.3 and 17.6, respectively) than penetrating patients (11.0 and 10.9, respectively). More centers used a clinical diagnostic strategy (57%) than a bacteriologic strategy (43%). Patients with VAP had a mean Injury Severity Score of 28.7, mean Intensive Care Unit length of stay of 20.8 days, and a 12.2% mortality rate. 50.5% of VAP patients had a traumatic brain injury. VAP rates at major trauma centers are markedly higher than those reported by NHSN and vary significantly among centers. Available data are insufficient to set benchmarks, because it is questionable whether any one data set is truly representative of most trauma centers. Application of a single benchmark to all centers may be inappropriate, and reliable diagnostic and reporting standards are needed. Prospective analysis of a larger data set is warranted, with attention to injury severity, risk factors specific to trauma patients, diagnostic method used, VAP definitions and exclusions, and reporting guidelines. III, prognostic study.

Psychological interventions for post-traumatic stress disorder and comorbid substance use disorder: A systematic review and meta-analysis.

PubMed

Roberts, Neil P; Roberts, Pamela A; Jones, Neil; Bisson, Jonathan I

2015-06-01

Co-morbid post-traumatic stress disorder (PTSD) and substance use disorder (SUD) are common, difficult to treat, and associated with poor prognosis. This review aimed to determine the efficacy of individual and group psychological interventions aimed at treating comorbid PTSD and SUD, based on evidence from randomised controlled trials. Our pre-specified primary outcomes were PTSD severity, drug/alcohol use, and treatment completion. We undertook a comprehensive search strategy. Included studies were rated for methodological quality. Available evidence was judged through GRADE. Fourteen studies were included. We found that individual trauma-focused cognitive-behavioural intervention, delivered alongside SUD intervention, was more effective than treatment as usual (TAU)/minimal intervention for PTSD severity post-treatment, and at subsequent follow-up. There was no evidence of an effect for level of drug/alcohol use post-treatment but there was an effect at 5-7 months. Fewer participants completed trauma-focused intervention than TAU. We found little evidence to support the use of individual or group-based non-trauma-focused interventions. All findings were judged as being of low/very low quality. We concluded that there is evidence that individual trauma-focused psychological intervention delivered alongside SUD intervention can reduce PTSD severity, and drug/alcohol use. There is very little evidence to support use of non-trauma-focused individual or group-based interventions. Copyright © 2015 Elsevier Ltd. All rights reserved.

Using a Checklist to Improve Family Communication in Trauma Care.

PubMed

Dennis, Bradley M; Nolan, Tracy L; Brown, Cecil E; Vogel, Robert L; Flowers, Kristin A; Ashley, Dennis W; Nakayama, Don K

2016-01-01

Modern concepts of patient-centered care emphasize effective communication with patients and families, an essential requirement in acute trauma settings. We hypothesized that using a checklist to guide the initial family conversation would improve the family's perception of the interaction. Institutional Review Board-approved, prospective pre/post study involving families of trauma patients admitted to our Level I trauma center for >24 hours. In the control group, families received information according to existing practices. In the study group, residents gave patient information to a first-degree family member using a checklist that guided the interaction. The checklist included a physician introduction, patient condition, list of known injuries, admission unit or intensive care unit, any consultants involved, plans for additional studies or operations, and opportunity for family to ask questions. An 11-item survey was administered 24 to 48 hours after admission to each group that evaluated the trauma team's communication in the areas of physician introduction, patient condition, ongoing treatment, and family perception of the interaction. Responses were on a Likert scale and analyzed using the Wilcoxon-Mann-Whitney test. There were 130 patients in each group. The study group had significantly (P < 0.05) better responses in 8 of 11 items surveyed: physician spoke to family, physician introduction, understanding of their relative's injuries, admitting unit, consultants involved, urgent surgical procedures required, ongoing diagnostic studies, and understanding of the treatment plan. In conclusion, using a checklist improves the perception of the initial communication between the trauma team and family members of trauma patients, especially their understanding of the treatment plan.

Are the paradigms in trauma disease changing?

PubMed

Alted López, E

2015-01-01

Despite an annual trauma mortality of 5 million people worldwide, resulting in countless physical disabilities and enormous expenses, there are no standardized guidelines on trauma organization and management. Over the last few decades there have been very notorious improvements in severe trauma care, though organizational and economical aspects such as research funding still need to be better engineered. Indeed, trauma lags behind other serious diseases in terms of research and organization. The rapid developments in trauma care have produced original models available for research projects, initial resuscitation protocols and radiological procedures such as CT for the initial management of trauma patients, among other advances. This progress underscores the need for a multidisciplinary approach to the initial management and follow-up of this complicated patient population, where intensivists play a major role in both the patient admission and subsequent care at the trauma unit. Copyright © 2015 Elsevier España, S.L.U. y SEMICYUC. All rights reserved.

Preparing Global Trauma Nurses for Leadership Roles in Global Trauma Systems.

PubMed

Muñiz, Sol Angelica; Lang, Richard W; Falcon, Lisa; Garces-King, Jasmine; Willard, Suzanne; Peck, Gregory L

Trauma leads to 5.7 million annual deaths globally, accounting for 25%-33% of global unintentional deaths and 90% of the global trauma burden in low- and middle-income countries. The Lancet Commission on Global Surgery and the World Health Organization assert that emergent and essential surgical capacity building and trauma system improvement are essential to address the global burden of trauma. In response, the Rutgers Global Surgery program, the School of Nursing and Medicine, and the Robert Wood Johnson University Hospital faculty collaborated in the first Interprofessional Models in Global Injury Care and Education Symposium in June 2016. This 2-week symposium combined lectures, high-fidelity simulation, small group workshops, site visits to Level I trauma centers, and a 1-day training course from the Panamerican Trauma Society. The aim was to introduce global trauma nurses to trauma leadership and trauma system development. After completing the symposium, 10 nurses from China, Colombia, Kenya, Puerto Rico, and Uruguay were surveyed. Overall, 88.8% of participants reported high levels of satisfaction with the program and 100% stated being very satisfied with trauma lectures. Symposia, such as that developed and offered by Rutgers University, prepare nurses to address trauma within system-based care and facilitate trauma nursing leadership in their respective countries.

Structured reporting of MRI of the shoulder - improvement of report quality?

PubMed

Gassenmaier, Sebastian; Armbruster, Marco; Haasters, Florian; Helfen, Tobias; Henzler, Thomas; Alibek, Sedat; Pförringer, Dominik; Sommer, Wieland H; Sommer, Nora N

2017-10-01

To evaluate the effect of structured reports (SRs) in comparison to non-structured narrative free text (NRs) shoulder MRI reports and potential effects of both types of reporting on completeness, readability, linguistic quality and referring surgeons' satisfaction. Thirty patients after trauma or with suspected degenerative changes of the shoulder were included in this study (2012-2015). All patients underwent shoulder MRI for further assessment and possible surgical planning. NRs were generated during clinical routine. Corresponding SRs were created using a dedicated template. All 60 reports were evaluated by two experienced orthopaedic shoulder surgeons using a questionnaire that included eight questions. Eighty per cent of the SRs were fully complete without any missing key features whereas only 45% of the NRs were fully complete (p < 0.001). The extraction of information was regarded to be easy in 92% of the SRs and 63% of the NRs. The overall quality of the SRs was rated better than that of the NRs (p < 0.001). Structured reporting of shoulder MRI improves the readability as well as the linguistic quality of radiological reports, and potentially leads to a higher satisfaction of referring physicians. • Structured MRI reports of the shoulder improve readability. • Structured reporting facilitates information extraction. • Referring physicians prefer structured reports to narrative free text reports. • Structured MRI reports of the shoulder can reduce radiologist re-consultations.

Implementation of the quality management system improves postoperative pain treatment: a prospective pre-/post-interventional questionnaire study

PubMed Central

Usichenko, T. I.; Röttenbacher, I.; Kohlmann, T.; Jülich, A.; Lange, J.; Mustea, A.; Engel, G.; Wendt, M.

2013-01-01

Background An organizational approach is proposed as an immediate solution for improving postoperative pain (POP) management. The aim was to evaluate the clinical effectiveness of a quality management system (QMS), based on procedure-specific, multimodal analgesic protocols, modified to meet the individual patients’ requirements. Methods Patients from the orthopaedic, gynaecological, visceral, and trauma surgery departments of the university hospital were involved in two prospective surveys. Survey 1 was performed at baseline and survey 2 was performed after the implementation of QMS within an interval of 1 year. The patients were asked to report pain intensity on the visual rating scale, incidence of analgesia-related side-effects, and incidence of pain interference with the items of life quality and their satisfaction with the treatment of POP. Results Patients from Survey 2 (n=251) reported 25–30% less pain than those from Survey 1 (n=269) (P<0.0001). Nausea was reported by 40% of the patients from Survey 1 vs 17% from Survey 2, vomiting by 25 vs 11% and fatigue by 76% in Survey 1 vs 30% in Survey 2 (P<0.0001). Life quality and patients’ satisfaction improved in Survey 2 vs Survey 1 (P<0.001). Conclusions The implementation of QMS allowed the reduction in POP intensity with a simultaneous decrease in analgesia-related side-effects. This has led to an increased quality of life and patient satisfaction. PMID:23048069

Essential trauma care in Ghana: adaptation and implementation on the political tough road.

PubMed

Quansah, Robert

2006-06-01

The main goal of the Essential Trauma Care (EsTC) project is to promote affordable and sustainable improvements in trauma care, on the ground in individual countries and their health care facilities. This has been occurring in several countries, including Ghana. The EsTC project has helped to solidify previously haphazard interactions between stakeholders from different sectors. It has allowed trauma care clinicians to interact more effectively with other groups, such as the Ministry of Health and the WHO country office. It has allowed the clinicians and other stakeholders to more effectively lobby government for increased attention to trauma care services. These interactions have led to a high-profile stakeholders meeting, the Road Safety and Essential Trauma Care Workshop, which has represented the highest level of attention to trauma care in the country thus far. This meeting has generated a set of policy recommendations, which has been presented to Parliament for study, and, it is hoped, adoption. To convert these recommendations to solid, sustainable action in improving care for the injured, we need to continue to engage in advocacy and to work with Parliament, the Ministry of Health, and other stakeholders, as well as to confront the deeper problems of Ghana's brain drain, civil strife, and poverty.

Implementation and Evaluation of a Ward-Based eLearning Program for Trauma Patient Management.

PubMed

Curtis, Kate; Wiseman, Taneal; Kennedy, Belinda; Kourouche, Sarah; Goldsmith, Helen

2016-01-01

The majority of trauma nursing education is focused on the emergency phases of care. We describe the development and evaluation of a trauma eLearning module for the ward environment. The module was developed using adult learning principles and implemented in 2 surgical wards. There were 3 phases of evaluation: (1) self-efficacy of nurses; (2) relevance and usability of the module and; (3) application of knowledge learnt. The majority indicated they had applied new knowledge, particularly when performing a physical assessment (85.7%), communicating (91.4%), and identifying risk of serious illness (90.4%). Self-efficacy relating to confidence in caring for patients, communication, and escalating clinical deterioration improved (p = .023). An eLearning trauma patient assessment module for ward nursing staff improves nursing knowledge and self-efficacy.

A model for identifying and ranking need for trauma service in nonmetropolitan regions based on injury risk and access to services.

PubMed

Schuurman, Nadine; Bell, Nathaniel; Hameed, Morad S; Simons, Richard

2008-07-01

Timely access to definitive trauma care has been shown to improve survival rates after severe injury. Unfortunately, despite development of sophisticated trauma systems, prompt, definitive trauma care remains unavailable to over 50 million North Americans, particularly in rural areas. Measures to quantify social and geographic isolation may provide important insights for the development of health policy aimed at reducing the burden of injury and improving access to trauma care in presently under serviced populations. Indices of social deprivation based on census data, and spatial analyses of access to trauma centers based on street network files were combined into a single index, the Population Isolation Vulnerability Amplifier (PIVA) to characterize vulnerability to trauma in socioeconomically and geographically diverse rural and urban communities across British Columbia. Regions with a sufficient core population that are more than one hour travel time from existing services were ranked based on their level of socioeconomic vulnerability. Ten regions throughout the province were identified as most in need of trauma services based on population, isolation and vulnerability. Likewise, 10 communities were classified as some of the least isolated areas and were simultaneously classified as least vulnerable populations in province. The model was verified using trauma services utilization data from the British Columbia Trauma Registry. These data indicate that including vulnerability in the model provided superior results to running the model based only on population and road travel time. Using the PIVA model we have shown that across Census Urban Areas there are wide variations in population dependence on and distances to accredited tertiary/district trauma centers throughout British Columbia. Many of the factors that influence access to definitive trauma care can be combined into a single quantifiable model that researchers in the health sector can use to predict where to place new services. The model can also be used to locate optimal locations for any basket of health services.

The Role of Communication During Trauma Activations: Investigating the Need for Team and Leader Communication Training.

PubMed

Raley, Jessica; Meenakshi, Rani; Dent, Daniel; Willis, Ross; Lawson, Karla; Duzinski, Sarah

Fatal errors due to miscommunication among members of trauma teams are 2 to 4 times more likely to occur than in other medical teams, yet most trauma team members do not receive communication effectiveness training. A needs assessment was conducted to examine trauma team members' miscommunication experiences and research scientists' evaluations of live trauma activations. The purpose of this study is to demonstrate that communication training is necessary and highlight specific team communication competencies that trauma teams should learn to improve communication during activations. Data were collected in 2 phases. Phase 1 required participants to complete a series of surveys. Phase 2 included live observations and assessments of pediatric trauma activations using the assessment of pediatric resuscitation team assessments (APRC-TA) and assessment of pediatric resuscitation leader assessments (APRC-LA). Data were collected at a southwestern pediatric hospital. Trauma team members and leaders completed surveys at a meeting and were observed while conducting activations in the trauma bay. Trained research scientists and clinical staff used the APRC-TA and APRC-LA to measure trauma teams' medical performance and communication effectiveness. The sample included 29 healthcare providers who regularly participate in trauma activations. Additionally, 12 live trauma activations were assessed monday to friday from 8am to 5pm. Team members indicated that communication training should focus on offering assistance, delegating duties, accepting feedback, and controlling emotional expressions. Communication scores were not significantly different from medical performance scores. None of the teams were coded as effective medical performance and ineffective team communication and only 1 team was labeled as ineffective leader communication and effective medical performance. Communication training may be necessary for trauma teams and offer a deeper understanding of the communication competencies that should be addressed. The APRC-TA and APRC-LA both include team communication competencies that could be used as a guide to design training for trauma team members and leaders. Researchers should also continue to examine recommendations for improved team and leader communication during activations using in-depth interviews and focus groups. Copyright © 2016 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

A review of the management of blunt splenic trauma in England and Wales: have regional trauma networks influenced management strategies and outcomes?

PubMed

Yiannoullou, P; Hall, C; Newton, K; Pearce, L; Bouamra, O; Jenks, T; Scrimshire, A B; Hughes, J; Lecky, F; Macdonald, Adh

2017-01-01

INTRODUCTION The spleen remains one of the most frequently injured organs following blunt abdominal trauma. In 2012, regional trauma networks were launched across England and Wales with the aim of improving outcomes following trauma. This retrospective cohort study investigated the management and outcomes of blunt splenic injuries before and after the establishment of regional trauma networks. METHODS A dataset was drawn from the Trauma Audit Research Network database of all splenic injuries admitted to English and Welsh hospitals from 1 April 2010 to 31 March 2014. Demographic data, injury severity, treatment modalities and outcomes were collected. Management and outcomes were compared before and after the launch of regional trauma networks. RESULTS There were 1457 blunt splenic injuries: 575 between 2010 and 2012 and 882 in 2012-14. Following the introduction of the regional trauma networks, use of splenic artery embolotherapy increased from 3.5% to 7.6% (P = 0.001) and splenectomy rates decreased from 20% to 14.85% (P = 0.012). Significantly more patients with polytrauma and blunt splenic injury were treated with splenic embolotherapy following 2012 (61.2% vs. 30%, P < 0.0001). Increasing age, injury severity score, polytrauma and Charlson Comorbidity Index above 10 were predictors of increased mortality (P < 0.001). Increasing systolic blood pressure (odds ratio, OR, 0.757, 95% confidence interval, CI, 0.716-0.8) and Glasgow Coma Scale (OR 0.988, 95% CI 0.982-0.995) were protective. CONCLUSIONS This study demonstrates a reduction in splenectomy rate and an increased use of splenic artery embolotherapy since the introduction of the regional trauma networks. This may have resulted from improved access to specialist services and reduced practice variation since the establishment of these networks.

Trauma patients: I can't get no (patient) satisfaction?

PubMed

Bentley-Kumar, Karalyn; Jackson, Theresa; Holland, Danny; LeBlanc, Brian; Agrawal, Vaidehi; Truitt, Michael S

2016-12-01

The Centers for Medicare and Medicaid Services (CMS) provides financial incentives to hospitals based on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient satisfaction survey. This data is made publicly available on their website to be utilized by patients and insurers. Hospitals are profoundly interested in identifying patient populations that negatively contribute to overall patient satisfaction scores. Hospitals consider trauma patients "high risk" from a HCAHPS perspective, but there is no data to inform this opinion. The purpose of this study is to evaluate trauma patient satisfaction scores and their impact on overall patient satisfaction. Three different analyses were performed. Group 1 was composed of ALL patients admitted to our hospital over a 7-month period who were administered a validated patient satisfaction survey by a 3rd party and compared patient satisfaction of trauma vs. non-trauma patients (ALL). Group 2 compared admitted patients with a specific ICD-9 procedure code to non-trauma patients who underwent a procedure with the same ICD-9 code (ICD). Group 3 examines patient satisfaction between three Level I Trauma Centers within our geographic area (TC). Patient satisfaction data of trauma vs non-trauma patients (ALL), those with a specific ICD-9 procedure code (ICD), and the 3 Level I Trauma Centers in our area (TC) were analyzed with the appropriate statistical test. In the ALL group, no difference in satisfaction was noted in 18/21 questions for trauma patients when compared to non-trauma patients at our hospital. In the ICD group, 57 ICD-9 procedure codes were analyzed. Of these, only patients who required spinal fusion secondary to trauma reported lower overall patient satisfaction. No meaningful difference was found in HCAHPS associated satisfaction between the Level I Trauma Centers in our area (TC). In contrast to commonly held opinion, trauma patients do not negatively contribute to overall patient satisfaction in our facility. Certain injuries may offer opportunities for improvement and efforts around improved physician-patient communication may be warranted. In the era of public reporting and financial penalties, surgeons should embrace patient satisfaction as it may be vital to the survival of the trauma center. Copyright © 2016. Published by Elsevier Inc.

