Getting patients to the right level of trauma center after motorcycle crashes in a rural trauma system.

PURPOSE: After a motorcycle crash (MCC), emergency medical services (EMS) responders must balance trauma center proximity with clinical needs of patients, which is especially challenging in rural states. The study purpose was to determine if MCC patients treated at lower-level trauma centers (LLTC) experienced higher mortality when compared to patients transported directly to the highest level of trauma care available in the state at Level II trauma centers. PROCEDURES: A retrospective study was conducted on MCC patients transported by EMS to Montana hospitals and met registry inclusion criteria in 2020-2021. The first study group included patients initially transported to state-designated trauma centers (equivalent to Level III-V) or non-designated hospitals (LLTC), and the second group included patients transported directly to American College of Surgeon verified Level II trauma centers (L2TC). Secondary transfer was defined as initial transport to a LLTC and subsequent transfer to a L2TC. Primary study outcome was mortality at the L2TC. Chi-square tests and Wilcoxon rank sum tests were used for analysis. FINDINGS: In the study period, 337 MCC patients were transported by EMS; 186 (55%) patients were transported to a LLTC while 151 patients (45%) were transported to a L2TC. There were no statistically significant differences in mortality (12% vs 8%, p = 0.30) when comparing secondary transfer patients to patients transported directly to a L2TC. CONCLUSIONS: Nearly half of patients initially evaluated at a LLTC required transfer to a higher-level of care. Secondary transfer was not associated with increased mortality.

Nursing and Chaplain Partnership for Pain Management: A Survey of Nurses.

PURPOSE: Pain is a universal experience for hospitalized patients, with physical, psychological, spiritual, and cognitive implications. As hospitals seek to identify nonpharmaceutical options for managing acute pain, the role of chaplains has been overlooked. The purpose of this study was to evaluate the perceptions of nurses regarding chaplain involvement in pain management. METHODS: A survey was distributed to nurses to determine if they would request spiritual care services in various patient and family scenarios. Respondents were dichotomized into two groups based on self-report of whether they would contact a chaplain for patients with uncontrolled pain. Differences between groups were calculated using chi-square tests. RESULTS: Of 45 nurse respondents, 27 (60%) reported they would not contact a chaplain for patients with uncontrolled pain. Nurses who would consult the chaplain for pain management did not differ from nurses who would not consult the chaplain in terms of their own religious identification, knowledge of patient religious documentation in the medical record, or past experience with chaplain services. CONCLUSIONS: Study findings suggest that nurses' perceptions of chaplain involvement in pain management must be addressed prior to implementing a new hospital pain management protocol. CLINICAL IMPLICATIONS: When developing and implementing new pain protocols based on holistic care of patients, hospitals should ensure that nursing staff are educated on when and how to incorporate chaplains as part of a holistic approach to managing acute pain.

Access to Trauma Care in a Rural State: A Descriptive Geographic and Demographic Analysis.

BACKGROUND: Montana is a rural state with limited access to higher-level trauma care; it also has higher injury fatality rates compared with the rest of the country. OBJECTIVES: The purpose of this study was to utilize Geographic Information System methodology to assess proximity to trauma care and identify the demographic characteristics of regions without trauma access. METHODS: Maptitude® Geographic Information System software (Caliper Corporation, Newton, MA) was used to identify regions in Montana within 60 min of trauma care; this included access to a Level II or Level III trauma center with general surgery capabilities and access to any level of trauma care. Demographic characteristics are reported to identify population groups lacking access to trauma care. RESULTS: Of the 1.1 million residents of Montana, 63% of residents live within 60 driving min of a higher-level trauma center, and 83% of residents live within 60 driving min of any level of trauma center. Elderly residents over age 65 years of age and American Indians had reduced access to both higher-level trauma care and any level trauma care. CONCLUSIONS: Prompt access to trauma care is significantly lower in Montana than in other parts of the country, with dramatic disparities for American Indians. In a rural state, it is important to ensure that all hospitals are equipped to provide some level of trauma care to reduce these disparities.

