Barriers and Facilitators to the Implementation of Injury Prevention Programs: A Qualitative Exploration and Model Development.

BACKGROUND: In 2006, the American College of Surgeons Committee on Trauma mandated implementation of injury prevention programs as a requirement for Level I and II trauma center designation. Little is known about the factors that facilitate or create barriers to establishing evidence-based injury prevention program implementation. The purpose of this research is to generate hypotheses regarding processes used to implement injury prevention programs at trauma centers, identify the factors that facilitate and serve as a barrier to implementation, and develop a model reflecting these factors and relationships. METHODS: This is a qualitative study of injury prevention programs at trauma centers. Study participants were chosen from 24 sites representing trauma centers of different patient volumes, geographic regions, and settings in the United States. Subjects participated in phone interviews based on guides developed from pilot interviews with prevention coordinators. Transcribed interviews from eight subjects were analyzed using a system of member checking to code; analysis informed the identification of factors that influence the establishment of evidence-based injury prevention programs. RESULTS: Five themes emerged from the data analysis: external factors, internal organizational factors, program capacity, program selection, and program success. Analysis revealed that successful program implementation was related to supportive leaders and collaborative, interdepartmental relationships. Additional themes indicated that while organizations were motivated primarily by verification requirements (external factor), strong institutional leadership (internal factor) was lacking. Employee readiness (program capacity) was hindered by limited training opportunities, and programs were often chosen (selection) based on implementation ease rather than evidence base or local data. CONCLUSIONS: Data analysis reveals five emerging themes of program implementation; using these data, we suggest an initial model of barriers and facilitators for implementing evidence-based injury prevention programs that could serve as the springboard for additional research involving a larger representative sample.

Internationalization at Home: An Occupational Therapy Synchronous Collaboration Between Cyprus and the United States.

IMPORTANCE: Designing, implementing, and measuring the effectiveness of sustainable Internationalization at Home programs will support the development of cultural competence among occupational therapy students. OBJECTIVE: To explore potential sustainable, effective methods for enhancing cultural competence in occupational therapy students through cross-cultural online collaborations. DESIGN: Pretest-posttest, parallel mixed-methods design. SETTING: An online collaboration using video conferencing technology and classrooms at the European University Cyprus and the University of St. Augustine for Health Sciences. PARTICIPANTS: Bachelor of science and master of occupational therapy students at the European University Cyprus and the University of St. Augustine for Health Sciences, respectively. INTERVENTION: Online video conferencing collaboration between occupational therapy students in which students discussed their perspectives and experiences regarding social injustice and occupational therapy's role in working with vulnerable populations. OUTCOMES AND MEASURES: Each campus participated in focus groups, and students completed individual reflections. Themes were derived from the qualitative information gathered. Quantitative data were collected using the Cultural Awareness Scale for Occupational Therapy Students (CASOTS). RESULTS: CASOTS did not reflect changes in cultural awareness. The qualitative measures identified students' desire to participate in more frequent and culturally diverse experiences. Challenges included length of preparation and actual communication time. Inclusion of prior asynchronous sessions and methods to overcome the language barrier was suggested for future implementation. CONCLUSION: Synchronous cross-cultural collaborations may enhance occupational therapy student's cultural awareness and may be more attractive than traditional in-class teaching. Further development is necessary to overcome challenges. WHAT THIS ARTICLE ADDS: Documenting the benefits and barriers of implementing Internationalization at Home experiences will allow academic institutions to create sustainable methods for enhancing occupational therapy students' cultural competence. Recommendations to further enhance Internationalization at Home experiences provide opportunities for increased cultural collaboration.

Assessment of Severe Extremity Wound Bioburden at the Time of Definitive Wound Closure or Coverage: Correlation With Subsequent Postclosure Deep Wound Infection (Bioburden Study).

Infection remains the most common and significant complication after high-energy fractures. The Bioburden Study is a multicenter, prospective, observational cohort study of wound bacterial bioburden and antibiotic care in severe open lower extremity fractures. The aims of this study are to (1) characterize the contemporary extremity wound "bioburden" at the time of definitive wound closure; (2) determine the concordance between polymerase chain reaction results and hospital microbiology; (3) determine, among those who develop deep infections, the concordance between the pathogens at wound closure and at deep infection; and (4) compare the probability of deep infection between those who did and did not receive an appropriate course of antibiotics based on bioburden at the time of wound closure. To address these aims, sites collected tissue samples from severe lower extremity injuries at the time of wound closure and at first surgery for treatment of a deep infection, nonunion, flap failure, amputation, or other complications (because these surgeries may be due to undetected infection). Otherwise, if no further surgical treatment occurred, participants were followed for 12 months. The study was conducted at 38 US trauma centers and has enrolled 655 participants aged 18-64 years. This is the first large multi-institutional study evaluating the wound bioburden of severe open tibia fractures and correlating this bioburden with the risk of wound complications after definitive soft tissue closure.