Military Trauma and Social Development: The Moderating and Mediating Roles of Peer and Sibling Relations in Mental Health

ERIC Educational Resources Information Center

Peltonen, Kirsi; Qouta, Samir; El Sarraj, Eyad; Punamaki, Raija-Leena

2010-01-01

We first examined how war-related traumatic events impact on peer and sibling relations, and how the quality of these relations in turn are associated with children's mental health, indicating a mediation model. Second, we tested the moderating (protective) effects of good peer and sibling relations in attenuating the link between trauma and…

Chest Wall Trauma.

PubMed

Majercik, Sarah; Pieracci, Fredric M

2017-05-01

Chest wall trauma is common, and contributes significantly to morbidity and mortality of trauma patients. Early identification of major chest wall and concomitant intrathoracic injuries is critical. Generalized management of multiple rib fractures and flail chest consists of adequate pain control (including locoregional modalities); management of pulmonary dysfunction by invasive and noninvasive means; and, in some cases, surgical fixation. Multiple studies have shown that patients with flail chest have substantial benefit (decreased ventilator and intensive care unit days, improved pulmonary function, and improved long-term functional outcome) when they undergo surgery compared with nonoperative management. Copyright © 2017 Elsevier Inc. All rights reserved.

Efficacy of a brief treatment for nightmares and sleep disturbances for veterans.

PubMed

Balliett, Noelle E; Davis, Joanne L; Miller, Katherine E

2015-11-01

Nightmares and sleep disturbances are common complaints among military Veterans (Plumb & Zelman, 2009) and may be difficult to eradicate (Forbes, Phelps, & McHugh, 2001). A treatment protocol (Exposure, Relaxation, and Rescription Therapy [ERRT]) targeting nightmares and sleep disturbances, which has been used effectively in civilian populations, was adapted for the military (ERRT-M). A pilot study evaluated the efficacy of ERRT-M in improving sleep quality and quantity and reducing nightmares, symptoms of posttraumatic stress disorder, and depression in a trauma-exposed, Veteran sample (N = 19). At 1 week after treatment, analyses revealed improvements in nightmare frequency and severity, depression, sleep quality, and insomnia severity. Treatment gains were maintained at a 2-month follow-up. Fifty percent of the sample was considered treatment responders (i.e., no nightmares in the previous week). Results of this pilot study suggest that directly targeting sleep and nightmares is successful in alleviating sleep disturbances and related psychopathology in some Veterans. (c) 2015 APA, all rights reserved).

Perceived social isolation moderates the relationship between early childhood trauma and pulse pressure in older adults.

PubMed

Norman, Greg J; Hawkley, Louise; Ball, Aaron; Berntson, Gary G; Cacioppo, John T

2013-06-01

Over a million children are subjected to some form of trauma in the United States every year. Early trauma has been shown to have deleterious effects on cardiovascular health in adulthood. However, the presence of strong social relationships as an adult can buffer an individual against many of the harmful effects of early trauma. Furthermore, the perception of social isolation has been shown to be a significant risk factor for the development of cardiovascular disease and is a strong predictor of all cause mortality. One likely mechanism thought to underlie the influence of perceived isolation on health is changes in arterial stiffness. One of the more widely used measures of arterial stiffness in older individuals is pulse pressure. The goal of the present study was to determine whether early childhood trauma is associated with elevations on pulse pressure. Furthermore, this study sought to determine whether perceived social isolation moderates the relationship between early trauma and pulse pressure. Results revealed that individuals with low perceived social isolation displayed no significant relationship between early trauma and pulse pressure. However, individuals who reported higher levels of perceived isolation showed a significant positive association between early trauma and pulse pressure. Therefore, the detrimental effects of early trauma may be partially dependent upon the quality of social relationships as an adult. Copyright © 2012 Elsevier B.V. All rights reserved.

The Evidence-Based Principles of Negative Pressure Wound Therapy in Trauma & Orthopedics

PubMed Central

A, Novak; Khan, Wasim S; J, Palmer

2014-01-01

Negative pressure wound therapy is a popular treatment for the management of both acute and chronic wounds. Its use in trauma and orthopedics is diverse and includes the acute traumatic setting as well as chronic troublesome wounds associated with pressure sores and diabetic foot surgery. Efforts have been made to provide an evidence base to guide its use however this has been limited by a lack of good quality evidence. The following review article explores the available evidence and describes future developments for its use in trauma and orthopaedic practice. PMID:25067971

Trauma morning report is the ideal environment to teach and evaluate resident communication and sign-outs in the 80 hour work week.

PubMed

Ottinger, Mary E; Monaghan, Sean F; Gregg, Shea C; Stephen, Andrew H; Connolly, Michael D; Harrington, David T; Adams, Charles A; Cioffi, William G; Heffernan, Daithi S

2017-09-01

The 80h work week has raised concerns that complications may increase due to multiple sign-outs or poor communication. Trauma Surgery manages complex trauma and acute care surgical patients with rapidly changing physiology, clinical demands and a large volume of data that must be communicated to render safe, effective patient care. Trauma Morning Report format may offer the ideal situation to study and teach sign-outs and resident communication. Surgery Residents were assessed on a 1-5 scale for their ability to communicate to their fellow residents. This consisted of 10 critical points of the presentation, treatment and workup from the previous night's trauma admissions. Scores were grouped into three areas. Each area was scored out of 15. Area 1 consisted of Initial patient presentation. Area 2 consisted of events in the trauma bay. Area 3 assessed clarity of language and ability to communicate to their fellow residents. The residents were assessed for inclusion of pertinent positive and negative findings, as well as overall clarity of communication. In phase 1, residents were unaware of the evaluation process. Phase 2 followed a series of resident education session about effective communication, sign-out techniques and delineation of evaluation criteria. Phase 3 was a resident-blinded phase which evaluated the sustainability of the improvements in resident communication. 50 patient presentations in phase 1, 200 in phase 2, and 50 presentations in phase 3 were evaluated. Comparisons were made between the Phase 1 and Phase 2 evaluations. Area 1 (initial events) improved from 6.18 to 12.4 out of 15 (p<0.0001). Area 2 (events in the trauma bay) improved from 9.78 to 16.53 (p<0.0077). Area 3 (communication and language) improved from 8.36 to 12.22 out of 15 (P<0.001). Phase 2 to Phase 3 evaluations were similar, showing no deterioration of skills. Trauma Surgery manages complex surgical patients, with rapidly changing physiologic and clinical demands. Trauma Morning Report, with diverse attendance including surgical attendings and residents in various training years, is the ideal venue for real-time teaching and evaluation of sign-outs and reinforcing good communication skills in residents. Copyright © 2017 Elsevier Ltd. All rights reserved.

Emergency Medical Service (EMS): Rotorcraft Technology Workshop

NASA Technical Reports Server (NTRS)

Bauchspies, J. S.; Adams, R. J.

1981-01-01

A lead organization on the national level should be designated to establish concepts, locations, and the number of shock trauma air medical services. Medical specialists desire a vehicle which incorporates advances in medical technology trends in health care. Key technology needs for the emergency medical services helicopter of the future include the riding quality of fixed wing aircraft (reduced noise and vibration), no tail rotor, small rotor, small rotor diameter, improved visibility, crashworthy vehicle, IFR capability, more affordability high reliability, fuel efficient, and specialized cabins to hold medical/diagnostic and communications equipment. Approaches to a national emergency medical service are discussed.

Traumatic event exposure and gambling: associations with clinical, neurocognitive, and personality variables.

PubMed

Leppink, Eric W; Grant, Jon E

2015-02-01

Epidemiological research has shown high comorbidity rates between at-risk/problem (ARP) gambling and trauma. However, few studies have assessed the neurocognitive implications of this comorbidity, and even fewer have been conducted with young adults. The present study sought to determine the neurocognitive, clinical, personality types associated with trauma in ARP gamblers. The present study analyzed young adult gamblers age 18 to 29 drawn from a study investigating impulsivity. Of the 230 gamblers, 52 (22.6%) reported experiencing a traumatic event during their life to which they responded with intense fear, helplessness, or horror. The remaining participants indicated no experience with trauma. ARP gamblers who had experienced trauma showed significant neurocognitive deficits on tasks related to decision-making, risk adjustment, sustained attention, and spatial working memory. We did not detect significant differences in gambling severity. Trauma was associated with lower perceived quality of life and self-esteem, and higher rates of current comorbid diagnoses, suicidality, substance use disorders, and nicotine use. This study suggests that trauma may not exacerbate the severity of gambling in ARP gamblers. However, significant differences in supplemental clinical and neurocognitive measures may indicate that trauma is an important consideration when assessing problems beyond those related directly to gambling severity.

The contribution of the Israeli trauma system to the survival of road traffic casualties.

PubMed

Goldman, Sharon; Siman-Tov, Maya; Bahouth, H; Kessel, B; Klein, Y; Michaelson, M; Miklosh, B; Rivkind, A; Shaked, G; Simon, D; Soffer, D; Stein, M; Peleg, Kobi

2015-01-01

According to the World Health Organization, over one million people die annually from traffic crashes, in which over half are pedestrians, bicycle riders and two-wheel motor vehicles. In Israel, during the last decade, mortality from traffic crashes has decreased from 636 in 1998 to 288 in 2011. Professionals attribute the decrease in mortality to enforcement, improved infrastructure and roads and behavioral changes among road users, while no credit is given to the trauma system. Trauma systems which care for severe and critical casualties improve the injury outcomes and reduce mortality among road casualties. 1) To evaluate the contribution of the Israeli Health System, especially the trauma system, on the reduction in mortality among traffic casualties. 2) To evaluate the chance of survival among hospitalized traffic casualties, according to age, gender, injury severity and type of road user. A retrospective study based on the National Trauma Registry, 1998-2011, including hospitalization data from eight hospitals. During the study period, the Trauma Registry included 262,947 hospitalized trauma patients, of which 25.3% were due to a road accident. During the study period, a 25% reduction in traffic related mortality was reported, from 3.6% in 1998 to 2.7% in 2011. Among severe and critical (ISS 16+) casualties the reduction in mortality rates was even more significant, 41%; from 18.6% in 1998 to 11.0% in 2011. Among severe and critical pedestrian injuries, a 44% decrease was reported (from 29.1% in 1998 to 16.2% in 2011) and a 65% reduction among bicycle injuries. During the study period, the risk of mortality decreased by over 50% from 1998 to 2011 (OR 0.44 95% 0.33-0.59. In addition, a simulation was conducted to determine the impact of the trauma system on mortality of hospitalized road casualties. Presuming that the mortality rate remained constant at 18.6% and without any improvement in the trauma system, in 2011 there would have been 182 in-hospital deaths compared to the actual 108 traffic related deaths. A 41% difference was noted between the actual number of deaths and the expected number. This study clearly shows that without any improvement in the health system, specifically the trauma system, the number of traffic deaths would be considerably greater. Although the health system has a significant contribution on reducing mortality, it does not receive the appropriate acknowledgment or resources for its proportion in the fight against traffic accidents.

Effect of Compression Devices on Preventing Deep Vein Thrombosis Among Adult Trauma Patients: A Systematic Review.

PubMed

Ibrahim, Mona; Ahmed, Azza; Mohamed, Warda Yousef; El-Sayed Abu Abduo, Somaya

2015-01-01

Trauma is the leading cause of death in Americans up to 44 years old each year. Deep vein thrombosis (DVT) is a significant condition occurring in trauma, and prophylaxis is essential to the appropriate management of trauma patients. The incidence of DVT varies in trauma patients, depending on patients' risk factors, modality of prophylaxis, and methods of detection. However, compression devices and arteriovenous (A-V) foot pumps prophylaxis are recommended in trauma patients, but the efficacy and optimal use of it is not well documented in the literature. The aim of this study was to review the literature on the effect of compression devices in preventing DVT among adult trauma patients. We searched through PubMed, CINAHL, and Cochrane Central Register of Controlled Trials for eligible studies published from 1990 until June 2014. Reviewers identified all randomized controlled trials that satisfied the study criteria, and the quality of included studies was assessed by Cochrane risk of bias tool. Five randomized controlled trials were included with a total of 1072 patients. Sequential compression devices significantly reduced the incidence of DVT in trauma patients. Also, foot pumps were more effective in reducing incidence of DVT compared with sequential compression devices. Sequential compression devices and foot pumps reduced the incidence of DVT in trauma patients. However, the evidence is limited to a small sample size and did not take into account other confounding variables that may affect the incidence of DVT in trauma patients. Future randomized controlled trials with larger probability samples to investigate the optimal use of mechanical prophylaxis in trauma patients are needed.

Emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma.

PubMed

Stengel, Dirk; Bauwens, Kai; Rademacher, Grit; Ekkernkamp, Axel; Güthoff, Claas

2013-07-31

Ultrasonography is regarded as the tool of choice for early diagnostic investigations in patients with suspected blunt abdominal trauma. Although its sensitivity is too low for definite exclusion of abdominal organ injury, proponents of ultrasound argue that ultrasound-based clinical pathways enhance the speed of primary trauma assessment, reduce the number of computed tomography scans and cut costs. To assess the effects of trauma algorithms that include ultrasound examinations in patients with suspected blunt abdominal trauma. We searched the Cochrane Injuries Group's Specialised Register, CENTRAL (The Cochrane Library), MEDLINE (OvidSP), EMBASE (OvidSP), CINAHL (EBSCO), publishers' databases, controlled trials registers and the Internet. Bibliographies of identified articles and conference abstracts were searched for further elligible studies. Trial authors were contacted for further information and individual patient data. The searches were updated in February 2013. randomised controlled trials (RCTs) and quasi-randomised trials (qRCTs). patients with blunt torso, abdominal or multiple trauma undergoing diagnostic investigations for abdominal organ injury. diagnostic algorithms comprising emergency ultrasonography (US). diagnostic algorithms without ultrasound examinations (for example, primary computed tomography [CT] or diagnostic peritoneal lavage [DPL]). mortality, use of CT and DPL, cost-effectiveness, laparotomy and negative laparotomy rates, delayed diagnoses, and quality of life. Two authors independently selected trials for inclusion, assessed methodological quality and extracted data. Where possible, data were pooled and relative risks (RRs), risk differences (RDs) and weighted mean differences, each with 95% confidence intervals (CIs), were calculated by fixed- or random-effects modelling, as appropriate. We identified four studies meeting our inclusion criteria. Overall, trials were of moderate methodological quality. Few trial authors responded to our written inquiries seeking to resolve controversial issues and to obtain individual patient data. We pooled mortality data from three trials involving 1254 patients; relative risk in favour of the US arm was 1.00 (95% CI 0.50 to 2.00). US-based pathways significantly reduced the number of CT scans (random-effects RD -0.52, 95% CI -0.83 to -0.21), but the meaning of this result is unclear. Given the low sensitivity of ultrasound, the reduction in CT scans may either translate to a number needed to treat or number needed to harm of two. There is currently insufficient evidence from RCTs to justify promotion of ultrasound-based clinical pathways in diagnosing patients with suspected blunt abdominal trauma.

The use of computer adaptive tests in outcome assessments following upper limb trauma.

PubMed

Jayakumar, P; Overbeek, C; Vranceanu, A-M; Williams, M; Lamb, S; Ring, D; Gwilym, S

2018-06-01

Aims Outcome measures quantifying aspects of health in a precise, efficient, and user-friendly manner are in demand. Computer adaptive tests (CATs) may overcome the limitations of established fixed scales and be more adept at measuring outcomes in trauma. The primary objective of this review was to gain a comprehensive understanding of the psychometric properties of CATs compared with fixed-length scales in the assessment of outcome in patients who have suffered trauma of the upper limb. Study designs, outcome measures and methodological quality are defined, along with trends in investigation. Materials and Methods A search of multiple electronic databases was undertaken on 1 January 2017 with terms related to "CATs", "orthopaedics", "trauma", and "anatomical regions". Studies involving adults suffering trauma to the upper limb, and undergoing any intervention, were eligible. Those involving the measurement of outcome with any CATs were included. Identification, screening, and eligibility were undertaken, followed by the extraction of data and quality assessment using the Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) criteria. The review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria and reg istered (PROSPERO: CRD42016053886). Results A total of 31 studies reported trauma conditions alone, or in combination with non-traumatic conditions using CATs. Most were cross-sectional with varying level of evidence, number of patients, type of study, range of conditions and methodological quality. CATs correlated well with fixed scales and had minimal or no floor-ceiling effects. They required significantly fewer questions and/or less time for completion. Patient-Reported Outcomes Measurement Information System (PROMIS) CATs were the most frequently used, and the use of CATs is increasing. Conclusion Early studies show valid and reliable outcome measurement with CATs performing as well as, if not better than, established fixed scales. Superior properties such as floor-ceiling effects and ease of use support their use in the assessment of outcome after trauma. As CATs are being increasingly used in patient outcomes research, further psychometric evaluation, especially involving longitudinal studies and groups of patients with specific injuries are required to inform clinical practice using these contemporary measures. Cite this article: Bone Joint J 2018;100-B:693-702.

[Challenges of implementing a geriatric trauma network : A regional structure].

PubMed

Schoeneberg, Carsten; Hussmann, Bjoern; Wesemann, Thomas; Pientka, Ludger; Vollmar, Marie-Christin; Bienek, Christine; Steinmann, Markus; Buecking, Benjamin; Lendemans, Sven

2018-04-01

At present, there is a high percentage and increasing tendency of patients presenting with orthogeriatric injuries. Moreover, significant comorbidities often exist, requiring increased interdisciplinary treatment. These developments have led the German Society of Trauma Surgery, in cooperation with the German Society of Geriatrics, to establish geriatric trauma centers. As a conglomerate hospital at two locations, we are cooperating with two external geriatric clinics. In 2015, a geriatric trauma center certification in the form of a conglomerate network structure was agreed upon for the first time in Germany. For this purpose, the requirements for certification were observed. Both structure and organization were defined in a manual according to DIN EN ISO 9001:2015. Between 2008 and 2016, an increase of 70% was seen in geriatric trauma cases in our hospital, with a rise of up to 360% in specific diagnoses. The necessary standards and regulations were compiled and evaluated from our hospitals. After successful certification, improvements were necessary, followed by a planned re-audit. These were prepared by multiprofessional interdisciplinary teams and implemented at all locations. A network structure can be an alternative to classical cooperation between trauma and geriatric units in one clinic and help reduce possible staffing shortage. Due to the lack of scientific evidence, future evaluations of the geriatric trauma register should reveal whether network structures in geriatric trauma surgery lead to a valid improvement in medical care.