Traumatic Brain Injury, Psychological Trauma Exposure, and Anxious and Depressive Symptoms in a Clinical Population.

BACKGROUND: Approximately 90% of adults endorse psychological trauma exposure. However, barriers to assessment of psychological trauma and sequelae include limited access to care, lack of standardized assessments in nonpsychiatric settings, and comorbid diagnoses, such as traumatic brain injury (TBI), that may mimic psychiatric syndromes. OBJECTIVES: This study aims to assess the prevalence rates of psychological trauma exposure and TBI to understand the relationship of these experiences with current psychiatric symptoms. METHODS: This is a cross-sectional study of a convenience sample of adult patients (age 18 years and older) referred for outpatient evaluation at a neuropsychology clinic in the Western United States between September 2021 and October 2022. Patients completed a clinical interview to assess their history of psychological trauma, TBI, and current psychiatric symptoms. RESULTS: A total of 118 patients met inclusion criteria. Patients in the TBI group (n = 83) endorsed significantly higher rates of childhood trauma and prior physical, emotional, and sexual abuse compared with the No TBI group (n = 35). Psychological trauma exposure and TBI significantly predicted current anxiety and depressive symptoms, but there was no interaction between these experiences in predicting current psychiatric symptoms. CONCLUSIONS: Individuals with prior TBI experienced psychological trauma, particularly childhood trauma, at a significantly higher rate than those without TBI. Psychological trauma exposure and TBI independently predicted anxious and depressive symptoms, suggesting both may be viable treatment targets. Evaluation of prior psychological trauma exposure during evaluation of TBI may provide opportunities for trauma-informed care and may allow for improved outpatient treatment planning.

Hemorrhage Control Training: Preparing Adolescents to Act at Home, at School, or in Public.

OBJECTIVES: Uncontrolled bleeding is the leading cause of preventable death after a traumatic event, and early intervention to control bleeding improves opportunities for survival. It is imperative to prepare for local and national disasters by increasing public knowledge on how to control bleeding, and this preparation should extend to both adults and children. The purpose of this study is to describe a training effort to teach basic hemorrhage control techniques to early adolescent children. METHODS: The trauma and emergency departments at a combined level I adult and level II pediatric trauma center piloted a training initiative with early adolescents (grades 6-8) focused on 2 skills: packing a wound and holding direct pressure, and applying a Combat Application Tourniquet. Students were evaluated on each skill and completed presurveys and postsurveys indicating their likelihood to use the skills. RESULTS: Of the 194 adolescents who participated in the trainings, 97% of the students could successfully pack a wound and hold pressure, and 97% of the students could apply a tourniquet. Before the training, 71% of the adolescents indicated that they would take action to assist a bleeding victim; this increased to 96% after the training. CONCLUSIONS: Results demonstrate that basic hemorrhage control skills can be effectively taught to adolescents as young as 6th grade (ages 11-12 years) in a small setting with age-appropriate content and hands-on opportunities to practice the skills and such training increases students' perceived willingness to take action to assist a bleeding victim.

Platelet Reactivity Testing for Aspirin Patients Who Sustain Traumatic Intracranial Hemorrhage.

BACKGROUND: Patients who take aspirin and sustain traumatic intracranial hemorrhage (tICH) are often transfused platelets in an effort to prevent bleeding progression. The efficacy of platelet transfusion is questionable, however, and some medical societies recommend that platelet reactivity testing (PRT) should guide transfusion decisions. The study hypothesis was that utilization of PRT to guide platelet transfusion for tICH patients suspected of taking aspirin would safely identify patients who did not require platelet transfusion. METHODS: This was a retrospective study of patients with blunt tICH who received PRT for known or suspected aspirin use between June 2014 and December 2017 at a level I trauma center. Chart abstraction was conducted to determine home aspirin status, and PRT values were used to classify patients as therapeutic or nontherapeutic on aspirin. Differences were assessed with Kruskal-Wallis and chi-square tests. RESULTS: 157 patients met study inclusion criteria, and 118 (75%) patients had documented prior aspirin use. PRT results were available approximately 1.7 h (IQR: 0.9, 3.2) after arrival. Upon initial PRT, 70% of patients were considered inhibited and 88% of those patients had aspirin documented as a home medication. Conversely, 18% of patients with home aspirin use had normal platelet reactivity. Clinically significant worsening of the tICH did not significantly differ when comparing those who received platelet transfusion with those who did not (8% versus 7%, P = 0.87). CONCLUSIONS: Platelet reactivity testing can detect platelet inhibition related to aspirin and should guide transfusion decisions for head injured patients in the initial hours after trauma.

