Single dose IV Antibiotic for Low-Energy Extremity Gunshot Wounds: A Prospective Protocol.

Objective: To prospectively determine infection rate following low-energy extremity GSWs with a single dose IV antibiotic protocol. Summary Background Data: Previous work suggests that a single IV antibiotic dose, without formal surgical debridement, mitigates infection risk. Methods: Over 35 months 530 adults with low-energy GSWs to the extremities were included. Three hundred fifty-two patients (66%) had ≥30 days follow-up. Patients were administered a single dose of first-generation IV cephalosporin antibiotics, and those with operative fractures received 24-hour perioperative antibiotics. Injury characteristics, treatment, protocol adherence, and outcomes (infection) were assessed between the protocol group (single-dose antibiotics) and the non-protocol group (no antibiotics or extra doses of antibiotics). Results: Compliance with the single-dose protocol occurred in 66.8%, while 33.2% received additional antibiotics or no antibiotics. The deep infection rate requiring surgical debridement was 0.8%, while the combined rate of all infections was 11.1%. Age, sex, injury location, multiple injuries, fracture presence, and type of surgery did not affect infection rate. Adherence to the antibiotic protocol was associated with a reduction in infection risk (odds ratio = 0.39, 95% confidence interval 0.19-0.83, P = 0.01). Receipt of additional antibiotics outside of our single-dose protocol did not predict further reduction in rate of infection (P = 0.64). Conclusions: A standardized protocol of single-dose IV antibiotic appears effective in minimizing infection after low-energy GSW to the extremities. Level of Evidence: Therapeutic Level II.

Applying Implementation Science in Surgical Infection Quality Improvement.

Background: Medical knowledge is constantly growing at an exponential rate. Despite this growth, it is estimated to take 17 years for medical innovation to reach the bedside and improve clinical care. Implementation science is the scientific study of methods to facilitate the update of evidence-based practice and research into regular use and policy. Discussion: Implementation science offers theories, models, and frameworks aimed at decreasing the time it takes to get medical innovation to the patient and to sustain the care improvements. Implementation science principles center around five main fundamental concepts that include information diffusion, dissemination, implementation, adoption, and sustainability. Understanding these fundamental concepts allow clinicians to prepare for an implementation by asking the correct questions such as: Are we ready for change?; What is our current process that we want to change?; Who needs to be involved in the implementation?; and How do we measure success? This article describes a successful catheter-associated urinary tract infection quality improvement program implemented using implementation science principles. Conclusion: Implementation science offers many proven tools and strategies to implement new evidence-based medicine and medical innovations into common practice. Clinicians are often the leaders of change and should develop an understanding of implementation science fundamentals to allow successful implementation of quality improvement and research initiatives.

Costs of Care for Low-Energy Extremity Gunshot Injuries are Reduced With Standardized Treatment.

OBJECTIVES: (1) To determine the overall treatment costs associated with isolated low-energy gunshot wounds (GSWs) to the extremity and (2) to estimate cost savings associated with a single-dose IV antibiotic strategy administered in the emergency room for patients with simple GSWs. DESIGN: Retrospective review. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: Patients (N = 380) with extremity-only GSW injuries from 2010 to 2015 were retrospectively reviewed. Treatment was recorded including type and duration of antibiotics, admission, and surgical intervention. MAIN OUTCOME MEASURES: Costs were calculated including facility services in the operating room and hospital. RESULTS: There were 460 GSWs in 380 patients with a mean age of 30 years old. There were 309 admissions, 273 operations performed, and 1010 days of antibiotics prescribed. The total inpatient facility cost to treat all patients was $1,701,154. Among 179 patients who could be treated by the single-dose antibiotic care pathway for simple GSWs, 132 patients (73%) received additional treatment with 108 hospital admissions, 26 debridement surgeries, and 322 days of additional oral and/or IV antibiotics. The single-dose antibiotic care pathway would have saved an average of $1436 per patient with simple GSWs in actual facility expenses. CONCLUSIONS: The overall cost associated with isolated low-energy GSWs to the extremity is high. Limiting antibiotics to a single IV dose in the emergency room can reduce treatment expenses substantially for patients with simple GSWs. LEVEL OF EVIDENCE: Economic Level IV. See instructions for authors for a complete description of levels of evidence.