Evaluation of massive transfusion protocol practices by type of trauma at a level I trauma center.

PubMed

Givergis, Roshan; Munnangi, Swapna; Fayaz M Fomani, Katayoun; Boutin, Anthony; Zapata, Luis Carlos; Angus, Ld George

2018-04-18

To evaluate massive transfusion protocol practices by trauma type at a level I trauma center. A retrospective analysis was performed on a sample of 76 trauma patients with MTP activation between March 2010 and January 2015 at a regional trauma center. Patient demographics, transfusion practices, and clinical outcomes were compared by type of trauma sustained. Penetrating trauma patients who required MTP activation were significantly younger, had lower injury severity score (ISS), higher probability of survival (POS), decreased mortality, and higher Glasgow Coma scale (GCS) compared to blunt trauma patients. Overall, the mortality rate was 38.16%. The most common injury sustained among blunt trauma patients was head injury (36.21%), whereas the majority of the penetrating trauma patients sustained abdominal injuries (55.56%). Although the admission coagulation parameters and timing of coagulopathy were not significantly different between the two groups of patients, a significantly higher proportion of penetrating trauma patients received high plasma content therapy relative to blunt trauma patients (p < 0.01). Despite the use of the same MTP for all injured patients requiring massive transfusion, significant differences existed between blunt trauma patients and penetrating trauma patients. These differences in transfusion characteristics and outcomes following MTP activation underscore the complexity of implementing MTPs and warrant vigilant transfusion practices to improve outcomes in trauma patients. Copyright © 2018 Daping Hospital and the Research Institute of Surgery of the Third Military Medical University. Production and hosting by Elsevier B.V. All rights reserved.

Strategically Leapfrogging Education in Prehospital Trauma Management: Four-Tiered Training Protocols

PubMed Central

Abraham, Rohit; Vyas, Dinesh; Narayan, Mayur; Vyas, Arpita

2016-01-01

Trauma-related injury in fast developing countries are linked to 90% of international mortality rates, which can be greatly reduced by improvements in often non-existent or non-centralized emergency medical systems (EMS)—particularly in the pre-hospital care phase. Traditional trauma training protocols—such as Advanced Trauma Life Support (ATLS), International Trauma Life Support (ITLS), and Basic Life Support (BLS)—have failed to produce an effective pre-hospital ground force of medical first responders. To overcome these barriers, we propose a new four-tiered set of trauma training protocols: Massive Open Online Course (MOOC) Trauma Training, Acute Trauma Training (ATT), Broad Trauma Training (BTT), and Cardiac and Trauma Training (CTT). These standards are specifically differentiated to accommodate the educational and socioeconomic diversity found in fast developing settings, where each free course is taught in native, lay language while ensuring the education standards are maintained by fully incorporating high-fidelity simulation, video-recorded debriefing, and retraining. The innovative pedagogy of this trauma education program utilizes MOOC for global scalability and a “train-the-trainer” approach for exponential growth—both components help fast developing countries reach a critical mass of first responders needed for the base of an evolving EMS. PMID:27419222

Strategically Leapfrogging Education in Prehospital Trauma Management: Four-Tiered Training Protocols.

PubMed

Abraham, Rohit; Vyas, Dinesh; Narayan, Mayur; Vyas, Arpita

2015-12-01

Trauma-related injury in fast developing countries are linked to 90% of international mortality rates, which can be greatly reduced by improvements in often non-existent or non-centralized emergency medical systems (EMS)-particularly in the pre-hospital care phase. Traditional trauma training protocols-such as Advanced Trauma Life Support (ATLS), International Trauma Life Support (ITLS), and Basic Life Support (BLS)-have failed to produce an effective pre-hospital ground force of medical first responders. To overcome these barriers, we propose a new four-tiered set of trauma training protocols: Massive Open Online Course (MOOC) Trauma Training, Acute Trauma Training (ATT), Broad Trauma Training (BTT), and Cardiac and Trauma Training (CTT). These standards are specifically differentiated to accommodate the educational and socioeconomic diversity found in fast developing settings, where each free course is taught in native, lay language while ensuring the education standards are maintained by fully incorporating high-fidelity simulation, video-recorded debriefing, and retraining. The innovative pedagogy of this trauma education program utilizes MOOC for global scalability and a "train-the-trainer" approach for exponential growth-both components help fast developing countries reach a critical mass of first responders needed for the base of an evolving EMS.

Testing a videogame intervention to recalibrate physician heuristics in trauma triage: study protocol for a randomized controlled trial.

PubMed

Mohan, Deepika; Rosengart, Matthew R; Fischhoff, Baruch; Angus, Derek C; Farris, Coreen; Yealy, Donald M; Wallace, David J; Barnato, Amber E

2016-11-11

Between 30 and 40 % of patients with severe injuries receive treatment at non-trauma centers (under-triage), largely because of physician decision making. Existing interventions to improve triage by physicians ignore the role that intuition (heuristics) plays in these decisions. One such heuristic is to form an initial impression based on representativeness (how typical does a patient appear of one with severe injuries). We created a video game (Night Shift) to recalibrate physician's representativeness heuristic in trauma triage. We developed Night Shift in collaboration with emergency medicine physicians, trauma surgeons, behavioral scientists, and game designers. Players take on the persona of Andy Jordan, an emergency medicine physician, who accepts a new job in a small town. Through a series of cases that go awry, they gain experience with the contextual cues that distinguish patients with minor and severe injuries (based on the theory of analogical encoding) and receive emotionally-laden feedback on their performance (based on the theory of narrative engagement). The planned study will compare the effect of Night Shift with that of an educational program on physician triage decisions and on physician heuristics. Psychological theory predicts that cognitive load increases reliance on heuristics, thereby increasing the under-triage rate when heuristics are poorly calibrated. We will randomize physicians (n = 366) either to play the game or to review an educational program, and will assess performance using a validated virtual simulation. The validated simulation includes both control and cognitive load conditions. We will compare rates of under-triage after exposure to the two interventions (primary outcome) and will compare the effect of cognitive load on physicians' under-triage rates (secondary outcome). We hypothesize that: a) physicians exposed to Night Shift will have lower rates of under-triage compared to those exposed to the educational program, and b) cognitive load will not degrade triage performance among physicians exposed to Night Shift as much as it will among those exposed to the educational program. Serious games offer a new approach to the problem of poorly-calibrated heuristics in trauma triage. The results of this trial will contribute to the understanding of physician quality improvement and the efficacy of video games as behavioral interventions. clinicaltrials.gov; NCT02857348 ; August 2, 2016.

Hazards of benchmarking complications with the National Trauma Data Bank: numerators in search of denominators.

PubMed

Kardooni, Shahrzad; Haut, Elliott R; Chang, David C; Pierce, Charles A; Efron, David T; Haider, Adil H; Pronovost, Peter J; Cornwell, Edward E

2008-02-01

Complication rates after trauma may serve as important indicators of quality of care. Meaningful performance benchmarks for complication rates require reference standards from valid and reliable data. Selection of appropriate numerators and denominators is a major consideration for data validity in performance improvement and benchmarking. We examined the suitability of the National Trauma Data Bank (NTDB) as a reference for benchmarking trauma center complication rates. We selected the five most commonly reported complications in the NTDB v. 6.1 (pneumonia, urinary tract infection, acute respiratory distress syndrome, deep vein thrombosis, myocardial infarction). We compared rates for each complication using three different denominators defined by different populations at risk. A-all patients from all 700 reporting facilities as the denominator (n = 1,466,887); B-only patients from the 441 hospitals reporting at least one complication (n = 1,307,729); C-patients from hospitals reporting at least one occurrence of each specific complication, giving a unique denominator for each complication (n range = 869,675-1,167,384). We also looked at differences in hospital characteristics between complication reporters and nonreporters. There was a 12.2% increase in the rate of each complication when patients from facilities not reporting any complications were excluded from the denominator. When rates were calculated using a unique denominator for each complication, rates increased 25% to 70%. The change from rate A to rate C produced a new rank order for the top five complications. When compared directly, rates B and C were also significantly different for all complications (all p < 0.01). Hospitals that reported complication information had significantly higher annual admissions and were more likely to be designated level I or II trauma centers and be university teaching hospitals. There is great variability in complication data reported in the NTDB that may introduce bias and significantly influence rates of complications reported. This potential for bias creates a challenge for appropriately interpreting complication rates for hospital performance benchmarking. We recognize the value of large aggregated registries such as the NTDB as a valuable tool for benchmarking and performance improvement purposes. However, we strongly advocate the need for conscientious selection of numerators and denominators that serve as the basic foundation for research.

The effects of parental components in a trauma-focused cognitive behavioral based therapy for children exposed to interparental violence: study protocol for a randomized controlled trial.

PubMed

Visser, Margreet M; Telman, Machteld D; de Schipper, J Clasien; Lamers-Winkelman, Francien; Schuengel, Carlo; Finkenauer, Catrin

2015-06-23

Interparental violence is both common and harmful and impacts children's lives directly and indirectly. Direct effects refer to affective, behavioral, and cognitive responses to interparental violence and psychosocial adjustment. Indirect effects refer to deteriorated parental availability and parent-child interaction. Standard Trauma Focused Cognitive Behavioral Therapy may be insufficient for children traumatized by exposure to interparental violence, given the pervasive impact of interparental violence on the family system. HORIZON is a trauma focused cognitive behavioral therapy based group program with the added component of a preparatory parenting program aimed at improving parental availability; and the added component of parent-child sessions to improve parent-child interaction. This is a multicenter, multi-informant and multi-method randomized clinical trial study with a 2 by 2 factorial experimental design. Participants (N = 100) are children (4-12 years), and their parents, who have been exposed to interparental violence. The main aim of the study is to test the effects of two parental components as an addition to a trauma focused cognitive behavioral based group therapy for reducing children's symptoms. Primary outcome measures are posttraumatic stress symptoms, and internalizing and externalizing problems in children. The secondary aim of the study is to test the effect of the two added components on adjustment problems in children and to test whether enhanced effects can be explained by changes in children's responses towards experienced violence, in parental availability, and in quality of parent-child interaction. To address this secondary aim, the main parameters are observational and questionnaire measures of parental availability, parent-child relationship variables, children's adjustment problems and children's responses to interparental violence. Data are collected three times: before and after the program and six months later. Both intention-to-treat and completer analyses will be done. The current study will enhance our understanding of the efficacy interparental violence-related parental components added to trauma focused cognitive behavioral group program for children who have been exposed to IPV. It will illuminate mechanisms underlying change by considering multiple dimensions of child responses, parenting variables and identify selection criteria for participation in treatment. Netherlands Trial Register NTR4015 . Registered 4th of June, 2013.

Maximizing efficiency on trauma surgeon rounds.

PubMed

Ramaniuk, Aliaksandr; Dickson, Barbara J; Mahoney, Sean; O'Mara, Michael S

2017-01-01

Rounding by trauma surgeons is a complex multidisciplinary team-based process in the inpatient setting. Implementation of lean methodology aims to increase understanding of the value stream and eliminate nonvalue-added (NVA) components. We hypothesized that analysis of trauma rounds with education and intervention would improve surgeon efficacy. Level 1 trauma center with 4300 admissions per year. Average non-intensive care unit census was 55. Five full-time attending trauma surgeons were evaluated. Value-added (VA) and NVA components of rounding were identified. The components of each patient interaction during daily rounds were documented. Summary data were presented to the surgeons. An action plan of improvement was provided at group and individual interventions. Change plans were presented to the multidisciplinary team. Data were recollected 6 mo after intervention. The percent of interactions with NVA components decreased (16.0% to 10.7%, P = 0.0001). There was no change between the two periods in time of evaluation of individual patients (4.0 and 3.5 min, P = 0.43). Overall time to complete rounds did not change. There was a reduction in the number of interactions containing NVA components (odds ratio = 2.5). The trauma surgeons were able to reduce the NVA components of rounds. We did not see a decrease in rounding time or individual patient time. This implies that surgeons were able to reinvest freed time into patient care, or that the NVA components were somehow not increasing process time. Direct intervention for isolated improvements can be effective in the rounding process, and efforts should be focused upon improving the value of time spent rather than reducing time invested. Copyright © 2016 Elsevier Inc. All rights reserved.

Association Between Helicopter vs Ground Emergency Medical Services and Survival for Adults With Major Trauma

PubMed Central

Galvagno, Samuel M.; Haut, Elliott R.; Zafar, S. Nabeel; Millin, Michael G.; Efron, David T.; Koenig, George J.; Baker, Susan P.; Bowman, Stephen M.; Pronovost, Peter J.; Haider, Adil H.

2012-01-01

Context Helicopter emergency medical services and their possible effect on outcomes for traumatically injured patients remain a subject of debate. Because helicopter services are a limited and expensive resource, a methodologically rigorous investigation of its effectiveness compared with ground emergency medical services is warranted. Objective To assess the association between the use of helicopter vs ground services and survival among adults with serious traumatic injuries. Design, Setting, and Participants Retrospective cohort study involving 223 475 patients older than 15 years, having an injury severity score higher than 15, and sustaining blunt or penetrating trauma that required transport to US level I or II trauma centers and whose data were recorded in the 2007–2009 versions of the American College of Surgeons National Trauma Data Bank. Interventions Transport by helicopter or ground emergency services to level I or level II trauma centers. Main Outcome Measures Survival to hospital discharge and discharge disposition. Results A total of 61 909 patients were transported by helicopter and 161 566 patients were transported by ground. Overall, 7813 patients (12.6%) transported by helicopter died compared with 17 775 patients (11%) transported by ground services. Before propensity score matching, patients transported by helicopter to level I and level II trauma centers had higher Injury Severity Scores. In the propensity score–matched multivariable regression model, for patients transported to level I trauma centers, helicopter transport was associated with an improved odds of survival compared with ground transport (odds ratio [OR], 1.16; 95% CI, 1.14–1.17; P<.001; absolute risk reduction [ARR], 1.5%). For patients transported to level II trauma centers, helicopter transport was associated with an improved odds of survival (OR, 1.15; 95% CI, 1.13–1.17; P < .001; ARR, 1.4%). A greater proportion (18.2%) of those transported to level I trauma centers by helicopter were discharged to rehabilitation compared with 12.7% transported by ground services (P < .001), and 9.3% transported by helicopter were discharged to intermediate facilities compared with 6.5% by ground services (P < .001). Fewer patients transported by helicopter left level II trauma centers against medical advice (0.5% vs 1.0%, P < .001). Conclusion Among patients with major trauma admitted to level I or level II trauma centers, transport by helicopter compared with ground services was associated with improved survival to hospital discharge after controlling for multiple known confounders. PMID:22511688

Efficacy of simulation-based trauma team training of non-technical skills. A systematic review.

PubMed

Gjeraa, K; Møller, T P; Østergaard, D

2014-08-01

Trauma resuscitation is a complex situation, and most organisations have multi-professional trauma teams. Non-technical skills are challenged during trauma resuscitation, and they play an important role in the prevention of critical incidents. Simulation-based training of these is recommended. Our research question was: Does simulation-based trauma team training of non-technical skills have effect on reaction, learning, behaviour or patient outcome? The authors searched PubMed, EMBASE and the Cochrane Library and found 13 studies eligible for analysis. We described and compared the educational interventions and the evaluations of effect according to the four Kirkpatrick levels: reaction, learning (knowledge, skills, attitudes), behaviour (in a clinical setting) and patient outcome. No studies were randomised, controlled and blinded, resulting in a moderate to high risk of bias. The multi-professional trauma teams had positive reactions to simulation-based training of non-technical skills. Knowledge and skills improved in all studies evaluating the effect on learning. Three studies found improvements in team performance (behaviour) in the clinical setting. One of these found difficulties in maintaining these skills. Two studies evaluated on patient outcome, of which none showed improvements in mortality, complication rate or duration of hospitalisation. A significant effect on learning was found after simulation-based training of the multi-professional trauma team in non-technical skills. Three studies demonstrated significantly increased clinical team performance. No effect on patient outcome was found. All studies had a moderate to high risk of bias. More comprehensive randomised studies are needed to evaluate the effect on patient outcome. © 2014 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.

