Association of COVID-19 Visitor Limitations and Goals of Care Discussions in the Intensive Care Unit.

INTRODUCTION: The COVID-19 pandemic led to visitor restrictions in many hospitals. Since care in the surgical intensive care unit (SICU) often engages visitors as surrogate decision-makers, we investigated whether there was an association between COVID-19-related visitor restrictions, goals of care discussions (GOCD), and patient outcomes in SICU patients. METHODS: We conducted a retrospective review of trauma and emergency general surgery (EGS) patients admitted to a rural tertiary SICU between July 2019 and April 2021, dividing patients into those admitted during COVID-19 visitor restrictions and those admitted at other times. Using univariate and multivariate logistic regression analyses, we compared the primary outcome, incidence of GOCD, and incidence of prolonged hospital (> 14 d) and intensive care unit length of stay (LOS, > 7 d) between the two groups. RESULTS: One hundred seventy nine of 368 study patients (48.6%) presented during restricted visitation. The proportion of GOCD was 38.0% and 36.5% in the restricted and nonrestricted visitation cohorts, respectively (P = 0.769). GOCD timing and outcomes were similar in both groups. The use of telecommunication increased during restricted visitation, as did the proportion of trauma patients admitted to the SICU. On multivariable logistic regression, age and patient category were independent predictors of GOCD. On outcomes analysis, visitor restriction was associated with prolonged hospital LOS for EGS patients (odds ratio 2.44, 95% confidence interval 1.01-5.91, P value 0.048). CONCLUSIONS: Restricted visitation was not associated with changes in frequency or outcome of GOCD, but was associated with prolonged hospital LOS among EGS patients who had SICU admissions. Further investigation of patient/surrogate satisfaction with virtual GOCD in the SICU setting is needed.

Defining Risk and Risk Factors for Unplanned ICU Admission of Trauma Patients.

BACKGROUND: Unplanned ICU admissions (up-ICUad) are associated with poor outcomes. It is difficult to identify who is at risk for up-ICUad in trauma patients. This study aimed to identify injury patterns and comorbidities associated with up-ICUad and develop a predictive tool for who is at risk. METHODS: A retrospective study compared trauma patients admitted to the floor who experienced an up-ICUad to similar patients without an up-ICUad. Univariate analysis and multivariate logistic regression identified independent risk factors associated with up-ICUad. Based on those factors, a Risk Score (RS) was created and compared between the two groups. RESULTS: 2.15% of the 7206 patients experienced an up-ICUad. The up-ICUad group was older, experienced longer length of stay, and had higher mortality. Age, congestive heart failure, COPD, peptic ulcer disease, mild liver disease, CKD, and significant injuries to the thorax, spine, and lower extremities were independently associated with up-ICUad. A RS equation was created and was used for each patient. CONCLUSIONS: Trauma patients are at increased risk for up-ICUad based on specific factors. These factors can be used to calculate a RS to determine who is at greatest risk for an up-ICUad which may be helpful for preventing up-ICUad.

Contribution by Dr Timothy C Fabian: liver trauma.

The liver is the most commonly injured organ within the abdomen. Dr Fabian and his associates have made remarkable contributions to our understanding and management of these injuries. The current review summarizes the contributions.

Current patterns of trauma center proliferation have not led to proportionate improvements in access to care or mortality after injury: An ecologic study.

