Clinical Decision Support Intervention for Rib Fracture Treatment.

BACKGROUND: Rib fractures are associated with significant morbidity and mortality. Despite the publication of management guidelines and national outcomes benchmarking, there is significant variation in evidence-based (EB) adherence and outcomes. Systems for clinical decision support intervention (CDSI) allow rapid ordering of bundled disease-specific EB treatments. We developed an EB rib fracture protocol and CDSI at our institution. The purpose of the current study was to evaluate implementation and clinical outcomes using this CDSI. STUDY DESIGN: A rib fracture care CDSI was developed, disseminated, and implemented in July 2018. Implementation outcomes were evaluated using the Proctor framework. Adherence was tracked monthly via run charts and acceptance was evaluated on a 7-point Likert scale using the Unified Theory of Acceptance and Use of Technology questionnaire. Propensity score matching was used to compare in-hospital morbidity and mortality in pre-implementation (January 1, 2016 through December 31, 2016) vs post-implementation (September 1, 2018 through April 30, 2019) cohorts. RESULTS: A total of 197 patients were eligible for the intervention. Provider CDSI adherence was 83% at 1 month and reached 100% after 7 months. Acceptance of CDSI using the Unified Theory of Acceptance and Use of Technology had a mean Likert score higher than 6 (range 6.1 to 6.8, SD 0.5 to 1.5), indicating high acceptance. A significant reduction in hospital length of stay was found post implementation (incident rate ratio 0.80; 95% CI, 0.66 to 0.98; p = 0.03) comparing propensity-matched subjects. CONCLUSIONS: The development and use of a CDSI resulted in improved provider delivery of EB practice and was associated with reduced hospital length of stay.

Implementation of a Prophylactic Anticoagulation Guideline for Patients with Traumatic Brain Injury.

BACKGROUND: Patients with traumatic brain injury (TBI) are at an increased risk of developing complications from venous thromboembolisms (VTEs [blood clots]). Benchmarking by the American College of Surgeons Trauma Quality Improvement Program identified suboptimal use of prophylactic anticoagulation in patients with TBI. We hypothesized that institutional implementation of an anticoagulation protocol would improve clinical outcomes in such patients. METHODS: A new prophylactic anticoagulation protocol that incorporated education, weekly audits, and real-time adherence feedback was implemented in July 2015. The trauma registry identified patients with TBI before (PRE) and after (POST) implementation. Multivariable regression analysis with risk adjustment was used to compare use of prophylactic anticoagulation, VTE events, and mortality. RESULTS: A total of 681 patients with TBI (368 PRE, 313 POST) were identified. After implementation of the VTE protocol, more patients received anticoagulation (PRE: 39.4%, POST: 80.5%, p < 0.001), time to initiation was shorter (PRE: 140 hours, POST: 59 hours, p < 0.001), and there were fewer VTE events (PRE: 19 [5.2%], POST: 7 [2.2%], p = 0.047). Multivariable analysis showed that POST patients were more likely to receive anticoagulation (odds ratio [OR] = 10.8, 95% confidence interval [CI] = 6.9-16.7, p < 0.001) and less likely to develop VTE (OR = 0.33, 95% CI = 0.1-1.0, p = 0.05). CONCLUSION: Benchmarking can assist institutions to identity potential clinically relevant areas for quality improvement in real time. Combining education and multifaceted protocol implementation can help organizations to better focus limited quality resources and counteract barriers that have hindered adoption of best practices.

Riding into the golden years: injury patterns and outcomes of advanced-age motorcycle trauma.

BACKGROUND: Our objectives were to characterize injury, complications, and outcomes for older riders after motorcycle accidents due to the rising trend in advanced-age motorcyclists. METHODS: From 2008 to 2013, injured motorcyclists were compared by age group: younger (0 to 54 years) vs older (≥55 years) in a retrospective review of the trauma databank at North Memorial Medical Center, a Level-1 trauma center. RESULTS: Of 432 patients, the older group (n = 100) had more fractures (60% vs 42%), injuries per patient (2 vs 1), intensive care unit admissions (48% vs 32%), ventilator days (8 vs 5), in-hospital complications (16% vs 8%), and hospital days (5.5 vs 3) than the younger group (n = 332), P < .01. The older group was also more likely to be discharged to a destination other than home, 35% vs 18%, P < .01. CONCLUSIONS: Older riders are at risk for more severe injury, longer and more complex hospitalizations, and higher care demands after discharge. Both age-specific treatment and care systems will need to evolve to accommodate the needs of the aging trauma population.