Hypersomnia Following Traumatic Brain Injury

PubMed Central

Watson, Nathaniel F; Dikmen, Sureyya; Machamer, Joan; Doherty, Michael; Temkin, Nancy

2007-01-01

Study Objectives: To evaluate the prevalence and natural history of sleepiness following traumatic brain injury. Methods: This prospective cohort study used the Sickness Impact Profile to evaluate sleepiness in 514 consecutive subjects with traumatic brain injury (TBI), 132 non-cranial trauma controls, and 102 trauma-free controls 1 month and 1 year after injury. Results: Fifty-five percent of TBI subjects, 41% of non-cranial trauma controls, and 3% of trauma-free controls endorsed 1 or more sleepiness items 1 month following injury (p < .001). One year following injury, 27% of TBI subjects, 23% of non-cranial trauma controls, and 1% of trauma-free controls endorsed 1 or more sleepiness items (p < .001). Patients with TBI were sleepier than non-cranial trauma controls at 1 month (p < .02) but not 1 year after injury. Brain-injured subjects were divided into injury-severity groups based on time to follow commands (TFC). At 1 month, the non-cranial trauma controls were less sleepy than the 1- to 6-day (p < .05), 7- to 13-day (p < .01), and 14-day or longer (p < .01) TFC groups. In addition, the ≤ 24-hour group was less sleepy then the 7- to 13-day and 14-day or longer groups (each p < .05). At 1 year, the non-cranial trauma control group (p < .05) and the ≤ 24-hour TFC group (p < .01) were less sleepy than the 14-day or longer TFC group. Sleepiness improved in 84% to 100% of subjects in the TBI TFC groups, as compared with 78% of the non-cranial trauma control group (p < .01). Conclusions: Sleepiness is common following traumatic injury, particularly TBI, with more severe injuries resulting in greater sleepiness. Sleepiness improves in many patients, particularly those with TBI. However, about a quarter of TBI subjects and non-cranial trauma control subjects remained sleepy 1 year after injury. Citation: Watson NF; Dikmen S; Machamer J et al. Hypersomnia following traumatic brain injury. J Clin Sleep Med 2007;3(4):363-368. PMID:17694724

Implementation, reliability testing, and compliance monitoring of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) in trauma patients

PubMed Central

Soja, Stacie L.; Pandharipande, Pratik P.; Fleming, Sloan B.; Cotton, Bryan A.; Miller, Leanna R.; Weaver, Stefanija G.; Lee, Byron T.; Ely, E. Wesley

2013-01-01

Objective To implement delirium monitoring, test reliability, and monitor compliance of performing the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) in trauma patients. Design and setting Prospective, observational study in a Level 1 trauma unit of a tertiary care, university-based medical center. Patients Acutely injured patients admitted to the trauma unit from February 1, 2006–April 16, 2006. Measurements and Results Following web-based teaching modules and group in-services, bedside nurses evaluated patients daily for depth of sedation with the Richmond Agitation-Sedation Scale (RASS) and for the presence of delirium with the CAM-ICU. On randomly assigned days over a 10-week period, evaluations by nursing staff were followed by evaluations by an expert evaluator of the RASS and the CAM-ICU, in order to assess compliance and reliability of the CAM-ICU in trauma patients. Following the audit period, the nurses completed a post-implementation survey. One thousand and eleven random CAM-ICU assessments were performed by the expert evaluator, within 1 hour of the bedside nurses’ assessments. Nurses completed the CAM-ICU assessments in 84% (849 of 1011) of evaluations. Overall agreement (κ) between nurses and the expert evaluator was 0.77 (0.721, 0.822; p<0.0001). In TBI patients κ was 0.75 (0.667, 0.829; p<0.0001), while in mechanically-ventilated patients κ was 0.62 (0.534, 0.704; p<0.0001). The survey revealed nurses were confident in performing the CAM-ICU, realized the importance of delirium, and were satisfied with the training they received. The survey also acknowledged obstacles to implementation including nursing time and failure of physicians/surgeons to address treatment approaches for delirium. Conclusions The CAM-ICU can be successfully implemented in a university-based trauma unit with high compliance and reliability. Quality improvement projects seeking to implement delirium monitoring would be wise to address potential pitfalls including time complaints and the negative impact of physician indifference regarding this form of organ dysfunction. PMID:18297270

Cervical spine collar clearance in the obtunded adult blunt trauma patient: A systematic review and practice management guideline from the Eastern Association for the Surgery of Trauma

PubMed Central

Patel, Mayur B.; Humble, Stephen S.; Cullinane, Daniel C.; Day, Matthew A.; Jawa, Randeep S.; Devin, Clinton J.; Delozier, Margaret S.; Smith, Lou M.; Smith, Miya A.; Capella, Jeannette M.; Long, Andrea M.; Cheng, Joseph S.; Leath, Taylor C.; Falck-Ytter, Yngve; Haut, Elliott R.; Como, John J.

2015-01-01

BACKGROUND With the use of the framework advocated by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group, our aims were to perform a systematic review and to develop evidence-based recommendations that may be used to answer the following PICO [Population, Intervention, Comparator, Outcomes] question: In the obtunded adult blunt trauma patient, should cervical collar removal be performed after a negative high-quality cervical spine (C-spine) computed tomography (CT) result alone or after a negative high-quality C-spine CT result combined with adjunct imaging, to reduce peri-clearance events, such as new neurologic change, unstable C-spine injury, stable C-spine injury, need for post-clearance imaging, false-negative CT imaging result on re-review, pressure ulcers, and time to cervical collar clearance? METHODS Our protocol was registered with the PROSPERO international prospective register of systematic reviews on August 23, 2013 (Registration Number: CRD42013005461). Eligibility criteria consisted of adult blunt trauma patients 16 years or older, who underwent C-spine CT with axial thickness of less than 3 mm and who were obtunded using any definition. Quantitative synthesis via meta-analysis was not possible because of pre-post, partial-cohort, quasi-experimental study design limitations and the consequential incomplete diagnostic accuracy data. RESULTS Of five articles with a total follow-up of 1,017 included subjects, none reported new neurologic changes (paraplegia or quadriplegia) after cervical collar removal. There is a worst-case 9% (161 of 1,718 subjects in 11 studies) cumulative literature incidence of stable injuries and a 91% negative predictive value of no injury, after coupling a negative high-quality C-spine CT result with 1.5-T magnetic resonance imaging, upright x-rays, flexion-extension CT, and/or clinical follow-up. Similarly, there is a best-case 0% (0 of 1,718 subjects in 11 studies) cumulative literature incidence of unstable injuries after negative initial imaging result with a high-quality C-spine CT. CONCLUSION In obtunded adult blunt trauma patients, we conditionally recommend cervical collar removal after a negative high-quality C-spine CT scan result alone. LEVEL OF EVIDENCE Systematic review, level III. PMID:25757133

Evaluation of a Trauma-Focused CBT Training Programme for IAPT services.

PubMed

Murray, Hannah

2017-09-01

Therapists in Improving Access to Psychological Therapies (IAPT) services are often expected to treat complex presentations of post-traumatic stress disorder (PTSD), such as individuals with multiple, prolonged or early life trauma histories and significant co-morbidity, for which they have received minimal training. Although high recovery rates for PTSD have been demonstrated in randomized controlled trials, these are not always replicated in routine practice, suggesting that training interventions are required to fill the research-practice gap. This study investigated the outcomes of a therapist training programme on treating PTSD with trauma-focused cognitive behavioural therapy (TF-CBT). Twenty therapists from ten IAPT services participated in the training, which consisted of workshops, webinars and consultation sessions over a 6-month period. Feedback indicated that participants found the training highly acceptable. PTSD knowledge and self- and supervisor-rated competence on TF-CBT measures improved following the training and improvements were maintained a year later. Client outcomes on a PTSD measure improved following the training. Participants reported attempts to disseminate learning from the course back to their teams. The findings indicate that the training programme was successful in improving TF-CBT knowledge, skills and outcomes for IAPT therapists. Tentative support for training 'trauma experts' within IAPT services was found, although institutional constraints and staff turnover may limit the sustainability of the model.

Improving Surgical Complications and Patient Safety at the Nation's Largest Military Hospital: An Analysis of National Surgical Quality Improvement Program Data.

PubMed

Maturo, Steve; Hughes, Charlotte; Kallingal, George; Silvey, Stephen; Johnson, A J; Soderdahl, Douglas; Renz, Evan; Brennan, Joseph

2017-03-01

The U.S. Military Health System cares for over 9 million patients and encompasses 63 hospitals and 413 clinics worldwide. Military medicine balances the simultaneous tasks of caring for those patients wounded in military engagements, treating large numbers of families of service men and women, and training the next generation of health care providers and ancillary staff. Similar to civilian health care delivery in the United States, military medicine has also seen increased scrutiny in the areas of cost and quality. In 2014, the U.S. military medical health care system was criticized for higher than average surgical complication rates and concerns regarding patient safety, quality of care, lack of transparency, and compartmentalized leadership. The San Antonio Military Medical Center was specifically cited as having "a perennial problem with surgical infection control…the infection rate of surgical wounds was 77% higher than expected given the mix of cases, according to a Pentagon-ordered comparison with civilian hospitals." To determine the scope of complication rates, data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) were analyzed. The goal of this article is to describe the NSQIP surgical outcome data for the U.S. Military's largest medical center from 2009 to 2014 and compare national averages in the areas of mortality, morbidity, cardiac occurrences, pneumonia, unplanned intubation, ventilator use greater than 48 hours, infections, readmissions, and return to operating room. Retrospective data analysis of NSQIP data from 2009 to 2014 at the San Antonio Military Medical Center, a level I trauma center for military members and eligible dependents along with civilian trauma patients. Observed event rates were compared with expected event rates for each year with the 2-tail Fisher's exact test to determine if rates were significantly different from each other. Cochran-Armitage Trend Test was performed to compare trends in time for the observed event rates. This study was exempt from institutional review board Approval. Complication rates remained stable or decreased over the 5 years studied. Significant improvement in morbidity and surgical site infections were observed during the observation period. All other variables except urinary tract infections were within expected range or decreased during this time. Urinary tract infection rates, although decreasing, remain above the expected value. NSQIP data at the Department of Defense's largest hospital reveals complication rates similar to civilian hospitals. The majority of areas studied revealed improving or stable complication rates. The ACS NSQIP is a nationally validated, risk-adjusted, outcomes program that is widely used by many leading hospital institutions. Similar to most quality data reporting articles, a weakness of our study may have been collection of all complications. Yet, we are confident that the majority of complications were captured as we have dedicated personnel monitoring the adverse events measured by ACS NSQIP. Future areas of study should focus on continued analysis of surgical quality improvement within the entire military system. Reprint & Copyright © 2017 Association of Military Surgeons of the U.S.

The effect of handover location on trauma theatre start time: An estimated cost saving of £131 000 per year.

PubMed

Nahas, Sam; Ali, Adam; Majid, Kiran; Joseph, Roshan; Huber, Chris; Babu, Victor

2018-02-08

The National Health Service was estimated to be in £2.45 billion deficit in 2015 to 2016. Trauma theatre utilization and efficiency has never been so important as it is estimated to cost £15/minute. Structured questionnaires were given to 23 members of staff at our Trust who are actively involved in the organization or delivery of orthopaedic trauma lists at least once per week. This was used to identify key factors that may improve theatre efficiency. Following focus group evaluation, the location of the preoperative theatre meeting was changed, with all staff involved being required to attend this. Our primary outcome measure was mean theatre start time (time of arrival in the anaesthetic room) during the 1 month immediately preceding the change and the month following the change. Theatre start time was improved on average 24 minutes (1 month premeeting and postmeeting change). This equates to a saving of £360 per day, or £131 040 per year. Changing the trauma meeting location to a venue adjacent to the trauma theatre can improve theatre start times, theatre efficiency, and therefore result in significant cost savings. Copyright © 2018 John Wiley & Sons, Ltd.

The influence of trauma and patient characteristics on provider burnout in VA post-traumatic stress disorder specialty programmes.

PubMed

Garcia, Hector A; McGeary, Cindy A; Finley, Erin P; McGeary, Donald D; Ketchum, Norma S; Peterson, Alan L

2016-03-01

Prolonged exposure (PE) and cognitive processing therapy (CPT) - post-traumatic stress disorder (PTSD) treatments now available at the Veterans Health Administration (VHA) - expose the provider to graphic traumatic material. Little is known about the impact of traumatic material on VHA providers. The purpose of this study was to examine the relationship between trauma content, patient characteristics, and burnout among VHA PTSD Clinical Team (PCT) providers. It was hypothesized that trauma content and patient characteristics would significantly predict burnout in this population. This cross-sectional study consisted of 137 participants. The sample was mostly female (67%), Caucasian (non-Hispanic; 81%), and married (70%) with a mean age of 44.3 years (SD = 11.3). Participants completed an electronic survey that assessed demographics, patient characteristics (i.e., anger, personality disorder, malingering), trauma content characteristics (e.g., killing of women and children) as well as burnout as measured by the Maslach Burnout Inventory-General Survey (MBI-GS; Maslach et al., 1996, Burnout inventory manual. Palo Alto: Consulting Psychologist Press). Over half of the study population reported being bothered by trauma content; however, trauma content did not predict burnout. Treating patients with personality disorders and suspected malingering predicted burnout in PCT providers. High numbers (77%) reported perceiving that emotional exhaustion impacted the quality of care they provided. These findings suggest an important role of burnout assessment, prevention, and treatment strategies at the VHA. This paper addresses the impact of provider burnout on perceived quality of care. This paper also addresses potential predictors of burnout in PCT settings. This paper outlines potential remedies to provider burnout in the VHA. © 2015 The British Psychological Society.

Quality of life after multiple trauma: validation and population norm of the Polytrauma Outcome (POLO) chart.

PubMed

Lefering, R; Tecic, T; Schmidt, Y; Pirente, N; Bouillon, B; Neugebauer, E

2012-08-01

Due to an increasing number of survivors after multiple injuries in Western countries, the health-related quality of life (QoL) is considered to be an important outcome parameter. Up to now, measuring instruments used in this field lacked validity and comparability. Within 6 years, our working group developed a new modular instrument, called the Polytrauma Outcome (POLO) chart. This study documents the validation of the trauma-specific module specifically designed for trauma patients, the Trauma Outcome Profile (TOP). A total of 172 multiply injured patients (mean Injury Severity Score [ISS] 26.7) recruited from eight trauma centres participating in the German Trauma Registry were compared with 166 marginally injured patients (mean ISS 3.9). The mean follow-up was 24.2 and 26.4 months, respectively. The validation questionnaires used were the Beck Depression Inventory (BDI), the State-Trait Anxiety Inventory (STAI), Impact of Event Scale-Revised (IES-R), Social Support Questionnaire (F-SOZU-K-22), Barthel Index of Activities of Daily Living (ADL) and the Short Form Health Survey (SF-36). The internal consistency of the different dimensions of QoL assessed with the TOP was good. Factor analysis provides evidence of the construct validity of the questionnaire. Correlation with external measures gives evidence of criterion validity for the various dimensions of QoL and similar exceedance of proposed cut-off points within TOP and external measures is verified. The TOP module is a reliable and valid instrument to assess health-related QoL in patients with multiple injuries. It can be used stand-alone or as part of the POLO chart together with the Glasgow Outcome Scale (GOS), the EuroQoL and the SF-36 as a regular systematic follow-up instrument.

Geographic Distribution of Trauma Burden, Mortality, and Services in the United States: Does Availability Correspond to Patient Need?

PubMed

Rios-Diaz, Arturo J; Metcalfe, David; Olufajo, Olubode A; Zogg, Cheryl K; Yorkgitis, Brian; Singh, Mansher; Haider, Adil H; Salim, Ali

2016-12-01

The association between the need for trauma care and trauma services has not been characterized previously. We compared the distribution of trauma admissions with state-level availability of trauma centers (TCs), surgical critical care (SCC) providers, and SCC fellowships, and assessed the association between trauma care provision and state-level trauma mortality. We obtained 2013 state-level data on trauma admissions, TCs, SCC providers, SCC fellowship positions, per-capita income, population size, and age-adjusted mortality rates. Normalized densities (per million population [PMP]) were calculated and generalized linear models were used to test associations between provision of trauma services (higher-level TCs, SCC providers, and SCC fellowship positions) and trauma burden, per-capita income, and age-adjusted mortality rates. There were 1,345,024 trauma admissions (4,250 PMP), 2,496 SCC providers (7.89 PMP), and 1,987 TCs across the country, of which 521 were Level I or II (1.65 PMP). There was considerable variation between the top 5 and bottom 5 states in terms of Level I/Level II TCs and SCC surgeon availability (approximately 8.0/1.0), despite showing less variation in trauma admission density (1.5/1.0). Distribution of trauma admissions was positively associated with SCC provider density and age-adjusted trauma mortality (p ≤ 0.001), and inversely associated with per-capita income (p < 0.001). Age-adjusted mortality was inversely associated with the number of SCC providers PMP. For every additional SCC provider PMP, there was a decrease of 618 deaths per year. There is an inequitable distribution of trauma services across the US. Increases in the density of SCC providers are associated with decreases in mortality. There was no association between density of trauma admissions and location of Level I/Level II TCs. In the wake of efforts to regionalize TCs, additional efforts are needed to address disparities in the provision of quality care to trauma patients. Copyright © 2016 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Final disposition and quality auditing of the rehabilitation process in wild raptors admitted to a Wildlife Rehabilitation Centre in Catalonia, Spain, during a twelve year period (1995-2007).

PubMed

Molina-López, Rafael A; Casal, Jordi; Darwich, Laila

2013-01-01

Variability in reporting and classification methods in previous published data of the final dispositions in the rehabilitation of wild raptors makes use of this data limited in trying to audit the quality of the rehabilitation process. Crude as well as stratified disposition rates are needed if quality auditing of the rehabilitation process is to be adequately performed. Final dispositions of 6221 hospitalized wild raptors admitted at a wildlife rehabilitation centre (WRC) of Catalonia during 1995-2007 were analyzed. These dispositions were calculated as the euthanasia (Er), unassisted mortality (Mr), release (Rr) and captivity rates (Cr)., time to death (Td) for dead and euthanized raptors, and length of stay for released (Tr) raptors was estimated. Stratified analyses by main causes of admission and clinical signs were performed. THE DISPOSITION FOR THE TOTAL POPULATION WERE: Er = 30.6%, Mr = 19.1%, Rr = 47.2%, and Cr = 3%. By main causes of admission, Er was higher in the trauma category (34.2%), whereas Mr was found similar between trauma (37.4%) and non-trauma categories (34.8%). The highest Rr was observed for the orphaned group (77.9%). Furthermore, Cr was low in all the categories (<4%). By clinical signs, the highest Er was found in animals suffering musculoskeletal (37.9%) or skin (32.3%) lesions; Mr was high in infectious/parasitic diseases (66.7%) and in case of neurological symptoms (64.5%). The euthanized birds had a median Td = 1 day (P10 = 0-P90 = 59) for both trauma and non-trauma categories, and Td = 36 days for the orphaned young group (P10 = 0; P90 = 596). The median Td in the unassisted dead birds was 2 days for all the categories (P10 = 0-P90 = 31). Finally, the median Tr in the centre was variable among categories. Reporting of final dispositions in wildlife rehabilitation should include the crude and stratified rates (Er, Mr, Rr, and Cr), by causes and clinical presentation, as well as Td and Tr, to allow meaningful auditing of the rehabilitation process quality.

Trauma-induced insurance instability: Variation in insurance coverage for patients who experience readmission after injury.