BACKGROUND: Timely access to high-level (I/II) trauma centers (HLTCs) is essential to minimize mortality after injury. Over the last 15 years, there has been a proliferation of HLTC nationally. The current study evaluates the impact of additional HLTC on population access and injury mortality. METHODS: A geocoded list of HLTC, with year designated, was obtained from the American Trauma Society, and 60-minute travel time polygons were created using OpenStreetMap data. Census block group population centroids, county population centroids, and American Communities Survey data from 2005 and 2020 were integrated. Age-adjusted nonoverdose injury mortality was obtained from CDC Wide-ranging Online Data for Epidemiologic Research and the Robert Wood Johnson Foundation. Geographically weighted regression models were used to identify independent predictors of HLTC access and injury mortality. RESULTS: Over the 15-year (2005-2020) study period, the number of HLTC increased by 31.0% (445 to 583), while population access to HLTC increased by 6.9% (77.5-84.4%). Despite this increase, access was unchanged in 83.1% of counties, with a median change in access of 0.0% (interquartile range, 0.0-1.1%). Population-level age-adjusted injury mortality rates increased by 5.39 per 100,000 population during this time (60.72 to 66.11 per 100,000). Geographically weighted regression controlling for population demography and health indicators found higher median income and higher population density to be positively associated with majority (≥50%) HLTC population coverage and negatively associated with county-level nonoverdose mortality. CONCLUSION: Over the past 15 years, the number of HLTC increased 31%, while population access to HLTC increased only 6.9%. High-level (I/II) trauma center designation is likely driven by factors other than population need. To optimize efficiency and decrease potential oversupply, the designation process should include population level metrics. Geographic information system methodology can be an effective tool to assess optimal placement. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Patient Factors Associated with High Opioid Consumption after Common Surgical Procedures Following State-Mandated Opioid Prescription Regulations.

BACKGROUND: State regulations have decreased prescribed opioids with more than 25% of patients abstaining from opioids. Despite this, 2 distinct populations of patients exist who consume "high" or "low" amounts of opioids. The aim of this study was to identify factors associated with postoperative opioid use after common surgical procedures and develop an opioid risk score. STUDY DESIGN: Patients undergoing 35 surgical procedures from 7 surgical specialties were identified at a 620-bed tertiary care academic center and surveyed 1 week after discharge regarding opioid use and adequacy of analgesia. Electronic medical record data were used to characterize postdischarge opioids, complications, demographics, medical history, and social factors. High opioid use was defined as >75th percentile morphine milligram equivalents for each procedure. An opioid risk score was calculated from factors associated with opioid use identified by backward multivariate logistic regression analysis. RESULTS: A total of 1,185 patients were enrolled between September 2017 and February 2019. Bivariate analyses revealed patient factors associated with opioid use including earlier substance use (p < 0.001), depression (p = 0.003), anxiety (p < 0.001), asthma (p = 0.006), obesity (p = 0.03), migraine (p = 0.004), opioid use in the 7 days before surgery (p < 0.001), and 31 Clinical Classifications Software Refined classifications (p < 0.05). Significant multivariates included: insurance (p = 0.005), employment status (p = 0.005), earlier opioid use (odds ratio [OR] 2.38 [95% CI 1.21 to 4.68], p = 0.01), coronary artery disease (OR 0.38 [95% CI 0.16 to 0.86], p = 0.02), acute pulmonary embolism (OR 9.81 [95% CI 3.01 to 32.04], p < 0.001), benign breast conditions (OR 3.42 [95% CI 1.76 to 6.64], p < 0.001), opioid-related disorders (OR 6.67 [95% CI 1.87 to 23.75], p = 0.003), mental and substance use disorders (OR 3.80 [95% CI 1.47 to 9.83], p = 0.006), headache (OR 1.82 [95% CI 1.24 to 2.67], p = 0.002), and previous cesarean section (OR 5.10 [95% CI 1.33 to 19.56], p = 0.02). An opioid risk score base was developed with an area under the curve of 0.696 for the prediction of high opioid use. CONCLUSIONS: Preoperative patient characteristics associated with high opioid use postoperatively were identified and an opioid risk score was derived. Identification of patients with a higher need for opioids presents an opportunity for improved preoperative interventions, the use of nonopioid analgesic therapies, and alternative therapies.

Bronchoalveolar lavage in the diagnosis of ventilator-associated pneumonia: to quantitate or not, that is the question.