Trauma Response for Elderly Anticoagulated Patients: An Initiative to Reduce Trauma Resource Utilization in the Emergency Department.

BACKGROUND: Trauma centers are challenged to have appropriate criteria to identify injured patients needing a trauma activation; one population that is difficult to triage is injured elderly patients taking anticoagulation or antiplatelet (ACAP) medications with suspected head injury. OBJECTIVE: The study purpose was to evaluate a hospital initiative to improve the trauma triage response for this population. METHODS: A retrospective study at a Level I trauma center evaluated revised trauma response criteria. In Phase 1 (June 2017 to April 2018; n = 91), a limited activation occurred in the trauma bay for injured patients 55 years and older, taking ACAP medications with evidence of head injury. In Phase 2 (June 2018 to April 2019; n = 142), patients taking ACAP medications with evidence of head injury received a rapid emergency department (ED) response. Primary outcomes were timeliness of ED interventions and hospital admission rates. Differences between phases were assessed with Kruskal-Wallis tests. RESULTS: An ED rapid response significantly reduced trauma team involvement (100%-13%, p < .001). Compared with Phase 1, patients in Phase 2 were more frequently discharged from the ED (48% vs. 68%, p = .003), and ED disposition decision was made more quickly (147 vs. 120 min, p = .01). In Phase 2, time to ED disposition decision was longer for patients who required hospital admission (108 vs. 179 min, p < .001); however, there were no significant differences between phases in reversal intervention (6% vs. 11%, p = .39) or timeliness of reversal intervention (49 vs. 118 min, p = .51). CONCLUSION: The ED rapid response delivered safe, timely evaluation to injured elderly patients without overutilizing trauma team activations.

Effect of Pain Management Electronic Order Sets on Opioid Use in Adult Rib Fracture Patients.

BACKGROUND: Inpatient pain management order sets are an important and necessary tool for standardizing and enhancing pain management for patients with traumatic injury. The purpose of this study was to assess the impact of revised inpatient pain management electronic order sets on opioid usage for patients with significant chest wall trauma. METHODS: A retrospective pre-post study was conducted for adult patients with 3 or more rib fractures admitted to the hospital at a Level 1 trauma center. Two periods were compared: 1 year prior to the order set changes and the period immediately after the revisions were implemented. Differences between medians were assessed using Kruskal-Wallis test by ranks, and differences between nominal variables were assessed with χ test. RESULTS: Twenty-five patients were analyzed for each period. There was no significant change between periods in the total amount of opioid received per day. There was a significant reduction in intravenous (IV) opioid use on the general inpatient floor (61% vs. 24%, p = .01), as well as in the percentage of patients who received IV opioid within 24 hr of discharge (40% vs. 4%, p = .002). CONCLUSION: Revised inpatient pain management order sets did not reduce overall opioid usage in a population of patients with 3 or more rib fractures. However, significant improvements were noted in decreased IV opioid usage on the general inpatient floors and within 24 hr of patient discharge from the hospital.

Anticoagulated Trauma Patients: A Level I Trauma Center's Response to a Growing Geriatric Population.