Supplemental Perioperative Oxygen to Reduce Surgical Site Infection After High-Energy Fracture Surgery (OXYGEN Study).

Supplemental perioperative oxygen (SPO) therapy has been proposed as one approach for reducing the risk of surgical site infection (SSI). Current data are mixed regarding efficacy in decreasing SSI rates and hospital inpatient stays in general and few data exist for orthopaedic trauma patients. This study is a phase III, double-blind, prospective randomized clinical trial with a primary goal of assessing the efficacy of 2 different concentrations of perioperative oxygen in the prevention of SSIs in adults with tibial plateau, pilon (tibial plafond), or calcaneus fractures at higher risk of infection and definitively treated with plate and screw fixation. Patients are block randomized (within center) in a 1:1 ratio to either treatment group (FiO2 80%) or control group (FiO2 30%) and stratified by each study injury location. Secondary objectives of the study are to compare species and antibacterial sensitivities of the bacteria in patients who develop SSIs, to validate a previously developed risk prediction model for the development of SSI after fracture surgery, and to measure and compare resource utilization and cost associated with SSI in the 2 study groups. SPO is a low cost and readily available resource that could be easily disseminated to trauma centers across the country and the world if proved to be effective.

Perioperative supplemental oxygen to reduce surgical site infection after open fixation of high-risk fractures: a randomized controlled pilot trial.

BACKGROUND: Higher concentrations of fraction of inspired oxygen (FIO2) have been shown to be associated with lower risk for surgical site infection in multiple studies outside the domain of orthopedic surgery. We evaluated the efficacy of high FIO2 administered during the perioperative period to reduce the rate of surgical site infection after open fixation of lower-extremity fractures at high risk of infection. METHODS: We conducted a randomized controlled, parallel design, double-blind study. Patients sustaining high-energy tibial plateau, tibial pilon, and calcaneus fractures treated in a staged fashion were selected for enrollment because these injuries are associated with high risk of infection. The study population included 222 patients with 235 fractures. Consenting patients were randomized by random number sequence to either the treatment or the control group. Treatment group patients received 80% FIO2 intraoperatively and for 2 hours afterward. Control group patients received 30% FIO2 during the same period. Surgeons, patients, and personnel who performed wound assessments were blinded to group assignment. The primary outcome measure was surgical site infection as defined by the Centers for Disease Control criteria for postoperative wound infection. RESULTS: The overall rates of postoperative surgical site infection were 12% (14 of 119 fractures) in the treatment group and 16% (19 of 116 fractures) in the control group (p = 0.31). Multivariate analysis, accounting for risk factors for infection, yielded the closest to a statistically significant reduction in the odds of infection with treatment (odds ratio, 0.54; p = 0.17). No treatment-associated events were observed. CONCLUSION: Use of a high concentration of FIO2 during the perioperative period is safe and shows a trend toward reduction of surgical site infection in patients undergoing open operative fixation of high-energy traumatic lower-extremity fractures. Further study in a larger patient population is indicated. LEVEL OF EVIDENCE: Therapeutic study, level III.

Predictive model for surgical site infection risk after surgery for high-energy lower-extremity fractures: development of the risk of infection in orthopedic trauma surgery score.

BACKGROUND: Current infection risk scores are not designed to predict the likelihood of surgical site infection after orthopedic fracture surgery. We hypothesized that the National Nosocomial Infections Surveillance (NNIS) System and the Study on the Efficacy of Nosocomial Infection Control (SENIC) scores are not predictive of infection after orthopedic fracture surgery and that risk factors for infection can be identified and a new score created (Emerg Infect Dis. 2003;9:196-203). METHODS: We conducted a secondary analysis of data from a trial involving internal fixation of 235 tibial plateau, pilon, and calcaneus fractures treated between 2007 and 2010 at a Level I trauma center. The predictive value of the NNIS System and SENIC scores was evaluated based on areas under the receiver operating characteristic (ROC) curve. Bivariate and multiple logistic regression analyses were used to build an improved prediction model, creating the Risk of Infection in Orthopedic Trauma Surgery (RIOTS) score. The predictive value of the RIOTS score was evaluated via the ROC curve. RESULTS: NNIS System and SENIC scores were not predictive of surgical site infection after orthopedic fracture surgery. In our final regression model, the relative odds of infection among patients with AO [Arbeitsgemeinschaft für Osteosynthesefragen] type C3 or Sanders type 4 fractures compared with fractures of lower classification was 5.40. American Society of Anesthesiologists class 3 or higher and body mass index less than 30 were also predictive of infection, with odds ratios of 2.87 and 3.49, respectively. The area under the ROC curve for the RIOTS score was 0.75, significantly higher than the areas for the NNIS System and SENIC scores. CONCLUSION: The NNIS System and SENIC scores were not useful in predicting the risk of infection after fixation of fractures. We propose a new score that incorporates fracture classification, American Society of Anesthesiologists classification, and body mass index as predictors of infection. LEVEL OF EVIDENCE: Prognostic study, level II.