Quantitative bronchoalveolar lavage (BAL) is used to diagnose ventilator-associated pneumonia (VAP). We prospectively compared semiquantitative (SQ) and quantitative (Qu) culture of BAL for VAP diagnosis. Ventilated patients suspected of VAP underwent bronchoscopic BAL. BAL fluid was examined by both Qu (colony-forming units [CFUs]/mL) and SQ culture (none, sparse, moderate, or heavy) and results were compared. VAP was defined as 105 CFU/mL or greater on Qu culture. Over 36 months, 319 BALs were performed. Sixty-three of 319 (20%) showed diagnostic growth by Qu culture identifying a total of 81 organisms causing VAP. All 63 specimens showed growth of some organism(s) on SQ culture with 79 of 81 causative organisms identified and two (Pseudomonas, one; Corynebacterium, one) not identified. The remaining 256 specimens did not meet the threshold for VAP by the Qu method. Among these, 79 did not show any growth on SQ culture. Among the 240 specimens showing some growth on SQ culture, a total of 384 organisms were identified. VAP rates in relation to strength of growth on SQ culture were: sparse, 10 of 140 (7%); moderate, 24 of 147 (16%); and heavy, 45 of 97 (46%). Sensitivity (Sn), specificity (Sp), positive (PPV), and negative (NPV) predictive values of SQ culture of BAL fluid for the diagnosis of VAP were 97, 21, 21, and 97 per cent, respectively. Nonquantitative culture of BAL fluid is fairly accurate in ruling out VAP (high Sn and NPV). It however has poor Sp and PPV and using this method will lead to unnecessary antimicrobial use with its attendant complications of toxicity, cost, and resistance.

National Emergency X-Radiography Utilization Study criteria is inadequate to rule out fracture after significant blunt trauma compared with computed tomography.

BACKGROUND: EAST guidelines now recommend computed tomography (CT) to evaluate cervical spine (c-spine) fractures after blunt trauma in patients who do not meet National Emergency X-Radiography Utilization Study criteria (NC), yet no imaging is required in those patients who do meet these criteria. NC are based on patients with both minor and severe (trauma team activation [TTA]) trauma. The purpose of this study was to evaluate the NC using CT as the gold standard in TTA patients. METHODS: We prospectively evaluated 2,606 blunt TTA patients at our Level I trauma center. NC defined as alertness (Glasgow Coma Scale [GCS] score = 15), evidence of intoxication, clinically distracting injury, midline c-spine tenderness, or neurologic deficits were documented. CT was used to determine the accuracy of these criteria. RESULTS: There were 157 patients with c-spine fractures and 2,449 patients without c-spine fractures. The fracture group was older (age, 43.4 years ± 19.3 years fracture group vs. 37.7 years ± 17.5 years no fracture group, p = 0.0003) with a lower GCS score (fracture group 13.7 ± 4.5 vs. no fracture group 14.4 ± 3.6, p = 0.0001) and initial systolic blood pressure (132.5 mm Hg ± 23.4 mm Hg vs. 139.9 mm Hg vs. 23.5 mm Hg, p = 0.0009). The sensitivity and specificity of clinical examination for all patients were 82.8% (130 of 157) and 45.7% (1,118 of 2,449), respectively. The positive predictive value (PPV) and negative predictive value (NPV) were 8.9% (130 of 1,461) and 97.6% (1,118 of 1,145), respectively. Patients with a GCS score of 15 had a sensitivity of 77%, specificity of 52.3%, PPV of 8.5%, and NPV of 97.5% for clinical examination. In those patients with the GCS score of 15, no intoxication or distracting injury, clinical examination had a sensitivity of 59.4%, specificity of 79.5%, PPV of 12.5%, and NPV of 97.5%. Of 26 patients with missed injuries based on NC, 19 (73.1%) required further intervention (16 collars, 2 OR, 1 Halo). CONCLUSION: As in our previous trial, NC is inaccurate compared with CT to diagnose c-spine fractures in TTA patients. CT should be used in all blunt TTA patients regardless of whether they meet NC.

Canadian Cervical Spine rule compared with computed tomography: a prospective analysis.