BACKGROUND: Injured older adults often receive delayed care in the emergency department (ED) because they do not meet criteria for trauma team activation (TTA). This is particularly dangerous for the increasing number of patients taking anticoagulant or antiplatelet (AC/AP) medication at the time of injury. OBJECTIVES: The present study examined improvements in processes of care and triage accuracy when TTA criteria include an escalated response for older anticoagulated patients. METHODS: A retrospective study was performed at a Level I trauma center. The study population (referred to as A55) included patients aged 55 years or older who were taking an AC/AP medication at the time of injury. Study periods included 11 months prior to the criteria change (Phase 1: July 2013-May 2014; n = 107) and 11 months after the change (Phase 2: July 2014-May 2015; n = 211). Differences were assessed with Kruskal-Wallis and chi-squared tests. RESULTS: More A55 patients received a full or limited TTA after criteria were revised (70% vs. 26%, p < 0.001). Undertriage was reduced from 13% to 2% (p < 0.001). The trauma center significantly decreased time to first laboratory result, time to first computed tomography scan, and total time in ED prior to admission for A55 patients arriving from the scene of injury or by private vehicle. CONCLUSION: Criteria that escalated the trauma response for A55 patients led to reductions in undertriage for anticoagulated older adults, as well as more timely mobilization of important clinical resources.

High-flow nasal cannula therapy for patients with blunt thoracic injury: A retrospective study.

OBJECTIVE: High-flow nasal cannula (HFNC) has been shown to reduce the need for mechanical ventilation (MV) and to decrease hospital and ICU days for patients with severe respiratory compromise. HFNC has not been evaluated in trauma patients, thus the goal of this study is to describe the use of HFNC in a chest-injured population. METHODS: A retrospective study examined trauma patients with moderate to severe thoracic injury admitted to the ICU at a tertiary hospital between March 2012 and August 2015. HFNC was delivered by the Fisher & Paykel Optiflow system. Primary outcomes were the need for intubation after HFNC for respiratory failure, length of hospitalization, and mortality. RESULTS: During the study period, 105 patients with blunt chest trauma were admitted to the ICU and received HFNC therapy. Eighteen percent received MV prior to HFNC. Overall, 69% of patients who received HFNC never received MV, and 92% of patients were discharged alive. The intubation rate for respiratory failure after HFNC was 18%. For patients who did not receive MV prior to HFNC, delay to first HFNC was correlated with increased hospital days (r s = 0.41, p = 0.001) and ICU days (r s = 0.41, p < 0.001). CONCLUSIONS: Study results suggest that HFNC is comparable with other methods of noninvasive ventilation and may be beneficial for patients with thoracic injury. Additional investigation is warranted to determine if early use of HFNC can deliver effective respiratory support and prevent intubation in this population.

Evaluation and treatment of depression in adult trauma patients.

A retrospective study examined in-hospital antidepressant medication (ADM) use in adult trauma patients with an intensive care unit stay of 5 or more days. One fourth of patients received an ADM, with only 33% of those patients having a documented history of depression. Of patients who received their first ADM from a trauma or critical care physician, only 5% were discharged with a documented plan for psychiatric follow-up. The study identified a need for standardized identification and management of depressive symptoms among trauma patients in the inpatient setting.

Infrequent assessment of pain in elderly trauma patients.

There are inherent difficulties in assessing and managing pain in elderly trauma patients, especially those with chronic health conditions or diminished capacities for self-reporting pain. This retrospective study identifies and describes patterns of pain assessment for a trauma population of older adults (age ≥65 years). Gaps between patient assessments existed in all phases of hospitalization and did not meet hospital guidelines for frequency of assessment. In addition, assessment methods were not always appropriate for the patient population. We conclude that older patients were not assessed for pain frequently enough, and that more regular and routine pain assessments may improve patient outcomes.

Implementation of High-Flow Nasal Cannula Therapy Outside the Intensive Care Setting.

