The national trauma triage protocol: how EMS perspective can inform the guideline revision.

OBJECTIVES: The Field Triage Guidelines (FTG) support emergency medical service (EMS) decisions regarding the most appropriate transport destination for injured patients. While the components of the algorithm are largely evidenced-based, the stepwise approach was developed with limited input from EMS providers. FTG are only useful if they can easily be applied by the field practitioner. We sought to gather end-user input on the current guidelines from a broad group of EMS stakeholders to inform the next revision of the FTG. METHODS: An expert panel composed an end-user feedback tool. Data collected included: demographics, EMS agency type, geographic area of respondents, use of the current FTG, perceived utility, and importance of each step in the algorithm (1: physiologic, 2: anatomic, 3 mechanistic, 4: special populations). The American College of Surgeons Committee on Trauma (ACS COT), in partnership with several key organizations, distributed the tool to reach as many providers as possible. RESULTS: 3958 responses were received (82% paramedics/emergency medical technicians, 9% physicians, 9% other). 94% responded directly to scene emergency calls and 4% were aeromedical providers. Steps 2 and 3 were used in 95% of local protocols, steps 1 and 4 in 90%. Step 3 was used equally in protocols across all demographics; however, step 1 was used significantly more in the air medical services than ground EMS (96% vs 88%, p<0.05). Geographic variation was demonstrated in FTG use based on the distance to a trauma center, but step 3 (not step 1) drove the majority of the decisions. This point was reinforced in the qualitative data with the comment, "I see the wreck before I see the patient." CONCLUSION: The FTG are widely used by EMS in the USA. The stepwise approach is useful; however, mechanism (not physiological criteria) drives most of the decisions and is evaluated first. Revision of the FTG should consider the experience of the end-users. LEVEL OF EVIDENCE: V.

Open fractures: it doesn't come out in the wash.

BACKGROUND: Six hours from injury to washout is considered the gold standard in the treatment of open traumatic fractures. Despite this being our hospital policy, the rural nature of our Level I trauma center causes delays in discovery and transport, creating a unique randomization of time to washout. We hypothesized that orthopedic complications after open fractures are related to the severity of the fractures, not the timing of the washout. METHODS: Patients and fractures were reviewed retrospectively over 6.3 years, evaluating for demographics, injury severity, location of fracture, mechanism of injury, Gustilo fracture grade, and time from injury to initial washout. Orthopedic wound complication rates were compared using logistic regression. RESULTS: A total of 1,487 open fractures in 1,278 patients were reviewed. Time from injury to washout was 26 to 4,749 min (mean, 510 min), with 48 patients having no washout. Overall, 8.2% of fractures (n=122) had an orthopedic complication, rates of which increased with severity (Injury Severity Score, Abbreviated Injury Score [AIS], and Gustilo class) and blunt injuries but were not related to time to washout. Penetrating injuries showed no difference in complication rates according to time to washout. Lower extremity fractures had a higher rate of complications than those of the upper extremity (odds ratio 2.2), likely because of differences in fracture grade. By multivariable logistic regression, only fracture grade, Revised Trauma Score (RTS), and male gender were independent predictors of wound complications; penetrating trauma was predictive of low risk. Time to washout was not an independent predictor of wound complications. CONCLUSIONS: Although grossly contaminated fractures should not be left unattended, the degree of initial injury, as judged by fracture grade and physiology (RTS), was predictive of orthopedic wound complications, whereas time to washout was not. Hence, there is little benefit of washout in Gustilo grade 1/AIS 1 fractures or penetrating injuries, regardless of grade, and adherence to a specific time to washout is not beneficial.

Trauma intensive care unit survival: how good is an educated guess?