Trauma team activation can be tailored by prehospital criteria.

A two phase prospective study was carried out at a regional Level I trauma center over 1 year. Phase I involved collecting observational data to determine which trauma criteria could potentially be used to identify patients that could be evaluated by a lower level trauma activation (category-3). A category-3 involved a smaller response team with priority access to imaging. Phase II involved implementing this third tier activation system and prospectively evaluating the outcomes related to resources and patient care. A total of 3104 patients were evaluated with 2076 patients in phase I and 1037 in phase II. Three commonly identified activation criteria out of the 36 studied were not associated with admission. These criteria were pedestrian struck by vehicle, high speed vehicular crash, and Glasgow Coma Score 12-14. These criteria were then used as triggers for a category-3 activation in phase II. Comparisons of patients with these three identified criteria between phase I and II demonstrated that significantly fewer patients were admitted, charges were reduced, emergency department times were similar, and less man-power hours were needed in phase II. The utilization of a third tiered activation system resulted in a decrease utilization of many resources without sacrificing patient care.

Who is monitoring your infections: shouldn't you be?

BACKGROUND: In the era of pay for performance and outcome comparisons among institutions, it is imperative to have reliable and accurate surveillance methodology for monitoring infectious complications. The current monitoring standard often involves a combination of prospective and retrospective analysis by trained infection control (IC) teams. We have developed a medical informatics application, the Surgical Intensive Care-Infection Registry (SIC-IR), to assist with infection surveillance. The objectives of this study were to: (1) Evaluate for differences in data gathered between the current IC practices and SIC-IR; and (2) determine which method has the best sensitivity and specificity for identifying ventilator-associated pneumonia (VAP). METHODS: A prospective analysis was conducted in two surgical and trauma intensive care units (STICU) at a level I trauma center (Unit 1: 8 months, Unit 2: 4 months). Data were collected simultaneously by the SIC-IR system at the point of patient care and by IC utilizing multiple administrative and clinical modalities. Data collected by both systems included patient days, ventilator days, central line days, number of VAPs, and number of catheter-related blood steam infections (CR-BSIs). Both VAPs and CR-BSIs were classified using the definitions of the U.S. Centers for Disease Control and Prevention. The VAPs were analyzed individually, and true infections were defined by a physician panel blinded to methodology of surveillance. Using these true infections as a reference standard, sensitivity and specificity for both SIC-IR and IC were determined. RESULTS: A total of 769 patients were evaluated by both surveillance systems. There were statistical differences between the median number of patient days/month and ventilator-days/month when IC was compared with SIC-IR. There was no difference in the rates of CR-BSI/1,000 central line days per month. However, VAP rates were significantly different for the two surveillance methodologies (SIC-IR: 14.8/1,000 ventilator days, IC: 8.4/1,000 ventilator days; p = 0.008). The physician panel identified 40 patients (5%) who had 43 VAPs. The SIC-IR identified 39 and IC documented 22 of the 40 patients with VAP. The SIC-IR had a sensitivity and specificity of 97% and 100%, respectively, for identifying VAP and for IC, a sensitivity of 56% and a specificity of 99%. CONCLUSIONS: Utilizing SIC-IR at the point of patient care by a multidisciplinary STICU team offers more accurate infection surveillance with high sensitivity and specificity. This monitoring can be accomplished without additional resources and engages the physicians treating the patient.

Fever and leukocytosis in critically ill trauma patients: it is not the blood.

