Improving CT scanner efficiency for trauma team activations in the emergency department.

BACKGROUND AND OBJECTIVES: A Trauma Team Activation (TTA) is initiated when a patient has sustained a life or limb-threatening injury thereby necessitating resources of a large care team. Previously, a CT scanner was cleared at the time of the prehospital TTA call. Wide variability in the time it took to stabilize patients often led to extended CT scanner idle time. A new policy was developed whereby the team leader would prompt the ED clerk to provide a '5-min heads-up' (5-min HU) notification to the CT scanner personnel as a patient was stabilized. At this point, the CT scanner was cleared. The purpose of this quality improvement project is to evaluate if the new policy saves CT scanner idle time. METHODS: Research interns prospectively followed incoming TTAs in the ED of a large, urban, Level I Trauma Center in November 2022. The interns collected the following time points: TTA notification page, 5-min HU notification, and arrival to CT. Data was analyzed using a non-parametric comparison test (Mann-Whitney U). RESULTS: A convenience sample of 46 TTAs was included. Trauma was blunt (85%; n = 39)) and penetrating (15%; n = 7). The median initial TTA announcement to CT arrival time was 24.0 min (IQR: 9.0 min). Previously, the scanner would have been held for this entire period. The median time from 5-min HU notification to CT arrival was 5.0 min (IQR: 4.0 min). The new policy saved a median of 19 min of CT scanner idle time per patient compared to the old policy (p < 0.0001). The total CT scanner time saved was 818 min (13.6 h). CONCLUSION: These data support the implementation of a 5-min HU policy in the ED for patients arriving as TTAs. This maximizes the availability of CT scanners for other patients in the ED while TTA patients are being stabilized.

Avoiding Cribari gridlock 2: The standardized triage assessment tool outperforms the Cribari matrix method in 38 adult and pediatric trauma centers.

OBJECTIVES: The Cribari Matrix Method (CMM) is the current standard to identify over/undertriage but requires manual trauma triage reviews to address its inadequacies. The Standardized Triage Assessment Tool (STAT) partially emulates triage review by combining CMM with the Need For Trauma Intervention, an indicator of major trauma. This study aimed to validate STAT in a multicenter sample. METHODS: Thirty-eight adult and pediatric US trauma centers submitted data for 97,282 encounters. Mixed models estimated the effects of overtriage and undertriage versus appropriate triage on the odds of complication, odds of discharge to a continuing care facility, and differences in length of stay for both CMM and STAT. Significance was assessed at p <0.005. RESULTS: Overtriage (53.49% vs. 30.79%) and undertriage (17.19% vs. 3.55%) rates were notably lower with STAT than with CMM. CMM and STAT had significant associations with all outcomes, with overtriages demonstrating lower injury burdens and undertriages showing higher injury burdens than appropriately triaged patients. STAT indicated significantly stronger associations with outcomes than CMM, except in odds of discharge to continuing care facility among patients who received a full trauma team activation where STAT and CMM were similar. CONCLUSIONS: This multicenter study strongly indicates STAT safely and accurately flags fewer cases for triage reviews, thereby reducing the subjectivity introduced by manual triage determinations. This may enable better refinement of activation criteria and reduced workload.

Predicting trauma admissions: the effect of weather, weekday, and other variables.

One of the challenges all hospitals, especially designated trauma centers, face is how to make sure they have adequate staffing on various days of the week and at various times of the year. A number of studies have explored whether factors such as weather, temporal variation, holidays, and events that draw mass gatherings may be useful for predicting patient volume. This article looks at the effects of weather, mass gatherings, and calendar variables on daily trauma admissions at the three Level I trauma hospitals in the Minneapolis-St. Paul metropolitan area. Using ARIMA statistical modeling, we found that weekends, summer, lack of rain, and snowfall were all predictive of daily trauma admissions; holidays and mass gatherings such as sporting events were not. The forecasting model was successful in reflecting the pattern of trauma admissions; however, it's usefulness was limited in that the predicted range of daily trauma admissions was much narrower than the observed number of admissions. Nonetheless, the observed pattern of increased admission in the summer months and year-round on Saturdays should be helpful in resource planning.