BACKGROUND: Resource utilization in medicine is becoming a more and more urgent issue with ongoing national discussions on healthcare coverage. In the management of a trauma system, large amounts of resources and money are expended on individual patients in hope of a "great save." In addition, those of us caring for these patients are required to estimate outcomes daily to the family in an effort to choose the best course of care for an individual patient. Hence, we undertook a study to analyze the accuracy of outcomes predictions of various members of the healthcare team. METHODS: During a period of 38 months (July 2005 to August 2008), an observational study of patients admitted to a Level I Trauma Center Intensive Care Unit (ICU) was undertaken. Institutional Review Board permission was obtained before starting the study. Only patients older than 18 years were included. Patients who were moribund or expected discharge within 72 hours were excluded.Our traumatized ICU patients are cared for by a multidisciplinary team consisting of a trauma/ICU attending, all of whom have additional certification in surgical critical care and who rotate through the ICU on a weekly basis, a surgical ICU fellow, residents and medical students of several levels of training who rotate on a monthly basis, trauma advanced-level practitioners who rotate weekly, and bedside ICU nurses who work routine shifts. Respiratory therapists, nutritionists, ICU pharmacists, and other members of the rounding team were not included in the study because they do not provide global patient care. Regardless of admitting physician, the patients are managed by the team, and our practice of care is similar across the group, based on protocols and consensus.For each of the study patients, a survey tool was filled out by the ICU rounding team on hospital day 1 and hospital day 3. The tool was completed by members of the team providing global care to the patient and varied depending on the members of the group at each day's rounds. All current and admission data on injuries, study and laboratory results, and current patient status were available to all members of the team. Each member was expected to fill out the survey tool independently, and the results of the tool were not discussed during rounds.Concurrently, data were collected by the ICU fellow and research nurse. These data and the results of the survey tools were entered in a database for analysis after patient discharge. A retrospective analysis was undertaken to analyze the relative accuracy of the care, team members' assessment, and actual survival. Statistical analysis was done using by-chance accuracy comparisons. RESULTS: Two hundred twenty-three patients had 326 observations performed. Day 3 accuracy improved for most groups. In all groups, accuracy was found to be statistically significantly better than by-chance accuracy. Given that the majority of patients in the trauma population are survivors, sensitivity and positive predictive value of the observer's ability to predict death were also evaluated. CONCLUSIONS: Although significantly better than chance prediction, the ability of members of the ICU team to predict survival of trauma patients remains poor, particularly on initial evaluation. A period of clinical observation improves the accuracy. Unfortunately, experience of the observer does not seem to improve accuracy of survival prediction. This data indicate that care must be taken when describing likely outcomes to patient family members.

Impact of hypothermia in the rural, pediatric trauma patient.

OBJECTIVE: Hypothermia is an independent predictor of mortality in adult trauma studies. However, the impact of hypothermia on the pediatric trauma population has not been described. The purpose of this study is to evaluate hypothermia as a cofactor to mortality, complications, and among survivors, hospital length of stay parameters in the pediatric trauma population. DESIGN: Retrospective review of a prospectively collected database (National Trauma Registry of the American College of Surgeons) over a 5-yr period (July 2002 to June 2007). SETTING: A rural, level I trauma center. PATIENTS: One thousand six hundred twenty-nine pediatric patients admitted with a traumatic injury. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Multivariate regression models were used to evaluate the association of hypothermia with mortality, infectious complications, organ dysfunction, and among survivors, hospital length of stay parameters. Of 1,629 pediatric trauma patients admitted, 182 (11.1%) patients were hypothermic (temperature below 36 degrees C) on admission. Hypothermia had an adjusted odds ratio (AOR) of 2.41 (95% confidence interval [CI], 1.12-5.22, p = .025) for mortality. After controlling for covariates, hypothermia had associations with developing pneumonia (AOR, 0.185, 95% CI, 0.040-0.853; p = .031) and a bleeding diathesis (AOR, 3.14, 95% CI, 1.04-9.44; p = .042). The median days in the hospital, intensive care unit (ICU), and ventilator were longer in the hypothermic cohort; however, after controlling for covariates, hypothermia was not associated with differences in hospital days, ICU days, or ventilator days. CONCLUSIONS: Hypothermia is a common problem at admission among pediatric trauma patients. Hypothermia is associated with an increase in the odds of death and the development of a bleeding diathesis, while having decreased odds for developing pneumonia. While the length of stay indicators were longer in the hypothermic cohort among survivors, no significant association was noted with hypothermia for hospital, ICU, or ventilator days after controlling for confounders.

