Identifying and addressing mentorship gaps in European trauma and emergency surgical training. Results from the Young European Society of Trauma and Emergency Surgery (yESTES) mentorship survey.

PURPOSE: European training pathways for surgeons dedicated to treating severely injured and critically ill surgical patients lack a standardized approach and are significantly influenced by diverse organizational and cultural backgrounds. This variation extends into the realm of mentorship, a vital component for the holistic development of surgeons beyond mere technical proficiency. Currently, a comprehensive understanding of the mentorship landscape within the European trauma care (visceral or skeletal) and emergency general surgery (EGS) communities is lacking. This study aims to identify within the current mentorship environment prevalent practices, discern existing gaps, and propose structured interventions to enhance mentorship quality and accessibility led by the European Society for Trauma and Emergency Surgery (ESTES). METHODS: Utilizing a structured survey conceived and promoted by the Young section of the European Society of Trauma and Emergency Surgery (yESTES), we collected and analyzed responses from 123 ESTES members (both surgeons in practice and in training) across 20 European countries. The survey focused on mentorship experiences, challenges faced by early-career and female surgeons, the integration of non-technical skills (NTS) in mentorship, and the perceived role of surgical societies in facilitating mentorship. RESULTS: Findings highlighted a substantial mentorship experience gap, with 74% of respondents engaging in mostly informal mentorship, predominantly centered on surgical training. Notably, mentorship among early-career surgeons and trainees was less reported, uncovering a significant early-career gap. Female surgeons, representing a minority within respondents, reported a disproportionately poorer access to mentorship. Moreover, while respondents recognized the importance of NTS, these were inadequately addressed in current mentorship practices. The current mentorship input of surgical societies, like ESTES, is viewed as insufficient, with a call for structured programs and initiatives such as traveling fellowships and remote mentoring. CONCLUSIONS: Our survey underscores critical gaps in the current mentorship landscape for trauma and EGS in Europe, particularly for early-career and female surgeons. A clear need exists for more formalized, inclusive mentorship programs that adequately cover both technical and non-technical skills. ESTES could play a pivotal role in addressing these gaps through structured interventions, fostering a more supportive, inclusive, and well-rounded surgical community.

What trauma patients need: the European dilemma.

There is a need for implementation and maturation of an inclusive trauma system in every country in Europe, with patient centered care by dedicated surgeons. This process should be initiated by physicians and medical societies, based on the best available evidence, and supported and subsequently funded by the government and healthcare authorities. A systematic approach to organizing all aspects of trauma will result in health gain in terms of quality of care provided, higher survival rates, better functional outcomes and quality of life. In addition, it will provide reliable data for both research, quality improvement and prevention programs. Severely injured patients need surgeons with broad technical and non-technical competencies to provide holistic, inclusive and compassionate care. Here we describe the philosophy of the surgical approach and define the necessary skills for trauma, both surgical and other, to improve outcome of severely injured patients. As surgery is an essential part of trauma care, surgeons play an important role for the optimal treatment of trauma patients throughout and after their hospital stay, including the intensive care unit (ICU). However, in most European countries, it might not be obvious to either the general public, patients or even the physicians that the surgeon must assume this responsibility in the ICU to optimize outcomes. The aim of this paper is to define key elements in terms of trauma systems, trauma-specific surgical skills and active critical care involvement, to organize and optimize trauma care in Europe.

Effectiveness and safety of whole blood compared to balanced blood components in resuscitation of hemorrhaging trauma patients - A systematic review.

