RESUMO
BACKGROUND: Management of acute traumatic spinal cord injuries is complex, and patients are at risk for severe complications while inpatient. Performance review revealed opportunities for improvement in the care of patients with acute traumatic spinal cord injury at our institution. OBJECTIVE: To compare mortality, failure-to-rescue, and health care utilization of patients with acute traumatic spinal cord injury after implementation of a revised multidisciplinary care pathway. METHODS: Using a pre- and post-between-subjects study design, a retrospective cross-sectional analysis of consecutive patients admitted to our Level I trauma center with acute traumatic spinal cord injury was performed. An updated care pathway for all patients who presented with acute traumatic spinal cord injury was implemented in July 2020. This pathway includes a revised order set in the electronic medical record, distribution of a "best practice" guide to inpatient providers, a formal twice-daily respiratory evaluation, and weekly clinical nurse specialist-led patient rounds. RESULTS: One hundred and eight patients were included in analysis (prepathway: n = 52, postpathway: n = 56). Total mean hospital length of stay was 15.2 (14.0) and 21.5 (24.8) days for the pre- and postpathway groups. Eleven patients (21%) compared with six patients (11%) died, and failure-to-rescue occurred in six patients (60%) compared with zero patient in the pre- and postpathway groups, respectively. In addition, 10 (20%) postpathway patients were discharged to home compared with one (2%) in the prepathway group. DISCUSSION: Following implementation of the updated acute traumatic spinal cord injury pathway, overall inpatient mortality decreased, and fewer patients died after experiencing a complication. Results highlight the need for continued review of care practices and multidisciplinary review in quality improvement initiatives.
Assuntos
Procedimentos Clínicos , Traumatismos da Medula Espinal , Estudos Transversais , Humanos , Tempo de Internação , Estudos Retrospectivos , Traumatismos da Medula Espinal/complicações , Traumatismos da Medula Espinal/diagnóstico , Traumatismos da Medula Espinal/terapia , Centros de TraumatologiaRESUMO
The reality of sexual harassment is unmasking in many fields, and medical trainees constitute a vulnerable and at-risk group. We report the prevalence of sexual harassment among GI, internal medicine, and pediatric residents, with a focus on identifying underlying reasons for lack of victim reporting. A modified previously validated Department of Defense survey on sexual harassment was e-mailed to 261 GI, 132 pediatric, and 271 internal medicine program directors. Three hundred eighty-one residents responded to the survey. Female trainees were more likely to be subject to sexual harassment (83% vs 44%, P <0 .0001). Offensive and/or suggestive jokes and comments were the most common type of harassment experienced. Most residents were unlikely to report the offender (87% females, 93% males). Although 77 per cent of residents believed they would be supported by their program if they reported a sexual harassment event, only 43 per cent were aware of institutional support in place for victims at their program. Although there is a persistently high incidence of harassment in training, the avenues in which to report it are largely unknown and underused. Further research should focus on evidence-based interventions to encourage reporting and to design institutional programs for victims of sexual harassment.
Assuntos
Educação de Pós-Graduação em Medicina , Medicina Interna/educação , Internato e Residência , Pediatria/educação , Assédio Sexual/estatística & dados numéricos , Adulto , Estudos Transversais , Feminino , Humanos , Masculino , Inquéritos e Questionários , Estados UnidosRESUMO
The Stop the Bleed (STB) course teaches trainees prehospital hemorrhage control with a focus on mass education. Identifying populations most likely to benefit can help save on the significant cost and limited resources. In this study, we attempted to identify those populations and performed a cost analysis. Trainees underwent STB education and completed a survey on completion to assess demographics and prior experiences where STB skills could have been useful. Five hundred seventy-one trainees categorized as first responders (14%), students (56%), and the working public (30%) completed the survey. Most trainees found the lecture and simulation helpful, 96 per cent and 98 per cent, respectively. There were significant differences among groups who had previously been in situations where the STB course would have been helpful (88% first responders versus 40% students versus 43% public workers) (P < 0.001). Teaching a class of 10 students costs approximately $455; the cost can be as high as $1246 for a class of 50 students. Most STB trainees found the course helpful. First responders are most likely to be exposed to situations where course information could be helpful. Focusing on specific high-yield groups rather than mass education might be a more efficient approach to STB education.
Assuntos
Serviços Médicos de Emergência/organização & administração , Socorristas/educação , Hemorragia/prevenção & controle , Incidentes com Feridos em Massa/prevenção & controle , Adulto , Distribuição de Qui-Quadrado , Educação Médica/organização & administração , Educação Profissionalizante/organização & administração , Tratamento de Emergência , Feminino , Pessoal de Saúde/educação , Humanos , Masculino , Pessoa de Meia-Idade , Saúde Pública/educação , Melhoria de Qualidade , Medição de Risco , Inquéritos e Questionários , Taxa de Sobrevida , Estados UnidosAssuntos
Contagem de Células Sanguíneas , Transtornos da Coagulação Sanguínea/diagnóstico , Transtornos da Coagulação Sanguínea/etiologia , Transfusão de Sangue , Ferimentos e Lesões/complicações , Ferimentos e Lesões/terapia , Adulto , Transtornos da Coagulação Sanguínea/sangue , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Ferimentos e Lesões/sangueRESUMO
Gunshot wounds (GSW) are becoming increasingly prevalent in urban settings. GSW to the trunk mandate full trauma activation and immediate surgeon response because of the high likelihood of operative intervention. Extremity GSW proximal to the knee/elbow also require full trauma activation based on American College of Surgeons Committee on trauma standards. However, whether isolated extremity GSW require frequent operative intervention is unclear. We evaluated GSW at our Level I trauma center from January 2012 to December 2016. Demographic data and injury patterns were abstracted from the trauma registry and charts. The number of GSW increased yearly but the age, gender, Injury Severity Score and injury pattern did not change (P = ns, not shown). There were 504 GSW that included an extremity and 194 (38%) involved multiple body regions. There were 310 GSW (62%) isolated to an extremity and 176 were proximal to the elbow/knee. If proximal GSW had an Emergency Department systolic blood pressure <90 mm Hg, 53 per cent underwent vascular repair, 12 per cent had soft tissue repair, and 29 per cent required no operation. If proximal GSW had an Emergency Department blood pressure >90 mm Hg, 57 per cent underwent orthopedic repair, 22 per cent required no surgery, and only 13 per cent required vascular repair (P < 0.01). In the absence of other criteria for full trauma activation such as shock, the need for the immediate presence of a general surgeon to perform emergency surgery for a GSW isolated to the extremity is low.