PubMed

Rajasingh, Charlotte Mary; Weiser, Thomas G; Knowlton, Lisa M; Tennakoon, Lakshika; Spain, David A; Staudenmayer, Kristan L

2018-06-01

Traumatic injuries result in a significant disruption to patients' lives, including their ability to work, which may place patients at risk of losing insurance coverage. Our objective was to evaluate the impact of injury on insurance status. We hypothesized that trauma patients with ongoing health needs experience changes in coverage. We used the Nationwide Readmission Database (2013-2014), a nationally representative sample of readmissions in the United States. We included patients aged 27 years to 64 years admitted with any diagnosis of trauma with at least one readmission within 6 months. Patients on Medicare and with missing payer information were excluded. The primary outcome was payer status. 57,281 patients met inclusion criteria, 11,006 (19%) changed insurance payer at readmission. Of these, 21% (n = 2,288) became uninsured, 25% (n = 2,773) gained coverage, and 54% (n = 5,945) switched insurance. Medicaid and Medicare gained the largest fraction of patients (from 16% to 30% and 0% to 18%, respectively), with a decrease in private payer coverage (37% to 17%). In multivariate analysis, patients who were younger (27-35 years vs. 56-64 years; odds ratio [OR], 1.30; p < 0.001); lived in a zip code with average income in the lowest quartile (vs. the highest quartile; OR, 1.37; p < 0.001); and had three or more comorbidities (vs. none; OR, 1.61; p < 0.001) were more likely to experience a change in insurance. Approximately one fifth of trauma patients who are readmitted within 6 months of their injury experience a change in insurance coverage. Most switch between insurers, but nearly a quarter lose their insurance. The government adopts a large fraction of these patients, indicating a growing reliance on government programs like Medicaid. Trauma patients face challenges after injury, and a change in insurance may add to this burden. Future policy and quality improvement initiatives should consider addressing this challenge. Epidemiologic, level III.

[Long-term outcome following multiple trauma in working age : A prospective study in a Swiss trauma center].

PubMed

Gross, T; Amsler, F

2016-11-01

Given the lack of data in the available literature, we were interested in the disability rate and corresponding insurance costs following multiple trauma in Switzerland. The possible impact of demographic, traumatic and hospital process factors as well as subjective and objective longer-term outcome variables on insurance data acquired were examined. Following multiple trauma the clinical and socioeconomic parameters in 145 survivors of working age were investigated over 2 and 4 years post-injury at a Swiss trauma center (University Hospital Basel). The correlation with the corresponding data provided by the largest Swiss accident insurance company (Suva, n = 63) was tested by univariate and multivariate analysis and patients insured at Suva were compared with those insured elsewhere (n = 82). The mean level of disability in this cohort of multiple trauma patients insured at Suva was 43 %. The insurer expected costs of more than 1 million Swiss Francs per multiply injured patient. In univariate analysis, only discrete correlations (maximum r = 0.37) were found with resulting disability, but significant correlations were found in subsequent multivariate testing most of all for age and the sequential organ failure assessment (SOFA 11 % and 15 % predictive capacity, p = 0.001; corrected R 2  = 0.26). Among variables of longer-term outcome the Euro Quality of Life Group health-related quality of life in five dimensions (EQ-5D) correlated almost as highly with the objective extent of disability as did the reduced capacity to work declared by the patients (0.64 and 0.7, respectively). The estimation of long-term disability following multiple trauma based on primary data following injury appears to be possible only to a limited extent. Given the clinical and socioeconomic relevance, comparable analyses are necessary by including all insurance providers involved.

Cellular Therapies in Trauma and Critical Care Medicine: Forging New Frontiers

PubMed Central

Pati, Shibani; Pilia, Marcello; Grimsley, Juanita M.; Karanikas, Alexia T.; Oyeniyi, Blessing; Holcomb, John B.; Cap, Andrew P.; Rasmussen, Todd E.

2015-01-01

ABSTRACT Trauma is a leading cause of death in both military and civilian populations worldwide. Although medical advances have improved the overall morbidity and mortality often associated with trauma, additional research and innovative advancements in therapeutic interventions are needed to optimize patient outcomes. Cell-based therapies present a novel opportunity to improve trauma and critical care at both the acute and chronic phases that often follow injury. Although this field is still in its infancy, animal and human studies suggest that stem cells may hold great promise for the treatment of brain and spinal cord injuries, organ injuries, and extremity injuries such as those caused by orthopedic trauma, burns, and critical limb ischemia. However, barriers in the translation of cell therapies that include regulatory obstacles, challenges in manufacturing and clinical trial design, and a lack of funding are critical areas in need of development. In 2015, the Department of Defense Combat Casualty Care Research Program held a joint military–civilian meeting as part of its effort to inform the research community about this field and allow for effective planning and programmatic decisions regarding research and development. The objective of this article is to provide a “state of the science” review regarding cellular therapies in trauma and critical care, and to provide a foundation from which the potential of this emerging field can be harnessed to mitigate outcomes in critically ill trauma patients. PMID:26428845

Mental practice: a simple tool to enhance team-based trauma resuscitation.

PubMed

Lorello, Gianni R; Hicks, Christopher M; Ahmed, Sana-Ara; Unger, Zoe; Chandra, Deven; Hayter, Megan A

2016-03-01

Effective trauma resuscitation requires the coordinated efforts of an interdisciplinary team. Mental practice (MP) is defined as the mental rehearsal of activity in the absence of gross muscular movements and has been demonstrated to enhance acquiring technical and procedural skills. The role of MP to promote nontechnical, team-based skills for trauma has yet to be investigated. We randomized anaesthesiology, emergency medicine, and surgery residents to two-member teams randomly assigned to either an MP or control group. The MP group engaged in 20 minutes of MP, and the control group received 20 minutes of Advanced Trauma Life Support (ATLS) training. All teams then participated in a high-fidelity simulated adult trauma resuscitation and received debriefing on communication, leadership, and teamwork. Two blinded raters independently scored video recordings of the simulated resuscitations using the Mayo High Performance Teamwork Scale (MHPTS), a validated team-based behavioural rating scale. The Mann-Whitney U-test was used to assess for between-group differences. Seventy-eight residents provided informed written consent and were recruited. The MP group outperformed the control group with significant effect on teamwork behaviour as assessed using the MHPTS: r=0.67, p<0.01. MP leads to improvement in team-based skills compared to traditional simulation-based trauma instruction. We feel that MP may be a useful and inexpensive tool for improving nontechnical skills instruction effectiveness for team-based trauma care.

Cellular Therapies in Trauma and Critical Care Medicine: Forging New Frontiers.

PubMed

Pati, Shibani; Pilia, Marcello; Grimsley, Juanita M; Karanikas, Alexia T; Oyeniyi, Blessing; Holcomb, John B; Cap, Andrew P; Rasmussen, Todd E

2015-12-01

Trauma is a leading cause of death in both military and civilian populations worldwide. Although medical advances have improved the overall morbidity and mortality often associated with trauma, additional research and innovative advancements in therapeutic interventions are needed to optimize patient outcomes. Cell-based therapies present a novel opportunity to improve trauma and critical care at both the acute and chronic phases that often follow injury. Although this field is still in its infancy, animal and human studies suggest that stem cells may hold great promise for the treatment of brain and spinal cord injuries, organ injuries, and extremity injuries such as those caused by orthopedic trauma, burns, and critical limb ischemia. However, barriers in the translation of cell therapies that include regulatory obstacles, challenges in manufacturing and clinical trial design, and a lack of funding are critical areas in need of development. In 2015, the Department of Defense Combat Casualty Care Research Program held a joint military-civilian meeting as part of its effort to inform the research community about this field and allow for effective planning and programmatic decisions regarding research and development. The objective of this article is to provide a "state of the science" review regarding cellular therapies in trauma and critical care, and to provide a foundation from which the potential of this emerging field can be harnessed to mitigate outcomes in critically ill trauma patients.

Development and validation of trauma surgical skills metrics: Preliminary assessment of performance after training.

PubMed

Shackelford, Stacy; Garofalo, Evan; Shalin, Valerie; Pugh, Kristy; Chen, Hegang; Pasley, Jason; Sarani, Babak; Henry, Sharon; Bowyer, Mark; Mackenzie, Colin F

2015-07-01

Maintaining trauma-specific surgical skills is an ongoing challenge for surgical training programs. An objective assessment of surgical skills is needed. We hypothesized that a validated surgical performance assessment tool could detect differences following a training intervention. We developed surgical performance assessment metrics based on discussion with expert trauma surgeons, video review of 10 experts and 10 novice surgeons performing three vascular exposure procedures and lower extremity fasciotomy on cadavers, and validated the metrics with interrater reliability testing by five reviewers blinded to level of expertise and a consensus conference. We tested these performance metrics in 12 surgical residents (Year 3-7) before and 2 weeks after vascular exposure skills training in the Advanced Surgical Skills for Exposure in Trauma (ASSET) course. Performance was assessed in three areas as follows: knowledge (anatomic, management), procedure steps, and technical skills. Time to completion of procedures was recorded, and these metrics were combined into a single performance score, the Trauma Readiness Index (TRI). Wilcoxon matched-pairs signed-ranks test compared pretraining/posttraining effects. Mean time to complete procedures decreased by 4.3 minutes (from 13.4 minutes to 9.1 minutes). The performance component most improved by the 1-day skills training was procedure steps, completion of which increased by 21%. Technical skill scores improved by 12%. Overall knowledge improved by 3%, with 18% improvement in anatomic knowledge. TRI increased significantly from 50% to 64% with ASSET training. Interrater reliability of the surgical performance assessment metrics was validated with single intraclass correlation coefficient of 0.7 to 0.98. A trauma-relevant surgical performance assessment detected improvements in specific procedure steps and anatomic knowledge taught during a 1-day course, quantified by the TRI. ASSET training reduced time to complete vascular control by one third. Future applications include assessing specific skills in a larger surgeon cohort, assessing military surgical readiness, and quantifying skill degradation with time since training.

Minimal acceptable care as a vital component to Missouri's trauma system.

PubMed

Helling, Thomas S

2002-07-01

Immediate attention to life-threatening injuries and expeditious transfer of major and complex wounds to tertiary care trauma centers are the cornerstones of any trauma system. Rapid assessment and "minimalization" of care should be the buzz-word of rural (Level III) and suburban (Level II) trauma centers in order to provide quickest treatment of injuries by timely referral of patients for definitive attention. This concept is called minimal acceptable care and may serve to improve patient outcome by reducing the interval to ultimate treatment and avoidance of duplication of services.

Childhood trauma exposure and toxic stress: what the PNP needs to know.

PubMed

Hornor, Gail

2015-01-01

Trauma exposure in childhood is a major public health problem that can result in lifelong mental and physical health consequences. Pediatric nurse practitioners must improve their skills in the identification of trauma exposure in children and their interventions with these children. This continuing education article will describe childhood trauma exposure (adverse childhood experiences) and toxic stress and their effects on the developing brain and body. Adverse childhood experiences include a unique set of trauma exposures. The adverse childhood experiences or trauma discussed in this continuing education offering will include childhood exposure to emotional abuse, physical abuse, sexual abuse, emotional neglect, physical neglect, domestic violence, household substance abuse, household mental illness, parental separation or divorce, and a criminal household member. Thorough and efficient methods of screening for trauma exposure will be discussed. Appropriate intervention after identification of trauma exposure will be explored. Copyright © 2015 National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved.

Emergency department patient satisfaction: customer service training improves patient satisfaction and ratings of physician and nurse skill.

PubMed

Mayer, T A; Cates, R J; Mastorovich, M J; Royalty, D L

1998-01-01

Customer service initiatives in healthcare have become a popular way of attempting to improve patient satisfaction. This study investigates the effect of clinically focused customer service training on patient satisfaction in the setting of a 62,000-visit emergency department and level I trauma center. Analysis of patient complaints, patient compliments, and a statistically verified patient-satisfaction survey indicate that (1) all 14 key quality characteristics identified in the survey increased dramatically in the study period; (2) patient complaints decreased by over 70 percent from 2.6 per 1,000 emergency department (ED) visits to 0.6 per 1,000 ED visits following customer service training; and (3) patient compliments increased more than 100 percent from 1.1 per 1,000 ED visits to 2.3 per 1,000 ED visits. The most dramatic improvement in the patient satisfaction survey came in ratings of skill of the emergency physician, likelihood of returning, skill of the emergency department nurse, and overall satisfaction. These results show that clinically focused customer service training improves patient satisfaction and ratings of physician and nurse skill. They also suggest that such training may offer a substantial competitive market advantage, as well as improve the patients' perception of quality and outcome.

A mental health intervention strategy for low-income, trauma-exposed Latina immigrants in primary care

PubMed Central

Kaltman, Stacey; de Mendoza, Alejandra Hurtado; Serrano, Adriana; Gonzales, Felisa A.

2016-01-01

Latinos in the United States face significant mental health disparities related to access to care, quality of care, and outcomes. Prior research suggests that Latinos prefer to receive care for common mental health problems (e.g., depression and anxiety disorders) in primary care settings, suggesting a need for evidence-based mental health services designed for delivery in these settings. This study sought to develop and preliminarily evaluate a mental health intervention for trauma-exposed Latina immigrants with depression and/or PTSD for primary care clinics that serve the uninsured. The intervention was designed to be simultaneously responsive to patients’ preferences for individual psychotherapy, to the needs of safety-net primary care clinics for efficient services, and to address the social isolation that is common to the Latina immigrant experience. Developed based on findings from the research team’s formative research, the resulting intervention incorporated individual and group sessions and combined evidence-based interventions to reduce depression and PTSD symptoms, increase group readiness, and improve perceived social support. Twenty-eight trauma-exposed low-income Latina immigrant women who screened positive for depression and/or PTSD participated in an open pilot trial of the intervention at a community primary care clinic. Results indicated that the intervention was feasible, acceptable, and safe. A randomized controlled trial of the intervention is warranted. PMID:26913774

Beta-blocker use is associated with improved outcomes in adult trauma patients.

PubMed

Arbabi, Saman; Campion, Eric M; Hemmila, Mark R; Barker, Melissa; Dimo, Mary; Ahrns, Karla S; Niederbichler, Andreas D; Ipaktchi, Kyros; Wahl, Wendy L

2007-01-01

Beta-adrenoreceptor blocker (beta-blocker) therapy may improve outcomes in surgical patients by decreasing cardiac oxygen consumption and hypermetabolism. Because beta-blockers can lower the systemic blood pressure and cerebral perfusion pressure, there is concern regarding their use in patients with head injury. However, beta-blockers may protect beta-receptor rich brain cells by attenuating cerebral oxygen consumption and metabolism. We hypothesized that beta-blockers are safe in trauma patients, even if they have suffered a significant head injury. Using pharmacy and trauma registry data of a Level I trauma center, we identified a cohort of trauma patients who received beta-blockers during their hospital stay (beta-cohort). Trauma admissions who did not receive beta-blockers were in the control cohort. beta-blocker status, in combination with other variables associated with mortality, were placed in a stepwise multivariate logistic regression to identify independent predictors of fatal outcome. In all, 303 (7%) of 4,117 trauma patients received beta-blockers. In the beta-cohort, 45% of patients were on beta-blockers preinjury. The most common reason to initiate beta-blocker therapy was blood pressure (60%) and heart rate (20%) control. The overall mortality rate was 5.6% and head injury was considered to be the major cause of death. After adjusting for age, Injury Severity Scale score, blood pressure, Glasgow Coma Scale score, respiratory status, and mechanism of injury, the odds ratio for fatal outcome was 0.3 (p < 0.001) for beta-cohort as compared with control. Decreased risk of fatal outcome was more pronounced in patients with a significant head injury. beta-blocker therapy is safe and may be beneficial in selected trauma patients with or without head injury. Further studies looking at beta-blocker therapy in trauma patients and their effect on cerebral metabolism are warranted.

The effect of paramedic training on pre-hospital trauma care (EPPTC-study): a study protocol for a prospective semi-qualitative observational trial

PubMed Central

2014-01-01

Background Accidents are the leading cause of death in adults prior to middle age. The care of severely injured patients is an interdisciplinary challenge. Limited evidence is available concerning pre-hospital trauma care training programs and the advantage of such programs for trauma patients. The effect on trauma care procedures or on the safety of emergency crews on the scene is limited; however, there is a high level of experience and expert opinion. Methods I – Video-recorded case studies are the basis of an assessment tool and checklist being developed to verify the results of programs to train participants in the care of seriously injured patients, also known as “objective structured clinical examination” (OSCE). The timing, completeness and quality of the individual measures are assessed using appropriate scales. The evaluation of team communication and interaction will be analyzed with qualitative methods and quantified and verified by existing instruments (e.g. the Clinical Team Scale). The developed assessment tool is validated by several experts in the fields of trauma care, trauma research and medical education. II a) In a German emergency medical service, the subjective assessment of paramedics of their pre-hospital care of trauma patients is evaluated at three time points, namely before, immediately after and one year after training. b) The effect of a standardized course concept on the quality of documentation in actual field operations is determined based on three items relevant to patient safety before and after the course. c) The assessment tool will be used to assess the effect of a standardized course concept on procedures and team communication in pre-hospital trauma care using scenario-based case studies. Discussion This study explores the effect of training on paramedics. After successful study completion, further multicenter studies are conceivable, which would evaluate emergency-physician staffed teams. The influence on the patients and prehospital measures should be assessed based on a retrospective analysis of the emergency room data. Trials registration German Clinical Trials Register, ID DRKS00004713. PMID:24528532

The relationship between childhood trauma and adult psychosis in a UK Early Intervention Service: results of a retrospective case note study.

PubMed

Reeder, Francesca D; Husain, Nusrat; Rhouma, Abdul; Haddad, Peter M; Munshi, Tariq; Naeem, Farooq; Khachatryan, Davit; Chaudhry, Imran B

2017-01-01

There is evidence that childhood trauma is a risk factor for the development of psychosis and it is recommended that childhood trauma is inquired about in all patients presenting with psychosis. This study aimed to determine the prevalence of childhood trauma in patients in the UK Early Intervention Service based on a case note review. This is a retrospective case note study of 296 patients in an UK Early Intervention Service. Trauma history obtained on service entry was reviewed and trauma experienced categorized. Results were analyzed using crosstab and frequency analysis. The mean age of the sample was 24 years, 70% were male, 66% were White, and 23% Asian (ethnicity not documented in 11% of the sample). Approximately 60% of patients reported childhood trauma, 21% reported no childhood trauma, and data were not recorded for the remaining 19%. Among those reporting trauma, the prevalence of most frequently reported traumas were: severe or repeated disruption (21%), parental mental illness (19%), bullying (18%), absence of a parent (13%), and 'other' trauma (24%) - the majority of which were victimization events. Sixty-six percent of those reporting trauma had experienced multiple forms of trauma. A high prevalence of childhood trauma (particularly trauma related to the home environment or family unit) was reported. This is consistent with other studies reporting on trauma and psychosis. The main weakness of the study is a lack of a control group reporting experience of childhood trauma in those without psychosis. Guidelines recommend that all patients with psychosis are asked about childhood trauma; but in 19% of our sample there was no documentation that this had been done indicating the need for improvement in assessment.

