Development and Validation of the Air Medical Prehospital Triage Score for Helicopter Transport of Trauma Patients.

OBJECTIVE: The aim of this study was to develop and internally validate a triage score that can identify trauma patients at the scene who would potentially benefit from helicopter emergency medical services (HEMS). SUMMARY BACKGROUND DATA: Although survival benefits have been shown at the population level, identification of patients most likely to benefit from HEMS transport is imperative to justify the risks and cost of this intervention. METHODS: Retrospective cohort study of subjects undergoing scene HEMS or ground emergency medical services (GEMS) in the National Trauma Databank (2007-2012). Data were split into training and validation sets. Subjects were grouped by triage criteria in the training set and regression used to determine which criteria had a survival benefit associated with HEMS. Points were assigned to these criteria to develop the Air Medical Prehospital Triage (AMPT) score. The score was applied in the validation set to determine whether subjects triaged to HEMS had a survival benefit when actually transported by helicopter. RESULTS: There were 2,086,137 subjects included. Criteria identified for inclusion in the AMPT score included GCS <14, respiratory rate <10 or >29, flail chest, hemo/pneumothorax, paralysis, and multisystem trauma. The optimal cutoff for triage to HEMS was ≥2 points. In subjects triaged to HEMS, actual transport by HEMS was associated with an increased odds of survival (AOR 1.28; 95% confidence interval [CI] 1.21-1.36, P < 0.01). In subjects triaged to GEMS, actual transport mode was not associated with survival (AOR 1.04; 95% CI 0.97-1.11, P = 0.20). CONCLUSIONS: The AMPT score identifies patients with improved survival following HEMS transport and should be considered in air medical triage protocols.

Geographic Variation in Outcome Benefits of Helicopter Transport for Trauma in the United States: A Retrospective Cohort Study.

OBJECTIVE: Evaluate the effect of US geographic region on outcomes of helicopter transport (HT) for trauma. BACKGROUND: HT is an integral component of trauma systems. Evidence suggests that HT is associated with improved outcomes; however, no studies examine the impact of geographic variation on outcomes for HT. METHODS: Retrospective cohort study of patients undergoing scene HT or ground transport in the National Trauma Databank (2009-2012). Subjects were divided by US census region. HT and ground transport subjects were propensity-score matched based on prehospital physiology and injury severity. Conditional logistic regression was used to evaluate the effect of HT on survival and discharge to home in each region. Region-level characteristics were assessed as potential explanatory factors. RESULTS: A total of 193,629 pairs were matched. HT was associated with increased odds of survival and discharge to home; however, the magnitude of these effects varied significantly across regions (P < 0.01). The South had the greatest survival benefit (odds ratio: 1.44; 95% confidence interval: 1.39-1.49, P < 0.01) and the Northeast had the greatest discharge to home benefit (odds ratio: 1.29; 95% confidence interval: 1.18-1.41, P < 0.01). A subset of region-level characteristics influenced the effect of HT on each outcome, including helicopter utilization, injury severity, trauma center and helicopter distribution, trauma center access, traffic congestion, and urbanicity (P < 0.05). CONCLUSIONS: Geographic region impacts the benefits of HT in trauma. Variations in resource allocation partially account for outcome differences. Policy makers should consider regional factors to better assess and allocate resources within trauma systems to optimize the role of HT.

To leave or not to leave: American Association for the Surgery of Trauma (AAST) panel discussion on personal, parental, and family leave.

Navigating planned and emergent leave during medical practice is very confusing to most physicians. This is especially challenging to the trauma and acute care surgeon, whose practice is unique due to overnight in-hospital call, alternating coverage of different services, and trauma center's staffing challenges. This is further compounded by a surgical culture that promotes the image of a 'tough' surgeon and forgoing one's personal needs on behalf of patients and colleagues. Frequently, surgeons find themselves having to make a choice at the crossroads of personal and family needs with work obligations: to leave or not to leave. Often, surgeons prioritize their professional commitment over personal wellness and family support. Extensive research has been conducted on the topic of maternity leave and inequality towards female surgeons, primarily focused on trainees. The value of paternity leave has been increasingly recognized recently. Consequently, significant policy changes have been implemented to support trainees. Practicing surgeon, however, often lack such policy support, and thus may default to local culture or contractual agreement. A panel session at the American Association for the Surgery of Trauma 2022 annual meeting was held to discuss the current status of planned or unanticipated leave for practicing surgeons. Experiences, perspectives, and propositions for change were discussed, and are presented here.