BACKGROUND: The Canadian cervical spine rule (CCS) has been found to be an effective tool to determine the need for radiographic evaluation of the cervical spine (c-spine) incorporating both clinical findings and mechanism. Previously, it has been validated only through clinical follow-up or selective use of X-rays. The purpose of this study was to validate it using computed tomography (CT) as the gold standard to identify fractures. METHODS: Prospective evaluation was performed on 3,201 blunt trauma patients who were screened by CCS and were compared with a complete c-spine CT. CSS positive indicated at least one positive clinical or mechanism finding, whereas CT positive indicated presence of a fracture. RESULTS: There were 192 patients with c-spine fractures versus 3,009 without fracture on CT. The fracture group was older (42.7 ± 19.0 years vs. 37.8 ± 17.5 years, p = 0.0006), had a lower Glasgow Coma Scale score (13.8 ± 4.2 vs. 14.4 ± 4.3, p < 0.0001), and lower systolic blood pressure (133.3 ± 23.8 mm Hg vs. 139.5 ± 23.1 mm Hg, p = 0.0023). The sensitivity of CCS was 100% (192/192), specificity was 0.60% (18/3009), positive predictive value was 6.03% (192/3183), and negative predictive value was 100% (18/18). Logistic regression identified only 8 of the 19 factors included in the CCS to be independent predictors of c-spine fracture. CONCLUSIONS: CCS is very sensitive but not very specific to determine the need for radiographic evaluation after blunt trauma. Based on this study, the rule should be streamlined to improve specificity while maintaining sensitivity.

Defining the limits of resuscitative emergency department thoracotomy: a contemporary Western Trauma Association perspective.

BACKGROUND: Since the promulgation of emergency department (ED) thoracotomy>40 years ago, there has been an ongoing search to define when this heroic resuscitative effort is futile. In this era of health care reform, generation of accurate data is imperative for developing patient care guidelines. The purpose of this prospective multicenter study was to identify injury patterns and physiologic profiles at ED arrival that are compatible with survival. METHODS: Eighteen institutions representing the Western Trauma Association commenced enrollment in January 2003; data were collected prospectively. RESULTS: During the ensuing 6 years, 56 patients survived to hospital discharge. Mean age was 31.3 years (15-64 years), and 93% were male. As expected, survival was predominant in those with thoracic injuries (77%), followed by abdomen (9%), extremity (7%), neck (4%), and head (4%). The most common injury was a ventricular stab wound (30%), followed by a gunshot wound to the lung (16%); 9% of survivors sustained blunt trauma, 34% underwent prehospital cardiopulmonary resuscitation (CPR), and the presenting base deficit was >25 mequiv/L in 18%. Relevant to futile care, there were survivors of blunt torso injuries with CPR up to 9 minutes and penetrating torso wounds up to 15 minutes. Asystole was documented at ED arrival in seven patients (12%); all these patients had pericardial tamponade and three (43%) had good functional neurologic recovery at hospital discharge. CONCLUSION: Resuscitative thoracotomy in the ED can be considered futile care when (a) prehospital CPR exceeds 10 minutes after blunt trauma without a response, (b) prehospital CPR exceeds 15 minutes after penetrating trauma without a response, and (c) asystole is the presenting rhythm and there is no pericardial tamponade.

Using performance frontiers to differentiate elective and capacity-based surgical services.

BACKGROUND: Acute care surgery (ACS) model of care delivery has many benefits. However, since the ACS surgeon has limited control over the volume, timing, and complexity of cases, traditional metrics of operating room (OR) efficiency almost always measure ACS service as "inefficient." The current study examines an alternative method-performance fronts-of evaluating changes in efficiency and tests the following hypotheses: (1) in an institution with a robust ACS service, performance front methodology is superior to traditional metrics in evaluating OR throughput/efficiency, and (2) introduction of an ACS service with block time allocation will improve OR throughput/efficiency. METHODS: Operating room metrics 1-year pre-ACS implementation and post-ACS implementation were collected. Overall OR efficiency was calculated by mean case volumes for the entire OR and ACS and general surgery (GS) services individually. Detailed analysis of these two specific services was performed by gathering median monthly minutes-in block, out of block, after hours, and opportunity unused. The two services were examined using a traditional measure of efficiency and the "fronts" method. Services were compared with each other and also pre-ACS implementation and post-ACS implementation. RESULTS: Overall OR case volumes increased by 5% (999 ± 50 to 1,043 ± 46: p < 0.05) with almost all of the increase coming through ACS (27 ± 4 to 68 ± 16: p < 0.05). By traditional metrics, ACS had significantly worse median efficiency versus GS in both periods: pre (0.67 [0.66-0.71] vs. 0.80 [0.78-0.81]) and post (0.75 [0.53-0.77] vs. 0.83 [0.84-0.85]) (p < 0.05). As compared with the pre, GS efficiency improved significantly in post (p < 0.05), but ACS efficiency remained unchanged (p > 0.05). The alternative fronts chart demonstrated the more accurate picture with improved efficiency observed for GS, ACS, and combined. CONCLUSION: In an institution with a busy ACS service, the alternative fronts methodology offers a more accurate evaluation of OR efficiency. The provision of an OR for the ACS service improves overall throughput/efficiency.