Don’t forget the posters! Quality and content variables associated with accepted abstracts at a national trauma meeting

PubMed Central

Dossett, Lesly A.; Fox, Erin E.; del Junco, Deborah J.; Zaydfudim, Victor; Kauffmann, Rondi; Shelton, Julia; Wang, Weiwei; Cioffi, William G.; Holcomb, John B.; Cotton, Bryan A.

2014-01-01

BACKGROUND As a primary venue for presenting research results, abstracts selected for presentation at national meetings should be of the highest scientific merit and research quality. It is uncertain to what degree this is achieved as the methodological quality of abstracts submitted to national surgical meetings has not been previously described. The objective of this study was to evaluate abstracts presented at a leading trauma meeting for methodological quality. METHODS All abstracts accepted for the 2009 American Association for the Surgery of Trauma meeting were reviewed and scored for methodological quality based on 10 criteria (scores, 0–10; 10 being the highest). Criteria were based on nationally published methodology guidelines. Two independent reviewers who were blinded to institution, region, and author reviewed each abstract. RESULTS A total of 187 abstracts were accepted for presentation (67 oral and 120 posters). The most frequent clinical topics were shock/transfusion (23%), abdomen (12%), and nervous system (11%). Shock/transfusion abstracts were more common in the oral presentations (31% vs. 19%; p =0.06). Abstracts from the northeast and south regions were the most common in both oral (26% and 29%) and posters (25% and 24%). Basic science accounted for 12% of accepted studies, while 51% were clinical and 28% were health services/outcomes. Only 8% of abstracts presented randomized data and only 11% reported null findings. Overall abstract scores ranged from 3 to 10 (median, 7; mean, 7.4). Abstracts selected for poster presentation had an overall higher score than those selected for oral presentation (7.4 ±1.7 vs. 6.8 ±1.7; p =0.02). CONCLUSION Although oral presentations traditionally receive the most attention and interest, the methodological quality of abstracts accepted for poster presentation equals (and sometimes exceeds) that of oral abstracts. Attendees of these national meetings should reconsider their time spent in viewing and visiting these poster sessions as with the oral presentations. In light of our findings, we highly encourage that all members and guests attend the American Association for the Surgery of Trauma Poster Rounds at each year’s scientific assembly. PMID:22673278

Don't forget the posters! Quality and content variables associated with accepted abstracts at a national trauma meeting.

PubMed

Dossett, Lesly A; Fox, Erin E; del Junco, Deborah J; Zaydfudim, Victor; Kauffmann, Rondi; Shelton, Julia; Wang, Weiwei; Cioffi, William G; Holcomb, John B; Cotton, Bryan A

2012-05-01

As a primary venue for presenting research results, abstracts selected for presentation at national meetings should be of the highest scientific merit and research quality. It is uncertain to what degree this is achieved as the methodological quality of abstracts submitted to national surgical meetings has not been previously described. The objective of this study was to evaluate abstracts presented at a leading trauma meeting for methodological quality. All abstracts accepted for the 2009 American Association for the Surgery of Trauma meeting were reviewed and scored for methodological quality based on 10 criteria (scores, 0-10; 10 being the highest). Criteria were based on nationally published methodology guidelines. Two independent reviewers who were blinded to institution, region, and author reviewed each abstract. A total of 187 abstracts were accepted for presentation (67 oral and 120 posters). The most frequent clinical topics were shock/transfusion (23%), abdomen (12%), and nervous system (11%). Shock/transfusion abstracts were more common in the oral presentations (31% vs. 19%; p = 0.06). Abstracts from the northeast and south regions were the most common in both oral (26% and 29%) and posters (25% and 24%). Basic science accounted for 12% of accepted studies, while 51% were clinical and 28% were health services/outcomes. Only 8% of abstracts presented randomized data and only 11% reported null findings. Overall abstract scores ranged from 3 to 10 (median, 7; mean, 7.4). Abstracts selected for poster presentation had an overall higher score than those selected for oral presentation (7.4 ± 1.7 vs. 6.8 ± 1.7; p = 0.02). Although oral presentations traditionally receive the most attention and interest, the methodological quality of abstracts accepted for poster presentation equals (and sometimes exceeds) that of oral abstracts. Attendees of these national meetings should reconsider their time spent in viewing and visiting these poster sessions as with the oral presentations. In light of our findings, we highly encourage that all members and guests attend the American Association for the Surgery of Trauma Poster Rounds at each year's scientific assembly.

Quality of care after early childhood trauma and well-being in later life: child Holocaust survivors reaching old age.

PubMed

van der Hal-Van Raalte, Elisheva; Van Ijzendoorn, Marinus H; Bakermans-Kranenburg, Marian J

2007-10-01

The link between deprivation and trauma during earliest childhood and psychosocial functioning and health in later life was investigated in a group of child Holocaust survivors. In a nonconvenience sample 203 survivors, born between 1935 and 1944, completed questionnaires on Holocaust survival experience and several inventories on current health, depression, posttraumatic stress, loneliness, and attachment style. Quality of postwar care arrangements and current physical health independently predicted lack of well-being in old age. Loss of parents during the persecution, year of birth of the survivors (being born before or during the war), and memories of the Holocaust did not significantly affect present well-being. Lack of adequate care after the end of World War II is associated with lower well-being of the youngest Holocaust child survivors, even after an intervening period of 60 years. Our study validates Keilson's (1992) concept of "sequential traumatization," and points to the importance of aftertrauma care in decreasing the impact of early childhood trauma.

Neurocognitive functioning over the course of trauma-focused psychotherapy for PTSD: Changes in verbal memory and executive functioning.

PubMed

Nijdam, Mirjam J; Martens, Irene J M; Reitsma, Johannes B; Gersons, Berthold P R; Olff, Miranda

2018-05-01

Individuals with post-traumatic stress disorder (PTSD) have neurocognitive deficits in verbal memory and executive functioning. In this study, we examined whether memory and executive functioning changed over the course of treatment and which clinical variables were associated with change. Neuropsychological assessments were administered at baseline and endpoint of a randomized controlled trial as secondary outcome. Trauma survivors (n = 88) diagnosed with PTSD received trauma-focused psychotherapy within a 17-week randomized controlled trial. Neuropsychological tests were the California Verbal Learning Test, Rivermead Behavioural Memory Test, Stroop Color Word Test, and Trail Making Test. Significant, small- to medium-sized improvements in verbal memory, information processing speed, and executive functioning were found after trauma-focused psychotherapy (Cohen's d 0.16-0.68). Greater PTSD symptom decrease was significantly related to better post-treatment neurocognitive performance (all p < .005). Patients with comorbid depression improved more than patients with PTSD alone on interference tasks (p < .01). No differences emerged between treatment conditions and between patients on serotonergic antidepressants and those who were not. This study suggests that neurocognitive deficits in PTSD can improve over the course of trauma-focused psychotherapy and are therefore at least partly reversible. Improvements over treatment are in line with previous neuropsychological and neuroimaging studies and effect sizes exceed those of practice effects. Future research should determine whether these changes translate into improved functioning in the daily lives of the patients. Patients with PTSD have difficulties performing verbal memory tasks (e.g., remembering a grocery list, recall of a story) and executive functioning tasks (e.g., shifting attention between two tasks, ignoring irrelevant information to complete a task). Verbal memory, information processing speed, and executive functioning significantly improved in patients with post-traumatic stress disorder over the course of trauma-focused psychotherapy. Improvements were equal in size for two different trauma-focused psychotherapies (Eye movement desensitization and reprocessing therapy and brief eclectic psychotherapy for PTSD). Medium-sized effects were found for recall of a story, whereas effects in other aspects of verbal memory, information processing speed, and executive functioning were small-sized. No causal attributions can be made because we could not include a control group without treatment for ethical reasons. Findings may be more reflective of patients who completed treatment than patients who prematurely dropped out as completers were overrepresented in our sample. © 2018 The British Psychological Society.

Patient volume per surgeon does not predict survival in adult level I trauma centers.

PubMed

Margulies, D R; Cryer, H G; McArthur, D L; Lee, S S; Bongard, F S; Fleming, A W

2001-04-01

The 1999 American College of Surgeons resources for optimal care document added the requirement that Level I trauma centers admit over 240 patients with Injury Severity Score (ISS) > 15 per year or that trauma surgeons care for at least 35 patients per year. The purpose of this study was to test the hypothesis that high volume of patients with ISS > 15 per individual trauma surgeon is associated with improved outcome. Data were obtained from the trauma registry of the five American College of Surgeons-verified adult Level I trauma centers in our mature trauma system between January 1, 1998, and March 31, 1999. Data abstracted included age, sex, Glasgow Coma Scale (GCS) score, intensive care unit length of stay, hospital length of stay, probability of survival (Ps), mechanism of injury, number of patients per each trauma surgeon and institution, and mortality. Multiple logistic regression was performed to select independent variables for modeling of survival. From the five Level I centers there were 11,932 trauma patients in this time interval; of these, 1,754 patients (14.7%) with ISS > 15 were identified and used for analysis. Patients with ISS > 15 varied from 173 to 625 per institution; trauma surgeons varied from 8 to 25 per institution; per-surgeon patient volume varied from 0.8 to 96 per year. Logistic regression analysis revealed that the best independent predictors of survival were Ps, GCS score, age, mechanism of injury, and institutional volume (p < 0.01). Age and institutional volume correlated negatively with survival. Analysis of per-surgeon patient caseload added no additional predictive value (p = 0.44). The significant independent predictors of survival in severely injured trauma patients are Ps, GCS score, age, mechanism of injury, and institutional volume. We found no statistically meaningful contribution to the prediction of survival on the basis of per-surgeon patient volume. Since this volume criterion for surgeon enpanelment and trauma center designation would not be expected to improve outcome, such a requirement should be justified by other measures or abandoned.

Vitreoretinal surgery of the posterior segment for explosive trauma in terrorist warfare.

PubMed

Bajaire, Boris; Oudovitchenko, Elena; Morales, Edgar

2006-08-01

To describe surgical management and establish anatomic and visual results of patients with explosive ocular trauma in terrorist attacks treated with extreme vitreoretinal surgery. Retrospective study of clinical records (6-month follow-up) of patients with visual acuity (VA) of light perception or better with posterior segment injuries [vitreous hemorrhage, retinal detachment (RD), intra-ocular foreign bodies (IOFB), perforating trauma (PT)] from explosive weapons who underwent vitreoretinal surgery. We reviewed the demographic characteristics, type of weapon, time between injury and surgery, VA at arrival and 6 months after surgery, and type of trauma according to the International Trauma Classification. Fifty-seven out of 236 patients with ocular injuries from explosive weapons were included in the study; all of them were military men, average age 22 years (range 16-53 years). The average time between the blast and primary closing was 1 day, and 10 days between primary closing and vitreoretinal surgery. Open traumas by laceration accounted for 96% of cases and 4% were closed traumas; 76% of the eyes had IOFB, of which 18% involved PT; 5% had endophthalmitis. Contusion was the diagnosis for 100% of the closed traumas. Of the open traumas, 40% were localized at zone I, 44% at zone II, and 16% at zone III. Upon arrival, 98% of patients had VA 20/800-LP and 2% had >20/40. The patients with closed trauma had the injuries at zone III and presented VA 20/800-LP. All patients underwent posterior vitrectomy, scleral buckling, endotaponade and when required, lensectomy (82%), IOFB removal (72%), and/or retinectomy (25%). Postoperative VA improved in 43% of the patients, stabilized in 41% and evolved to NLP in 15% of the cases. Initial expressions of ocular trauma such as RD, PT and endophthalmitis suggest bad prognosis. We presented a series of patients with severe ocular trauma of the posterior segment from explosive weapons. These patients were treated according to our surgical protocol with extreme vitreoretinal surgery within the first 2 weeks after the blast; with our procedure we obtained stabilization or improvement of the VA for 84% of the cases.

Team-based simulations for new surgeons: Does early and often make a difference?

PubMed

AbdelFattah, Kareem R; Spalding, M Chance; Leshikar, David; Gardner, Aimee K

2018-04-01

Current work hour restrictions and the expansion of requirements for surgery residents has led to decreased time on high-acuity rotations such as trauma and acute care surgery. In an effort to improve resident competency, we examined the efficacy of a new team-based trauma curriculum for postgraduate year 1 (PGY1) residents. After completing required Advanced Trauma Life Support certification, PGY1s participated in a series of trauma simulations in 3-person teams from June to August. Scenarios were created to develop skills related to trauma management, teamwork, and communication. Each simulation was followed by video-based debriefing with a faculty facilitator. Clinical performance on a 1-month trauma rotation during the year was assessed by trauma faculty using a 24-item evaluation assessing management of acutely ill patients, leadership, communication, cooperation, and professionalism on a 1 (poor) to 5 (very effective) scale. Performance metrics of this intern class were compared with 2 years of previous cohorts who had not participated in any trauma-focused simulation curricula. One-way analysis of variance was used to examine differences in performance ratings across groups. The 2015 intern class (n = 30) each participated in 6 scenarios during their first 2 months in residency. Trauma as intended specialty and performance on preinternship Advanced Trauma Life Support course were similar across 2013, 2014, and 2015 cohorts. Average performance on the trauma rotation was 3.55 ± 0.56 for the 2013 cohort (n = 11), 3.50 ± 0.57 for the 2014 cohort (n = 11), and 4.35 ± 0.68 for the 2015 cohort (n = 12). Post hoc analyses indicated no difference between means of the 2013 and 2014 cohort. However, the mean of the 2015 cohort was statistically significantly better than both the 2013 cohort (P < .01) and the 2014 cohort (P < .01). Trauma-focused simulation improved PGY1 faculty ratings of performance in the clinical setting compared with previous cohorts with no such simulation experience. Adoption of these curricula is both feasible and beneficial. Copyright © 2017 Elsevier Inc. All rights reserved.

The Trauma Center Organizational Culture Survey: development and conduction.

PubMed

Davis, Matthew L; Wehbe-Janek, Hania; Subacius, Haris; Pinto, Ruxandra; Nathens, Avery B

2015-01-01

The Trauma Center Organizational Culture Survey (TRACCS) instrument was developed to assess organizational culture of trauma centers enrolled in the American College of Surgeons Trauma Quality Program (ACS TQIP). The objective is to provide evidence on the psychometric properties of the factors of TRACCS and describe the current organizational culture of TQIP-enrolled trauma centers. A cross-sectional study was conducted by surveying a sampling of employees at 174 TQIP-enrolled trauma centers. Data collection was preceded by multistep survey development. Psychometric properties were assessed by an exploratory factor analysis (construct validity) and the item-total correlations and Cronbach alpha were calculated (internal reliability). Statistical outcomes of the survey responses were measured by descriptive statistics and mixed effect models. The response rate for trauma center participation in the study was 78.7% (n = 137). The factor analysis resulted in 16 items clustered into three factors as described: opportunity, pride, and diversity, trauma center leadership, and employee respect and recognition. TRACCS was found to be highly reliable with a Cronbach alpha of 0.90 in addition to the three factors (0.91, 0.90, and 0.85). Considerable variability of TRACCS overall and factor score among hospitals was measured, with the largest interhospital deviations among trauma center leadership. More than 80% of the variability in the responses occurred within rather than between hospitals. TRACCS was developed as a reliable tool for measuring trauma center organizational culture. Relationships between TQIP outcomes and measured organizational culture are under investigation. Trauma centers could apply TRACCS to better understand current organizational culture and how change tools can impact culture and subsequent patient and process outcomes. Copyright © 2015 Elsevier Inc. All rights reserved.

Pediatric Trauma Transfer Imaging Inefficiencies-Opportunities for Improvement with Cloud Technology.

PubMed

Puckett, Yana; To, Alvin

2016-01-01

This study examines the inefficiencies of radiologic imaging transfers from one hospital to the other during pediatric trauma transfers in an era of cloud based information sharing. Retrospective review of all patients transferred to a pediatric trauma center from 2008-2014 was performed. Imaging was reviewed for whether imaging accompanied the patient, whether imaging was able to be uploaded onto computer for records, whether imaging had to be repeated, and whether imaging obtained at outside hospitals (OSH) was done per universal pediatric trauma guidelines. Of the 1761 patients retrospectively reviewed, 559 met our inclusion criteria. Imaging was sent with the patient 87.7% of the time. Imaging was unable to be uploaded 31.9% of the time. CT imaging had to be repeated 1.8% of the time. CT scan was not done per universal pediatric trauma guidelines 1.2% of the time. Our study demonstrated that current imaging transfer is inefficient, leads to excess ionizing radiation, and increased healthcare costs. Universal implementation of cloud based radiology has the potential to eliminate excess ionizing radiation to children, improve patient care, and save cost to healthcare system.

Exposure to 100% Oxygen Abolishes the Impairment of Fracture Healing after Thoracic Trauma

PubMed Central

Kemmler, Julia; Bindl, Ronny; McCook, Oscar; Wagner, Florian; Gröger, Michael; Wagner, Katja; Scheuerle, Angelika; Radermacher, Peter; Ignatius, Anita

2015-01-01

In polytrauma patients a thoracic trauma is one of the most critical injuries and an important trigger of post-traumatic inflammation. About 50% of patients with thoracic trauma are additionally affected by bone fractures. The risk for fracture malunion is considerably increased in such patients, the pathomechanisms being poorly understood. Thoracic trauma causes regional alveolar hypoxia and, subsequently, hypoxemia, which in turn triggers local and systemic inflammation. Therefore, we aimed to unravel the role of oxygen in impaired bone regeneration after thoracic trauma. We hypothesized that short-term breathing of 100% oxygen in the early post-traumatic phase ameliorates inflammation and improves bone regeneration. Mice underwent a femur osteotomy alone or combined with blunt chest trauma 100% oxygen was administered immediately after trauma for two separate 3 hour intervals. Arterial blood gas tensions, microcirculatory perfusion and oxygenation were assessed at 3, 9 and 24 hours after injury. Inflammatory cytokines and markers of oxidative/nitrosative stress were measured in plasma, lung and fracture hematoma. Bone healing was assessed on day 7, 14 and 21. Thoracic trauma induced pulmonary and systemic inflammation and impaired bone healing. Short-term exposure to 100% oxygen in the acute post-traumatic phase significantly attenuated systemic and local inflammatory responses and improved fracture healing without provoking toxic side effects, suggesting that hyperoxia could induce anti-inflammatory and pro-regenerative effects after severe injury. These results suggest that breathing of 100% oxygen in the acute post-traumatic phase might reduce the risk of poorly healing fractures in severely injured patients. PMID:26147725

Direct peritoneal resuscitation improves obesity-induced hepatic dysfunction after trauma.