Outcomes after Child Physical Abuse and Association with Community-Level Social Determinants of Health.

BACKGROUND: Child physical abuse is a significant cause of pediatric injury and death. Previous studies have described disparities in outcomes for physically abused children according to insurance status. We hypothesized that children treated for physical abuse would be more likely to live in neighborhoods with increased socioeconomic deprivation. STUDY DESIGN: We performed a retrospective review of children who were admitted with suspected physical abuse from 2011 to 2021. Home addresses at the time of admission were used to assign an Area Deprivation Index (ADI) of the neighborhood. Clinicopathologic and outcome variables were compared between children from neighborhoods in the top 10th and bottom 90th national neighborhood ADI percentile. Univariate and multivariate logistic models were constructed. RESULTS: One hundred eighty-four children were included for analysis. Children from the top 10th (more impoverished) ADI percentile presented with more severe injuries, had higher area injury scores in the abdomen and extremities, and required admission to the intensive care unit more often, compared with children from the bottom 90th ADI percentile (all p Values <0.05). Children from high ADI neighborhoods were more likely to be discharged to a different caretaker than children from low ADI neighborhoods (71% caretaker change vs 49% caretaker change, p = 0.005). Univariate and multivariate logistic regression demonstrated statistically significant association between the ADI score and the need for caretaker change at the time of discharge (p = 0.004). CONCLUSIONS: Community-level social determinants of health are closely associated with child physical abuse. Child abuse reduction strategies might consider increased support for families with fewer resources and social support systems.

Helicopters improve survival in seriously injured patients requiring interfacility transfer for definitive care.

BACKGROUND: Helicopter transport (HT) is frequently used for interfacility transfer of injured patients to a trauma center. The benefits of HT over ground transport (GT) in this setting are unclear. By using a national sample, the objective of this study was to assess whether HT impacted outcomes following interfacility transfer of trauma patients. METHODS: Patients transferred by HT or GT in 2007 were identified using the National Trauma Databank (version 8). Injury severity, resource utilization, and survival to discharge were compared. Stepwise logistic regression was used to determine whether transport modality was a predictor of survival after adjusting for covariates. Regression analysis was repeated in subgroups with Injury Severity Score (ISS)≤15 and ISS>15. RESULTS: There were 74,779 patients transported by helicopter (20%) or ground (80%). Mean ISS was higher in patients transported by helicopter (17±11 vs. 12±9; p<0.01) as was the proportion with ISS>15 (49% vs. 28%; odds ratio [OR], 2.53; 95% confidence interval [CI], 2.43-2.63). Patients transported by helicopter had higher rates of intensive care unit admission (54% vs. 29%; OR, 2.86; 95% CI, 2.75-2.96), had shorter transport time (61±55 minutes vs. 98±71 minutes; p<0.01), and had shorter overall prehospital time (135±86 minutes vs. 202±132 minutes; p<0.01). HT was not a predictor of survival overall or in patients with ISS≤15. In patients with ISS>15, HT was a predictor of survival (OR, 1.09; 95% CI, 1.02-1.17; p=0.01). CONCLUSIONS: Patients transported by helicopter were more severely injured and required more hospital resources than patients transported by ground. HT offered shorter transport and overall prehospital times. For patients with ISS>15, HT was a predictor of survival. These findings should be considered when developing interfacility transfer policies for patients with severe injuries.

Mechanism of injury and special consideration criteria still matter: an evaluation of the National Trauma Triage Protocol.

