Acceptance of Acute Kidney Injury Alert by Providers in Cardiac Surgery Intensive Care Unit.

BACKGROUND: Acute kidney injury (AKI) is a common complication after cardiac surgery and is associated with worse outcomes. Its management relies on early diagnosis, and therefore, electronic alerts have been used to alert clinicians for development of AKI. Electronic alerts are, however, associated with high rates of alert fatigue. OBJECTIVES: We designed this study to assess the acceptance of user-centered electronic AKI alert by clinicians. METHODS: We developed a user-centered electronic AKI alert that alerted clinicians of development of AKI in a persistent yet noninterruptive fashion. As the goal of the alert was to alert toward new or worsening AKI, it disappeared 48 hours after being activated. We assessed the acceptance of the alert using surveys at 6 and 12 months after the alert went live. RESULTS: At 6 months after their implementation, 38.9% providers reported that they would not have recognized AKI as early as they did without this alert. This number increased to 66.7% by 12 months of survey. Most providers also shared that they re-dosed or discontinued medications earlier, provided earlier management of volume status, avoided intravenous contrast use, and evaluated patients by using point-of-care ultrasounds more due to the alert. Overall, 83.3% respondents reported satisfaction with the electronic AKI alerts at 6 months and 94.4% at 12 months. CONCLUSION: This study showed high rates of acceptance of a user-centered electronic AKI alert over time by clinicians taking care of patients with AKI.

Trauma Recidivism Predicts Long-term Mortality: Missed Opportunities for Prevention (Retrospective Cohort Study).

OBJECTIVES: The objectives of this study were to determine the association between recurrent trauma admissions (recidivism) and subsequent long-term mortality, and to identify those in most need for preventive interventions. BACKGROUND: Patients with a single intentional injury have been shown to have a higher risk of future injury mortality than those with unintentional injury with 5-year mortality rates as high as 20% being reported for recurrent penetrating trauma. Trauma recidivism identifies a high-risk population, but its association with long-term mortality is largely unknown. METHODS: Patients with 1 or more previous admissions to an urban trauma center (recidivists) were identified and compared with those with single admissions (nonrecidivists) from 1997 to 2008. The trauma registry was linked to the National Death Index to determine both the cause and time to death after hospital discharge. Statistical analysis included chi-square tests, Kaplan-Meier survival curves, and Cox proportional-hazards models. RESULTS: Trauma recidivists were 7% of the total trauma population from 1997 to 2008, representing 3147 patients. Recidivists were more likely to be male (P < 0.0001), Black (P < 0.0001), have a blood alcohol content above 80 mg/dL (P < 0.0001), and suffer a penetrating injury (P < 0.0001) compared with nonrecidivists. Recidivists with both initial blunt and penetrating injuries had higher rates of long-term mortality after discharge. Recidivists were more likely to die of any cause based on Cox proportional-hazard ratios [hazard ratio (HR) 1.77, 95% confidence interval (CI) 1.57-2.01], injury death (HR 2.02, 95% CI 1.66-2.47), and disease death (HR 1.65, 95% CI 1.41-1.92) than nonrecidivists. CONCLUSIONS: Male sex, Black race, and elevated blood alcohol content and penetrating injury are associated with trauma recidivism which leads to a higher risk of death. There is a critical public health need to develop interventions to reduce trauma recidivism and preventable death.

Outcomes of trauma admission for falls: influence of race and age on inhospital and post-discharge mortality.

BACKGROUND: Racial disparities in trauma outcomes occur, but disparities in fall mortality are unknown. The objective of this study was to determine inhospital and 1-year fall mortality among patients discharged from an urban trauma center. METHODS: We conducted a retrospective analysis of fall patients in our trauma registry (1997 to 2008) linked to the National Death Index to determine postdischarge mortality. Statistical analysis included chi-square tests, multivariable logistic regression, and Cox proportional hazards models. RESULTS: There were 7,541 fall admissions. There was no clinically significant difference in inhospital mortality between blacks and whites with age stratification. One year after discharge, blacks younger than 65 years were more likely to die of disease (hazard ratio, 1.37; 95% confidence interval, 1.14 to 1.62). CONCLUSIONS: Although rates of inhospital mortality are similar, blacks younger than 65 years have a higher risk of dying after discharge due to disease when stratified by age highlighting the need for continued medical follow-up and prevention efforts.

Sex differences in mortality following isolated traumatic brain injury among older adults.