Delay in ICU transfer is protective against ICU readmission in trauma patients: a naturally controlled experiment.

BACKGROUND: Unplanned intensive care unit (ICU) readmission-ICU bounce back (ICUbb)-is associated with worse outcomes. Patients not requiring organ system support or intensive nursing are deemed 'ICU discharge ready' and transfer orders are placed. However, actual transfer only occurs when an appropriate, non-ICU bed is available. This is dependent on inherent system inefficiencies resulting in a naturally controlled experiment between when patients actually transfer: Early (<24 hours) or Delayed (>24 hours) transfers, after order placement. This study leverages that natural experiment to determine if additional ICU time is protective against ICUbb. We hypothesize that Delayed transfer is protective against ICUbb. METHODS: Using a retrospective, cohort design, we queried a trauma research repository and electronic medical record during a 10-year period to capture traumatized patients admitted to the ICU. Patients were categorized into Early (<24 hours) or Unintended-Delayed (>24 hours) groups based on actual transfer time after order placement. Patient characteristics (age, Charlson Comorbidity Index (CCI)) and Injury Severity Score (ISS) were analyzed. Univariate and multivariate analyses were performed to compare ICUbb rates among Early and Unintended-Delayed groups. RESULTS: Of the 2004 patients who met the criteria, 1690 fell into the Early group, and 314 fell into the Delayed. The Early group was younger (mean age 52±23 vs. 55±22 years), had fewer comorbidities (median CCI score 1 (0, 3) vs. 2 (1, 3)), and was less injured (median ISS 17 (10-22) vs. 17 (13-25)), all p<0.05. Overall, 113 (5.6%) patients experienced ICUbb: Early 109 (6.5%) versus Unintended-Delay 4 (1.3%), p<0.05. By regression analysis, age, CCI, and ISS were independently associated with ICUbb while Delayed transfer was protective. DISCUSSION: Despite higher age, CCI score, and ISS, the Unintended-Delayed group experienced fewer ICUbb. After controlling for age, CCI and ISS, Delayed transfer reduced ICUbb risk by 78%. Specific care elements affording this protection remain to be elucidated. LEVEL OF EVIDENCE: Level III. STUDY TYPE: Therapeutic study.

Frequency and importance of small amount of isolated pelvic free fluid detected with multidetector CT in male patients with blunt trauma.