What price commitment: what benefit? The cost of a saved life in a developing level I trauma center.

BACKGROUND: In 1999, a Level I Trauma Center committed significant resources for development, recruitment of trauma surgeons, and call pay for subspecialists. Although this approach has sparked a national ethical debate, little has been published investigating efficacy. This study examines the price of commitment and outcomes at a Level I Trauma Center. METHODS: Direct personnel costs including salary, call pay, and personnel expenses were analyzed against outcomes for two periods defined as PRE (1994-1999) and POST (2000-2005). Patient care costs and 1999 to 2000 transition data were excluded. Demographics, outcomes, and direct personnel costs were compared. Significant mortality reductions stratified by age and injury severity score (ISS) were used to calculate lives saved in relation to direct personnel costs. Student's t test and chi were used (significance *p < 0.05). RESULTS: In the PRE period, there were 7,587 admissions compared with 11,057 POST. There were no significant differences PRE versus POST for age (41.4 +/- 24.4 years vs. 41.3 +/- 24.9 years), gender (62.4% vs. 63.7% male), mechanism of injury (11.5% vs. 11.8% penetrating), and percent intensive care unit admissions (30.1 vs. 29.9). Significant differences were noted for ISS (10.5 +/- 9.7 vs. 11.6 +/- 10.1*), percent admissions with ISS >or=16 (18.5 vs. 27.3*), and revised trauma score (10.8 +/- 2.8 vs. 10.7 +/- 2.8*). Both the average length of stay (6.8 +/- 8.8 vs. 6.5 +/- 9.8*) and percent mortality for ISS >or=16 (23 vs. 17*) were reduced. When mortality was stratified by both age and ISS, significant reductions were noted and a total of 173 lives were saved as a result. However, direct personnel costs increased from $7.6 million to $22.7 million. When cost is allocated to lives saved; the cost of a saved life was more than $87,000. CONCLUSIONS: Resources for program development, including salary and call pay, significantly reduced mortality. Price of commitment: $3 million per year. The cost of a saved life: $87,000. The benefit: 173 surviving patients who would otherwise be dead.

Impact of hypothermia (below 36 degrees C) in the rural trauma patient.

BACKGROUND: Hypothermia is an independent predictor of mortality based on urban studies. But this association has not been described in the rural setting. This study's purpose was to evaluate hypothermia as a cofactor to mortality, complications, and hospital length of stay (LOS) parameters in the rural trauma setting. STUDY DESIGN: The National Trauma Registry of the American College of Surgeons database for our rural, Level I trauma center was queried for a 5-year period (July 2002 to June 2007) to identify adult trauma patients. Multivariate regression models were used to evaluate the association of hypothermia with mortality; infectious complications; organ dysfunction; and, among survivors, hospital LOS parameters. RESULTS: Of 9,482 adult patients admitted, 1,490 (15.7%) patients were hypothermic. Hypothermia had an adjusted odds ratio of 1.70 for mortality (95% CI, 1.35 to 2.12; p < 0.001). After controlling for covariates, hypothermia was not significantly associated with infectious complications or organ dysfunction, except for arrhythmia (adjusted odds ratio, 1.40; CI, 1.03 to 1.90; p = 0.031). Hypothermia was not associated with a difference in ICU (p = 0.310) or ventilator (p = 0.144) LOS. But a slight increase in hospital days was noted in the hypothermic patient (hazards ratio, 0.890 for discharge; 95% CI, 0.838 to 0.946; p < 0.001). CONCLUSIONS: Hypothermia is a common problem at admission in a rural trauma center. It is associated with an increase in hospitalized days but not with increased ICU or ventilator days among survivors. Other than arrhythmias, it was not significantly associated with other National Trauma Registry of the American College of Surgeons infectious or organ dysfunction complications. Hypothermia is an independent risk factor for mortality in the rural trauma patient.

Tissue oxygenation monitoring in the field: a new EMS vital sign.