INTRODUCTION: Hemorrhage is a leading cause of death among trauma patients, and is the most common cause of preventable death after trauma. Since the advent of blood component fractioning, most patients receive blood components rather than whole blood (WB). WB contains all of the individual blood components and has the advantages of simplifying resuscitation logistics, providing physiological ratios of components, reducing preservative volumes and allowing transfusion of younger red blood cells (RBC). Successful experience with fresh whole blood (FWB) by the US military is well documented. In the civilian setting, transfusion of cold-stored low titer type O whole blood (LTOWB) was shown to be safe. Reports of WB are limited by small numbers and low transfusion volumes. STUDY DESIGN: We conducted a systematic review of the available published studies, comparing efficacy and safety of resuscitation with WB to resuscitation with blood components, in hemorrhaging trauma patients, using MEDLINE, EMBASE and ISI Web of Science. The main outcomes of interest were 24 hour and 30-day survival, blood product utilization and adverse events. Two reviewers independently abstracted the studies and assessed for bias. Sub-group analyses were pre-planned on the FWB and LTOWB groups separately. RESULTS: Out of 126 references identified through our search strategy, five studies met the inclusion criteria. Only one study of FWB showed a significant benefit on 24 hour and 30-day survival. Other studies of both FWB and LTOWB showed no statistically significant difference in survival. There is an apparent benefit in blood product utilization with the use of WB across most studies. There were no reports of transfusion related reactions, however there was an increase in the organ failure rates in the FWB groups. CONCLUSIONS: WB was not associated with a significant survival benefit or reduced blood product utilization. Nonetheless, it seems that the use of LTOWB is safe and might carry a significant logistic benefit. The quality of the existing data is poor and further high quality studies are required.

Delivering trauma mastery with an international trauma masters.

INTRODUCTION: Trauma is a global problem. The goal of optimising multidisciplinary trauma care through speciality education is a challenge. No single pathway exists to educate care providers in trauma knowledge, management and skills. Queen Mary University of London (QMUL) devised an online electronic learning (e-learning) Master's degree (MSc) in Trauma Sciences in 2011. E-learning is increasingly popular however low progression rates question effectiveness. The further post-graduate impact is unknown. Our goal was to establish whether this program is a successful method of delivering multidisciplinary trauma education to an international community. We hypothesized that graduating students make a global impact in trauma care, education and research. METHODS: The Trauma Sciences MSc programs launched in 2011. Electronic surveys were distributed worldwide to students who successfully completed the program between 2013-2016. Graduation rates, degree/qualification awarded, clinical involvement in trauma management, presentation of MSc work, academic progression and roles in trauma education were explored. Supporting demographics were extracted from the QMUL student database. RESULTS: A total of 176 students, of 29 nationalities, enrolled in the two year course between 2011 and 2014. Clinical backgrounds included multi-speciality physicians (83.5%), nurses (9.6%) and paramedics (6.8%). 119 (67.6%) graduated within the study period, 108 (60.8%) with the full masters award. Completion was independent of clinical background (p = 0.20) and age (p = 0.99). Highest completion rates were seen in students from Australia and New Zealand, Asia and Europe (p = 0.03). All survey responders were currently providing regular clinical care to trauma patients. 73% (n = 36) were delivering trauma education, many at national or international level. 49% (n = 24) had presented work from the MSc and 23% (n = 11) published their dissertation.12% (n = 6) subsequently enrolled in a PhD program. CONCLUSION: Compared with other e-learning courses this Masters program has an enviable completion rate. Graduates go on to make an international multidisciplinary impact with diverse roles in clinical management, research and trauma education. This programme provides a robust trauma education curriculum. The QMUL Trauma Sciences MSc program is an excellent resource for clinicians participating in any form of trauma care or who wish to augment sub-speciality training in trauma.

Functional inclusivity of trauma networks: a pilot study of the North West London Trauma Network.