The diagnosis of bacteremia in critically ill patients is classically based on fever and/or leukocytosis. The objectives of this study were to determine 1) if our intensive care unit obtains blood cultures based on fever and/or leukocytosis over the initial 14 days of hospitalization after trauma; and 2) the efficacy of this diagnostic workup. An 18-month retrospective cohort analysis was performed on consecutively admitted trauma patients. Data collected included demographics, injuries, and the first 14 days maximal daily temperature, leukocyte count, and results of blood and catheter tip cultures. Fever was defined as a maximum daily temperature of 38.5 degrees C or greater and leukocytosis as a leukocyte count 12,000/mm3 or greater of blood. Five hundred ten patients were evaluated for a total of 3,839 patient-days. The mean age and injury severity score were 49 +/- 1 years and 19 +/- 1, respectively. Four hundred twenty-five blood culture episodes were obtained and 25 (6%) bacteremias were identified in 23 patients (5%). A significant association was found between obtaining blood cultures in patients with fever (relative risk [RR], 7.7), leukocytosis (RR, 1.3), and fever + leukocytosis (RR, 3.2). However, no significant association was found between these clinical signs and the diagnosis of bacteremia. In fact, fever alone was inversely associated with bacteremia. Our intensive care unit follows the common "fever workup" practice and obtains blood cultures based on the presence of fever and leukocytosis. However, fever and leukocytosis were not associated with bacteremia, suggesting inefficiency and that other factors are more important after trauma.

The Surgical Intensive Care-infection Registry: a research registry with daily clinical support capabilities.

Infections in the surgical and trauma intensive care unit (STICU) are responsible for significant patient morbidity and mortality. Research into these infectious complications often uses administrative databases or clinical information systems designed for documenting and billing daily patient care. Neither of these sources is intended for research, and many investigators have questioned their accuracy. The Surgical Intensive Care-Infection Registry (SIC-IR) was developed as a research data repository to use to monitor STICU infections. SIC-IR is a relational database application designed to collect quality data and to integrate with daily patient care. SIC-IR prospectively collects and archives more than 100 clinical variables daily on each STICU patient to ensure completeness and correctness of the registry. Furthermore, SIC-IR aids in clinical activities by providing patient summaries and medical record documentation. SIC-IR provides accurate data for STICU infection research and enables the users to easily undertake quality-of-care improvement initiatives.

Prevention of Surgical Infections: Building or Renovating a New Intensive Care Unit.

BACKGROUND: Renovating or building a new intensive care unit (ICU) can be a challenging project. Planning the renovation or rebuild as a quality improvement project will help break down the process into manageable pieces with clear goals. METHODS: Literature was reviewed with regards to ICU design and renovation, with specific attention to patient quality improvement, process and structural change, healthcare systems engineering, emerging technology, and infection control. RESULTS: In any quality improvement initiative, a first step is to create a multidisciplinary change team charged with leading the rebuild process. This team should include frontline providers, administration, architects, infection prevention specialists, and healthcare system engineers. Healthcare system engineers (HSEs) are specialized system and human factors engineers who can assist with data analysis, create mathematical models to anticipate areas of difficulty, and perform simulations to assist with the actual structural changes as well as the process changes aimed at eliminating nosocomial infections. Every aspect of creating a new ICU space should begin with infection control standards of practice ranging from selection of furniture and computer keyboards, to identifying the best location of the soiled utility rooms. There are many infection control products that may be considered during the building process such as tele-tracking hand hygiene stations and heavy-metal-coated surfaces aimed at decreasing surface colonization and subsequent infections. CONCLUSIONS: This article offers suggestions on renovating or rebuilding an ICU aimed at eliminating the preventable harm associated with hospital acquired infections.

Fever and leukocytosis in critically ill trauma patients: it's not the urine.