BACKGROUND: The Centers for Disease Control recently updated the National Trauma Triage Protocol. This field triage algorithm guides emergency medical service providers through four decision steps (physiologic [PHY], anatomic [ANA], mechanism, and special considerations) to identify patients who would benefit from trauma center care. The study objective was to analyze whether trauma center need (TCN) was accurately predicted solely by the PHY and ANA criteria using national data. METHODS: Trauma patients aged 18 years and older were identified in the NTDB (2002-2006). PHY data and ANA injuries (International Classification of Diseases, ninth revision codes) were collected. TCN was defined as Injury Severity Score (ISS)>15, intensive care unit admission, or need for urgent surgery. Test characteristics were calculated according to steps in the triage algorithm. Logistic regression was performed to determine independent association of criteria with outcomes. Receiver operating characteristic curves were constructed for each model. RESULTS: A total of 1,086,764 subjects were identified. Sensitivity of PHY criteria was highest for ISS>15 (42%) and of ANA criteria for urgent surgery (37%). By using PHY and ANA steps, sensitivity was highest (56%) and undertriage lowest (45%) for ISS>15. Undertriage for TCN based on actual treating trauma center level was 11%. CONCLUSION: Current PHY and ANA criteria are highly specific for TCN but result in a high degree of undertriage when applied independently. This implies that additional factors such as mechanism of injury and the special considerations included in the Centers for Disease Control decision algorithm contribute significantly to the effectiveness of this field triage tool.

The aging road warrior: national trend toward older riders impacts outcome after motorcycle injury.

Industry statistics suggest that motorcycle owners in the United States are getting older. Our objective was to analyze the effect of this demographic shift on injuries and outcomes after a motorcycle crash. Injured motorcyclists aged 17 to 89 years in the National Trauma Databank were reviewed from 1996 to 2005. Age trends and injury patterns were assessed over time. Injury Severity Score (ISS), length of stay (LOS), intensive care unit (ICU) use, comorbidities, complications, mortality, injury patterns, helmet use, and alcohol use were compared for subjects 40 and older versus those younger than 40-years-old. There were 61,689 subjects included. Over the study period, the mean age increased from 33.9 to 39.1 years (P < 0.01), and the proportion of subjects 40 years of age or older increased from 27.9 to 48.3 per cent. ISS, LOS, ICU LOS, and mortality were higher in the 40 years of age or older group (P < or = 0.01). The rates of admission to the ICU (32.3 vs. 27.3%), pre-existing comorbidities (20 vs. 9.7%), and complications (7.6 vs. 5.5%) were all higher in the 40 years of age and older group (P < 0.01). The average age of the injured motorcyclist is increasing. Older riders' injuries appear more serious, and their hospital course is more likely to be challenged by comorbidities and complications contributing to poorer outcomes. Motorcycle safety education and training initiatives should be expanded to specifically target older motorcyclists.

Trauma center designation correlates with functional independence after severe but not moderate traumatic brain injury.

BACKGROUND: The mortality of traumatic brain injury (TBI) continues to decline, emphasizing functional outcomes. Trauma center designation has been linked to survival after TBI, but the impact on functional outcomes is unclear. The objective was to determine whether trauma center designation influenced functional outcomes after moderate and severe TBI. METHODS: Trauma subjects presenting to an American College of Surgeons (ACS) Level I or II trauma center with a Glasgow Coma Score (GCS)

Helicopters and the civilian trauma system: national utilization patterns demonstrate improved outcomes after traumatic injury.

BACKGROUND: The role of helicopter transport (HT) in civilian trauma care remains controversial. The objective of this study was to compare patient outcomes after transport from the scene of injury by HT and ground transport using a national patient sample. METHODS: Patients transported from the scene of injury by HT or ground transport in 2007 were identified using the National Trauma Databank version 8. Injury severity, utilization of hospital resources, and outcomes were compared. Stepwise logistic regression was used to determine whether transport modality was a predictor of survival or discharge to home after adjusting for covariates. RESULTS: There were 258,387 patients transported by helicopter (16%) or ground (84%). Mean Injury Severity Score was higher in HT patients (15.9 ± 12.3 vs. 10.2 ± 9.5, p < 0.01), as was the percentage of patients with Injury Severity Score >15 (42.6% vs. 20.8%; odds ratio [OR], 2.83; 95% confidence interval [CI], 2.76-2.89). HT patients had higher rates of intensive care unit admission (43.5% vs. 22.9%; OR, 2.58; 95% CI, 2.53-2.64) and mechanical ventilation (20.8% vs. 7.4%; OR, 3.30; 95% CI, 3.21-3.40). HT was a predictor of survival (OR, 1.22; 95% CI, 1.17-1.27) and discharge to home (OR, 1.05; 95% CI, 1.02-1.07) after adjustment for covariates. CONCLUSIONS: Trauma patients transported by helicopter were more severely injured, had longer transport times, and required more hospital resources than those transported by ground. Despite this, HT patients were more likely to survive and were more likely to be discharged home after treatment when compared with those transported by ground. Despite concerns regarding helicopter utilization in the civilian setting, this study shows that HT has merit and impacts outcome.

