Epidemiology of traumatic brain injuries at a rural-serving Level II trauma center, 2004 - 2016.

OBJECTIVE: To describe the epidemiology of traumatic brain injury (TBI) and quantify rural and urban differences. METHODS: Patient characteristics, injury characteristics, imaging, and outcomes were extracted from the trauma registry of the level II trauma center at Essentia Health-St. Mary's Medical Center, Duluth, MN, for patients admitted for a TBI from January 1, 2004, through December 31, 2016. Estimated relative risk (RR) per year, Wald 95% confidence intervals, and p-values were calculated. RESULTS: Of the 5,079 TBI admissions during the study period, just under half (2,510, 49.4%) resided in rural areas at the time of admission. Overall, there was a 3.8% unadjusted annual increase in TBI risk rom 2004-2016, with 2.9% and 4.7% annual increases among rural and urban U.S. residents, respectively. Rural residents had significant annual increases in risk of TBI admission resulting in 30-day post-discharge emergency department readmission and 30-day post-discharge combined inpatient/emergency department readmission of 35.2% and 22.4%, respectively. CONCLUSIONS: We found that risk of rural resident TBI admission due to MVC was significantly greater than that for urban residents. Public health and medical interventions to decrease the rural/urban disparity are warranted, including public health campaigns to increase seat belt use, and supportive care post-discharge into rural communities.

Development, Implementation, and Evaluation of an Early Mobility Protocol in a Regional Level II Trauma Center.

The purpose of this project was to develop and evaluate a collaborative nursing/therapist protocol for early mobility in a medical-surgical intensive care unit (MICU) in a regional level II trauma center. Data for patients in the MICU were compared for the periods August 3, 2015-August 2, 2016, and August 3, 2014-August 2, 2015. Semistructured interviews were conducted with 10 nurses and 1 therapist. Average MICU length of stay decreased from 3.81 to 3.50 days (P = .057). Mean time in mobility chairs did not change (0.12 days vs 0.11 days, P = .389). Mean number of days to first documented level 2-5 activity decreased significantly, from 1.81 to 1.51 days (P = .036). The percentage of hospitalizations with any documented level 3 or 4 activity increased significantly (from 3.8% to 7.4% and from 61.5% to 66.7%, P = .003 and P = .031, respectively). Barriers/challenges to implementation included having enough people to assist, space, documentation, having to coax the physician to place order for upright mobility, availability of therapists for later stages of protocol, patient variability, fear of patient falls, availability of therapy chairs, staff changes, time, and patient refusal. A multidisciplinary approach to protocol development for early mobility in an intensive care unit was successfully implemented at a regional level II trauma center.

Preventing Exercise-Associated Collapse Using Online Runner Education: A Randomized, Controlled Trial.

OBJECTIVE: To determine whether online exercise-associated collapse (EAC) prevention education decreases medical tent EAC visits among first-time marathoners. DESIGN: A prospective controlled study, with age- and sex-stratified randomization, evaluated rates of medical tent diagnosed EAC among runners randomized to the intervention group and intervention participants, compared with a control group. SETTING: Grandma's Marathon Medical Tent in Duluth, MN, June 2016. PARTICIPANTS: Runners in the 2016 Grandma's Marathon who never previously ran a marathon (n = 2943), randomized into control (n = 1482) and intervention (n = 1461) groups. Intervention participants opened the EAC prevention video (n = 590). INTERVENTIONS: Online EAC education included an introductory webpage and 5-minute professional video describing EAC and prevention. MAIN OUTCOME MEASURES: Medical tent visit with EAC diagnosis. RESULTS: Intervention participants had no decreased likelihood of EAC, compared with controls [odds ratio (OR), 0.88, 95% confidence interval (CI), 0.46-1.69]. Exercise-associated collapse occurred less frequently in those with longer race times (OR, 0.58, 95% CI, 0.43-0.79). Intervention participation was associated with longer race times (OR, 1.12, 95% CI, 1.10-1.23). CONCLUSIONS: Those opening the EAC prevention video and controls had similar EAC rates. Slower running speed was associated with lower EAC rates. Video viewing was a predictor of slower running pace.