PURPOSE: To retrospectively determine the frequency and importance of a small amount of isolated pelvic free fluid seen at multidetector computed tomography (CT) in male patients who have blunt trauma without an identifiable cause. MATERIALS AND METHODS: Institutional review board approval was obtained, and the requirement for informed consent was waived for this HIPAA-compliant study. One thousand male patients with blunt trauma who underwent abdominopelvic CT at a level 1 trauma center between January 2004 and June 2006 were entered into this study. The CT images of the 1000 patients were reviewed independently by two abdominal radiologists. CT scan assessment included evaluation for presence or absence of pelvic free fluid, any traumatic or nontraumatic cause of the free fluid, pelvic free fluid attenuation and volume measurements, and determination of the location of pelvic free fluid. Interobserver agreement was determined with kappa statistics, and the Student t test was used to assess differences in the mean volume and mean attenuation of the pelvic free fluid in the patients with and those without injury. RESULTS: Pelvic free fluid was identified in 10.2% (102 of 1000) of patients. A small amount of isolated pelvic free fluid without any identifiable cause was identified in 4.8% (48 of 1000) of patients by reader 1 and in 5.0% (50 of 1000) of patients by reader 2 (kappa value, 0.76) and was located at or below the level of the third sacral vertebral body in all 49 patients with isolated pelvic free fluid. The mean volume and mean attenuation of the small amount of isolated pelvic free fluid were 2.3 mL +/- 1.5 (standard deviation) and 8.1 HU +/- 3.9, respectively. None of the patients in this group had an undiagnosed bowel and/or mesenteric injury. CONCLUSION: In male patients with blunt trauma, a small amount of isolated pelvic free fluid with attenuation equal to that of simple fluid and located in the deep region of the pelvis likely is not a sign of bowel and/or mesenteric injury.

Do flexion extension plain films facilitate treatment after trauma?

We hypothesized that flexion extension (FE) films do not facilitate the diagnosis or treatment of ligamentous injury of the cervical spine after blunt trauma. From January 2000 to December 2008 we reviewed all patients who underwent FE films and compared five-view plain films (5 view) and cervical spine CTC with FE in the diagnosis of ligamentous injury. There were 22,929 patients with blunt trauma and of these, 271 patients underwent 303 FE films. Average age was 39.6 years, Injury Severity Score was 10.8, Glasgow Coma Score was 14.1, lactate was 2.6 mmol/L, and hospital length of stay was 6 days. Compared with FE, 5 view and CTC had a sensitivity of 80 per cent (8 of 10), positive predictive value of 47.1 per cent (8 of 17), specificity of 96.55 per cent (252 of 261), and negative predictive value of 99.21 per cent (252 of 254). For purposes of analysis, incomplete and ambiguous FE films were listed as negative; however, 20.5 per cent (62 of 303) were incomplete and 9.2 per cent (28 of 303) were ambiguous. Management did not change for the 2 patients with missed ligament injuries. The 303 studies cost $162,105.00 to obtain. FEs are often incomplete and unreliable making it difficult to use them to base management decisions. They do not facilitate treatment and may lead to increased cost and prolonged cervical collars.

Flexion-extension cervical spine plain films compared with MRI in the diagnosis of ligamentous injury.

The purpose of this study was to compare flexion-extension (FE) plain films with MRI as the gold standard in the diagnosis of ligamentous injury (LI) of the cervical spine after trauma. A retrospective review of patients sustaining blunt trauma from January 2000 to December 2008 (n = 22929) who had both FE and MRI of the cervical spine was performed. Two hundred seventy-one patients had 303 FE films. Forty-nine also had MRI. The average Injury Severity Score was 15.6 +/- 10.2, Glasgow Coma Scale was 13.8 +/- 3.5, lactate 2.2 +/- 1.7 mmol/L, and hospital stay of 8 +/- 11.2 days. FE failed to identify all eight LIs seen on MRI. FE film sensitivity was 0 per cent (zero of eight), specificity 98 per cent (40 of 41), positive predictive value 0 per cent (zero of one), and negative predictive value 83 per cent (40 of 48). Although classified as negative for purposes of analysis, FE was incomplete 20.5 per cent (62 of 303) and ambiguous 9.2 per cent (28 of 303) of the time. The charge of FE is $535 so $48150 (90 incomplete/ambiguous films) could have been saved by eliminating these films. FE should no longer be used to diagnose LI. Given the rare incidence of these injuries, MRI should be used when there is high clinical suspicion of injury.

Preservation of splenic immunocompetence after splenic artery angioembolization for blunt splenic injury.