BACKGROUND: Metrics exist to assess and validate trauma system outcomes; however, these are clinically focused and do not evaluate the appropriateness of admission patterns, relative to geography and triage category. We propose the term "functional inclusivity", defined as the number and proportion of triage-negative, and/or nonseverely injured patients, who were injured in proximity to a level II/III trauma center but admitted to a level I facility. The aim of this study was to evaluate this metric in the North West London Trauma Network. METHODS: Retrospective, geospatial, observational analysis of registry data from the North West London Trauma Network. We included all adult (≥16 years) patients transported to the level I trauma center at St. Mary's Hospital between 1/1/13-31/12/16. Incident location data were geocoded into longitude/latitude, and drive times were calculated from incident location to each hospital in London's Trauma System, using Google Maps. RESULTS: Of 2051 patients, 907 (44%) were severely injured (injury severity score [ISS] ≥15), and 1144 (56%) were nonseverely injured (ISS 1-15). Seven hundred ninety five of the 1144 nonseverely injured patients (69%) were injured in proximity to a level II/III but taken to the level I facility. A total of 488 (24%) patients were triage-negative, and 229 (47%) of these were injured in proximity to a level II/III, but taken to the level I trauma center. CONCLUSIONS: This study has demonstrated the concept of functional inclusivity in characterizing trauma system performance. Further work is required to establish what constitutes an acceptable level of functional inclusivity and what the denominator should be, as well as validating and further evaluating the concept of functional inclusivity.

Beliefs and expectations of rural hospital practitioners towards a developing trauma system: A qualitative case study.

BACKGROUND: An understanding of stakeholders' views is key to the successful development and operation of a rural trauma system. Scotland, which has large remote and rural areas, is currently implementing a national trauma system. The aim of this study was to identify key barriers and enablers to the development of an effective trauma system from the perspective of rural healthcare professionals. METHODS: This is a qualitative study, which was conducted in rural general hospitals (RGH) in Scotland, from April to June 2017. We used an opportunistic sampling strategy to include hospital providers of rural trauma care across the region. Semi-structured interviews were conducted, recorded, and transcribed. Thematic analysis was used to identify and group participant perspectives on key barriers and enablers to the development of the new trauma system. RESULTS: We conducted 15 interviews with 18 participants in six RGHs. Study participants described barriers and enablers across three themes: 1) quality of care, 2) interfaces within the system and 3) interfaces with the wider healthcare system. For quality of care, enablers included confidence in basic trauma management, whilst a perceived lack of change from current management was seen as a barrier. The theme of interfaces within the system identified good interaction with other services and a single point of contact for referral as enablers. Perceived barriers included challenges in referring to tertiary care. The final theme of interfaces with the wider healthcare system included an improved transport system, increased audit resource and coordinated clinical training as enablers. Perceived barriers included a rural staffing crisis and problematic patient transfer to further care. CONCLUSIONS: This study provides insight into rural professionals' perceptions regarding the implementation of a trauma system in rural Scotland. Barriers included practical issues, such as retrieval, transfer and referral processes. Importantly, there is a degree of uncertainty, discontent and disengagement towards trauma system development, and concerns regarding staffing levels and governance. These issues are unlikely to be unique to Scotland and warrant further study to inform service planning and the effective delivery of rural trauma systems.

The role of splenic angioembolization as an adjunct to nonoperative management of blunt splenic injuries: A systematic review and meta-analysis.

BACKGROUND: Nonoperative management (NOM) of hemodynamically normal patients with blunt splenic injury (BSI) is the standard of care. Guidelines recommend additional splenic angioembolization (SAE) in patients with American Association for the Surgery of Trauma (AAST) Grade IV and Grade V BSI, but the role of SAE in Grade III injuries is unclear and controversial. The aim of this systematic review was to compare the safety and effectiveness of SAE as an adjunct to NOM versus NOM alone in adults with BSI. METHODS: A systematic literature search (Medline, Embase, and CINAHL) was performed to identify original studies that compared outcomes in adult BSI patients treated with SAE or NOM alone. Primary outcome was failure of NOM. Secondary outcomes included morbidity, mortality, hospital length of stay, and transfusion requirements. Bayesian meta-analyses were used to calculate an absolute (risk difference) and relative (risk ratio [RR]) measure of treatment effect for each outcome. RESULTS: Twenty-three studies (6,684 patients) were included. For Grades I to V combined, there was no difference in NOM failure rate (SAE, 8.6% vs NOM, 7.7%; RR, 1.09 [0.80-1.51]; p = 0.28), mortality (SAE, 4.8% vs NOM, 5.8%; RR, 0.82 [0.45-1.31]; p = 0.81), hospital length of stay (11.3 vs 9.5 days; p = 0.06), or blood transfusion requirements (1.8 vs 1.7 units; p = 0.47) between patients treated with SAE and those treated with NOM alone. However, morbidity was significantly higher in patients treated with SAE (SAE, 38.1% vs NOM, 18.6%; RR, 1.83 [1.20-2.66]; p < 0.01). When stratified by grade of splenic injury, SAE significantly reduced the failure rate of NOM in patients with Grade IV and Grade V splenic injuries but had minimal effect in those with Grade I to Grade III injuries. CONCLUSION: Splenic angioembolization should be strongly considered as an adjunct to NOM in patients with AAST Grade IV and Grade V BSI but should not be routinely recommended in patients with AAST Grade I to Grade III injuries. LEVEL OF EVIDENCE: Systematic review and meta-analysis, level III.