PubMed

Matheson, Paul J; Franklin, Glen A; Hurt, Ryan T; Downard, Cynthia D; Smith, Jason W; Garrison, Richard N

2012-04-01

The metabolic syndrome and associated fatty liver disease are thought to contribute to poor outcomes in trauma patients. Experimentally, obesity compromises liver blood flow. We sought to correlate the effect of obesity, injury severity, and liver dysfunction with trauma outcomes. We hypothesized that obesity-related liver dysfunction could be mitigated with the novel technique of adjunctive direct peritoneal resuscitation (DPR). This study has clinical and experimental arms. The clinical study was a case-controlled retrospective analysis of ICU trauma patients (n = 72 obese, n = 187 nonobese). The experimental study was a hemorrhagic shock model in obese rats to assess the effect of DPR on liver blood flow, liver function, and inflammatory mediators. In trauma patients, univariate and multivariate analyses demonstrated increasing mortality (p < 0.05), septic complications (p < 0.05), liver dysfunction (p < 0.001), and renal impairment (p < 0.05) with increasing body mass index and injury severity score. Obesity in rats impairs liver blood flow, liver function, renal function, and inflammation (interleukin [IL]-1β, IL-6, high mobility group protein B1[HMGB-1]). The addition of DPR to shock resuscitation restores liver blood flow, improves organ function, and reverses the systemic proinflammatory response. Our clinical review substantiates that obesity worsens trauma outcomes regardless of injury severity. Obesity-related liver and renal dysfunction is aggravated by injury severity. In an obese rat model of resuscitated hemorrhagic shock, the addition of DPR abrogates trauma-induced liver, renal, and inflammatory responses. We conclude that the addition of DPR to the clinical resuscitation regimen will benefit the obese trauma patient. Published by Elsevier Inc.

Outcomes following trauma laparotomy for hypotensive trauma patients: a UK military and civilian perspective.

PubMed

Marsden, Max; Carden, Rich; Navaratne, Lalin; Smith, Iain M; Penn-Barwell, Jowan G; Kraven, Luke M; Brohi, Karim; Tai, Nigel R M; Bowley, Douglas M

2018-05-25

The management of trauma patients has changed radically in the last decade and studies have shown overall improvements in survival. However, reduction in mortality for the many may obscure a lack of progress in some high-risk patients. We sought to examine the outcomes for hypotensive patients requiring laparotomy in UK military and civilian cohorts. We undertook a review of two prospectively maintained trauma databases; the UK Joint Theatre Trauma Registry (JTTR) for the military cohort (4th February 2003 to 21st September 2014), and the trauma registry of the Royal London Hospital MTC (1st January 2012 to 1st January 2017) for civilian patients. Adults undergoing trauma laparotomy within 90 minutes of arrival at the Emergency Department (ED) were included. Hypotension was present on arrival at the ED in 155/761 (20.4%) military patients. Mortality was higher in hypotensive casualties 25.8% vs 9.7% normotensive casualties (p<0.001). Hypotension was present on arrival at the ED in 63/176 (35.7%) civilian patients. Mortality was higher in hypotensive patients 47.6% vs 12.4% normotensive patients (p<0.001). In both cohorts of hypotensive patients neither the average injury severity, the prehospital time, the ED arrival SBP, nor mortality rate changed significantly during the study period. Despite improvements in survival after trauma for patients overall, the mortality for patients undergoing laparotomy who arrive at the Emergency Department with hypotension has not changed and appears stubbornly resistant to all efforts. Specific enquiry and research should continue to be directed at this high-risk group of patients. IV; Observational Cohort Study.

Undertreatment of acute pain (oligoanalgesia) and medical practice variation in prehospital analgesia of adult trauma patients: a 10 yr retrospective study.

PubMed

Albrecht, E; Taffe, P; Yersin, B; Schoettker, P; Decosterd, I; Hugli, O

2013-01-01

Prehospital oligoanalgesia is prevalent among trauma victims, even when the emergency medical services team includes a physician. We investigated if not only patients' characteristics but physicians' practice variations contributed to prehospital oligoanalgesia. Patient records of conscious adult trauma victims transported by our air rescue helicopter service over 10 yr were reviewed retrospectively. Oligoanalgesia was defined as a numeric rating scale (NRS) >3 at hospital admission. Multilevel logistic regression analysis was used to predict oligoanalgesia, accounting first for patient case-mix, and then physician-level clustering. The intraclass correlation was expressed as the median odds ratio (MOR). A total of 1202 patients and 77 physicians were included in the study. NRS at the scene was 6.9 (1.9). The prevalence of oligoanalgesia was 43%. Physicians had a median of 5.7 yr (inter-quartile range: 4.2-7.5) of post-graduate training and 27% were female. In our multilevel analysis, significant predictors of oligoanalgesia were: no analgesia [odds ratio (OR) 8.8], National Advisory Committee for Aeronautics V on site (OR 4.4), NRS on site (OR 1.5 per additional NRS unit >4), female physician (OR 2.0), and years of post-graduate experience [>4.0 to ≤5.0 (OR 1.3), >3.0 to ≤4.0 (OR 1.6), >2.0 to ≤3.0 (OR 2.6), and ≤2.0 yr (OR 16.7)]. The MOR was 2.6, and was statistically significant. Physicians' practice variations contributed to oligoanalgesia, a factor often overlooked in analyses of prehospital pain management. Further exploration of the sources of these variations may provide innovative targets for quality improvement programmes to achieve consistent pain relief for trauma victims.

A Model to Predict Psychological- and Health-Related Adjustment in Men with Prostate Cancer: The Role of Post Traumatic Growth, Physical Post Traumatic Growth, Resilience and Mindfulness.

PubMed

Walsh, Deirdre M J; Morrison, Todd G; Conway, Ronan J; Rogers, Eamonn; Sullivan, Francis J; Groarke, AnnMarie

2018-01-01

Background: Post traumatic growth (PTG) can be defined as positive change following a traumatic event. The current conceptualization of PTG encompasses five main dimensions, however, there is no dimension which accounts for the distinct effect of a physical trauma on PTG. The purpose of the present research was to test the role of PTG, physical post traumatic growth (PPTG), resilience and mindfulness in predicting psychological and health related adjustment. Method: Ethical approval was obtained from relevant institutional ethics committees. Participants ( N = 241), who were at least 1 year post prostate cancer treatment, were invited to complete a battery of questionnaires either through an online survey or a paper and pencil package received in the post The sample ranged in age from 44 to 88 years ( M = 64.02, SD = 7.76). Data were analysis using confirmatory factor analysis and structural equation modeling. Results: The physical post traumatic growth inventory (P-PTGI) was used to evaluate the role of PPTG in predicting adjustment using structural equation modeling. P-PTGI predicted lower distress and improvement of quality of life, whereas conversely, the traditional PTG measure was linked with poor adjustment. The relationship between resilience and adjustment was found to be mediated by P-PTGI. Conclusion: Findings suggest the central role of PTG in the prostate cancer survivorship experience is enhanced by the inclusion of PPTG. Adjusting to a physical trauma such as illness (internal transgressor) is unlike a trauma with an external transgressor as the physical trauma creates an entirely different framework for adjustment. The current study demonstrates the impact of PPTG on adjustment. This significantly adds to the theory of the development of PTG by highlighting the interplay of resilience with PTG, PPTG, and adjustment.

Oral Health-Related Quality of Life and Traumatic Dental Injuries in Young Permanent Incisors in Brazilian Schoolchildren: A Multilevel Approach.

PubMed

Freire-Maia, Fernanda Bartolomeo; Auad, Sheyla Márcia; Abreu, Mauro Henrique Nogueira Guimarães de; Sardenberg, Fernanda; Martins, Milene Torres; Paiva, Saul Martins; Pordeus, Isabela Almeida; Vale, Míriam Pimenta

2015-01-01

Traumatic dental injury (TDI) during childhood may negatively impact the quality of life of children. To describe the association of oral health-related quality of life (OHRQoL) and domains (oral symptons, functional limitation, emotional- and social-well-being) of children with individual and contextual variables. A cross-sectional study was performed using a representative sample of 1,201 schoolchildren, 8-10 years-old, from public and private schools of Belo Horizonte, Brazil. The CPQ8-10 was used to assess OHRQoL, dichotomized in low and high impact. Sociodemographic information was collected through questionnaires to parents. Children were examined at schools, using the Andreasen criteria. Individual variables were gender, age, number of residents in home, parents/caregivers' level of education, family income, and TDI (dichotomized into without trauma/mild trauma and severe trauma). Dental caries and malocclusion were considered co-variables. Contextual variables were the Social Vulnerability Index and type of school. Ethical approval and consent forms were obtained. Data were analyzed using SPSS for Windows 19.0 and HLM 6.06, including frequency distribution, chi-squared test and multilevel approach (p < 0.05). The prevalence of a negative impact on OHRQoL in children with severe trauma was 55.9%. The TDI negatively impacted emotional and social domains of OHRQoL. A multilevel analysis revealed a significant difference in OHRQoL according to the type of school and showed that 16% of the total variance was due to contextual characteristics (p < 0.001; ICC = 0.16). The negative impact on OHRQoL was higher in girls (p = 0.009), younger children (p = 0.023), with severe TDI (p = 0.014), those from public schools (p = 0.017) and whose parents had a lower education level (p = 0.001). Severe trauma impacts OHRQoL on emotional and social domains. Contextual dimensions add information to individual variability to explain higher impact, emphasizing socioeconomic inequalities.

Disparities in Rates of Inpatient Mortality and Adverse Events: Race/Ethnicity and Language as Independent Contributors

PubMed Central

Hines, Anika L.; Andrews, Roxanne M.; Moy, Ernest; Barrett, Marguerite L.; Coffey, Rosanna M.

2014-01-01

Patients with limited English proficiency have known limitations accessing health care, but differences in hospital outcomes once access is obtained are unknown. We investigate inpatient mortality rates and obstetric trauma for self-reported speakers of English, Spanish, and languages of Asia and the Pacific Islands (API) and compare quality of care by language with patterns by race/ethnicity. Data were from the United States Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, 2009 State Inpatient Databases for California. There were 3,757,218 records. Speaking a non-English principal language and having a non-White race/ethnicity did not place patients at higher risk for inpatient mortality; the exception was significantly higher stroke mortality for Japanese-speaking patients. Patients who spoke API languages or had API race/ethnicity had higher risk for obstetric trauma than English-speaking White patients. Spanish-speaking Hispanic patients had more obstetric trauma than English-speaking Hispanic patients. The influence of language on obstetric trauma and the potential effects of interpretation services on inpatient care are discussed. The broader context of policy implications for collection and reporting of language data is also presented. Results from other countries with and without English as a primary language are needed for the broadest interpretation and generalization of outcomes. PMID:25514153

Health-related quality of life two years after injury due to terrorism.

PubMed

Tuchner, Maya; Meiner, Zeev; Parush, Shula; Hartman-Maeir, Adina

2010-01-01

During the past few decades, terrorist acts have been an unfortunate reality worldwide. There is a striking paucity of research investigating the multitude of long-term outcomes after severe physical injury due to terrorist attacks, a unique subgroup of trauma patients. The purpose of this study was to provide a profile of the long-term health-related quality of life (HR-QOL) after injury due to terrorist attacks and to explore the relationships between Post Traumatic Stress Disorder (PTSD), occupational status and injury severity with HR-QOL. We included 35 survivors of terrorist attacks living in the community, two years on average after the injury, mean age at follow-up = 32.1 (±13.8), mean Injury Severity Score (ISS) = 27 (±14.2). The subjects were recruited from consecutive admissions to a rehabilitation department in a tertiary care center between September 2000 - June 2004. Most of the subjects suffered multiple trauma. The main outcome measures were the Short-Form Health Survey (SF-36), Post Traumatic Diagnostic Scale and return to work rates. The mean scores on 6/8 of the SF-36 subscales were significantly lower among the survivors compared to normative population norms. Post Traumatic Stress Disorder (PTSD) was found in 39% of the sample and 43% did not resume their main occupation two years after the injury. Multivariate analysis of variance of PTSD and occupational status (returned vs. did not return to work) on quality of life scores revealed significant main effects for both PTSD (p=. 000) and occupational status (p=. 005) with no interaction effect (p=. 476). No significant correlations were found between injury severity and the SF-36 scores. This study demonstrated the long-term impact of injury due to terrorism. Results showed independent effects of PTSD and occupational status on health related quality of life, two years after injury. These findings suggest that this group may benefit from intervention focusing on their emotional and occupational status in order to improve their quality of life.

Relationship of Religiousness and Religious Coping with Quality of Life among War Trauma Survivors.

PubMed

Fadilpašić, Senadin; Maleč, Daniel; Džubur-Kulenović, Alma

2017-09-01

Long-term posttraumatic outcomes such as quality of life are dependent on a series of factors from the very exposure to traumatic events and stress appraisals, personality traits, posttraumatic growth, symptoms of Posttraumatic stress disorder (PTSD) and different coping strategies to religiousness and religious coping styles. Except of exposure to traumatic events and related stress, all other variables may have indirect mediating effects on long-term posttraumatic outcomes. The main aim of this cross-sectional study is to explore relative independent contribution of these variables in the explanation of quality of life among war trauma survivors, with a special emphasis on the variables of religiousness and religious coping. The research was conducted on 353 subjects who experienced war related traumatic events during the war in Bosnia and Herzegovina (B&H). The data was collected through several self-report measuring instruments: Manchester Short Assessment of Quality of Life, Stressors Check List (SCL); Religiousness Scale, Social Support Resources Scale; Religious Problem-Solving Scale, Brief RCOPE, Posttraumatic Growth Inventory and Mississippi Scale for PTSD. According to the results of the study, experience of loss and frequent exposure to war trauma and high levels on the primary stress appraisals, self-directing coping style and PTSD-symptoms were associated with lower perceived quality of life among the subjects. High levels of extrinsic religious orientation, effect of religiousness on social behavior, positive religious coping and posttraumatic growth were associated with higher perceived quality of life among subjects. These variables showed significant independent contribution to the prediction of the values on quality of life. Results of the study have a scientific significance in understanding the importance and mediating role of religiousness and religious coping for quality of life perception as one of long-term posttraumatic outcomes. Effects of religiousness on social behavior and positive religious coping showed particularly significant contribution across all prediction models for the quality of life.

Adult Dental Trauma: What Should the Dental Practitioner Know?

PubMed

Chauhan, Ravi; Rasaratnam, Lakshmi; Alani, Aws; Djemal, Serpil

2016-05-01

The management of adult dental trauma can be a daunting challenge for practitioners at any level. Like medical emergencies, initial management can have a large influence on prognosis. It is important that practitioners understand the basic principles of managing the acute presentations of dental trauma. This article aims to illustrate a step-by-step approach in order to improve the management within general dental practice for better outcomes for patients.

The alpha1-adrenergic antagonist prazosin ameliorates combat trauma nightmares in veterans with posttraumatic stress disorder: a report of 4 cases.

PubMed

Raskind, M A; Dobie, D J; Kanter, E D; Petrie, E C; Thompson, C E; Peskind, E R

2000-02-01

Central nervous system (CNS) adrenergic hyperresponsiveness may be involved in the pathophysiology of posttraumatic stress disorder (PTSD). Two Vietnam combat veterans with PTSD prescribed the centrally active alpha1-adrenergic antagonist prazosin for symptoms of benign prostatic hypertrophy unexpectedly reported elimination of combat trauma nightmares. This observation prompted an open-label feasibility trial of prazosin for combat trauma nightmares in chronic combat-induced PTSD. Four consecutively identified combat veterans with chronic DSM-IV PTSD and severe intractable combat trauma nightmares participated in an 8-week open trial of escalating-dose prazosin. Nightmare severity response was rated using the nightmare item of the Clinician Administered PTSD Scale and the Clinical Global Impressions-Change scale. The 2 patients who achieved a daily prazosin dose of at least 5 mg were markedly improved, with complete elimination of trauma nightmares and resumption of normal dreaming. The 2 subjects limited to 2 mg of prazosin to avoid excessive blood pressure reduction were moderately improved with at least 50% reduction in nightmare severity. These clinical observations, together with neurobiological evidence for alpha1-adrenergic regulation of CNS neurobiological systems relevant to PTSD, provide rationale for placebo-controlled trials of prazosin for PTSD combat trauma nightmares.

A review of the management of blunt splenic trauma in England and Wales: have regional trauma networks influenced management strategies and outcomes?

PubMed Central

Hall, C; Pearce, L; Bouamra, O; Jenks, T; Scrimshire, AB; Hughes, J; Lecky, F; Macdonald, ADH

2017-01-01

INTRODUCTION The spleen remains one of the most frequently injured organs following blunt abdominal trauma. In 2012, regional trauma networks were launched across England and Wales with the aim of improving outcomes following trauma. This retrospective cohort study investigated the management and outcomes of blunt splenic injuries before and after the establishment of regional trauma networks. METHODS A dataset was drawn from the Trauma Audit Research Network database of all splenic injuries admitted to English and Welsh hospitals from 1 April 2010 to 31 March 2014. Demographic data, injury severity, treatment modalities and outcomes were collected. Management and outcomes were compared before and after the launch of regional trauma networks. RESULTS There were 1457 blunt splenic injuries: 575 between 2010 and 2012 and 882 in 2012–14. Following the introduction of the regional trauma networks, use of splenic artery embolotherapy increased from 3.5% to 7.6% (P = 0.001) and splenectomy rates decreased from 20% to 14.85% (P = 0.012). Significantly more patients with polytrauma and blunt splenic injury were treated with splenic embolotherapy following 2012 (61.2% vs. 30%, P < 0.0001). Increasing age, injury severity score, polytrauma and Charlson Comorbidity Index above 10 were predictors of increased mortality (P < 0.001). Increasing systolic blood pressure (odds ratio, OR, 0.757, 95% confidence interval, CI, 0.716–0.8) and Glasgow Coma Scale (OR 0.988, 95% CI 0.982–0.995) were protective. CONCLUSIONS This study demonstrates a reduction in splenectomy rate and an increased use of splenic artery embolotherapy since the introduction of the regional trauma networks. This may have resulted from improved access to specialist services and reduced practice variation since the establishment of these networks. PMID:27791418

A statewide model program to improve emergency department readiness for pediatric care.