Understanding Respiratory Rate Assessment by Emergency Nurses: A Health Care Improvement Project.

INTRODUCTION: Respiratory rate is the first sign of patient decline. Monitoring and recording respiratory rate are essential nursing competencies. However, health care system emergency nurses' ability to differentiate normal from abnormal respiratory rates was unknown. We conducted a health care improvement project to assess emergency nurses' accuracy in "spot" and "formal" assessments, understand assessment practices, and determine competency and training needs. METHODS: In an anonymous cross-sectional survey, 78 emergency nurses from 1 health care system viewed 3 "spot" and 3 "formal" mock patient videos and answered questions in REDCap (Vanderbilt University, Nashville, TN). Accuracy (abnormal/normal), systematic error (bias), and random error (imprecision) were assessed. Descriptive statistics, bivariate analyses, and qualitative content analysis of open-ended questions were reported. RESULTS: Most emergency nurses identified respiration as abnormal in spot and formal assessment videos. Accuracy was lowest for the video displaying 6 breaths per minute. Emergency nurses were more likely to identify abnormal breathing in all formal assessment videos (n = 59, 75.7%) than in all spot assessment videos (n = 41, 52.6%) (McNemar χ2 = 10.32, P = 0.001). Most emergency nurses reported a willingness to use formal assessments and thought that respiratory rate was a good indicator of a patient's condition. The barriers to accurate assessment included time limitations, prior training focusing on assessments lasting less than 30 seconds, and monitor and staff errors. DISCUSSION: Respiratory rate assessment may be best assessed formally, particularly for bradypnea, where formal checks may outperform spot checks. The results present areas for improving respiratory rate assessment training and clinical practice.

Implementation of a "Serenity Room": Promoting resiliency in the ED.

Work-related stress is common within the nursing profession, especially in the ED. Studies have shown that interventions to improve hospital working environments positively impact retention and help prevent burnout. This nursing practice innovation project describes the development, implementation, and evaluation of a restorative space (the "Serenity Room") in a busy regional ED. The evaluation of this project focused on the effectiveness of the room at reducing stress and the value ED staff place on having access to a restorative space. Data were gathered through pre- and postimplementation surveys.

Implementation of the MEDFRAT to Promote Quality Care and Decrease Falls in Community Hospital Emergency Rooms.

ABSTRACTPURPOSE: To identify and implement an evidence-based fall-risk assessment tool for use in emergency departments at Essentia Health, a large, primarily rural health care delivery system with 12 emergency departments. METHODS: The Iowa Model of Evidence-Based Practice to Promote Quality Care was used to guide the process. The Memorial Emergency Department Fall-Risk Assessment Tool (MEDFRAT) was programmed into the electronic medical record, along with interventions that could be selected for 2 fall-risk levels. An education session was developed for emergency nurses about falls and MEDFRAT, with planned time for discussion about any concerns in the implementation of MEDFRAT. MEDFRAT was selected for implementation by nursing leadership because it is evidence based and appeared to be conducive to implementation in the diverse emergency departments across 12 sites in 3 states. RESULTS: Education sessions were presented to nurses at 11 of 12 emergency departments. Suggestions to support site-specific implementation were programmed into the electronic health record. Nurses expressed appreciation that they were consulted, and their feedback was incorporated into the tool before it was implemented. Resources needed at each site to implement recommended MEDFRAT interventions in the tool were identified. Needed resources were then provided to the emergency departments before implementation of MEDFRAT. CONCLUSIONS: The Iowa Model was a useful framework to select an evidence-based tool and then engage nurses in the process of implementing evidence-based practice changes in emergency departments across a diverse health care system serving a largely rural population. Ongoing follow-up will determine if this process results in fewer falls.