An Exploratory Analysis of the Geographical Distribution of Trauma Incidents in Shenzhen, China.

BACKGROUND: The city of Shenzhen, China, is planning to establish a trauma system. At present, there are few data on the geographical distribution of incidents, which is key to deciding on the location of trauma centres. The aim of this study was to perform a geographical analysis in order to inform the development of a trauma system in Shenzhen. METHODS: Retrospective analysis of trauma incidents attended by Shenzhen Emergency Medical Services (EMS) in 2014. Data were obtained from Shenzhen EMS. Incident distribution was explored using dot and kernel density estimate maps. Clustering was determined using the nearest neighbour index. The type of healthcare facilities which patients were taken to was compared against patients' needs, as assessed using the Field Triage Decision Scheme. RESULTS: There were 49,082 recorded incidents. A total of 3513 were classed as major trauma. Mapping demonstrates that incidents predominantly occurred in the western part of Shenzhen, with identifiable clusters. Nearest neighbour index was 0.048. Of patients deemed to have suffered major trauma, 8.5% were taken to a teaching hospital, 13.6% to a regional hospital, 42.6% to a community hospital, and 35.3% to a private hospital. The proportions of Step 1 or 2 negative patients were almost identical. CONCLUSION: The majority of trauma patients, including trauma patients who are at greater likelihood of severe injury, are taken to regional and community hospitals. There are areas with identifiable concentrations of volume, which should be considered for the siting of high-level trauma centres, although further modelling is required to make firm recommendations.

Managing the surge in demand for blood following mass casualty events: Early automatic restocking may preserve red cell supply.

BACKGROUND: Traumatic hemorrhage is a leading preventable cause of mortality following mass casualty events (MCEs). Improving outcomes requires adequate in-hospital provision of high-volume red blood cell (RBC) transfusions. This study investigated strategies for optimizing RBC provision to casualties in MCEs using simulation modeling. METHODS: A computerized simulation model of a UK major trauma center (TC) transfusion system was developed. The model used input data from past MCEs and civilian and military trauma registries. We simulated the effect of varying on-shelf RBC stock hold and the timing of externally restocking RBC supplies on TC treatment capacity across increasing loads of priority one (P1) and two (P2) casualties from an event. RESULTS: Thirty-five thousand simulations were performed. A casualty load of 20 P1s and P2s under standard TC RBC stock conditions left 35% (95% confidence interval, 32-38%) of P1s and 7% (4-10%) of P2s inadequately treated for hemorrhage. Additionally, exhaustion of type O emergency RBC stocks (a surrogate for reaching surge capacity) occurred in a median of 10 hours (IQR, 5 to >12 hours). Doubling casualty load increased this to 60% (57-63%) and 30% (26-34%), respectively, with capacity reached in 2 hours (1-3 hours). The model identified a minimum requirement of 12 U of on-shelf RBCs per P1/P2 casualty received to prevent surge capacity being reached. Restocking supplies in an MCE versus greater permanent on-shelf RBC stock holds was considered at increasing hourly intervals. T-test analysis showed no difference between stock hold versus supply restocking with regard to overall outcomes for MCEs up to 80 P1s and P2s in size (p < 0.05), provided the restock occurred within 6 hours. CONCLUSION: Even limited-sized MCEs threaten to overwhelm TC transfusion systems. An early-automated push approach to restocking RBCs initiated by central suppliers can produce equivocal outcomes compared with holding excess stock permanently at TCs. LEVEL OF EVIDENCE: Therapeutic/care management study, level IV.