Rethinking the definition of major trauma: The need for trauma intervention outperforms Injury Severity Score and Revised Trauma Score in 38 adult and pediatric trauma centers.

BACKGROUND: Patients' trauma burdens are a combination of anatomic damage, physiologic derangement, and the resultant depletion of reserve. Typically, Injury Severity Score (ISS) >15 defines major anatomic injury and Revised Trauma Score (RTS) <7.84 defines major physiologic derangement, but there is no standard definition for reserve. The Need For Trauma Intervention (NFTI) identifies severely depleted reserves (NFTI+) with emergent interventions and/or early mortality. We hypothesized NFTI would have stronger associations with outcomes and better model fit than ISS and RTS. METHODS: Thirty-eight adult and pediatric U.S. trauma centers submitted data for 88,488 encounters. Mixed models tested ISS greater than 15, RTS less than 7.84, and NFTI's associations with complications, survivors' discharge to continuing care, and survivors' length of stay (LOS). RESULTS: The NFTI had stronger associations with complications and LOS than ISS and RTS (odds ratios [99.5% confidence interval]: NFTI = 9.44 [8.46-10.53]; ISS = 5.94 [5.36-6.60], RTS = 4.79 [4.29-5.34]; LOS incidence rate ratios (99.5% confidence interval): NFTI = 3.15 [3.08-3.22], ISS = 2.87 [2.80-2.94], RTS = 2.37 [2.30-2.45]). NFTI was more strongly associated with continuing care discharge but not significantly more than ISS (relative risk [99.5% confidence interval]: NFTI = 2.59 [2.52-2.66], ISS = 2.51 [2.44-2.59], RTS = 2.37 [2.28-2.46]). Cross-validation revealed that in all cases NFTI's model provided a much better fit than ISS greater than 15 or RTS less than 7.84. CONCLUSION: In this multicenter study, NFTI had better model fit and stronger associations with the outcomes than ISS and RTS. By determining depletion of reserve via resource consumption, NFTI+ may be a better definition of major trauma than the standard definitions of ISS greater than 15 and RTS less than 7.84. Using NFTI may improve retrospective triage monitoring and statistical risk adjustments. LEVEL OF EVIDENCE: Prognostic, level IV.

Is distal aortic perfusion in traumatic thoracic aortic injuries necessary to avoid paraplegic postoperative outcomes?

OBJECTIVES: Traumatic thoracic aorta injuries account for nearly 8,000 deaths annually in the United States. Clamp-and-sew techniques can lead to high rates of paraplegia. Use of distal aortic perfusion can lead to heparin-related complications, particularly with associated head trauma. Our objective was to evaluate whether or not an individualized approach to operative management provides acceptable neurologic outcomes. METHODS: A retrospective review (1991-2004) of patients with a traumatic thoracic aortic injury at a Level I trauma center was performed. RESULTS: A total of 67 patients fit the study criteria. Ninety-one percent of patients had concomitant injuries. Median time from injury to evaluation was 38.0 minutes and from evaluation to operating room (OR) 111.0 minutes. Fifty-three percent of patients died before definitive repair could be undertaken; 29% were in the emergency department and 24% were in the OR. When definitive repair occurred, distal aortic perfusion was used in 81% of cases (75% left heart bypass, 6% cardiopulmonary bypass). The remaining 19% underwent clamp-and-sew technique without heparinization. There were no spinal cord deficits or adverse cerebral events related to repair. If definitive repair was completed, the mortality was 16%. Male sex and increasing time, both to evaluation and to OR, were the only risk factors associated with increased mortality. CONCLUSIONS: Judicious use of clamp-and-sew techniques can achieve excellent neurologic outcomes, equivalent to distal aortic perfusion. Prompt evaluation leads to improved survival. Factors such as age, mechanism of injury, site of aortic injury, or operative technique did not affect mortality.

Penetrating Colon Trauma Outcomes in Black and White Males.