Ground level falls are associated with significant mortality in elderly patients.

BACKGROUND: Falls from height are considered to be high risk for multisystem injury. Ground-level falls (GLF) are often deemed a low-energy mechanism of injury (MOI) and not a recommended triage criterion for trauma team activation. We hypothesize that in elderly patients, a GLF may represent a high-risk group for injury and concurrent comorbidities that warrant trauma service evaluation and should be triaged appropriately. METHODS: This is a retrospective study based on the National Trauma Data Bank. All patients with MOI consistent with GLF were identified. Demographics, type and severity of injuries, and outcomes were analyzed. RESULTS: We identified 57,302 patients with GLF. The group had 34% men, with mean age of 68 years ± 17 years and injury severity score of 8 ± 5. Overall mortality was 3.2%. There were 32,320 elderly patients (older than 70 years). The mortality in the elderly was significantly higher than the nonelderly (4.4% vs. 1.6%, p < 0.0001). The elderly were more likely to sustain long-bone fracture (54.5% vs. 35.9%, p < 0.0001), pelvic fracture (7.6% vs. 2.4%, p < 0.0001), and intracranial injury (10.6% vs. 8.7%, p<0.0001). Multivariate analysis showed that Glasgow Coma Scale (GCS) score <15 (odds ratio, 4.98) and older than 70 years (odds ratio, 2.75) were significant predictors of mortality inpatients after GLF. CONCLUSIONS: Patients older than 70 years and with GCS score <15 represent a group with significant inhospital mortality.

The incidence and clinical significance of pneumomediastinum found on computed tomography scan in blunt trauma patients.

With the increased use of chest computed tomography (CT) scan in the initial evaluation of major trauma, findings that were not seen on a chest radiograph (CXR) are increasingly identified. Pneumomediastinum (PM) seen on CXR in blunt trauma patients is considered worrisome for airway and/or esophageal injury. The purpose of this study was to determine the incidence and clinical significance of PM found on CT in blunt trauma patients. Blunt trauma patients admitted to a single Regional Trauma Center over a 2-year period were identified. Records were reviewed for demographics, mechanism, diagnostic evaluations, injuries, and outcome. A total of 2052 patients met study criteria. Fifty-five (2.7%) had PM; 49 patients (89%) had PM identified on CT alone, whereas six patients (11%) had it identified on both CXR and CT. There was no significant difference in gender or age between the two groups. Associated injuries were similar between groups. No patients had tracheobronchial or esophageal injuries. In this study, PM seen on CT was found to have little clinical significance other than as a marker for severe blunt trauma. No patients with airway or esophageal injuries were seen in any of the PM patients.

Prehospital spinal immobilization does not appear to be beneficial and may complicate care following gunshot injury to the torso.

BACKGROUND: Prehospital spinal immobilization (PHSI) is routinely applied to patients sustaining torso gunshot wounds (GSW). Our objective was to evaluate the potential benefit of PHSI after torso GSW versus the potential to interfere with other critical aspects of care. METHODS: A retrospective analysis of all patients with torso GSW in the Strong Memorial Hospital (SMH) trauma registry during a 41-month period and all patients with GSW in the National Trauma Data Bank (NTDB) during a 60-month period was conducted. PHSI was considered potentially beneficial in patients with spine fractures requiring surgical stabilization in the absence of spinal cord injury (SCI). RESULTS: Three hundred fifty-seven subjects from SMH and 75,210 from NTDB were included. A total of 9.2% of SMH subjects and 4.3% of NTDB subjects had spine injury, with 51.5% of SMH subjects and 32.3% of NTDB subjects having SCI. No SMH subject had an unstable spine fracture requiring surgical stabilization without complete neurologic injury. No subjects with SCI improved or worsened, and none developed a new deficit. Twenty-six NTDB subjects (0.03%) had spine fractures requiring stabilization in the absence of SCI. Emergent intubation was required in 40.6% of SMH subjects and 33.8% of NTDB subjects. Emergent surgical intervention was required in 54.5% of SMH subjects and 43% of NTDB subjects. CONCLUSIONS: Our data suggest that the benefit of PHSI in patients with torso GSW remains unproven, despite a potential to interfere with emergent care in this patient population. Large prospective studies are needed to clarify the role of PHSI after torso GSW.