BACKGROUND: A tissue hemoglobin oxygen saturation (STO2) monitor was created to assess the perfusion status of a peripheral muscle bed using near infrared light to directly measure oxygen saturation in the microcirculation. Hypoperfusion has been noted when the STO2 is <75%. The use of this technology has not been tested in the prehospital setting. This pilot study was performed to assess the technology's ease of use in the field and to correlate STO2 readings with patient outcomes. METHODS: Hospital-based transport vehicles were equipped with STO2 monitors and personnel were asked to evaluate the functionality of the technology. Initial, average, and minimal STO2 values were collected and compared with data of the trauma registry. RESULTS: Forty five of 55 surveys were returned with 100% reporting ease of use and no reports of interference with monitors or avionics. Monitoring length averaged 16.9 minutes +/- 6.9 minutes. Forty-one patients had complete data sets and five deaths were reported for a mortality rate of 12%. STO2 endpoints revealed and increased risk of death for every 10% decrease in STO2. CONCLUSION: The STO2 monitor can easily be used in the prehospital environment. In addition, initial recordings were significantly different between survivors and nonsurvivors with every 10% decrease in STO2 increasing mortality threefold. This monitor seems to give the prehospital provider a noninvasive tool for assessment of hypoperfusion in the field and may allow for earlier resuscitative efforts to commence.

The elderly trauma patient: an investment for the future?

BACKGROUND: The cost of care in elderly (ELD) trauma patients is high compared with younger patients, but the association between age and reimbursement relative to cost is less clear. The purpose of this study was to explore the relationship between total costs (TC) and reimbursement in young (YNG) and ELD trauma patients. METHODS: The National Trauma Registry of the American College of Surgeons was queried for patients admitted to a level I trauma center between January 2002 and December 2004. YNG patients (18-64 years) were compared with ELD patients (> or =65 years) for mechanism of injury, Injury Severity Score, and outcome variables. Data obtained from the hospital cost accounting system included TC, total payment, and net margin (P-L). Virtually, all patients were reimbursed based on the fixed diagnostic-related group payment. RESULTS: There were 641 ELD and 3,470 YNG patients included in the study. ELD patients were more commonly injured via a blunt mechanism than the YNG patients (97% vs. 83%; p < 0.001). The ELD were more severely injured (Injury Severity Score 14.9 +/- 10.8 vs. 13.3 +/- 10.9), developed more complications (54% vs. 34%), and died more frequently (17% vs. 4.7%; all p < 0.05). TC for the ELD were significantly higher than the YNG ($20,788.92 +/- $28,305.54 vs. $19,161.11 +/- $30,441.56; p = 0.02). Total payment ($20,049.75 +/- $29,754.52 vs. $16,766.14 +/- $31,169.15) and P-L (-$739.18 +/- $17,207.84 vs. -$2,294.98 +/- $22,309.51; both p < 0.05) were significantly better for the ELD cohort. However, a financial loss was realized for all patients with trauma. CONCLUSION: When compared with YNG trauma patients, reimbursement in the ELD appears favorable. However, compensation via diagnostic-related group payment fails to cover costs even in the ELD. Reimbursement for all patients with trauma is suboptimal and needs to be improved.

High-frequency oscillatory ventilation as a rescue therapy for adult trauma patients.

BACKGROUND: High-frequency oscillatory ventilation is an alternative ventilation mode that improves oxygenation in trauma patients in whom conventional ventilation strategies have been unsuccessful. OBJECTIVE: To evaluate the effect of high-frequency oscillatory ventilation on oxygenation, survival, and parameters predictive of survival in trauma patients. METHODS: A retrospective case series of 24 adult patients admitted to the trauma intensive care unit at a level I trauma center between November 2001 and July 2005 and treated with high-frequency oscillatory ventilation. Survivors and nonsurvivors were compared for mechanism and severity of injury, oxygenation parameters related to high-frequency oscillatory ventilation, and hospital course. RESULTS: Of the 8577 patients admitted during the study period, acute respiratory distress syndrome developed in 103 (1%). Of those 103 patients, 24 (23%) were treated with high-frequency oscillatory ventilation. Most of the patients treated with high-frequency oscillatory ventilation had sustained blunt trauma (79%). Oxygenation parameters improved significantly with high-frequency oscillatory ventilation in all patients, regardless of survival. Of the 24 patients treated with this ventilation mode, 15 (62%) survived. Survival did not correlate with improved oxygenation parameters but with the number of failed organ systems and injury severity. CONCLUSION: Although high-frequency oscillatory ventilation improves oxygenation, severity of traumatic injury and organ failure, not respiratory parameters, are predictors of survival. High-frequency oscillatory ventilation should be considered for pulmonary rescue of severely injured patients with acute respiratory distress syndrome.