BACKGROUND: High-flow nasal cannula (HFNC) is an option for respiratory support in patients with acute hypoxic respiratory failure. To improve patient outcomes, reduce ICU-associated costs, and ease ICU bed availability, a multi-phased, comprehensive strategy was implemented to make HFNC available outside the ICU under the supervision of pulmonology or trauma providers in cooperation with a dedicated respiratory therapy team. The purpose of this study was to describe the education and implementation process for initiating HFNC therapy outside the ICU and to convey key patient demographics and outcomes from the implementation period. METHODS: HFNC therapy was implemented at a tertiary hospital in the Midwest, with systematic roll-out to all in-patient floors over a 9-month period. Utilization of the therapy and patient outcomes were tracked to ensure safety and efficacy of the effort. RESULTS: During the implementation period, 346 unique subjects met study inclusion criteria. Median (interquartile range) hospital length of stay was 8 d (4-12), and median duration of HFNC therapy was 44 h (18-90). Two thirds of subjects (n = 238) received the entire course of HFNC therapy outside the ICU, and more than half of subjects (n = 184) avoided the ICU for their entire hospitalization. Moreover, 6% of subjects in the study group escalated from HFNC to noninvasive ventilation, and 5% of subjects escalated from HFNC to mechanical ventilation. CONCLUSIONS: A comprehensive implementation process and a robust therapy protocol were integral to initiating and managing HFNC in all hospital locations. Study findings indicate that patients with acute hypoxic respiratory failure can safely receive HFNC therapy outside the ICU with appropriate patient selection and staff education.

Prevalence of risk for sleep apnea among hospitalized patients who survived a medical emergency team activation.

STUDY OBJECTIVES: Sleep-disordered breathing (SDB) is a common disorder that causes people to stop breathing in their sleep, and obstructive sleep apnea (OSA) is the most common form of SDB in the general population. Because OSA is often undiagnosed and undermanaged, it has been associated with adverse events and morbidity in hospitalized patients. The purpose of the study was to evaluate prevalence of OSA risk in a population of patients who survived a medical emergency team (MET) activation during hospitalization. METHODS: This prospective study was conducted at a hospital in the Midwest in 2014. Patients who survived a MET activation and consented to participate were administered the STOP-Bang questionnaire and asked other health and lifestyle questions. Review of the medical record was conducted to ascertain patient characteristics, comorbidities, and medications. Differences were assessed using Kruskal-Wallis one-way analysis of variance and the chi-square test. RESULTS: Of 148 study patients, median age was 68 years (interquartile range: 55-78) and 15% were morbidly obese (body mass index ≥ 40 kg/m²). Fifty percent of patients (n = 74) were found to be at high risk for OSA, yet only 38% (n = 28) of those patients received a previous diagnosis of OSA. Variables available in the medical record were highly correlated with the overall STOP-Bang score (r =. 75, P < .001). CONCLUSIONS: Half of patients who survived a MET activation during hospitalization screened at high risk for OSA. Standardized screening for risk of sleep apnea, as well as a truncated risk score generated by variables in the medical record, could guide clinical decision making in this at-risk population.

Driving with undiagnosed obstructive sleep apnea (OSA): High prevalence of OSA risk in drivers who experienced a motor vehicle crash.

Objective: Obstructive sleep apnea (OSA) is a risk factor for motor vehicle crashes (MVC), and patients with diagnosed OSA have a higher likelihood of being involved in a traffic accident. OSA, however, is often underdiagnosed in the general population. The purpose of this study was to assess the risk of undiagnosed OSA among hospitalized patients involved in MVCs.Methods: This is a prospective, observational pilot study of adult trauma patients admitted to a Level 1 trauma center after being the driver in a MVC. Patients were administered the STOP-Bang to assess risk of OSA and were asked questions about the circumstances of the MVC. Patients with a STOP-Bang score 5-8 were considered to be at high risk for OSA. Differences between variables were assessed using independent t-tests and chi-square.Results: Eighty patients participated in the study, and 26% (n = 21) were considered to be at high risk for OSA based on the STOP-Bang score. Compared to patients at low and intermediate risk, patients at high risk for OSA were significantly older (p < .001), had longer hospitalization (p = .06), and were less likely to discharge home from the hospital (p = .01). Patients at moderate and high risk had higher rates of hospital readmission within 1 year of discharge, when compared to the low risk group. Eighty-four percent of all crashes involved a single occupant (driver) in the vehicle, 58% involved only a single vehicle, and 40% occurred on a rural road. There were no significant differences between risk groups for number of vehicles involved in the accident, location of the accident, or number of vehicle occupants.Conclusions: Results of this pilot study suggest that more than one-quarter of drivers hospitalized after motor vehicle crashes were at high risk for OSA. Diagnosed or undiagnosed OSA is a significant public health concern and an established risk factor for motor vehicle accidents. Standardized screening for risk of sleep apnea should be considered by primary care physicians when guiding patients on health and behavior decisions, particularly in regards to driving and road safety.