BACKGROUND: Splenic artery angioembolization (SAE) is increasingly being used as an adjunct to nonoperative management for stable patients with blunt splenic injury (BSI). However, little is known about splenic immunocompetence after SAE. This study aims at assessing splenic immunocompetence after SAE for BSI. METHODS: Peripheral blood was obtained from BSI patients (n = 8) who had SAE >6 months prior. Splenic immunocompetence was assessed by isolating mononuclear cells and incubating with CD4 and CD45RA and CD45RO antibody to analyze the proportion of T-cells expressing CD4 receptor, or coexpressing CD4 and either CD45RA or CD45RO receptors. Cells were counted by fluorescence-activated cell sorting and compared with trauma patients that had splenectomy for BSI also >6 months prior (n = 4, negative controls) and normal healthy volunteers with intact spleens (n = 4, positive controls). RESULTS: The test was discriminatory for the asplenic state. %CD4 cells were significantly lower in splenectomized patients (16 ± 1) versus normal (40 ± 2), p < 0.05. This was due to significant decrease (8 ± 2 vs. 26 ± 4, p < 0.05) in %CD4CD45RA cells whereas the proportion of CD4CD45RO cells were maintained similar to normal. SAE patients had values (CD4, 36 ± 2, and CD4CD45RA, 24 ± 2) comparable to normal (p > 0.05) and significantly higher than splenectomized patients (p < 0.05). When the SAE group was subdivided into main (total, n = 4) and branch vessel (partial, n = 4) SAE, results were the same for both types of SAE. CONCLUSION: Splenic immune function, measured by T-cell subset, generated only in the presence of an immunocompetent spleen, is preserved after SAE for BSI, main or partial.

Alternative clinical trial designs.

High-quality clinical trials are needed to advance the care of injured patients. Traditional randomized clinical trials in trauma have challenges in generating new knowledge due to many issues, including logistical difficulties performing individual randomization, unclear pretrial estimates of treatment effect leading to often unpowered studies, and difficulty assessing the generalizability of an intervention given the heterogeneity of both patients and trauma centers. In this review, we discuss alternative clinical trial designs that can address some of these difficulties. These include pragmatic trials, cluster randomization, cluster randomized stepped wedge designs, factorial trials, and adaptive designs. Additionally, we discuss how Bayesian methods of inference may provide more knowledge to trauma and acute care surgeons compared with traditional, frequentist methods.

A central venous line protocol decreases bloodstream infections and length of stay in a trauma intensive care unit population.

We evaluated the benefit of a central venous line (CVL) protocol on bloodstream infections (BSIs) and outcome in a trauma intensive care unit (ICU) population. We prospectively compared three groups: Group 1 (January 2003 to June 2004) preprotocol; Group 2 (July 2004 to June 2005) after the start of the protocol that included minimizing CVL use and strict universal precautions; and Group 3 (July 2005 to December 2006) after the addition of a line supply cart and nursing checklist. There were 1622 trauma patients admitted to the trauma ICU during the study period of whom 542 had a CVL. Group 3 had a higher Injury Severity Score (ISS) compared with both Groups 2 and 1 (28.3 +/- 13.0 vs 23.5 +/- 11.7 vs 22.8 +/- 12.0, P = 0.0002) but had a lower BSI rate/1000 line days (Group 1: 16.5; Group 2: 15.0; Group 3: 7.7). Adjusting for ISS group, three had shorter ICU length of stay (LOS) compared with Group 1 (12.11 +/- 1.46 vs 18.16 +/- 1.51, P = 0.01). Logistic regression showed ISS (P = 0.04; OR, 1.025; CI, 1.001-1.050) and a lack of CVL protocol (P = 0.01; OR, 0.31; CI, 0.13-0.76) to be independent predictors of BSI. CVL protocols decrease both BSI and LOS in trauma patients. Strict enforcement by a nurse preserves the integrity of the protocol.

Alcohol's role on the reliability of clinical examination to rule out pelvic fractures.