BACKGROUND: Infectious complications are a major cause of morbidity and mortality in critically ill trauma patients. Therefore, fever and leukocytosis often trigger an extensive laboratory workup that includes a urine culture (UCx). The purposes of this study were to: 1) Define the current practice for obtaining UCxs in trauma patients admitted to the surgical and trauma intensive care unit (STICU); and 2) determine if there is an association between fever or leukocytosis and urinary tract infections (UTIs) during the initial 14 hospital days. METHODS: An 18-month retrospective cohort analysis was performed on consecutive trauma patients admitted for at least two days to the STICU at a level I trauma center. Data collected included demographics, injuries, and daily maximal temperature (T(max)), leukocyte count, and UCx results for the first 14 days. Fever and leukocytosis were defined as T(max) > or =38.5 degrees C and leukocyte count > or =12,000/mm(3), respectively. Urinary tract infections were diagnosed with a positive UCx (> or =10(5) organisms/mL of urine). RESULTS: Five hundred ten patients were evaluated for a total of 3,839 patient-days. Their mean age and Injury Severity Score were 49 +/- 1 years and 19 +/- 1 points, respectively. Seventy-two percent were men, and 91% had sustained blunt injuries. Four hundred seven UCxs were obtained; 42 patients (8%) had 60 UTIs. The cohort had an indwelling urinary catheter for 97% of the patient-days, yielding an infection density of 16 UTIs/1,000 urinary catheter-days. There was a significant association between obtaining a UCx and fever and between fever and leukocytosis (both, p < 0.001), but no association of UTI with fever, leukocytosis, or the combination of fever and leukocytosis. Analysis using temperature and leukocyte count as continuous variables identified no temperature or leukocyte range associated with UTIs. Independent risk factors for UTI calculated by logistic regression were female sex, older age, low Injury Severity Score, and no antibiotics within 24 h before the UCx was obtained. CONCLUSIONS: The practice of obtaining a UCx from the STICU trauma patient was related to fever and fever with leukocytosis. However, neither fever nor leukocytosis nor both were associated with UTIs. These data suggest that there is an unnecessary emphasis on UTI as a source of fever and leukocytosis in injured patients during their first 14 STICU days. Our results suggest that the paradigm for evaluating UTI as a cause of fever needs to be reevaluated in critically ill trauma patients.

Isolated cervical spine fractures in the elderly: a deadly injury.

BACKGROUND: Traumatic injury in the elderly is an increasing problem and studies have shown that elderly patients (>/=65 years old) with cervical spine fractures and spinal cord injury (SCI) carry a mortality rate of 21% to 30%. However, little has been described with regard to outcomes for elderly patients with isolated cervical spine fractures (ICSF). HYPOTHESIS: Outcomes for elderly patients with ICSF will be similar to elderly patients with cervical fractures and associated traumatic injuries (ATI) or SCI. METHODS: A 9-year retrospective analysis was performed on all patients >/=65 years old admitted to a level I trauma center with any cervical spine fracture. Primary outcomes were defined as favorable (discharge to home or rehabilitation hospital) or unfavorable (death, discharge to a long-term acute care facility, or a skilled nursing facility). ICSF was defined as those fractures without ATI or SCI. Long-term mortality data were gathered using the Social Security Death Index. RESULTS: A total of 177 patients with mean age of 78 +/- 1 and Injury Severity Score of 17 +/- 1 were evaluated. Fifty-six percent were men and falls were the most common mechanism (62%). An unfavorable outcome was seen in 56% of the study population with a mortality rate of 25%. ATIs were seen in 57% of the population and 22% had SCI. Patients with SCI had a significantly higher mortality compared with patients without SCI (38% vs. 22%, p = 0.032). However, there was no difference in unfavorable outcomes. Patients with ICSF had no differences in unfavorable outcomes compared with patients with SCI or ATI. Long-term survival analysis after discharge (mean = 2.8 years) demonstrated that patients with a favorable outcome had a significantly improved survival compared with patients with unfavorable outcomes (p < 0.001). CONCLUSION: ICSFs were associated with an unfavorable outcome in the elderly population regardless of ATI or SCI. These unfavorable outcomes were also associated with long-term mortality. Strategies to reduce morbidity and mortality in this devastating injury will be essential to improve outcomes and maximize resource utilization.

Trauma Surgeons Save Lives-Scribes Save Trauma Surgeons!

With the advent of the electronic medical record, the documentation burden of the trauma surgeon has become overwhelming. To help, our trauma division added scribes to the rounding team. We hypothesized that scribe utilization would improve our documentation efficiency and offer a financial benefit to the institution. A review of trauma surgeon documentation and billing was performed at a Level I trauma center over two time periods: January to May 2014 (no scribes) and January to May 2015 (scribes). The number of notes written by trauma surgeons was obtained, as were documentation charges. Documentation efficiency was determined by noting both the hour of the day in which inpatient progress notes were written and the number of notes written after patient discharge. In the 2014 period, a total of 9726 notes were written by trauma attendings. In the 2015 period, 10,933 were written. Despite having 407 fewer trauma patient-days in the 2015 period, the group wrote 343 notes/week versus 298 notes/week (P = 0.008). More inpatient progress notes were written earlier in the working day and fewer were written in the evening. Fewer notes were written after patient discharge (12.7 vs 8.4%). A total of 1,664 hours of scribe time were used over the 5-month period, generating an expense of $32,787. The additional notes generated by scribes resulted in $191,394 in charges. Conservatively, assuming a 20 per cent charge reimbursement, the cost of the scribes was covered. The addition of scribes to the daily trauma rounding team improved note efficiency and increased charge capture at our center.