Alcohol Use at the Time of Traumatic Brain Injury: Screening and Brief Intervention in a Community Hospital.

The use of screening and brief interventions (SBI) has been proposed to reduce future alcohol misuse and injury in traumatic brain injury (TBI) patients. As a result a SBI protocol for TBI patients was introduced with nursing training at a community hospital. In the 2 years following the implementation of a SBI protocol and nursing training, the number of patients with positive alcohol results decreased. The number of brief interventions increased to 83 (40.1%, 95% confidence limit [CL] = 33.4, 46.8), and CAGE questionnaire screenings decreased to 88 (42.5%, 95% CL = 35.8, 49.2), with 31 (35.2%) having positive results. These results highlight the need to assess processes and training in the emergency department to ensure that SBIs occur.

Increased Morbidity and One-Year Post-Discharge Mortality in Patients with Bacteremia Undergoing Emergent Cholecystectomy: An Exploratory Retrospective Observational Study.

Background: Gallbladder disease, one of the most common diseases in the United States, ranges from symptomatic gallstones to severe systemic infections from cholangitis. Little research is available on how often patients undergoing emergent cholecystectomy also have bacteremia. We hypothesized that blood cultures would be performed rarely in patients undergoing emergent cholecystectomy, and that positive cultures would be associated with worse outcomes. Methods: Exploratory retrospective observational cohort study of patients admitted to a single institution from January 17, 2011, to December 31, 2018, and undergoing emergent cholecystectomy by acute care surgeons within ∼72 hours, or three days, of admission. Analyses included descriptive and by-variable statistics, binary logistic regression, and negative binomial regression. Results: Of 892 patients undergoing emergent cholecystectomy, 145 (16.2%) had blood cultures obtained three days before or on the day of surgery, of whom 33 (22.8%) had at least one positive blood culture. Male and older patients had significantly higher rates of blood cultures being obtained. One-year post-discharge mortality and complication rates were significantly higher in those with blood cultures. Versus patients with negative blood cultures, those with positive cultures were significantly older and had higher rates of sepsis and septicemia, longer hospital stays, lower rates of being discharged home, and higher one-year post-discharge mortality rates (18.2% vs. 6.3%). Cholangitis, accounting for 29% of positive blood cultures, was diagnosed in 4.5% of emergent cholecystectomies performed. Gram-negative Escherichia coli were the most common bacteria isolates. Conclusions: Positive blood cultures were associated with significantly worse patient outcomes. Surgeons performing emergent cholecystectomies could consider implementing blood culture protocols to better identify patients at risk for greater hospital morbidity and post-discharge mortality.

Implementing a Screening and Brief Intervention Protocol for Excessive Alcohol Use in a Trauma Center: A Healthcare Improvement Project.

OBJECTIVE: The aim of this healthcare improvement project was to evaluate healthcare provider use of screening and brief interventions (SBIs) for patients screening positive for alcohol at an upper Midwestern adult trauma center transitioning from Level II to Level I. METHOD: Trauma registry data for 2,112 adult patients with trauma who screened positive for alcohol were compared between three periods: pre-formal-SBI protocol (January 1, 2010, to November 29, 2011); first post-SBI protocol (February 6, 2012, to April 17, 2016) after protocol implementation, healthcare provider training, and documentation changes; and second post-SBI protocol (June 1, 2016, to June, 30, 2019) after additional training and process improvements. Data analysis included descriptive statistics and logistic regression for comparisons over time and between admitting services. RESULTS: For the trauma admitting service, SBI rates increased from 32% to 90% over time, compared with 18%-51% for other admitting services combined. Trauma-service-admitted patients screening positive for alcohol had higher odds of receiving a brief intervention than other admitting services in each period in adjusted models: pre-SBI (OR = 1.99, 95% CI [1.15, 3.43], p = .014), first post-SBI (OR = 2.89, 95% CI [2.04, 4.11], p < .001), and second post-SBI (OR = 11.40, 95% CI [6.27, 20.75], p < .001) protocol periods. Within trauma service admissions, first post-SBI protocol (OR = 2.15, 95% CI [1.64, 2.82], p < .001) and second post-SBI protocol (OR = 21.56, 95% CI [14.61, 31.81], p < .001) periods had higher rates and odds of receiving an SBI than the pre-SBI protocol period. CONCLUSION: The number of SBIs completed with alcohol-positive adult patients with trauma significantly increased over time through SBI protocol implementation, healthcare provider training, and process improvements, suggesting other admitting services with lower SBI rates could adopt similar approaches.