What helps or hinders the transformation from a major tertiary center to a major trauma center? Identifying barriers and enablers using the Theoretical Domains Framework.

BACKGROUND: Major Trauma Centers (MTCs), as part of a trauma system, improve survival and functional outcomes from injury. Developing such centers from current teaching hospitals is likely to generate diverse beliefs amongst staff. These may act as barriers or enablers. Prior identification of these may make the service development process more efficient. The importance of applying theory to systematically identify barriers and enablers to changing clinical practice in emergency medicine has been emphasized. This study systematically explored theory-based barriers and enablers towards implementing the transformation of a tertiary hospital into a MTC. Our goal was to demonstrate the use of a replicable method to identify targets that could be addressed to achieve a successful transformation from an organization evolved to provide a particular type of clinical care into a clinical system with different demands, requirements and expectations. METHODS: The Theoretical Domains Framework (TDF) is a tool designed to elicit and analyze beliefs affecting behavior. Semi-structured interviews based around the TDF were conducted in a major tertiary hospital in Scotland due to become a MTC with a purposive sample of major stakeholders including clinicians and nurses from specialties involved in trauma care, clinical managers and administration. Belief statements were identified through qualitative analysis, and assessed for importance according to prevalence, discordance and evidence base. RESULTS AND DISCUSSION: 1728 utterances were recorded and coded into 91 belief statements. 58 were classified as important barriers/enablers. There were major concerns about resource demands, with optimism conditional on these being met. Distracting priorities abound within the Emergency Department. Better communication is needed. Staff motivation is high and they should be engaged in skills development and developing performance improvement processes. CONCLUSIONS: This study presents a systematic and replicable method of identifying theory-based barriers and enablers towards complex service development. It identifies multiple barriers/enablers that may serve as a basis for developing an implementation intervention to enhance the development of MTCs. This method can be used to address similar challenges in developing specialist centers or implementing clinical practice change in emergency care across both developing and developed countries.

Can old dogs learn new "transfusion requirements in critical care": a survey of packed red blood cell transfusion practices among members of The American Association for the Surgery of Trauma.

BACKGROUND: The objective of this study was to characterize variations in packed red blood cell (PRBC) transfusion practices in critically ill patients and to identify which factors influence such practices. We hypothesized that significant variation in transfusion triggers exists among acute care surgeons. METHODS: A survey of PRBC transfusion practices was administered to the American Association for the Surgery of Trauma members. The scenarios examined hemoglobin thresholds for which participants would transfuse PRBCs. RESULTS: A hemoglobin threshold of less than or equal to 7 g/dL was adopted by 45% of respondents in gastrointestinal bleeding, 75% in penetrating trauma, 66% in sepsis, and 62% in blunt trauma. Acute care surgeons modified their transfusion trigger significantly in the majority of the modifications of these scenarios, often inappropriately so. CONCLUSIONS: This study documents continued evidence-practice gaps and wide variations in the PRBC transfusion practices of acute care surgeons. Numerous clinical factors altered such patterns despite a lack of supporting evidence (for or against).

Outcomes and complications of open abdomen technique for managing non-trauma patients.