Field hypotension in patients who arrive at the hospital normotensive: a marker of severe injury or crying wolf?

INTRODUCTION: Trauma patients with hypotension in the field who arrive at a hospital with a normal blood pressure (BP) may not be recognized as significantly injured. METHODS: Over a 5-year period, demographic, injury severity, and disposition data were retrospectively analyzed for patients > or =16 years of age with documented hypotension in the field (systolic BP < or =90 mm Hg) and normal BP (systolic BP >90 mmHg) on hospital arrival (hypotensive group). This group was compared to patients with normal BP in the field and on hospital arrival (normotensive group). RESULTS: During the study, 2207 patients with documented BP were transported directly from the scene. Of this number 44 (2%) were assigned to the hypotensive group, 2086 (94%) were assigned to the normotensive group, and 77 (4%) patients were hypotensive on hospital arrival. The hypotensive group had a systolic BP in the field of 70 +/- 26 mmHg compared to 140 +/- 26 mmHg in the normotensive group (p < 0.0001). Arrival BP at the hospital was normal in both groups. Compared to the normotensive group, the hypotensive group had higher Injury Severity Scores (22.0 vs. 11.1, p < 0.0001), lower Glasgow Coma Scores (10.8 vs. 14.0, p < 0.0001), lower Revised Trauma Scores (65 vs. 7.4, p < 0.0O01), more emergency department deaths (7% vs. 0%, p < 0.001), longer lengths of stay in the intensive care unit (8.6 vs. 7.0 days, p < 0.0001) and hospital (14.0 vs. 7.0 days, p < 0.0001), and increased hospital mortality (18% vs. 4%, p < 0.001). LIMITATIONS: The retrospective design and exclusion of patients without documentation of BP in the field may have resulted in selection bias. CONCLUSION: Despite these limitations, field hypotension is a marker of significant injury in patients arriving at the hospital normotensive.

Morbidity reduction in critically ill trauma patients through use of a computerized insulin infusion protocol: a preliminary study.

BACKGROUND: Recent data have demonstrated that intensive glycemic control during critical illness improves outcome. The purpose of our study was to evaluate the effect of a computerized hospital insulin protocol (CHIP) on glycemic control and outcome in critically ill trauma patients. METHODS: Two, 6-month cohorts were compared, one 6 months prior to chip implementation (pre-CHIP) and one from the 6-month period after implementation (post-CHIP), using finger stick blood glucose values and demographic, injury severity, and outcome variables for adult patients with intensive care unit length of stay (LOS) > or =72 hours. Infectious morbidity was based upon the National Trauma Registry of the American College of Surgeons definitions. Differences between cohorts were assessed using Student's t test and Fisher's exact test for continuous and categorical variables. RESULTS: The 129 pre- and 128 post-CHIP patients were well matched for demographics and injury severity. Significant reductions in mean finger stick blood glucose, rates of ventilator- associated pneumonia, central venous line infection, total infections, and all LOS categories were demonstrated in the post-CHIP cohort. However, mortality was significantly higher in the post-CHIP cohort. CONCLUSION: This preliminary study demonstrates significant morbidity and LOS reductions with the use of a CHIP, but significantly increased mortality. Further prospective studies are necessary to assess the effects of intensive glycemic control on outcome after injury, particularly in sub populations who might be adversely affected.

Body mass index and outcomes in critically injured blunt trauma patients: weighing the impact.