The objective of this study was to determine if clinical examination accurately ruled out pelvic fractures in intoxicated patients sustaining blunt trauma A prospective comparison of intoxicated (blood alcohol level [BAL] greater than 0.08 g/dL) to nonintoxicated (BAL less than 0.08 g/dL) patients sustaining blunt trauma was performed between February 2004 and March 2007. Clinical factors were compared and subset analysis performed in which patients with factors known to compromise the clinical examination were excluded. Two hundred ninety-six intoxicated patients were compared with 1071 nonintoxicated patients. Intoxicated patients were younger and more often male. Intoxicated patients had a higher heart rate (97.1 beats/min +/- 17.9 vs 91.4 beats/min +/- 18.7, P < 0.0001) and lower systolic blood pressure (136.2 mmHg +/- 21.2 vs 141.9 mmHg +/- 26.6, P = 0.0005) than nonintoxicated patients. Intoxicated patients had a lower incidence of pelvic fracture (6.1 vs 10.6%). In subset analysis, the majority of the intoxicated patients did not have exclusion factors on examination and could be evaluated (66.6%). There were eight pelvic fractures diagnosed in this group and no missed injuries on clinical examination (sensitivity 100%). Clinical examination was not compromised by intoxication. Routine pelvic x-rays are not needed in the alert, intoxicated patient sustaining blunt trauma.

Elderly patients with pelvic fracture: interventions and outcomes.

We examined the outcome of elderly trauma patients with pelvic fractures. Patients 65 years of age and older (elderly) with pelvic fractures were retrospectively compared with patients younger than 65 years with pelvic fractures and also with elderly patients without fracture. Over the study period, 1223 patients sustained a pelvic fracture (younger than 65 years, n=1066, 87.2%; elderly, n=157, 12.8%). These patients were also compared with 1770 elderly patients with blunt trauma without fracture. Although the pelvic fracture patients were equally matched for Injury Severity Score (21.2 +/- 13.4 nonelderly vs. 20.5 +/- 13.6 elderly), hospital length of stay was increased in the elderly (12.5 +/- 13.1 days vs. 11.5 +/- 14.1 days) and they had a higher mortality rate (20.4% [32 of 157] vs. 8.3% 88 of 10661). The elderly without fracture also had a higher mortality rate when compared with the younger patients (10.9% [191 of 1760]; P < 0.03). The elderly were more likely to die from multisystem organ failure (25.0% [eight of 32] vs. 10.2% [nine of 88]), whereas the nonelderly group was more likely to die from exsanguination (45.5% [40 of 88] younger than 65 years vs. 21.9% [seven of 32] 65 years or older; P < 0.05). Elderly patients with pelvic fracture have worse outcomes than their younger counterparts despite aggressive management at a Level I trauma center.

What are we missing: results of a 13-month active follow-up program at a level I trauma center.

BACKGROUND: Poor follow-up by patients with trauma results in a lack of knowledge of postdischarge health-related issues. This study reports on postdischarge health-related issues discovered by a program of active postdischarge contact or follow-up. METHODS: All patients discharged home from the trauma service were followed up in the following manner: within 4 weeks of discharge, telephonic follow-up was attempted three times followed by scanning of electronic records. Failing that, other physicians (specialists or primary care) were contacted. Once contact was established, the patient, family member, or physician was questioned about the general well-being, any specific health-related issue, and the resolution. RESULTS: During the 13-month study period ending September 2007, a total of 1,353 patients met entry criteria. Contact was established with 692 (51%). Of these, 116 (17%) were found to have significant health issues: (1) severe uncontrolled pain, 45; (2) missed injury, 17 (spine fractures, 4; clavicle or hand or foot fractures, 6; facial bone fractures, 3; soft tissue, 3; hematuria, 1); (3) wound infections, 17; (4) other infections, 17 (urinary, 8; pulmonary, 7; blood stream, 2) (5) venous thromboembolism, 10; and (6) other, 9 (psychiatric, 6; nontraumatic, 3). One patient died at home within 24 hours of discharge. The issues were significant enough for the patients to seek medical care (outpatient, 39; emergency department visits, 52; hospitalization, 24). CONCLUSION: A significant proportion of patients with trauma have moderate to severe health-related issues postdischarge that are often not found by the trauma team or the trauma registry. Active follow-up can identify the nature of the medical issues and help in designing system changes to reduce or eliminate them.