Assuntos
Traumatismos do Braço/cirurgia , Traumatismos da Perna/cirurgia , Traumatismo Múltiplo/cirurgia , Seleção de Pacientes , Centros de Traumatologia , Ferimentos por Arma de Fogo/cirurgia , Adolescente , Adulto , Traumatismos do Braço/complicações , Traumatismos do Braço/diagnóstico , Feminino , Necessidades e Demandas de Serviços de Saúde , Humanos , Hipotensão/diagnóstico , Hipotensão/etiologia , Escala de Gravidade do Ferimento , Traumatismos da Perna/complicações , Traumatismos da Perna/diagnóstico , Masculino , Pessoa de Meia-Idade , Traumatismo Múltiplo/complicações , Traumatismo Múltiplo/diagnóstico , Estudos Retrospectivos , Ferimentos por Arma de Fogo/complicações , Ferimentos por Arma de Fogo/diagnóstico , Adulto JovemRESUMO
BACKGROUND: Hemorrhage is the most common cause of early death in trauma patients. Massive transfusion protocols (MTPs) have been designed to accelerate the release of blood products but can result in waste if activated inappropriately. The Assessment of Blood Consumption (ABC) score has become a widely accepted score for MTP activation. In this study, we compared the use of ABC criteria to physician judgment in MTP activation. METHODS: Adult trauma patients treated at University of Louisville Trauma Center from January 2016 to December 2016 were studied. Activation via ABC score was assessed retrospectively from emergency department (ED) data. Location, timing of activation, percent of patients using more than 5 units of packed red blood cells, amount of product waste, factors associated with early activation by physicians, and mortality were analyzed. RESULTS: Three thousand four hundred twenty-one patients were included in this study. Only 33% of the patients who would have had MTP activation based on the ABC criteria used more than 5 units of blood products within 24 hours of admission compared with 65% of the patients in whom clinical judgment was used. Seventy-six percent of all MTP activations from clinical judgment would have been activated by the ABC criteria in the ED. Fifty-five percent of all MTP activations via clinical judgment were activated in the operating room and 41% in the ED. Eighty-one percent of activations that occurred in the operating room by physician judgment could have been activated earlier in the ED if the ABC criteria had been used. However, ABC score can lead to higher potential fresh frozen plasma waste (588 vs. 84 units) compared with physician judgment. CONCLUSIONS: The ABC criteria overestimate need for massive transfusion and can lead to increased product waste compared with physician judgment, but its use leads to earlier MTP activation. Criteria to trigger MT activation should rely on both clinical acumen and validated prediction tools. LEVEL OF EVIDENCE: Prognostic, level III.
Assuntos
Transfusão de Sangue/estatística & dados numéricos , Técnicas de Apoio para a Decisão , Hemorragia/mortalidade , Hemorragia/terapia , Índices de Gravidade do Trauma , Adulto , Transfusão de Sangue/normas , Feminino , Mortalidade Hospitalar , Humanos , Kentucky/epidemiologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Centros de TraumatologiaAssuntos
Analgésicos Opioides/uso terapêutico , Internato e Residência , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Padrões de Prática Médica/estatística & dados numéricos , Cirurgiões/estatística & dados numéricos , Humanos , Estados Unidos/epidemiologiaAssuntos
Hérnia Diafragmática/diagnóstico , Hérnia Diafragmática/cirurgia , Ruptura Espontânea/diagnóstico , Ruptura Espontânea/cirurgia , Situs Inversus/complicações , Adulto , Lateralidade Funcional , Hérnia Diafragmática/diagnóstico por imagem , Humanos , Masculino , Ruptura Espontânea/diagnóstico por imagem , Situs Inversus/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
The regulation of innate immune responses to pathogens occurs through the interaction of Toll-like receptors (TLRs) with pathogen-associated molecular patterns and the activation of several signaling pathways whose contribution to the overall innate immune response to pathogens is poorly understood. We demonstrate a mechanism of control of murine macrophage responses mediated by TLR1/2 heterodimers through c-Jun N-terminal kinase 1 (JNK1) activity. JNK controls tumor necrosis factor alpha production and TLR-mediated macrophage responses to Borrelia burgdorferi, the causative agent of Lyme disease, and the TLR1/TLR2-specific agonist PAM(3)CSK(4). JNK1, but not JNK2, activity regulates the expression of the tlr1 gene in the macrophage cell line RAW264.7, as well as in primary CD11b(+) cells. We also show that the proximal promoter region of the human tlr1 gene contains an AP-1 binding site that is subjected to regulation by the kinase and binds two complexes that involve the JNK substrates c-Jun, JunD, and ATF-2. These results demonstrate that JNK1 regulates the response to TLR1/2 ligands and suggest a positive feedback loop that may serve to increase the innate immune response to the spirochete.