BACKGROUND: Damage control surgery and the open abdomen technique have been widely used in trauma. These techniques are now being utilized more often in non-trauma patients but the outcomes are not clear. We hypothesized that the use of the open abdomen technique in non-trauma patients 1) is more often due to peritonitis, 2) has a lower incidence of definitive fascial closure during the index hospitalization, and 3) has a higher fistula rate. METHODS: Retrospective case series of patients treated with the open abdomen technique over a 5-year period at a level-I trauma center. Data was collected from the trauma registry, operating room (OR) case log, and by chart review. The main outcome measures were number of operations, definitive fascial closure, fistula rate, complications, and length of stay. RESULTS: One hundred and three patients were managed with an open abdomen over the 5-year period and we categorized them into three groups: elective (n = 31), urgent (n = 35), and trauma (n = 37). The majority of the patients were male (69%). Trauma patients were younger (39 vs 53 years; P < 0.05). The most common indications for the open abdomen technique were intraabdominal hypertension in the elective group (n = 18), severe intraabdominal infection in the urgent group (n = 19), and damage control surgery in the trauma group (n = 28). The number of abdominal operations was similar (3.1-3.7) in the three groups, as was the duration of intensive care unit (ICU) stay (average: 25-31 days). The definitive fascial closure rates during initial hospitalization were as follows: 63% in the elective group, 60% in the urgent group, and 54% in the trauma group. Intestinal fistula formation occurred in 16%, 17%, and 11%, respectively, in the three groups, with overall mortality rates of 35%, 31%, and 11%. CONCLUSION: Intra-abdominal infection was a common reason for use of the open abdomen technique in non-trauma patients. However, the definitive fascial closure and fistula rates were similar in the three groups. Despite differences in indications, damage control surgery and the open abdomen technique have been successfully transitioned to elective and urgent non-trauma patients.

Assessing the efficacy of the fundamentals of research and career development course overseas.

BACKGROUND: As the Fundamentals of Research and Career Development Course (FRCDC) is conducted internationally, questions have arisen regarding the cultural appropriateness of the United States (US) course. We therefore assessed the US-based teaching methodology during the FRCDC in Abuja, Nigeria. We hypothesized that the US-based instructional methods would be effective. METHODS: Twenty questions were distributed to attendees of the FRCDC prior to commencement. The same 20 questions were administered at the conclusion of the course after random reordering. Differences between the pre- and post-test results were assessed for normalcy and compared using the paired t-test. RESULTS: There were 89 attendees, of whom 60 completed the pre-test and 77 completed the post-test. The pre-test group answered 12.3 ± 2.6 questions correctly, which improved to 15.0 ± 2.6 in the post-test group (P < 0.001). On the pre-test, the least common correct answers were for questions regarding type 1 and 2 error (16.7% correct), the definition of health services and outcomes research (26.7%), and how to best address missing data (26.7%). On the post-test, the questions with the least common correct answers were regarding the definition of health services and outcomes research (35%), and the components of an NIH grant (37.7%). CONCLUSIONS: Our results suggest that the FRCDC in Nigeria as given by US faculty has short-term efficacy. Attendees were able to improve their scores despite the cultural differences between them and the lecturers. Our next goal will be to demonstrate long-term efficacy at future courses in the region using similar questionnaire strategies.

Demographic and Financial Analysis of EMTALA Hand Patient Transfers.

In the United States, the Emergency Medical Treatment and Active Labor Act (EMTALA) effectively requires Level I trauma centers to accept hand trauma transfers for higher level of care if capacity exists. However, patient transfer for non-medical reasons, such as ability to pay, is still perceived as a common practice. We hypothesized that EMTALA would cause selective transfer of hand patients who were underinsured or uninsured, thus, effectively burdening a Level I trauma center. A dedicated transfer center documented the demographics and outcomes of all calls for hand trauma transfers from December 2003 to September 2005. This data registry was reviewed for age, gender, race, insurance status, and length of hospital stay. This data was compared with direct admissions to the emergency room for hand emergencies during that same time period. During the 2-year time period, a total of 151 calls for EMTALA transfer were received for hand emergencies. Our institution accepted 92 of these patients for transfer. Reasons for not accepting transfer included lack of bed availability and unavailability of the on-call surgeon due to other emergency operative cases. Compared with hand emergency patients brought directly to our emergency department during the same time period, transferred patients were younger and had a shorter length of stay. Interestingly, they were very similar in terms of sex, race, and insurance status. These data suggest that the primary motivations for EMTALA hand trauma transfers are truly complexity of patient care and specialist availability. Given the often urgent nature of hand trauma surgery and the limited resources available, expansion and development of hand and microsurgery regional centers will be vital to adequately meet demand without overburdening existing centers.