Not all head injured patients on antiplatelet drugs need platelets: Integrating platelet reactivity testing into platelet transfusion guidelines.

INTRODUCTION: Antiplatelet medication use continues to rise in an aging population, and these agents can have a deleterious effect for patients with traumatic intracranial hemorrhage (tICH). The purpose of the current investigation is to assess the safety and efficacy of using platelet reactivity testing (PRT) to direct platelet transfusion for tICH patients. PATIENTS AND METHODS: A Level I trauma center adopted a targeted platelet transfusion guideline using PRT to determine whether platelets were inhibited by an antiplatelet medication (aspirin or P2Y12 inhibitors). Non-inhibited patients were monitored without platelet transfusion, regardless of severity of the head injury. The guideline was analyzed retrospectively to evaluate patient outcomes during the study period (June 2014-December 2016). All patients sustained blunt tICH and received a PRT for known or suspected antiplatelet medication use. Differences were assessed with Kruskal-Wallis and Fisher's Exact tests. RESULTS: 166 patients met study inclusion criteria. PRT results indicated that 48 patients (29%) were not inhibited by an antiplatelet medication, and 92% of those patients (n = 44) were spared platelet transfusion. Seven percent (n = 11) of all patients had a clinically significant progression of the head bleed, but this did not differ by inhibition or transfusion status. Implementation of this guideline reduced platelet transfusions by an estimated 30-50% and associated healthcare costs by 42%. CONCLUSIONS: A targeted platelet transfusion guideline using PRT reduced platelet usage for patients with tICH. If appropriately tested, results suggest that not all tICH patients taking or suspected of taking antiplatelet drugs need platelet transfusion. Platelet reactivity testing can significantly reduce healthcare costs and resource usage.

Who Hurts More? A Multicenter Prospective Study of In-Hospital Opioid Use in Pediatric Trauma Patients in the Midwest.

BACKGROUND: Despite increased national attention on misuse of prescription and nonprescription opioids for adolescents and children, little is known about opioid use in a pediatric population during hospitalization for injury. The purpose of this investigation is to describe opioid administration and magnitude of opioid exposure in the first 48 hours of hospitalization in a pediatric trauma population. STUDY DESIGN: This is a secondary analysis of data collected for a randomized, prospective intervention study at 4 Midwestern children's trauma centers. Participants included children ages 10 to 17 years old, admitted to the hospital for unintentional injury. Descriptive statistics and multivariable modeling were used to characterize demographic factors and measure prevalence and magnitude of opioid use within the first 48 hours of hospitalization. RESULTS: Among 299 participants, 82% received at least 1 opioid administration. Children had increased odds of receiving an opioid (odds ratio [OR] 4.25; 95% CI 2.16 to 8.35) for every log increase of Injury Severity Scores (ISS), yet the majority of children with minor injury (61%) also received an opioid. Children with fractures and older children had higher odds of receiving an opioid. Amount of opioid, expressed as morphine milligrams equivalent (MME), significantly increased with child age, ISS, and fracture. CONCLUSIONS: Most pediatric trauma patients received an opioid in the first 48 hours of hospitalization, although prevalence and exposure varied by age, injury, and acuity. Aggressive pain management can be appropriate for injured pediatric patients; however, study results indicate areas for improvement, specifically for children with minor injuries and those receiving excessive opioid amounts.

Efficient Hemorrhage Control Skills Training for Healthcare Employees.