Consequences of Implementing a "Better" Blood Culture System.

BACKGROUND: Blood cultures (BCx) are the gold standard for diagnosing blood stream infections. However, contamination remains a challenge and can increase cost, hospital days, and unnecessary antibiotic use. National goals are to keep overall BCx contamination rates to ≤3%. Our healthcare system recently moved to a BCx system with better organism recovery, especially for gram-negative, fastidious, and anaerobic bacteria. The study objectives were to determine the benefits/consequences of implementing a more sensitive blood culture system, specifically on contamination rates. METHODS: The electronic health record was queried for all BCx obtained within our tertiary-care health system from April 2015 to October 2016. Cultures were divided into those obtained 12 months before and six months after the new system was introduced. A positive BCx was defined as one with any growth. Contaminated BCx were defined as those showing coagulase-negative Staphylococcus, Corynebacterium, Bacillus, Micrococcus, or Propionibacterium acnes. Cultures with Staphylococcus aureus, Klebsiella pneumoniae, or Escherichia coli were said to contain a true pathogen. Results based on hospital location of blood drawing also were determined. RESULTS: A total of 20,978 blood cultures were included, 13,292 before and 7,686 after the new system was introduced. With the new system, positive BCx rates increased from 7.5% to 15.7% (p < 0.001). Contaminants increased from 2.3% to 5.4% (p < 0.001), and pathogens increased from 2.5% to 5.8% (p < 0.001). Contaminated BCx increased significantly in the surgical/trauma intensive care unit (STICU), emergency department (ED), and medical ICU (MICU), while pathogen BCx increased on the surgical floor, ED, and MICU. CONCLUSIONS: A new blood culture system resulted in significant increases in the rates of positive, contaminated, and pathogen BCx. After the new system, multiple hospital units had contamination rates >3%. These data suggest that a "better" BCx system may not be superior regarding overall infection rates. More research is needed to determine the impact of identifying more contaminants and pathogens with the new system.

Variation in treatment of low energy gunshot injuries - A survey of OTA members.

The purpose of this study was to determine current practice patterns in the treatment of low energy gunshot wounds involving bones and joints. One hundred seventy-three Orthopaedic Trauma Association (OTA) members completed a web-based survey. The survey included practices for antibiotic therapy and operative treatment for different types of low-energy gunshot injuries. Six different scenarios of soft tissue injury, intra-articular injury, and fractures were described. Several permutations of antibiotic therapy and operative or non-operative management options were given as choices on the survey. Survey responses had a high degree of heterogeneity with only two treatment options receiving more than 50% agreement among responders: 54% agreed on joint exploration with perioperative antibiotics for gunshot wounds (GSWs) traversing a joint and 55% agreed on treating operative tibial shaft fractures from GSWs with fixation, along with debridement and irrigation of the GSW tract, and perioperative antibiotics. The majority of participants (69%) were either not aware of or not sure of an established protocol for treatment of GSW to bones and joints at their institution. Moreover, there is still wide variation in treatments among 31% of the participants who reported a protocol in place at their institutions. We conclude there is wide variation among orthopaedic surgeons in the antimicrobial prophylaxis and treatment of GSWs. Opportunity exists to develop standardized practices to minimize related infections, other complications, and costs.

Bedside dysphagia screens in patients with traumatic cervical injuries: An ideal tool for an under-recognized problem.