Massive transfusion protocols: the role of aggressive resuscitation versus product ratio in mortality reduction.

BACKGROUND: Exsanguinating hemorrhage necessitating massive blood product transfusion is associated with high mortality rates. Recent data suggest that altering the fresh frozen plasma to packed red blood cell ratio (FFP:PRBC) results in significant mortality reductions. Our purpose was to evaluate mortality and blood product use in the context of a newly initiated massive transfusion protocol (MTP). STUDY DESIGN: In July 2005, our American College of Surgeons-verified Level I trauma center implemented an MTP supporting a 1:1.5 FFP:PRBC ratio, improved communications, and enhanced systems flow to optimize rapid blood product availability. During the 4 years surrounding protocol implementation, we reviewed data on trauma patients directly admitted through the emergency department and requiring 10 or more units PRBCs during the first 24 hours. RESULTS: For the 2 years before and subsequent to MTP initiation, there were 4,223 and 4,414 trauma activations, of which 40 and 37 patients, respectively, met study criteria. The FFP:PRBC ratios were identical, at 1:1.8 and 1:1.8 (p = 0.97). Despite no change in FFP:PRBC ratio, mortality decreased from 45% to 19% (p = 0.02). Other significant findings included decreased mean time to first product: cross-matched RBCs (115 to 71 minutes; p = 0.02), FFP (254 to 169 minutes; p = 0.04), and platelets (418 to 241 minutes; p = 0.01). CONCLUSIONS: MTP implementation is associated with mortality reductions that have been ascribed principally to increased plasma use and decreased FFP:PRBC ratios. Our study found a significant reduction in mortality despite unchanged FFP:PRBC ratios and equivalent overall mean numbers of transfusions. Our data underscore the importance of expeditious product availability and emphasize that massive transfusion is a complex process in which product ratio and time to transfusion represent only the beginning of understanding.

Commitment to COT verification improves patient outcomes and financial performance.

BACKGROUND: After an unsuccessful American College of Surgery Committee on Trauma visit, our level I trauma center initiated an improvement program that included (1) hiring new personnel (trauma director and surgeons, nurse coordinator, orthopedic trauma surgeon, and registry staff), (2) correcting deficiencies in trauma quality assurance and process improvement programs, and (3) development of an outreach program. Subsequently, our trauma center had two successful verifications. We examined the longitudinal effects of these efforts on volume, patient outcomes and finances. METHODS: The Trauma Registry was used to derive data for all trauma patients evaluated in the emergency department from 2001 to 2007. Clinical data analyzed included number of admissions, interfacility transfers, injury severity scores (ISS), length of stay, and mortality for 2001 to 2007. Financial performance was assessed for fiscal years 2001 to 2007. Data were divided into patients discharged from the emergency department and those admitted to the hospital. RESULTS: Admissions increased 30%, representing a 7.6% annual increase (p = 0.004), mostly due to a nearly fivefold increase in interfacility transfers. Severe trauma patients (ISS >24) increased 106% and mortality rate for ISS >24 decreased by 47% to almost half the average of the National Trauma Database. There was a 78% increase in revenue and a sustained increase in hospital profitability. CONCLUSION: A major hospital commitment to Committee on Trauma verification had several salient outcomes; increased admissions, interfacility transfers, and acuity. Despite more seriously injured patients, there has been a major, sustained reduction in mortality and a trend toward decreased intensive care unit length of stay. This resulted in a substantial increase in contribution to margin (CTM), net profit, and revenues. With a high level of commitment and favorable payer mix, trauma center verification improves outcomes for both patients and the hospital.

The challenge of eliminating cervical cancer in the United States: a story of politics, prudishness, and prevention.