PubMed

Cichon, Mark E; Fuchs, Susan; Lyons, Evelyn; Leonard, Daniel

2009-08-01

Pediatric emergency patients have unique needs, requiring specialized personnel, training, equipment, supplies, and medications. Deficiencies in these areas have resulted in historically poorer outcomes for pediatric patients versus adults. Since 1985, federally funded Emergency Medical Services for Children (EMSC) programs in each state have been working to improve the quality of pediatric emergency care. The Health Resources and Services Administration now requires that all EMSC grantees report on specific performance measures. This includes implementation of a standardized system recognizing hospitals that are able to stabilize or manage pediatric medical emergencies and trauma cases. We describe the steps involved in implementing Illinois' 3-level facility recognition process to illustrate a model that other states might use to provide appropriate pediatric care and comply with new Health Resources and Services Administration performance measures.

Integrated Cognitive Behavioral Therapy Versus Cognitive Processing Therapy for Adults With Depression, Substance Use Disorder, and Trauma.

PubMed

Haller, Moira; Norman, Sonya B; Cummins, Kevin; Trim, Ryan S; Xu, Xiaomin; Cui, Ruifeng; Allard, Carolyn B; Brown, Sandra A; Tate, Susan R

2016-03-01

The comorbidity of substance use disorder (SUD), depression, and PTSD is common among veterans. Prior research has shown that among veterans with SUD and depression, those with PTSD did not maintain cognitive-behavioral treatment gains as well as those without PTSD. Thus, the current study was designed to evaluate whether adding trauma-focused treatment following an initial group-based integrated cognitive behavioral treatment (ICBT) for SUD and depression improved treatment outcomes. Participants were 123 veterans (89% male) recruited from the VA San Diego Healthcare System. All participants received ICBT in twice weekly, group-delivered sessions for 12 weeks (Phase 1). Participants were then randomized to receive 12 sessions of individual follow-up sessions (Phase 2) utilizing either ICBT or cognitive processing therapy that was modified to integrate SUD treatment (CPT-M). Results indicated that PTSD and depression symptoms slightly improved at the end of Phase 1 group ICBT and further improved through Phase 2 individual treatment (except for participants without PTSD who received CPT-M), with treatment gains maintained one year later. Substance use significantly improved at the end of Phase 1 group ICBT and these improvements were maintained through Phase 2 and the one year follow-up. Participants in the trauma-focused Phase 2 treatment (CPT-M) exhibited similar levels of symptom reduction and maintenance of treatment gains as those in the non-trauma-focused Phase 2 treatment (ICBT). However, there was a slight advantage for Phase 2 CPT-M over Phase 2 ICBT with respect to heavy drinking outcomes for individuals with PTSD. Overall, the combination of group ICBT followed by either CPT-M or ICBT individual therapy appears to be effective for veterans with depression, SUD, and trauma history. Copyright © 2015. Published by Elsevier Inc.

Plasma transfusion for patients with severe hemorrhage: what is the evidence?

PubMed

Callum, Jeannie L; Rizoli, Sandro

2012-05-01

The following review will detail the current knowledge in massive hemorrhage with regard to the pathophysiology of the coagulation disturbance, the role of plasma, the role of alternatives to plasma, and the clinical value of having a massive transfusion protocol. The coagulation disturbance in trauma patients is more than just the result of consumption of clotting factors at sites of injury and dilution from the infusion of intravenous fluids and red blood cells (RBCs). Even before substantial amounts of fluid resuscitation and RBC transfusion, one-quarter of trauma patients already have abnormal coagulation variables. There is an apparent role for the activation of protein C, hypofibrinogenemia, and fibrin(gen)olysis in the coagulation disturbance after trauma and massive hemorrhage. None of these three disturbances would be completely mitigated by the use of plasma alone, suggesting that there may be an opportunity to improve care of these patients with alternative strategies, such as fibrinogen concentrates and antifibrinolytics. Despite numerous retrospective cohort studies evaluating 1:1 plasma to RBC formula-driven resuscitation, the overall clinical value of this approach is unclear. Studies have even raised concerns regarding a potential increase in morbidity associated with this approach, particularly for patients overtriaged to 1:1 where a massive transfusion is unlikely. We also do not have sufficient evidence to recommend either goal-directed therapy with thromboelastography or early use of fibrinogen replacement, with either cryoprecipitate or fibrinogen concentrates. We have high-quality data that argue against the role for recombinant Factor VIIa that should prompt removal of this strategy from existing protocols. In contrast, we have high-level evidence that all bleeding trauma patients should receive tranexamic acid as soon as possible after injury. This therapy must be included in hemorrhage protocols. If we are to improve the care of massively bleeding patients on a firm scientific ground, we will need large-scale randomized trials to delineate the role of coagulation replacement and the utility of laboratory monitoring. But even until these trials are completed, it is clear that a massive transfusion protocol is needed in all hospitals that manage bleeding patients, to ensure a prompt and coordinated response to hemorrhage. © 2012 American Association of Blood Banks.

Improved clinical documentation leads to superior reportable outcomes: An accurate representation of patient's clinical status.

PubMed

Elkbuli, Adel; Godelman, Steven; Miller, Ashley; Boneva, Dessy; Bernal, Eileen; Hai, Shaikh; McKenney, Mark

2018-05-01

Clinical documentation can be an underappreciated. Trauma Centers (TCs) are now routinely evaluated for quality performance. TCs with poor documentation may not accurately reflect actual injury burden or comorbidities and can impact accuracy of mortality measures. Markers exist to adjust crude death rates for injury severity: observed over expected deaths (O/E) adjust for injury; Case Mix Index (CMI) reflects disease burden, and Severity of Illness (SOI) measures organ dysfunction. We aim to evaluate the impact of implementing a Clinical Documentation Improvement Program (CDIP) on reported outcomes. Review of 2-years of prospectively collected data for trauma patients, during the implementation of CDIP. A two-group prospective observational study design was used to evaluate the pre-implementation and the post-implementation phase of improved clinical documentation. T-test and Chi-Squared were used with significance defined as p < 0.05. In the pre-implementation period, there were 49 deaths out of 1419 (3.45%), while post-implementation period, had 38 deaths out of 1454 (2.61%), (non-significant). There was however, a significant difference between O/E ratios. In the pre-phase, the O/E was 1.36 and 0.70 in the post-phase (p < 0.001). The two groups also differed on CMI with a pre-group mean of 2.48 and a post-group of 2.87 (p < 0.001), indicating higher injury burden in the post-group. SOI started at 2.12 and significantly increased to 2.91, signifying more organ system dysfunction (p < 0.018). Improved clinical documentation results in improved accuracy of measures of mortality, injury severity, and comorbidities and a more accurate reflection in O/E mortality ratios, CMI, and SOI. Copyright © 2018 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.

The spiritual intelligence of nurses in Taiwan.

PubMed

Yang, Ke-Ping

2006-03-01

The purposes of the study included: (1) defining the profile of nurses' spiritual intelligence; (2) examining the relationship between nurses' demographic characteristics and spiritual intelligence; and (3) exploring the mode of nurses' spiritual intelligence and related factors, among nurses in Taiwan. A cross-sectional descriptive study was designed and administered to 299 hospital registered nurses, who were distributed throughout metropolitan Taipei. Wolman's (2001) PsychoMatrix Spirituality Inventory, a 4-point scaled, self-reported, 49-item questionnaire covering seven spiritual factors (divinity, mindfulness, extrasensory perception, community, intellectuality, trauma, and childhood spirituality) was used to measure nurses' spiritual intelligence. Results showed that nurses' spiritual intelligence was centralized in a moderate degree, while trauma and childhood spirituality were either moderate or high. Age and childhood spirituality were the most significant variables affecting nurses' spiritual intelligence, accounting for 61.4% of the variance in nurses' spiritual intelligence. This study may contribute to a better understanding of the spiritual intelligence profile of nurses and may also help facilitate a program for nurses' spiritual development as well as improve the quality of spiritual care.

Postpartum posttraumatic stress disorder in a fetal high-risk maternity hospital in the city of Rio de Janeiro, Brazil.

PubMed

Henriques, Tatiana; Moraes, Claudia Leite de; Reichenheim, Michael E; Azevedo, Gustavo Lobato de; Coutinho, Evandro Silva Freire; Figueira, Ivan Luiz de Vasconcellos

2015-12-01

The objectives of this study were to estimate the prevalence of postpartum posttraumatic stress disorder (PTSD) in a maternity hospital for fetal high-risk pregnancies and to identify vulnerable subgroups. This was a cross-sectional study at a fetal high-risk maternity hospital in Rio de Janeiro, Brazil, with a sample of 456 women who had given birth at this hospital. The Trauma History Questionnaire and Post-Traumatic Stress Disorder Checklist were used to screen for lifetime traumatic events and PTSD symptoms, respectively. Overall prevalence of PTSD was 9.4%. Higher PTSD prevalence was associated with three or more births, a newborn with a 1-minute Apgar score of seven or less, history of mental disorder prior to or during the index pregnancy, postpartum depression, physical or psychological intimate partner violence during the pregnancy, a history of unwanted sexual experience, and lifetime exposure to five or more traumas. Rapid diagnosis and treatment of PTSD are essential to improve the mother's quality of life and the infant's health.

Stigma, American military personnel and mental health care: challenges from Iraq and Afghanistan.

PubMed

Schreiber, Michael; McEnany, Geoffry Phillips

2015-02-01

Since 2001, more than 2.5 million United States military personnel have been deployed for combat. Over one million have served multiple deployments. Combat generally involved repeated exposure to highly traumatic events. Personnel were also victims of military sexual trauma (MST), a major risk factor for psychiatric illness. Most survivors do not seek or receive mental health care. Stigma is one of the main barriers to that care. To explore the impact of stigma on personnel with psychiatric illness, and suggest some innovative ways to potentially reduce stigma and improve care. Cinahl and PubMed databases were searched from 2001 to 2014. Anonymity, the use of non-stigmatizing language, peer-to-peer, and stigma-reduction programs help military personnel receive mental health care. Technology offers the opportunity for effective and appropriate education and treatment. Although stigma is formidable, several innovative services are available or being developed for military victims of trauma. Commitment of resources for program development and further research to explore which interventions offer the best clinical outcomes are needed to increase efforts to combat stigma and ensure quality care.

The role of point of care ultrasound in prehospital critical care: a systematic review.

PubMed

Bøtker, Morten Thingemann; Jacobsen, Lars; Rudolph, Søren Steemann; Knudsen, Lars

2018-06-26

In 2011, the role of Point of Care Ultrasound (POCUS) was defined as one of the top five research priorities in physician-provided prehospital critical care and future research topics were proposed; the feasibility of prehospital POCUS, changes in patient management induced by POCUS and education of providers. This systematic review aimed to assess these three topics by including studies examining all kinds of prehospital patients undergoing all kinds of prehospital POCUS examinations and studies examining any kind of POCUS education in prehospital critical care providers. By a systematic literature search in MEDLINE, EMBASE, and Cochrane databases, we identified and screened titles and abstracts of 3264 studies published from 2012 to 2017. Of these, 65 studies were read in full-text for assessment of eligibility and 27 studies were ultimately included and assessed for quality by SIGN-50 checklists. No studies compared patient outcome with and without prehospital POCUS. Four studies of acceptable quality demonstrated feasibility and changes in patient management in trauma. Two studies of acceptable quality demonstrated feasibility and changes in patient management in breathing difficulties. Four studies of acceptable quality demonstrated feasibility, outcome prediction and changes in patient management in cardiac arrest, but also that POCUS may prolong pauses in compressions. Two studies of acceptable quality demonstrated that short (few hours) teaching sessions are sufficient for obtaining simple interpretation skills, but not image acquisition skills. Three studies of acceptable quality demonstrated that longer one- or two-day courses including hands-on training are sufficient for learning simple, but not advanced, image acquisition skills. Three studies of acceptable quality demonstrated that systematic educational programs including supervised examinations are sufficient for learning advanced image acquisition skills in healthy volunteers, but that more than 50 clinical examinations are required for expertise in a clinical setting. Prehospital POCUS is feasible and changes patient management in trauma, breathing difficulties and cardiac arrest, but it is unknown if this improves outcome. Expertise in POCUS requires extensive training by a combination of theory, hands-on training and a substantial amount of clinical examinations - a large part of these needs to be supervised.

Protocol compliance and time management in blunt trauma resuscitation.

PubMed

Spanjersberg, W R; Bergs, E A; Mushkudiani, N; Klimek, M; Schipper, I B

2009-01-01

To study advanced trauma life support (ATLS) protocol adherence prospectively in trauma resuscitation and to analyse time management of daily multidisciplinary trauma resuscitation at a level 1 trauma centre, for both moderately and severely injured patients. All victims of severe blunt trauma were consecutively included. Patients with a revised trauma score (RTS) of 12 were resuscitated by a "minor trauma" team and patients with an RTS of less than 12 were resuscitated by a "severe trauma" team. Digital video recordings were used to analyse protocol compliance and time management during initial assessment. From 1 May to 1 September 2003, 193 resuscitations were included. The "minor trauma" team assessed 119 patients, with a mean injury severity score (ISS) of 7 (range 1-45). Overall protocol compliance was 42%, ranging from 0% for thoracic percussion to 93% for thoracic auscultation. The median resuscitation time was 45.9 minutes (range 39.7-55.9). The "severe team" assessed 74 patients, with a mean ISS of 22 (range 1-59). Overall protocol compliance was 53%, ranging from 4% for thoracic percussion to 95% for thoracic auscultation. Resuscitation took 34.8 minutes median (range 21.6-44.1). Results showed the current trauma resuscitation to be ATLS-like, with sometimes very low protocol compliance rates. Timing of secondary survey and radiology and thus time efficiency remains a challenge in all trauma patients. To assess the effect of trauma resuscitation protocols on outcome, protocol adherence needs to be improved.

Trafficking and Trauma: Insight and Advice for the Healthcare System From Sex-trafficked Women Incarcerated on Rikers Island.

PubMed

Ravi, Anita; Pfeiffer, Megan R; Rosner, Zachary; Shea, Judy A

2017-12-01

Sex-trafficked persons experience significant trauma while exploited, resulting in complex health issues and barriers to health care. Incorporating survivor perspectives is critical in optimizing health care delivery for this population. We interviewed sex-trafficking survivors regarding their experiences with trauma while being trafficked and elicited advice about health care delivery. Qualitative interviews were conducted in New York City's Rikers Island jail from July to September 2015. In total, 21 English-speaking women who had experienced sex trafficking were the subjects of the study. Interview domains included: interpersonal violence, behavioral health, and health care delivery advice. Interviewees described experiencing severe and chronic trauma perpetrated by traffickers and sex buyers. Substance use was the primary method of coping with trauma. With regard to mental health, interviewees noted diagnoses of depression, anxiety and posttraumatic stress disorder, low self-esteem, and challenges in intimate relationships. Health care delivery themes included approaches to discussing trafficking in health care settings, concerns regarding sexual assault examinations, and suggestions for improving direct-services and prevention programming. With this perspective into the complex intersection of trauma and behavioral health that sex-trafficked women can experience, health care providers can better understand the context and recommendations regarding trauma-informed care practices for this population. Our results also offer several avenues for future studies with regard to discussing trafficking in clinical settings and an opportunity for stakeholders to incorporate survivor-based input to improve health care for this population.

Testing the Community-Based Learning Collaborative (CBLC) implementation model: a study protocol.

PubMed

Hanson, Rochelle F; Schoenwald, Sonja; Saunders, Benjamin E; Chapman, Jason; Palinkas, Lawrence A; Moreland, Angela D; Dopp, Alex

2016-01-01

High rates of youth exposure to violence, either through direct victimization or witnessing, result in significant health/mental health consequences and high associated lifetime costs. Evidence-based treatments (EBTs), such as Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), can prevent and/or reduce these negative effects, yet these treatments are not standard practice for therapists working with children identified by child welfare or mental health systems as needing services. While research indicates that collaboration among child welfare and mental health services sectors improves availability and sustainment of EBTs for children, few implementation strategies designed specifically to promote and sustain inter-professional collaboration (IC) and inter-organizational relationships (IOR) have undergone empirical investigation. A potential candidate for evaluation is the Community-Based Learning Collaborative (CBLC) implementation model, an adaptation of the Learning Collaborative which includes strategies designed to develop and strengthen inter-professional relationships between brokers and providers of mental health services to promote IC and IOR and achieve sustained implementation of EBTs for children within a community. This non-experimental, mixed methods study involves two phases: (1) analysis of existing prospective quantitative and qualitative quality improvement and project evaluation data collected pre and post, weekly, and monthly from 998 participants in one of seven CBLCs conducted as part of a statewide initiative; and (2) Phase 2 collection of new quantitative and qualitative (key informant interviews) data during the funded study period to evaluate changes in relations among IC, IOR, social networks and the penetration and sustainment of TF-CBT in targeted communities. Recruitment for Phase 2 is from the pool of 998 CBLC participants to achieve a targeted enrollment of n = 150. Study aims include: (1) Use existing quality improvement (weekly/monthly online surveys; pre-post surveys; interviews) and newly collected quantitative (monthly surveys) and qualitative (key informant interviews) data and social network analysis to test whether CBLC strategies are associated with penetration and sustainment of TF-CBT; and (2) Use existing quantitative quality improvement (weekly/monthly on-line surveys; pre/post surveys) and newly collected qualitative (key informant interviews) data and social network analysis to test whether CBLC strategies are associated with increased IOR and IC intensity. The proposed research leverages an on-going, statewide implementation initiative to generate evidence about implementation strategies needed to make trauma-focused EBTs more accessible to children. This study also provides feasibility data to inform an effectiveness trial that will utilize a time-series design to rigorously evaluate the CBLC model as a mechanism to improve access and sustained use of EBTs for children.