BACKGROUND: We initiated a prospective interventional study using a nurse-driven bedside dysphagia screen (BDS) in patients with cervical spine injury (CI) to address three objectives: (1) determine the incidence of dysphagia, (2) determine the utility of the new BDS as a screening tool, and (3) compare patient outcomes, specifically dysphagia-related complications, in the study period with a retrospective cohort. METHODS: All patients with CI admitted to a Level I trauma center were enrolled in a prospective 12-month study (June 2016-June 2017) and then were compared with a previous 18-month cohort of similar patients. Our new protocol mandated that every patient underwent a BDS before oral intake. If the patient failed the BDS, a modified barium swallow (MBS) was obtained. Exclusion criteria were emergency department discharge, inability to participate in a BDS, leaving against medical advice, BDS protocol violations, or death before BDS. A failed MBS was defined as a change in diet and a need for a repeat MBS. Dysphagia was defined as a failed MBS or the presence of a dysphagia-related complication. RESULTS: Of 221 consecutive prospective patients identified, 114 met inclusion criteria. The incidence of dysphagia was 16.7% in all prospective study patients, 14.9% in patients with isolated CI, and 30.8% in patients with spinal cord injury. The BDS demonstrated 84.2% sensitivity, 95.8% specificity, 80.0% positive predictive value, and 96.8% negative predictive value. There were no dysphagia-related complications. The prospective study patients demonstrated significantly less dysphagia-related complications (p = 0.048) when compared with the retrospective cohort of 276 patients. CONCLUSIONS: The introduction of the BDS resulted in increased dysphagia diagnoses, with a significant reduction in dysphagia-related complications. We recommend incorporating BDS into care pathways for patients with CI. LEVEL OF EVIDENCE: Study type diagnostic test, level III.

Current Pneumonia Surveillance Methodology: Similar Underestimation in Trauma and Surgical Patients in the Intensive Care Unit.

BACKGROUND: In 2013, the Centers for Disease Control and Prevention (CDC) developed new surveillance definitions for ventilator-associated events (VAE), leading to concerns that hospitals may be underreporting the true incidence of ventilator-associated pneumonias (VAPs). We sought to compare rates of clinically diagnosed VAP with CDC defined possible VAPs (PVAPs) in patients with a VAE in the surgical/trauma intensive care unit (STICU). HYPOTHESIS: Significant difference exists between rates of clinical VAP and PVAP in patients with at least one VAE. PATIENTS AND METHODS: All STICU patients with ≥1 VAE, between 1/1/2013 and 10/31/2015 were identified. Age, length of stay (LOS), ICU and ventilator days were collected. RESULTS: There were 134 patients who had ≥1 VAE. Mean age was 54.3 (±17.1) years. Mean LOS, median ICU, and median ventilator days were 26.3 (±14.1), 21.0 (17.0-33.0), and 17.0 (12.8-24.0) days, respectively. There were 68 cases of clinically diagnosed VAP, but only 37% met PVAP criteria. We compared 43 cases of clinical VAP, not meeting PVAP criteria, with the 25 PVAPs. Both groups had similar outcomes. The PVAPs were more likely to have an abnormal temperature (48.0% vs. 14.0%, p = 0.004), abnormal white blood cell count (84.0% vs. 18.6%, p < 0.001), or new antibiotic agent initiated (100% vs. 18.6%, p < 0.001) as VAE triggers. Comparison of the 93 trauma and 41 surgical patients demonstrated trauma patients were younger (51.2 vs. 61.5 y, p = 0.001), but had similar outcomes and rates of clinical VAP (48.4% and 43.9%, p = NS). Only 20.4% of trauma and 14.6% of surgical patients, however, had a PVAP reported. For patients with at least one VAE, the sensitivity and specificity for PVAP detecting VAP was 36.8% and 96.0%, respectively. CONCLUSION: The new CDC definition for PVAP grossly underestimates the clinical diagnosis of VAP and reports less than a third of the patients treated for VAP. Reporting differences were similar for trauma and surgical patients.

Infection Rates and Treatment of Low-Velocity Extremity Gunshot Injuries.