BACKGROUND: Older adults have the highest rates of hospitalization and mortality from traumatic brain injury (TBI), yet outcomes in this population are not well studied. In particular, contradictory reports on the protective effect of female sex on mortality following TBI may have been related to age differences in TBI and other injury severity and mechanism. The objective of this study was to determine if there are sex differences in mortality following isolated TBI among older adults and compare with findings using all TBI. A secondary objective was to characterize TBI severity and mechanism by sex in this population. METHODS: This was a retrospective cohort study conducted among adults aged 65 and older treated for TBI at a single large Level I trauma center from 1996 to 2012 (n = 4,854). Individuals treated for TBI were identified using International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Isolated TBI was defined as an Abbreviated Injury Scale score of 0 for other body regions. Our primary outcome was mortality at discharge. RESULTS: Among those with isolated TBI (n = 1,320), women (45% of sample) were older (mean [SD], 78.9 [7.7] years) than men (76.8 [7.5] years) (p < 0.001). Women were more likely to have been injured in a fall (91% vs. 84%; p < 0.001). Adjusting for multiple injury severity measures, female sex was not significantly associated with decreased odds of mortality following isolated TBI (odds ratio, 1.01; 95% confidence interval, 0.66-1.54). Using all TBI cases, adjusted analysis found that female sex was significantly associated with decreased odd of mortality (odds ratio, 0.73; 95% confidence interval, 0.59-0.89). CONCLUSION: We found no sex differences in mortality following isolated TBI among older adults, in contrast with other studies and our own analyses using all TBI cases. Researchers should consider isolated TBI in outcome studies to prevent residual confounding by severity of other injuries. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level IV.

Failure to clear elevated lactate predicts 24-hour mortality in trauma patients.

BACKGROUND: Lactate clearance is a standard resuscitation goal in patients in nontraumatic shock but has not been investigated adequately as a tool to identify trauma patients at risk of dying. Our objective was to determine if trauma patients with impaired lactate clearance have a higher 24-hour mortality rate than patients whose lactate concentration normalizes. METHODS: A retrospective chart review identified patients who were admitted directly from the scene of injury to an urban trauma center between 2010 and 2013 and who had at least one lactate concentration measurement within 24 hours. Transfers, patients without lactate measurement, and those who were dead on arrival were excluded. Of the 26,545 screened patients, 18,304 constituted the initial lactate measurement population, and 3,887 were the lactate clearance cohorts. RESULTS: Initial lactate had an area under the receiver operating characteristic curve of 0.86 and 0.73 for mortality at 24 hours and in the hospital, respectively. An initial concentration of 3 mmol/L or greater had a sensitivity of 0.86 and a specificity of 0.73 for mortality at 24 hours. The mortality rate among patients with elevated lactate concentrations (n = 2,381; 5.6 [2.8] mmol/L) that did not decline to less than 2.0 mmol/L in response to resuscitative efforts (mean [SD] second measurement, 3.7 [1.9] mmol/L) was nearly seven times higher (4.1% vs. 0.6%, p < 0.001) than among those with an elevated concentration (n = 1,506, 5.3 [2.7] mmol/L) that normalized (1.4 [0.4] mmol/L). Logistic regression analysis showed that failure to clear lactate was associated with death more than any other feature (odds ratio, 7.4; 95% confidence interval, 1.5-35.5), except having an Injury Severity Score (ISS) greater than 25 (odds ratio, 8.2; 95% confidence interval, 2.7-25.2). CONCLUSION: Failure to clear lactate is a strong negative prognostic marker after injury. An initial lactate measurement combined with a second measurement for high-risk individuals might constitute a useful method of risk stratifying injured patients. LEVEL OF EVIDENCE: Prognostic study, level III.

Alcohol exposure, injury, and death in trauma patients.

BACKGROUND: The association of alcohol use with in-hospital trauma deaths remains unclear. This study identifies the association of blood alcohol content (BAC) with in-hospital death accounting for injury severity and mechanism. METHODS: This study involves a historical cohort of 46,222 admissions to a statewide trauma center between January 1, 2002, and October 31, 2011. Blood alcohol was evaluated as an ordinal variable: 1 mg/dL to 100 mg/dL as moderate blood alcohol, 101 mg/dL to 230 mg/dL as high blood alcohol, and greater than 230 mg/dL as very high blood alcohol. RESULTS: Blood alcohol was recorded in 44,502 patients (96.3%). Moderate blood alcohol was associated with an increased odds for both penetrating mechanism (odds ratio [OR], 2.22; 95% confidence interval [CI], 2.04-2.42) and severe injury (OR, 1.25; 95% CI, 1.16-1.35). Very high blood alcohol had a decreased odds for penetrating mechanism (OR, 0.75; 95% CI, 0.67-0.85) compared with the undetectable blood alcohol group. An inverse U-shaped association was shown for severe injury and penetrating mechanism by alcohol group (p < 0.001). Moderate blood alcohol had an increased odds for in-hospital death (OR, 1.50; 95% CI, 1.25-1.79), and the odds decreased for very high blood alcohol (OR, 0.69; 95% CI, 0.54-0.87). An inverse U-shaped association was also shown for in-hospital death by alcohol group (p < 0.001). Model discrimination for in-hospital death had an area under the receiver operating characteristic curve of 0.64 (95% CI, 0.63-0.65). CONCLUSION: Injury severity and mechanism are strong intermediate outcomes between alcohol and death. Severe injury itself carried the greatest odds for death, and with the moderate BAC group at greatest odds for severe injury and the very high BAC group at the lowest odds for severe injury. The result was a similar inverse-U shaped curve for odds for in-hospital death. Clear associations between blood alcohol and in-hospital death cannot be analyzed without consideration for the different injuries by blood alcohol groups. LEVEL OF EVIDENCE: Epidemiologic study, level III.