BACKGROUND: The influence of increased body mass index (BMI) on morbidity and mortality in critically injured trauma patients has been studied, with conflicting results. The objective of this study was to investigate the relationship between stratified BMI and outcomes in blunt injured patients. STUDY DESIGN: Consecutive adult trauma patients from July 2001 to November 2005 with Injury Severity Score (ISS) > or = 16 and blunt mechanism were evaluated using the National Trauma Registry of the American College of Surgeons. Demographics, injury severity, hospital course, complications, and mortality were compared among standard BMI strata. Logistic regression was used to determine odds ratios (OR) with 95% confidence intervals and evaluate BMI as an independent risk factor for morbidity and mortality. Statistical significance was set at p < 0.05. RESULTS: The study group consisted of 1,543 patients. Controlling for age, gender, Injury Severity Score, and Revised Trauma Score, and using BMI 18.5 to 24.9 kg/m(2) as the reference category, morbid obesity (BMI> or =40 kg/m(2)) was associated with acute respiratory distress syndrome (OR 3.675, 95% CI, 1.237 to 10.916), acute respiratory failure (OR 2.793, 95% CI, 1.633 to 4.778), acute renal failure (OR 13.506, 2.388 to 76.385), multisystem organ failure (OR 2.639, 95% CI, 1.085 to 6.421), pneumonia (OR 2.487, 95% CI, 1.483 to 4.302), urinary tract infection (OR 2.332, 95% CI, 1.229 to 4.427), deep venous thrombosis (OR 4.112, 95% CI, 1.253 to 13.496), and decubitus ulcer (OR 2.841, 95% CI, 1.382 to 5.841). Morbid obesity was not associated with increased mortality (OR 0.810, 95% CI, 0.353 to 1.856). CONCLUSIONS: This is the largest study to date evaluating the relationship between BMI and outcomes in critically injured trauma patients. Increasing BMI increases morbidity while having no proved influence on mortality.

A collaborative systems approach to rural burn care.

A collaborative systems approach was created between the regional verified burn center (BC) and the rural verified Level 1 trauma center (TC) to treat minor burns. This study assesses the feasibility of providing outpatient burn care at the TC. A retrospective review was performed from January 2000 to June 2005 of burn patients seen at the TC. Seven trauma/critical care surgeons and a dedicated burn nurse staffed the clinic twice a week. Burn surgeons from the BC provided consultation via email and telephone links and served as the regional resource. In the TC clinic, 314 injuries occurred in 311 patients. 196 patients were male with an average age of 34.5 +/- 1.1 years. The mean burn TBSA was 2.9 +/- 0.2%. Fourteen patients (4%) required skin grafts. Patients averaged 3.5 +/- 0.1 clinic visits over a mean follow-up period of 42.9 +/- 7.4 days from initial injury. There were 1252 scheduled appointments during the study period. Silver sulfadiazine or triple antibiotic ointment was applied in the majority of the cases. Thirty-one patients (9.9%) were documented to have complications, most of which were local wound infections. Long-term sequelae (scarring, chronic pain, and contractures) occurred in 13.4% of patients. Clinical success in outpatient burn care can be achieved at a non burn center with dedicated personnel. The successful collaboration between the BC and TC can unload some minor burn care from the burn center, while providing good clinical care to the local rural population.

Rural trauma recidivism: a different disease.