Wells criteria for DVT is a reliable clinical tool to assess the risk of deep venous thrombosis in trauma patients.

BACKGROUND: Deep Vein Thrombosis (DVT) is a common complication in trauma patients. Venous duplex surveillance is used widely for the diagnosis of DVT, however, there is controversy concerning its appropriate use. The Wells criterion is a clinically validated scoring system in an outpatient setting, but its use in trauma patients has not been studied. This study evaluated the application of the Wells scoring system in trauma population. METHODS: Wells scores were calculated retrospectively for all patients who were admitted to the trauma service and underwent Venous Duplex Scanning (VDS) at the author's institution between 2012 and 2013. Correlation of Wells score with DVT and its efficacy in risk stratifying the patients after trauma was analyzed using linear correlation and receiver operating characteristic (ROC) curve. Sensitivity and specificity of Wells score in ruling out or ruling in DVT were calculated in various risk groups. RESULTS: Of 298 patients evaluated, 18 (6 %) patients were positive for DVT. A linear correlation was present between Wells score and DVT with R (2) = 0.88 (p = 0.0016). Median Wells score of patients without DVT was 1 (1-3) compared to a median score of 2 (1-5) in those with DVT (p < 0.0001). In low risk patients (scores <1), Wells scoring was able to rule out the possibility of DVT with a sensitivity of 100 % and NPV of 100 %, while in moderate-high risk patients (scores ≥2), it was able to predict DVT with a specificity of 90 %. Area under ROC curve was 0.859 (p < 0.0001) demonstrating the accuracy of Wells scoring system for DVT risk stratification in post trauma patients. CONCLUSIONS: A Wells score of <1 can reliably rule out the possibility of DVT in the trauma patients. Risk of developing DVT correlates linearly with Wells score, establishing it as a valid pretest tool for risk stratification.

Non-weight-based enoxaparin dosing subtherapeutic in trauma patients.

BACKGROUND: We report our experience dosing and monitoring enoxaparin with anti-factor Xa activity (anti-FXaA) levels for venous thromboembolism prophylaxis in trauma patients (TP). MATERIALS AND METHODS: TP receiving standard, non-weight-based dosed enoxaparin administered every 12 h for venous thromboembolism prophylaxis with peak anti-FXaA levels measured were prospectively monitored and evaluated and those whose first anti-FXaA levels ≥ or <0.2 IU/mL were compared. Anti-FXaA levels and enoxaparin dose (mg/kg actual body weight) were evaluated for correlation. RESULTS: Of the fifty-one TP included, initial anti-FXaA levels were <0.2 IU/mL in 37 (72.5%) whose dose was lower than those within target range (0.38 [0.32-0.42] mg/kg versus 0.45 [0.39-0.48] mg/kg, P = 0.003). Thirty-seven TP achieved anti-FXaA level ≥0.2 IU/mL (23 requiring dose increases) at a dose of 0.49 [0.44-0.54] mg/kg. Correlation between dose and anti-FXaA levels for the initial 51 anti-FXaA levels (r = 0.360, P = 0.009) and for all 103 anti-XaA levels (r = 0.556, P < 0.001) was noted. CONCLUSIONS: Non-weight-based enoxaparin dosing did not achieve target anti-FXaA levels in most TP. Higher anti-FXaA levels correlated with larger weight-based enoxaparin doses. Weight-based enoxaparin dosing (i.e., 0.5 mg/kg subcutaneously every 12 h) would better achieve target anti-FXaA levels.

Universal Pressure Ulcer Prevention Bundle With WOC Nurse Support.