BACKGROUND: Several national initiatives are aimed at training citizens to assist bleeding victims. The purpose of this study was to evaluate an effort to quickly and efficiently teach basic bleeding control techniques to a clinical and nonclinical workforce. STUDY DESIGN: The research study was conducted at 4 hospitals in a mid-sized metropolitan area. In spring 2017, the trauma department at a Level I trauma center set an ambitious goal to provide hands-on training to 1,000 employees during the course of 6 weeks. Trainings occurred in small groups and lasted approximately 6 to 10 minutes, during which time participants were taught and practiced 2 skills: packing a wound and holding direct pressure, and applying a stretch-wrap-and-tuck tourniquet. Participants completed pre- and post-surveys indicating their likelihood to use these skills. RESULTS: More than 1,000 individuals were trained, and there were survey data for 870 participants. More than 40% of participants worked in nonclinical roles and 29% had no first aid or medical training. After completing skills training, 98% of participants indicated that they would be likely to take action to assist a bleeding victim and that they could correctly apply direct pressure or a tourniquet to control severe bleeding. CONCLUSIONS: Results demonstrate that basic hemorrhage control skills can be taught to clinical and nonclinical people in brief, hands-on training. Efforts like this can be deployed across large workplace environments to prepare the maximum number of employees to take action to assist bleeding victims.

Proactive Use of High-Flow Nasal Cannula With Critically Ill Subjects.

INTRODUCTION: It has been suggested that use of a high-flow nasal cannula (HFNC) could be a first-line therapy for patients with acute hypoxic respiratory failure. The purpose of this study was to determine if protocolized use of HFNC decreases unplanned intubation and adverse outcomes in an ICU population. METHODS: The study was a prospective evaluation of 2 cohorts who received HFNC per protocol. Control groups were retrospective selections of subjects who received HFNC in the pre-protocol period. Cohort 1 (n = 88) received mechanical ventilation for ≥ 24 h and was extubated directly to HFNC following strict protocol criteria. Cohort 2 (n = 83) were placed on HFNC when oxygen requirements escalated (>4 L/min). RESULTS: Cohort 1 did not differ from its control group in mortality, hospital stay, or ICU days, but there were significant decreases in incidence of Gram-negative pulmonary infection (30% vs 9%, P = .001) and use of bronchodilator therapy (81% vs 61%, P = .008). Failed extubation rates were nearly identical across groups, but time to re-intubation was shorter in the protocol group (24 vs 13 h, P = .19). Cohort 2 did not differ significantly from its control group in intubation rates or mortality, but subjects managed by protocol experienced significant decreases in ICU days (4 vs 3 d, P = .03) and hospital days (12 vs 8 d, P = .007). There was a trend toward fewer hours on HFNC (33 vs 24 h, P = .10) and faster time to intubation when HFNC failed (19 vs 9 h, P = .08). CONCLUSIONS: Extubation to HFNC led to a significant decrease in pulmonary infections and bronchodilator therapy in Cohort 1 but did not reduce length of stay or rates of failed extubation. When HFNC was used early and per protocol (Cohort 2), ICU and hospital lengths of stay were reduced and HFNC was initiated more quickly when the need for respiratory support escalated.

Head CT before Transfer Does Not Decrease Time to Craniotomy for TBI Patients.

Rural trauma education emphasizes that radiologic imaging should be discouraged if it delays transfer to definitive care. With increased capacity for image sharing, however, radiography obtained at referring hospitals (RH) could help providers at trauma centers (TC) prepare for patients with traumatic brain injury. We evaluated whether a head CT prior to transfer accelerated time to neurosurgical intervention at the TC. The study was conducted at a combined adult Level I and pediatric Level II TC with a catchment area that includes rural hospitals within a 150 mile radius. The trauma registry was used to identify patients with traumatic brain injury who went to surgery for a neurosurgical procedure immediately after arrival at the TC. All patients were transferred in from a RH. Differences between groups were assessed using analysis of variance and chi-square. Fifty-six patients met study criteria during the study period (2010-2015). The majority (86%) of patients received head CT imaging at the RH, including a significant percentage of patients (18%) who presented with GCS ≤8. There was no statistically significant decrease in time to surgery when patients received imaging at the RH. CT imaging was associated with a delay in transfer that exceeded 90 minutes. Findings demonstrate that imaging at the RH delayed transfer to definitive care and did not improve time to neurosurgical intervention at the TC. Transfer to the TC should not be obstructed by imaging, especially for patients with severe TBI.