Transclavicular approach for brachial plexus reconstruction.

Brachial plexus injuries requiring extensive exposure might benefit from a transclavicular approach. At a level 1 trauma center, 20 patients underwent surgical intervention for brachial plexus injuries, 10 via a transclavicular approach. For 5 patients, the transclavicular approach was accomplished through osteotomy with a technique presented herein, and for the other 5, through an established nonunion. All osteotomies and nonunions healed. No hardware-related complications occurred. We think that in the appropriate setting, a transclavicular approach facilitates exposure, decreases surgical time, and is associated with minimal risk.

Monteggia fractures and variants: review of distribution and nine irreducible radial head dislocations.

One hundred and twenty one cases of Monteggia fractures (68) and Monteggia fracture equivalent variant transolecranon fracture dislocations (53) in adults were reviewed to determine the frequency of Bado types and the occurrences of irreducible radial head dislocations. The distribution of Monteggia fractures was 53 Bado type I, two Bado type II, eight Bado type III, and five Bado type IV. Nine (13%) irreducible radial head dislocations were encountered (8 in Bado type I fractures and one in Bado type IV), including an unreported occurrence of biceps tendon interposition. The distribution in the Monteggia variants was 35 Bado type I, 14 Bado type II, one Bado type III, and two Bado type IV, without any irreducible radial heads. The present study demonstrates a greater preponderance of Bado type I than any other type among adult Monteggia fractures.

Salvage of functional elbow range of motion in complex open injuries using a sensate transposition lateral arm flap.

Complex open posterior elbow injuries pose three principal challenges to the reconstructive surgeon. First, the surgeon must provide stable soft-tissue closure over the joint/skeletal reconstruction. Second, the coverage must be thin and supple and promote the free gliding of the underlying structures. Finally, secondary and tertiary procedures must be anticipated beneath the flap, because a stiff, scarred, and adherent flap will only compromise these procedures. The results of 10 consecutive fasciocutaneous transposition lateral arm flaps for coverage of posterior elbow wounds are reported. This flap provides coverage that is thin and supple and that allows subsequent elevation for secondary procedures. Functionally, these flaps allowed for the development of an average arc of motion of 20 to 114 degrees and an average pronation-supination motion of 119 degrees.

A review of outcomes in 18 patients with floating elbow.

OBJECTIVE: To assess functional outcomes and predictors of success in floating elbow injuries. DESIGN: Retrospective clinical review. SETTING: Level 1 trauma center. PATIENTS: Eighteen patients with floating elbow injuries seen at the trauma center from 1995-2001. INTERVENTION: All injuries were managed surgically. Each forearm fracture was managed with open reduction and internal fixation. Humerus fractures were managed with either open reduction and internal fixation or intramedullary nail. Definitive fixation was performed in all cases within 48 hours of arrival at the trauma center. MAIN OUTCOME MEASUREMENTS: Eighteen patients were available for follow-up at a minimum of 1 year and consented to enroll in the study. Each patient was evaluated with a standardized elbow score based on a 100-point scale. These scores were correlated with injury features including age, severity of fracture (AO classification), open fractures, nerve injuries, vascular injuries, type of fixation on the humerus, and the presence of concomitant intra-articular elbow injuries. RESULTS: The average elbow score was 68/100. Outcomes were divided into two groups. Eleven patients had a score greater than 75 (group I), with a mean score of 83, and were considered to have a good or excellent result. Seven patients had a score less than 75 (group II), with a mean score of 45, and were considered to have a satisfactory or poor result. The distribution of outcomes revealed two statistically distinct clusters. Additionally, there was a significantly higher incidence of nerve injuries in group 2 compared with group 1. CONCLUSIONS: Functional outcomes in floating elbow injuries tend to cluster into two groups-patients with good or excellent results and patients with poor results. Patients with associated nerve injuries have lower functional outcomes at a minimum of 1-year follow-up.