PURPOSE: This study examined the effectiveness of a universal pressure ulcer prevention bundle (UPUPB) applied to intensive care unit (ICU) patients combined with proactive, semiweekly WOC nurse rounds. The UPUBP was compared to a standard guideline with referral-based WOC nurse involvement measuring adherence to 5 evidence-based prevention interventions and incidence of pressure ulcers. DESIGN: The study used a quasi-experimental, pre-, and postintervention design in which each phase included different subjects. Descriptive methods assisted in exploring the content of WOC nurse rounds. SUBJECT AND SETTING: One hundred eighty-one pre- and 146 postintervention subjects who met inclusion criteria and were admitted to ICU for more than 24 hours participated in the study. The research setting was 3 ICUs located at North Memorial Medical Center in Minneapolis, Minnesota. METHODS: Data collection included admission/discharge skin assessments, chart reviews for 5 evidence-based interventions and patient characteristics, and WOC nurse rounding logs. Study subjects with intact skin on admission identified with an initial skin assessment were enrolled in which prephase subjects received standard care and postphase subjects received the UPUPB. Skin assessments on ICU discharge and chart reviews throughout the stay determined the presence of unit-acquired pressure ulcers and skin care received. Analysis included description of WOC nurse rounds, t-tests for guideline adherence, and multivariate analysis for intervention effect on pressure ulcer incidence. Unit assignment, Braden Scale score, and ICU length of stay were covariates for a multivariate model based on bivariate logistic regression screening. RESULTS: The incidence of unit-acquired pressure ulcers decreased from 15.5% to 2.1%. WOC nurses logged 204 rounds over 6 months, focusing primarily on early detection of pressure sources. Data analysis revealed significantly increased adherence to heel elevation (t = -3.905, df = 325, P < .001) and repositioning (t = -2.441, df = 325, P < .015). Multivariate logistic regression modeling showed a significant reduction in unit-acquired pressure ulcers (P < .001). The intervention increased the Nagelkerke R-Square value by 0.099 (P < .001) more than 0.297 (P < .001) when including only covariates, for a final model value of 0.396 (P < .001). CONCLUSION: The UPUPB with WOC nurse rounds resulted in a statistically significant and clinically relevant reduction in the incidence of pressure ulcers.

Prospective, protocolized study evaluating effects of antibiotics on sputum culture results in injured patients.

BACKGROUND: Appropriate utilization of antibiotics for critically ill patients involves tailoring the drug to culture results; however, the culture results must be reliable. We hypothesized that antimicrobial agents reduce significantly the reliability of cultures obtained between 1 and 24 h after antibiotic administration. METHODS: Patients were eligible for the study if they were ventilated mechanically and were suspected to have pneumonia. After enrollment, sputum cultures were obtained, and broad-spectrum antibiotics were started. Sputum cultures were repeated at 1, 6, 12, and 24 h after delivery of the first dose of antibiotic. Twenty-one patients whose initial culture was positive were included in the analysis. Their average age was 49.4 years, and the average Injury Severity Score was 27.7 points. RESULTS: The average intensive care unit and hospital lengths of stay were 20.2 days and 24.7 days, respectively. All of the organisms grown from the pre-antibiotic cultures also grew in the cultures obtained 1 h after antibiotics were given. However, a significant number of these organisms were unable to be grown in subsequent cultures. The rate of negative cultures increased to 21%, 32%, and 42% in the 6-, 12-, and 24-h groups (p<0.01), respectively. Gram-positive organisms accounted for 42.9% of infections, with Staphylococcus aureus being the most common. All patients positive for S. aureus prior to antibiotic administration remained positive at each subsequent time. By 6 h, 21.5% of the gram-negative organisms could no longer be cultured. At 12 h, among the gram-positive organisms, 11 of 12 cultures were still positive, whereas only 50% of gram-negative organisms were still recoverable. CONCLUSION: Antibiotics have a substantial effect on culture results that is most pronounced in gram-negative organisms and is observed in cultures obtained beginning 1 h after antibiotics are given. As a result, cultures obtained more than 1 h after antibiotics are started cannot be used to tailor antibiotic choice in injured patients with suspected infections.

Therapeutic anticoagulation can be safely accomplished in selected patients with traumatic intracranial hemorrhage.