Artificial neural networks can predict trauma volume and acuity regardless of center size and geography: A multicenter study.

BACKGROUND: Trauma has long been considered unpredictable. Artificial neural networks (ANN) have recently shown the ability to predict admission volume, acuity, and operative needs at a single trauma center with very high reliability. This model has not been tested in a multicenter model with differing climate and geography. We hypothesize that an ANN can accurately predict trauma admission volume, penetrating trauma admissions, and mean Injury Severity Score (ISS) with a high degree of reliability across multiple trauma centers. METHODS: Three years of admission data were collected from five geographically distinct US Level I trauma centers. Patients with incomplete data, pediatric patients, and primary thermal injuries were excluded. Daily number of traumas, number of penetrating cases, and mean ISS were tabulated from each center along with National Oceanic and Atmospheric Administration data from local airports. We trained a single two-layer feed-forward ANN on a random majority (70%) partitioning of data from all centers using Bayesian Regularization and minimizing mean squared error. Pearson's product-moment correlation coefficient was calculated for each partition, each trauma center, and for high- and low-volume days (>1 standard deviation above or below mean total number of traumas). RESULTS: There were 5,410 days included. There were 43,380 traumas, including 4,982 penetrating traumas. The mean ISS was 11.78 (SD = 6.12). On the training partition, we achieved R = 0.8733. On the testing partition (new data to the model), we achieved R = 0.8732, with a combined R = 0.8732. For high- and low-volume days, we achieved R = 0.8934 and R = 0.7963, respectively. CONCLUSION: An ANN successfully predicted trauma volumes and acuity across multiple trauma centers with very high levels of reliability. The correlation was highest during periods of peak volume. This can potentially provide a framework for determining resource allocation at both the trauma system level and the individual hospital level. LEVEL OF EVIDENCE: Care Management, level IV.

Surgical Management of Solid Organ Injuries.

Surgery used to be the treatment of choice in patients with solid organ injuries. This has changed over the past 2 decades secondary to advances in noninvasive diagnostic techniques, increased availability of less invasive procedures, and a better understanding of the natural history of solid organ injuries. Now, nonoperative management (NOM) has become the initial management strategy used for most solid organ injuries. Even though NOM has become the standard of care in patients with solid organ injuries in most trauma centers, surgeons should not hesitate to operate on a patient to control life-threatening hemorrhage.

Paying it forward: Four-year analysis of the Eastern Association for the Surgery of Trauma Mentoring Program.

BACKGROUND: Mentorship programs in surgery are used to overcome barriers to clinical and academic productivity, research success, and work-life balance. We sought to determine if the Eastern Association for the Surgery of Trauma (EAST) Mentoring Program has met its goals of fostering academic and personal growth in young acute care surgeons. METHODS: We conducted a systematic program evaluation of EAST Mentoring Program's first 4 years. Demographic information was collected from EAST records, mentorship program applications, and mentee-mentor career development plans. We reviewed the career development plans for thematic commonalities and results of a structured, online questionnaire distributed since program inception. A mixed methods approach was used to better understand the program goals from both mentee and mentor perspectives, as well as attitudes and barriers regarding the perceived success of this career development program. RESULTS: During 2012 to 2015, 65 mentoring dyads were paired and 60 completed the program. Of 184 surveys distributed, 108 were returned (57% response rate). Respondents were evenly distributed between mentees and mentors (53 vs. 55, p = 0.768). In participant surveys, mentoring relationships were viewed to focus on research (45%), "sticky situations" (e.g., communication, work-life balance) (27%), education (18%), or administrative issues (10%). Mentees were more focused on research and education versus mentors (74% vs. 50%; p = 0.040). Mentees felt that goals were "always" or "usually" met versus mentors (89% vs. 77%; p = 0.096). Two barriers to successful mentorship included time and communication, with most pairs communicating by email. Most respondents (91%) planned to continue the relationship beyond the EAST Mentoring Program and recommended the experience to colleagues. CONCLUSION: Mentee satisfaction with the EAST Mentoring Program was high. Mentoring is a beneficial tool to promote success among EAST's young members, but differences exist between mentee and mentor perceptions. Revising communication expectations and time commitment to improve career development may help our young acute care surgeons.