Exciting strides in reducing the incidence of and mortality from cervical cancer have been made over the last century in the United States. The issues surrounding the implementation of the human papillomavirus vaccine are remarkably similar to the issues involved in the gradual adoption of the Pap test and initiation of cervical cancer screening beginning nearly a century ago. The following review of the reduction of cervical cancer morbidity and mortality demonstrates the importance of the interplay between basic science, clinical medicine, social mores, and public policy.

Validation of a prehospital trauma triage tool: a 10-year perspective.

BACKGROUND: Triage of the trauma patient in the field is a complex and challenging issue, especially deciding when to use aeromedical transport. The American College of Surgeons Committee on Trauma recently defined an acceptable under-triage rate [seriously injured patient not taken to a trauma center (TC)] as 5%, whereas over-triage rates may be as high as 25% to 50%. Effective utilization of prehospital helicopter transport requires both accurate assessment of patients and effective communication. The rural county adjacent to our developed trauma system uses standardized triage criteria to identify patients for direct transport to our TCs. We hypothesized these criteria accurately identify major trauma victims (MTV) and further that communication could be simplified to expedite transport. METHODS: Prehospital personnel use a MAP (mechanism, anatomy, and physiology) scoring system to triage trauma patients. Patients with > or = 2 "hits" are defined as MTV. In 2004, the triage policy was changed so that MTV would be transported directly to a TC without base hospital consultation (previously required). The Emergency Medical Services (EMS) Medical Director reviewed cases transported to the TC to determine the appropriateness of triage decisions (over- and under-triage using the American College of Surgeons Committee on Trauma definitions). Data were compared before and after this policy change. RESULTS: For 2004 to 2006, we evaluated 676 air transports to TC and compared them to 468 in the prior 56 months. The overall transport rate increased slightly 7% to 10%. During the study period the over-triage rate was 31% compared with 21%, before the policy change. The MAP triage tool yielded a 93.8% sensitivity and a 99.5% specificity. Therefore, it determined the need for air-medical transport out of a rural environment into an established trauma system with > 90% accuracy. CONCLUSIONS: Prehospital personnel can accurately use a trauma triage tool to identify MTV. Eliminating base station contact, a potential for introducing communication error, did increase over-triage but still well within accepted limits. The system change also resulted in the transport of a greater proportion of minor trauma patients who later proved to have major injuries.

Insulin increases the release of proinflammatory mediators.

BACKGROUND: Strict glucose control with insulin is associated with decreased mortality in a mixed patient population in the intensive care unit. Controversy exists regarding the relative benefits of glucose control versus a direct advantageous effect of exogenous insulin. As a combined medical/surgical population differs significantly from the critically injured patient primed for secondary insult, our purpose was to determine the influence of insulin on activated macrophages. Our hypothesis was that insulin would directly abrogate the inflammatory cascade. METHODS: Differentiated human monocytic THP-1 cells were stimulated with endotoxin (lipopolysaccharide [LPS], 100 ng/mL) for 6 hours. Cells were treated +/-10(-7) M insulin for 1 hour and 24 hours. Total RNA was isolated and gene expression for TNF-alpha and IL-6 performed using Q-RT-PCR. Supernatants were assayed for TNF-alpha and IL-6 protein by ELISA. RESULTS: At 1 hour, compared with macrophages treated with LPS alone, macrophages treated with insulin produced significantly more TNF-alpha protein (11.4 +/- 5.9 pg/mL vs. 32.5 +/- 3.1 pg/mL; p < 0.03). At 24 hours compared with macrophages treated with LPS alone, macrophages treated with insulin produced significantly more TNF-alpha protein (83 +/- 2.02 pg/mL vs. 114 +/- 6.54 pg/mL; p < 0.01). However, gene expression of TNF-alpha and IL-6 was not different in LPS stimulated macrophages with and without insulin treatment at both 1 hour and 24 hours. CONCLUSION: Contrary to our hypothesis, insulin does not have direct anti-inflammatory properties in this experimental model. In fact, insulin increases proinflammatory cytokine protein levels from activated macrophages.