INTRODUCTION: Therapeutic anticoagulation is an important treatment of thromboembolic complications, such as DVT, PE, and blunt cerebrovascular injury. Traumatic intracranial hemorrhage has traditionally been considered to be a contraindication to anticoagulation. HYPOTHESIS: Therapeutic anticoagulation can be safely accomplished in select patients with traumatic intracranial hemorrhage. METHODS: Patients who developed thromboembolic complications of DVT, PE, or blunt cerebrovascular injury were stratified according to mode of treatment. Patients who underwent therapeutic anticoagulation with a heparin infusion or enoxaparin (1 mg/kg BID) were evaluated for neurologic deterioration or hemorrhage extension by CT scan. RESULTS: There were 42 patients with a traumatic intracranial hemorrhage that subsequently developed a thrombotic complication. Thirty-five patients developed a DVT or PE. Blunt cerebrovascular injury was diagnosed in four patients. 26 patients received therapeutic anticoagulation, which was initiated an average of 13 days after injury. 96% of patients had no extension of the hemorrhage after anticoagulation was started. The degree of hemorrhagic extension in the remaining patient was minimal and was not felt to affect the clinical course. CONCLUSION: Therapeutic anticoagulation can be accomplished in select patients with intracranial hemorrhage, although close monitoring with serial CT scans is necessary to demonstrate stability of the hemorrhagic focus.

Reducing complications in trauma patients: use of a standardized quality improvement approach.

Injured patients are especially prone to developing complications. Using a multidisciplinary standardized approach to complication review is an effective method of evaluating quality improvement in patients on the trauma service. Collaboration between trauma surgeons and nurse clinicians is instrumental in improving the care of patients in each of the areas we identified. Using this consistently, quality improvement strategies can be put in place and tracked for outcomes. This has allowed for better quantification of the problem as well as any change that may result from applying this formal review process and subsequent intervention.

Nasal swabs collected routinely to screen for colonization by methicillin-resistant Staphylococcus aureus in intensive care units are a sensitive screening test for the organism in clinical cultures.

BACKGROUND: Many hospitals screen patients for methicillin-resistant Staphylococcus aureus (MRSA) on admission to the intensive care unit (ICU). We hypothesized that this screening information could be used to assist with empiric antibiotic decisions. METHODS: The medical records of patients admitted to a university-affiliated community hospital as well as a tertiary-care university hospital were reviewed. Patients admitted to the ICU were screened for MRSA colonization with a nasal swab that was analyzed with either chromogenic medium (hospital 1) or polymerase chain reaction (PCR) (hospital 2). The results of the nasal swab were compared with clinical culture results. RESULTS: There were 141 patients, and 167 cultures were obtained. The majority of the cultures (70%) were performed on sputum specimens in an effort to diagnose pneumonia. The remaining cultures were performed on blood (10.1%), incisions (21.5%), and urine (3.4%). The overall sensitivity of nasal swab results was 69.5%. However, the sensitivity was significantly higher for nasal swab screening performed within six days of clinical cultures compared with screening performed seven days or more before cultures were obtained. (79% vs. 46%; p < 0.0001). Sensitivity also differed significantly depending on the surveillance method, being significantly higher among patients screened with PCR within six days of developing an infection than in patients screened with chromogenic medium (88% vs. 65.5%; p = 0.006). CONCLUSION: Screening with PCR analysis of nasal swab specimens is a highly sensitive test for MRSA in clinical cultures. Clinicians may be able to use the swab results to tailor more appropriate empiric antimicrobial regimens. The results with chromogenic medium screening are markedly poorer, which suggests that clinicians should view them with caution.

Early enteral nutrition can be successfully implemented in trauma patients with an "open abdomen".

BACKGROUND: The presence of an "open abdomen" after a trauma laparotomy can complicate the nutritional management of injured patients. METHODS: The medical records of patients admitted to an American College of Surgeons-verified level 1 trauma center were evaluated. The timing of nutritional support was noted. The method to obtain abdominal closure was also noted. RESULTS: Twenty-three patients were included in the study. Enteral nutrition was successfully initiated in 52% of patients before fascial closure. Enteral nutrition was initiated 3.8 days after the initial laparotomy in these patients. All patients successfully achieved fascial and skin closure, obviating the need for delayed hernia repair or skin grafting. CONCLUSIONS: Enteral nutrition can be successfully initiated in patients with "open abdomens." In our series, early enteral nutrition did not alter our ability to ultimately obtain fascial and skin closure.