External validation of the Air Medical Prehospital Triage score for identifying trauma patients likely to benefit from scene helicopter transport.

BACKGROUND: The Air Medical Prehospital Triage (AMPT) score was developed to identify injured patients who may benefit from scene helicopter emergency medical services (HEMS) transport. External validation using a different data set is essential to ensure reliable performance. The study objective was to validate the effectiveness of the AMPT score to identify patients with a survival benefit from HEMS using the Pennsylvania Trauma Outcomes Study registry. METHODS: Patients 16 years or older undergoing scene HEMS or ground EMS (GEMS) transport in the Pennsylvania Trauma Outcomes Study registry 2000-2013 were included. Patients with 2 or higher AMPT score points were triaged to HEMS, while those with less than 2 points were triaged to GEMS. Multilevel Poisson regression determined the association of survival with actual transport mode across AMPT score triage assignments, adjusting for demographics, mechanism, vital signs, interventions, and injury severity. Successful validation was defined as no survival benefit for actual HEMS transport in patients triaged to GEMS by the AMPT score, with a survival benefit for actual HEMS transport in patients triaged to HEMS by the AMPT score. Subgroup analyses were performed in patients treated by advanced life support providers and patients with transport times longer than 10 minutes. RESULTS: There were 222,827 patients included. For patients triaged to GEMS by the AMPT score, actual transport mode was not associated with survival (adjusted relative risk, 1.004; 95% confidence interval, 0.999-1.009; p = 0.08). For patients triaged to HEMS by the AMPT score, actual HEMS transport was associated with a 6.7% increase in the relative probability of survival (adjusted relative risk, 1.067; 95% confidence interval, 1.040-1.083, p < 0.001). Similar results were seen in all subgroups. CONCLUSIONS: This study is the first to externally validate the AMPT score, demonstrating the ability of this tool to reliably identify trauma patients most likely to benefit from HEMS transport. The AMPT score should be considered when protocols for HEMS scene transport are developed and reviewed. LEVEL OF EVIDENCE: Epidemiologic/prognostic study, level III; therapeutic/care management study, level IV.

Helicopter transport improves survival following injury in the absence of a time-saving advantage.

BACKGROUND: Although survival benefits have been shown at the population level, it remains unclear what drives the outcome benefits for helicopter emergency medical services (HEMS) in trauma. Although speed is often cited as the vital factor of HEMS, we hypothesized a survival benefit would exist in the absence of a time savings over ground emergency medical services (GEMS). The objective was to examine the association of survival with HEMS compared with GEMS transport across similar prehospital transport times. METHODS: We used a retrospective cohort of scene HEMS and GEMS transports in the National Trauma Databank (2007-2012). Propensity score matching was used to match HEMS and GEMS subjects on the likelihood of HEMS transport. Subjects were stratified by prehospital transport times in 5-minute increments. Conditional logistic regression determined the association of HEMS with survival across prehospital transport times strata controlling for confounders. Transport distance was estimated from prehospital transport times and average HEMS/GEMS transport speeds. RESULTS: There were 155,691 HEMS/GEMS pairs matched. HEMS had a survival benefit over GEMS for prehospital transport times between 6 and 30 minutes. This benefit ranged from a 46% increase in odds of survival between 26 and 30 minutes (adjusted odds ratio [AOR], 1.46; 95% CI, 1.11-1.93; P < .01) to an 80% increase in odds of survival between 16 and 20 minutes (AOR, 1.80; 95% CI, 1.51-2.14; P < .01). This prehospital transport times window corresponds to estimated transport distance between 14.3 and 71.3 miles for HEMS and 3.3 and 16.6 miles for GEMS. CONCLUSION: When stratified by prehospital transport times, HEMS had a survival benefit concentrated in a window between 6 and 30 minutes. Because there was no time-savings advantage for HEMS, these findings may reflect care delivered by HEMS providers.