Epidemiology, Management, and Outcomes of Accidental Hypothermia: A Multicenter Study of Regional Care.

BACKGROUND: Hypothermia is an uncommon, potentially life-threatening condition. We hypothesized (1) advanced rewarming techniques were more frequent with increased hypothermia severity, (2) active rewarming is increasingly performed with smaller intravascular catheters and decreased cardiopulmonary bypass, and (3) mortality was associated with age, hypothermia severity, and type. METHODS: Trauma patients with temperatures <35°C at 4 ACS-verified trauma centers in Wisconsin and Minnesota from 2006 to 2016 were reviewed. Statistical analysis included chi-square and Fisher's exact tests. A P value < .05 was considered significant. RESULTS: 337 patients met inclusion criteria; primary hypothermia was identified in 127 (38%), secondary in 113 (34%), and mixed primary/secondary in 96 (28%) patients. Hypothermia was mild in 69%, moderate in 26%, and severe in 5% of patients. Intravascular rewarming catheter was the most frequent advanced modality (2%), used increasingly since 2014. Advanced techniques were used for primary (12%) vs. secondary (0%) and mixed (5%) (P = .0002); overall use increased with hypothermia severity but varied by institution. Dysrhythmia, acute kidney injury, and frostbite risk worsened with hypothermia severity (P < .0001, P = .031, and P < .0001, respectively). Mortality was greatest in patients with mixed hypothermia (39%, P = .0002) and age >65 years (33%, P = .03). Thirty-day mortality rates were similar among severe, moderate, and mild hypothermia (P = .44). CONCLUSION: Advanced rewarming techniques were used more frequently in severe and primary hypothermia but varied among institutions. Advanced rewarming was less common in mixed hypothermia; mortality was highest in this subgroup. Reliance on smaller intravascular catheters for advanced rewarming increased over time. Given inconsistencies in management, implementation of guidelines for hypothermia management appears necessary.

Predictive utility of the Activity Measure for Post-Acute Care '6-Clicks' short forms on discharge disposition and effect on readmissions: a retrospective observational cohort study.

OBJECTIVES: To evaluate the predictive utility of the Activity Measure for Post-Acute Care '6-Clicks' daily activity and basic mobility functional assessment short forms on inpatient discharge to home compared with skilled nursing facilities, including by diagnostic group (trauma injury, major lower joint replacement/reattachment, spinal fusion excluding cervical), as well as assess the effect of the short forms on 30-day inpatient readmissions. DESIGN: Retrospective, observational cohort study of electronic health record data. SETTING: Five hospitals in a multistate, integrated healthcare system serving a large, rural US population. PARTICIPANTS: The population-based adult (age ≥18) sample of acute care hospitalised patients receiving rehabilitation services included 10 316 patients with 12 314 hospital admissions from the year prior to 6-Clicks implementation (1 June 2015-31 May 2016) (pre-6-Clicks cohort) and 10 931 patients with 13 241 admissions from the year after 6-Clicks implementation (1 January 2017-31 December 2017) (post-6-Clicks cohort). Patients were admitted for major lower joint replacement/reattachment, spinal fusion excluding cervical, trauma injury or another reason. INTERVENTION: Occupational and physical therapist use of 6-Clicks daily activity and basic mobility short forms in the post-6-Clicks cohort. PRIMARY AND SECONDARY OUTCOMES: Discharge disposition (home, including to assisted living, or skilled nursing facility, including swing beds) and 30-day inpatient readmissions. RESULTS: Areas under the receiver operating characteristic curve were 0.82-0.92 (daily activity) and 0.87-0.94 (basic mobility) for discharge to home or skilled nursing facilities, with trauma and spinal fusion patients having the highest values. Daily activity and basic mobility standardised positive and negative predictive values were highest for the three diagnostic groups compared with the full study sample. Few significant differences in 30-day readmissions were seen between pre- and post-6-Clicks cohorts. CONCLUSIONS: 6-Clicks performed well when distinguishing between discharge home or skilled nursing facilities, especially by diagnostic group, supporting use by occupational and physical therapists in discharge planning. Future research could assess where additional intervention or training may reduce 30-day readmissions.