HYPOTHESIS: Unlike the well-characterized urban trauma recidivist (RC), factors associated with the rural RC remain undefined. In an attempt to devise preventative strategies, we theorized that the rural RC profile would be similar to that of urban counterparts. DESIGN: Retrospective review. SETTING: Rural, university-affiliated, level I trauma center. PATIENTS: All trauma patients admitted between January 1, 1994, and December 30, 2002. INTERVENTIONS: Identification and characterization of rural trauma RCs. MAIN OUTCOME MEASURES: Trauma recidivism incidence, risk factors, and cost. RESULTS: Of 15 370 consecutive admissions, 528 (3.4%) were RCs. Demographic comparisons to a non-RC cohort demonstrated rural RCs to be significantly older (mean +/- SD age, 55.9 +/- 24.8 vs 39.7 +/- 24.1 years), disproportionately white (65.2% [344/528] vs 56.5% [8386/14 842]), and more likely female (49.1% [259/528] vs 37.3% [5537/14 842]) (P<.001 for all). Clinical comparisons revealed significant associations between recidivism and substance abuse. The percentage of positive blood ethanol screen results (58.7% [310/528] vs 39.9% [5923/14 842]) and the mean +/- SD blood ethanol content (132.1 +/- 139.9 mg/dL [28.7 +/- 30.4 mmol/L] vs 69.5 +/- 114.4 mg/dL [15.1 +/- 24.8 mmol/L]) were higher for RCs (P<.001 for both). In addition, cocaine use was significantly higher in the RC cohort (6.4% [34/528] vs 4.1% [607/14 842]; P=.02). The total cost for all RC admissions exceeded $7 million. CONCLUSIONS: The rural RC profile is strikingly different from urban counterparts. The common feature seems to be substance abuse. Correspondingly, prevention strategies for recidivism must be considerably different among rural and urban populations.

Alcohol withdrawal syndrome: Turning minor injuries into a major problem.

BACKGROUND: Abrupt cessation of chronic drinking patterns places hospitalized patients at risk for alcohol withdrawal syndrome (AWS). The purpose of this study was to investigate the effect of AWS on length of stay, morbidity, mortality, and cost in low injury acuity trauma patients. METHODS: A retrospective review of the National Trauma Registry of the American College of Surgeons database from July 1999 to February 2004 was performed. All patients 15 years or older admitted to our Level I trauma center with an Injury Severity Score (ISS) <16 were included. AWS patients were compared with those without AWS. Demographics, mechanism of injury (MOI), ISS, revised trauma score, Glasgow Coma score, hospital course, morbidity, requirement of additional procedures, mortality, and cost were compared. Analysis was done with chi2 test and Student's t test. A p value of < or =0.05 determined significance. RESULTS: Of 6,431 patients, 55 (0.9%) developed AWS. AWS patients were likely men (p < 0.001); had a higher ISS (p = 0.001) and lower Glasgow Coma score (p = 0.01); had more ventilator days (p = 0.008), intensive care unit days (p < 0.0001), and hospital days (p < 0.0001); suffered more complications, including respiratory failure (p < 0.0001), pneumonia (p < 0.0001), urinary tract infection (p = 0.0005), sepsis (p < 0.0001), tracheostomy (p < 0.0001), and percutaneous endoscopic gastrostomy (p < 0.0001); and had higher cost (p < 0.0001). Mortality was similar (p = 0.38) among groups. CONCLUSIONS: Low injury acuity patients with AWS have increased morbidity, leading to increased hospital stay and cost. To allow minor injuries to remain minor problems, the best modality to identify patients at risk and to achieve AWS prophylaxis require further investigation.

Intravesicular pressure monitoring does not cause urinary tract infection.

OBJECTIVE: To determine whether intravesicular pressure monitoring using a closed system increases the risk of nosocomial urinary tract infection. DESIGN: Retrospective chart and database review. SETTING: Surgical/trauma intensive care units of a regional level-I trauma center. PATIENTS: 3108 critically ill patients of which 122 patients underwent intravesicular pressure monitoring. INTERVENTIONS: Severity-adjusted urinary tract infection rates were compared among patients with and without intravesicular pressure monitoring. MEASUREMENTS AND RESULTS: Over a 24-month period, 122 consecutive patients had 2202 intravesicular pressure measurements performed. During 1448 urinary catheter days, 15 patients who required intravesicular pressure monitoring developed a urinary tract infection with a severity-adjusted device-related infection rate of 7.9 infections per 1000 catheter days. Of the 2986 patients who did not require such monitoring, 98 patients developed a urinary tract infection with an infection rate of 6.5 infections per 1000 catheter days (p=0.56). CONCLUSIONS: Intravesicular pressure monitoring using the closed transducer technique is safe and does not increase the risk of urinary tract infection.