OBJECTIVES: To determine the rates of infection in low-energy gunshot wounds (GSWs) to the extremity. DESIGN: Retrospective review. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: Patients (N = 140) with at least 90-day follow-up for extremity-only low-energy GSW injuries from 2010-2014 were retrospectively reviewed. Treatment was recorded, including type and duration of antibiotics and details of nonoperative and operative managements. MAIN OUTCOME MEASURES: The rates of superficial and deep infections. RESULTS: The overall infection rate was 15.7% (22 patients), and the deep infection rate was 3.6% (5 patients). Age, sex, and injury location were similar between the groups that did and did not receive antibiotic prophylaxis. Injury Severity Scores were higher in the group that did receive antibiotics. Regarding soft tissue-only injuries, antibiotic prophylaxis trended toward a lower rate of overall infection versus no antibiotic prophylaxis (6.1% vs. 25.9%, respectively, P = 0.07). Multiple doses of antibiotics did not reduce the rate of infection when compared with a single dose (14.6% vs. 12.5%, respectively, P = 1.00). No deep infections occurred in patients with nonoperatively treated fractures, regardless of antibiotic administration. All operatively treated fractures received antibiotic prophylaxis and demonstrated superficial and deep infection rates of 15.1% and 5.7%, respectively. CONCLUSIONS: Infections after low-energy extremity GSWs are infrequent. For soft tissue injuries without fracture, a single dose of intravenous antibiotics in the emergency department was associated with a lower rate of infection compared with no antibiotics. Operatively treated low-energy GSW fractures should receive standard perioperative antibiotics. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Infection and Complications After Low-velocity Intra-articular Gunshot Injuries.

OBJECTIVES: The purpose of this study is to characterize the demographics, interventions, infection rates, and other complications after intra-articular (IA) gunshot wounds. DESIGN: Retrospective review. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: Fifty-three patients with 55 civilian low-velocity IA gunshot injuries with a minimum of 4 weeks follow-up were included in the study. Seven patients had associated vascular injuries. INTERVENTIONS: Most patients (84.9%) received antibiotic prophylaxis, consisting most often of cefazolin (93.3%). Based on injury pattern and surgeon preference, joint injuries were either treated nonoperatively (43.6%), with surgical debridement only (20.0%), with surgical debridement plus fracture fixation and/or neurovascular repair (32.7%), or with percutaneous fracture fixation without debridement (3.6%). MAIN OUTCOME MEASURES: Incidence of deep infection. RESULTS: Two joints (3.6%) developed deep infections. Both had associated vascular injuries. Patients with vascular injuries were at higher risk of infection compared with those without vascular injury (28.6% vs. 0.0%, P = 0.02). Two of 24 (8.3%) injuries that were originally managed nonoperatively required delayed surgical procedures, 1 for bullet removal and 1 for ulnar nerve allograft. No patient treated nonoperatively developed an infection. CONCLUSIONS: The incidence of infection after IA gunshot injuries is low with the routine use of antibiotic prophylaxis. In the absence of IA pathology, IA gunshot injuries do not appear to necessitate surgical debridement to decrease the risk of infection. Patients with vascular injury deserve special attention, as they are at higher risk of infection. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for authors for a complete description of levels of evidence.

The painful truth: The documentation burden of a trauma surgeon.

BACKGROUND: Implementation of the electronic medical record (EMR) has introduced several unintended consequences, including increased documentation demands. The purpose of this study was to define the EMR documentation burden and its economic impact at a busy regional Level I trauma center, comparing attending trauma surgeons (TSs) with orthopedic surgeons (OSs), and neurosurgeons (NSs). METHODS: The EMR was queried to determine the number of attending documentation entries during 2014 for TS, OS, and NS. The eight TSs were then surveyed to estimate the time it took to write each note type, and this was used to calculate the total time needed for documentation. The hospital financial database was queried for 2014 hospital charges and work relative value units (WRVUs) for TSs, OSs, and NSs to generate a comparison. The charges and WRVUs were broken down into those generated from nonprocedural documentation and procedures. RESULTS: During 2014, there were 5,864 trauma activations with 3,111 patient admissions. The attending TSs wrote a total of 26,455 documentation entries. Of these notes, 92% were from inpatients, and 74% were progress notes. Documentation time estimates for TSs demonstrated that it took 1,760.5 hours or 73.3 twenty-four-hour days to complete these 26,455 notes. Financial data revealed that 44% of the TS charges were directly related to nonprocedural documentation, compared with 14% for OSs and 7% for NSs. Evaluation of WRVUs demonstrated that 55% of the TS WRVUs were directly related to nonprocedural documentation, compared with 28% for OSs and 19% for NSs. CONCLUSION: The EMR has introduced a significant documentation burden to the busy TSs. This documentation burden is critical for defining hospital charges and WRVUs, and it differs from that of OSs and NSs. Workflow changes, such as the introduction of scribes, may lessen the documentation burden and improve hospital charges and WRVUs of the TSs.