Blunt traumatic brachial plexus injuries in a northern rural US setting: increased likelihood in unshielded motor-powered crashes.

BACKGROUND: Blunt traumatic brachial plexus injuries (BTBPI) are severe peripheral nerve injuries which present in a small portion of trauma patients but can result in long-term neurological disability and severe chronic pain. OBJECTIVE: The goal of this study was to describe the epidemiology of BTBPI in a northern rural setting caused by motor-powered collisions, and to determine the relative risk of these injuries in shielded (cars, trucks, vans, and so on) and unshielded vehicles (snowmobiles, all-terrain vehicles and motorcycles). METHODS: This retrospective study describes the epidemiology of BTBPI caused by motor-powered collisions and treated at two level II trauma centers in northeast Minnesota and determines the relative risk of these injuries in shielded (cars, trucks, vans, and so on) and unshielded vehicles (snowmobiles, all-terrain vehicles and motorcycles). We hypothesized unshielded motor vehicle crashes in rural areas are at an increased risk of incurring BTBPI. RESULTS: Out of all injuries resulting from motor-powered collisions in a 20-year period (9951), BTBPIs were found in 63 trauma patients, a prevalence of 0.6%. The rate of BTBPI involving unshielded vehicles (1.0%) was significantly higher than those involving a shielded vehicle (0.4%) and primarily occurred in rural areas (70%). CONCLUSIONS: Unshielded vehicle crashes, particularly snowmobiles, have the highest risk for BTBPI in our rural region. The overall incidence of these injuries appears to be declining. LEVEL OF EVIDENCE: Level III.

Evaluation of a protocol for early detection of delayed brain hemorrhage in head injured patients on warfarin.

PURPOSE: In 2007, Essentia Health St. Mary's Medical Center (SMMC), a Level II trauma center in northeastern Minnesota, implemented a protocol for patients who presented with blunt head trauma and were receiving warfarin for anticoagulation. The purpose of this study was to determine the incidence and risk factors of early delayed, warfarin-associated intracranial hemorrhage (ICH). METHODS: Adult patients with signs and symptoms of head injury on warfarin who were admitted by protocol to SMMC between March 2007 and June 2015 were included. Patients were observed for neurologic change and received a follow-up head CT scan within 24 h after an initial negative scan. RESULTS: Among the 232 episodes of care studied, there were 204 patients. The average age was 71; 51% of patients were female. Most patients presented with Glasgow Coma Scale score of 15 and had signs of head trauma. The majority of patients (63%) had a therapeutic International Normalized Ratio (INR) for their indicated condition, but 19% of patients had a supratherapeutic INR and 19% had a subtherapeutic INR. The incidence of early delayed ICH was 1.7%; none of these cases required operative intervention or were fatal. CONCLUSIONS: For patients who were anticoagulated with warfarin and had sustained minor traumatic brain injury, implementation of our protocol showed low incidence of early delayed ICH in the first 24 h. We believe withholding warfarin for several days and careful follow-up regarding its resumption is warranted, especially in the setting of supratherapeutic INR.