Measuring satisfaction: factors that drive hospital consumer assessment of healthcare providers and systems survey responses in a trauma and acute care surgery population.

Hospital quality metrics now reflect patient satisfaction and are measured by Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys. Understanding these metrics and drivers will be integral in providing quality care as this process evolves. This study identifies factors associated with patient satisfaction as determined by HCAHPS survey responses in trauma and acute care surgery patients. HCAHPS survey responses from acute care surgery and trauma patients at a single institution between 3/11 and 10/12 were analyzed. Logistic regression determined which responses to individual HCAHPS questions predicted highest hospital score (a rating of 9-10/10). Demographic and clinical variables were also analyzed as predictors of satisfaction. Subgroup analysis for trauma patients was performed. In 70.3 per cent of 182 total survey responses, a 9-10/10 score was given. The strongest predictors of highest hospital ranking were respect from doctors (odds ratio [OR] = 24.5, confidence interval [CI]: 5.44-110.4), doctors listening (OR: 9.33, CI: 3.7-23.5), nurses' listening (OR = 8.65, CI: 3.62-20.64), doctors' explanations (OR = 8.21, CI: 3.5-19.2), and attempts to control pain (OR = 7.71, CI: 3.22-18.46). Clinical factors and outcomes (complications, intensive care unit/hospital length of stay, mechanism of injury, and having an operation) were nonsignificant variables. For trauma patients, Injury Severity Score was inversely related to score (OR = 0.93, CI: 0.87-0.98). Insurance, education, and disposition were also tied to satisfaction, whereas age, gender, and ethnicity were nonsignificant. In conclusion, patient perception of interactions with the healthcare team was most strongly associated with satisfaction. Complications did not negatively influence satisfaction. Insurance status might potentially identify patients at risk of dissatisfaction. Listening to patients, treating them with respect, and explaining the care plan are integral to a positive perception of hospital stay.

Prevention of hypophosphatemia after burn injury with a protocol for continuous, preemptive repletion.

Severe burn injury has been shown to result in hypophosphatemia. Hypophosphatemia can cause cardiac, hematologic, immunologic, and neuromuscular dysfunction. This study compares serum phosphate levels and outcomes in patients who were administered a continuous, preemptive phosphate repletion protocol vs those who only received phosphate supplementation after they developed hypophosphatemia. Records of patients with greater than 19% TBSA burn admitted to the intensive care unit from 2006 to 2010 were reviewed. Patients were divided into two groups: historical controls who received responsive repletion when serum phosphate levels were less than 2.5 mg/dl (2006-2008) and the experimental group that received 30 mmol intravenous every 6 hours starting at approximately 24 hours after injury as long as serum phosphate levels were less than 4 mg/dl (2008-2010). Patients with chronic kidney disease or acute kidney injury were excluded. Data collected included age, weight, burn size, age, all serum phosphate levels, and total amount of phosphate administered. Differences in groups were compared with Mann-Whitney U test and Fisher's exact test. A total of 30 patients were included in the study, 20 in the responsive repletion group and 10 in the continuous repletion group. No significant difference was detected in age, sex, burn size, or full thickness burn size between groups. The continuous group had a statistically lower percentage of hypophosphatemic lab values compared with the responsive group, 13 ± 14% vs 45 ± 21% (P < .0001). No difference was found in percent of observations reflecting hyperphosphatemia (median of 2% in each group, P = .7). Four patients in the continuous group suffered cardiac and/or infectious complications compared with 16 in the responsive group (P = .04). Continuous, pre-emptive repletion of phosphate prevents hypophosphatemia after severe burn injury when compared with responsive repletion in historical controls. The protocol resulted in less hypophosphatemia without increasing the risk of hyperphosphatemia. This study also suggests that continuous repletion may result in fewer complications, but this needs to be confirmed in larger, prospective studies.