Benefit of TeamSTEPPS Rounding Improvement Project on Infection-Related Monitoring.

BACKGROUND: Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) was developed to improve teamwork and patient safety. It was shown to benefit patient care in complex clinical settings including intensive care units (ICUs). Our two trauma/surgical ICUs received TeamSTEPPS training, but only Unit 1 participated in a TeamSTEPPS Rounding Improvement Project (TRIP). Our goal was to assess any unintended benefit to infection-related monitoring and prevention from TRIP. We hypothesized that TRIP implementation in ICUs would be associated with increased monitoring, resulting in improved antibiotic and invasive catheter/tube stewardship. METHODS: From September through November 2014, observers prospectively collected data on rounds in both units. Unit personnel were blinded to the data collection process. Monitoring parameters obtained for each patient encounter included review of invasive catheter/tube presence and review of antibiotic indication and course. For patients who received antibiotic and had invasive catheter/tube, we conducted a retrospective review for treatment parameters such as antibiotic duration and adherence to treatment plan, inappropriate antibiotics duration, and invasive catheter/tube duration. RESULTS: A total of 416 patient encounters were observed. The use of invasive catheter/tube was reviewed on rounds substantially more in Unit 1 than Unit 2 (83% vs. 51%, p < 0.005). In the 135 encounters with patients on antibiotic, review of antibiotic indication, stop date, day into course, and all three components occurred substantially more in Unit 1. On the basis of the 65 different antibiotic courses encompassed by the 135 encounters, antibiotic duration, adherence to antibiotic treatment plan, and inappropriate antibiotic days were not substantially different between the units. From the same 135 encounters, 125 encounters also had invasive catheter/tube placement. Substantially more discussion of catheter/tube presence occurred in Unit 1, but the duration of its presence was not substantially different. CONCLUSION: The TeamSTEPPS Rounding Improvement Project was associated with an unintended, increased discussion and monitoring of antibiotic and invasive catheter/tube usage. However, this did not translate into substantial immediate treatment differences.

Where's the difference? Presentation of nosocomial infection in critically ill trauma versus general surgery patients.

BACKGROUND: Diagnosing infection efficiently is integral to managing critically ill patients. Knowing if and how trauma and general surgery patients differ in their presentation of new infectious complications could be useful. We hypothesized these populations would differ in presentation in the intensive care unit (ICU). METHODS: We analyzed data collected prospectively from all 1,657 trauma and general surgery patients admitted to the surgical and trauma ICU (STICU) over a 21-month period. Clinical data from the first day of a newly diagnosed infection were compared for trauma (82% of the series) and general surgery (18%) patients. RESULTS: A total of 10,424 STICU days were included, and 267 nosocomial infections were diagnosed. Trauma patients were younger (50 vs. 62 years; p<0.001) and more likely to be male (78% vs. 46%; p<0.001) than were general surgery patients. Similar percentages of the two groups were infected (11% and 13%, respectively), and infections occurred after a similar number of days in the STICU. The mean maximum temperature on the day prior to diagnosis was higher in trauma patients (38.4°C vs. 37.7°C; p<0.001), and the mean leukocyte count was lower (13,500 vs. 15,800 10(6)/L; p=0.013). General surgery patients were more likely to be hypotensive (13% vs. 2%; p=0.002) and to have a positive fluid balance >2 L on the first day of infection (27% vs. 13%; p=0.02). Respiratory infections were more common in trauma patients (40% vs. 7%; p<0.001), and urinary tract infections were less common (19% vs. 36%; p=0.011). CONCLUSION: Differences exist in how new infections manifest in trauma and general surgery patients in the ICU. General surgery patients appeared sicker on their first day of infection, as evidenced by a higher leukocyte count, lower blood pressure, and substantial positive fluid balance. Intensivists may need differing thresholds for triggering infection workups when employed in a mixed unit.