INTRODUCTION: Racial disparities have been both published and disputed in trauma patient mortality, outcomes, and rehabilitation. In this study, the objective was to assess racial disparities in patients with penetrating colon trauma. METHODS: The National Trauma Data Bank was searched for males aged ≥14years from 2010 through 2014 who underwent operative intervention for penetrating colon trauma. The primary outcomes for this study were stoma formation and transfer to rehabilitation; secondary outcomes were postoperative morbidity and mortality. Analyses were performed in 2016-2018. RESULTS: There were 7,324 patients identified (4,916 black, 2,408 white). Black and white patients underwent fecal diversion with stoma formation at a similar rate (19.6% vs 18.5%, p=0.28). Black patients were more likely than white patients to be uninsured (self-pay; 37.1% vs 29.9%) and more likely to be injured by firearms (88.3% vs 70.2%, p<0.001), but had a lower overall postoperative morbidity rate (52.6% vs 55.3%, p=0.04). The odds of stoma formation (OR=0.92, 95% CI=0.78, 1.09, p=0.35) and the odds of transfer to rehabilitation (OR=1.03, 95% CI=0.82, 1.30, p=0.78) were similar for black versus white patients. CONCLUSIONS: Black patients experienced similar rates of stoma formation and transfer to rehabilitation as white patients with penetrating colon trauma. Multivariate analysis confirmed expected findings that trauma severity increased the odds of receiving an ostomy and rehabilitation placement. The protocol-based management approach to emergency trauma care potentially decreases the risk for the racial biases that could lead to healthcare disparities. SUPPLEMENT INFORMATION: This article is part of a supplement entitled African American Men's Health: Research, Practice, and Policy Implications, which is sponsored by the National Institutes of Health.

Increasing numbers of rib fractures do not worsen outcome: an analysis of the national trauma data bank.

Increasing age and number of rib fractures are thought to portend a worse outcome with blunt chest trauma, although this is not clearly substantiated in the literature. We hypothesized that these parameters have a significant and synergistic effect, worsening patient outcome. Using the National Trauma Data Bank, we evaluated patients from 2002 to 2006. Patients with a rib fracture International Classification of Diseases, 9th Revision code were included; those with sternal fractures were excluded. Data on demographics, injury, comorbidity, complications, intensive care unit duration, ventilator duration, length of stay, and death were collected. Significant univariate predictors were included in the multivariate logistic regression analysis to adjust for any potential confounders. We identified 35,467 patients who met the inclusion. The mean age was 45.5 years with a mean Injury Severity Score of 19.3. There were 2.1 per cent open rib fractures. Using univariate analysis, rib fracture number was significant. However, once multivariate analyses were applied, the number of rib fractures was not found to be an independent predictor of outcome. The number of rib fractures is not an independent predictor of outcome. Age and overall trauma burden are more powerful predictors of poor outcomes. Treatment focus should shift from the chest to the broader scope of injuries and comorbidities.

Protocol-driven ventilator weaning reduces use of mechanical ventilation, rate of early reintubation, and ventilator-associated pneumonia.

BACKGROUND: Mechanical ventilation is the defining event of intensive care unit management. To reduce use, a literature-based protocol was introduced to facilitate weaning. The effect of protocol-driven ventilator weaning on ventilator use, ventilator-associated pneumonia (VAP), and intensive care unit (ICU) length of stay (LOS) is described in a survey of 2 years' activity in a multidisciplinary surgical ICU. METHODS: Data were gathered from April to September 2000 and from April to September 2002 before and after introduction of nurse/therapist-driven weaning. VAP was identified by chest radiography, clinical presentation, Gram's stains, and cultures from tracheal aspirates or bronchoalveolar lavage. Infection control practitioners diagnosed VAP. Failed extubation was defined as reintubation within 72 hours. RESULTS: Overall, there was a 2:1 ratio of male patients to female patients. The total number of patients and days of mechanical ventilation increased, but the use ratio (ventilator days/ICU days) fell from 0.47 to 0.33. Patients failing extubation fell from 43 (in 2000) to 25 (in 2002). From these patients, 17 cases of VAP occurred in 2000 and 5 in 2002. Mean age (40 years), Injury Severity Score (24), and ICU LOS (5.7-7.4 days; p = not significant) were unchanged in injured patients. ICU discharge was frequently delayed because of the need for subsequent respiratory care. CONCLUSION: Protocol-driven weaning reduces use of mechanical ventilation and VAP. Injured and general surgical patients show reduction in complications, but shorter ICU LOS depends on resources elsewhere in the health care system.