Blood alcohol content, injury severity, and adult respiratory distress syndrome.

BACKGROUND: Elevated blood alcohol content (BAC) is a risk factor for injury. Associations of BAC with adult respiratory distress syndrome (ARDS) have not been conclusively established.We evaluated the association of a BAC greater than 0 mg/dL with the intermediate outcomes, Injury Severity Score (ISS) and Glasgow Coma Scale (GCS) score, and their association with ARDS development. METHODS: This is an observational retrospective cohort study of 26,305 primary trauma admissions to a statewide referral trauma center from July 11, 2003, to October 31, 2011. Logistic regression was performed to assess the relationship between admission BAC, ISS, GCS score, and ARDS development within 5 days of admission. RESULTS: The case rate for ARDS was 5.5% (1,447). BAC greater than 0 mg/dL was associated with ARDS development in adjusted analysis (odds ratio, 1.50; 95% confidence interval [CI], 1.33-1.71; p < 0.001). High ISS (≥16) had a stronger association with ARDS development (odds ratio, 17.99; 95% CI, 15.51-20.86), as did low GCS score (≤8) (odds ratio, 8.77; 95% CI, 7.64-10.07; p < 0.001). Patients with low GCS score and high ISS had the most frequent ARDS (33.6%) and the highest case-fatality rate without ARDS (24.7%). CONCLUSION: Elevated BAC is associated with ARDS development. In the analysis of alcohol exposure, ISS and GCS score occur after alcohol ingestion, making them intermediate outcomes. ISS and GCS score were strong predictors of ARDS and may be useful to identify at-risk patients. Elevated BAC may increase the frequency of the ARDS through influence on injury severity or independent molecular mechanisms, which can be discriminated only in experimental models. LEVEL OF EVIDENCE: Epidemiologic study, level III.

Sociodemographic characteristics associated with substance use status in a trauma inpatient population.

Substance use is significantly associated with physical injury, yet relatively little is known about the prevalence of specific substance use disorders among trauma patients, or their associated sociodemographic characteristics. We evaluated these issues in an unselected sample of 1,118 adult inpatients at the University of Maryland Shock Trauma Center, Baltimore, MD, who were interviewed with the psychoactive substance use disorder section of the Structured Clinical Interview for DSM-III-R. Among trauma inpatients, lifetime alcohol users (71.8% of subjects) were more likely male; users of illegal drugs (45.3%) were also more likely to be younger, unmarried, and poor. Patients with current drug abuse/dependence (18.8%) were more likely to be non-white, less educated, and poor; those with current alcohol abuse/dependence (32.1%) were also more likely male, unmarried, and older. These findings highlight the need for screening for substance use disorders in trauma settings and referral of patients to substance abuse treatment programs.

Declared and undeclared substance use among emergency department patients: a population-based study.

AIMS: To estimate both self-reported and corrected prevalences of substance use in a population-based study of general hospital emergency department (ED) patients and predict undeclared use. DESIGN: A state-wide cross-sectional, two-stage probability sample survey that incorporates toxicological screening. SETTING: Seven Tennessee EDs in acute care, adult, civilian, non-psychiatric hospitals. PARTICIPANTS: A total of 1502 Tennessee residents, 18 years of age and older, possessing intact cognition, able to give informed consent and not in police custody. Measurements Prevalence of self-reported current substance use by age, sex and type with correction for under-reporting based on toxicological screening. Covariates in the multivariate analysis of undeclared use were socio-demographics, ED visit circumstances, health-care coverage, prior health status and treatment history and tobacco addiction. FINDINGS: Declared current use was highest for alcohol (females 26%, males 47%), marijuana (males 11%, females 6%) and benzodiazepines (females 10%, males 7%). After correction for under-reporting, overall use for any of the eight targeted substances rose from 44% to 56% for females and 61% to 69% for males. Largest absolute changes involved opioids, benzodiazepines, marijuana, amphetamines and/or methamphetamine, with little change for alcohol. Patients aged 65 years and older manifested excess undeclared use relative to patients aged 18-24 years, as did patients not reporting tobacco addiction or receiving substance abuse treatment. CONCLUSION: Adjustment for under-reporting produced minimal change in the estimated prevalence of alcohol use. However, toxicological screening markedly increased estimates of other drug use, especially for the elderly, who may under-report medication use. Screening tests are useful tools for detecting undeclared substance use.

Unmet substance abuse treatment need, health services utilization, and cost: a population-based emergency department study.

STUDY OBJECTIVE: There is a high prevalence of unmet substance abuse treatment need among adult hospital emergency department (ED) patients. We examine the association between this unmet need and excess utilization of health services and estimate costs. METHODS: A statewide, 2-stage, probability sample survey was conducted in 7 Tennessee general hospital EDs from June 1996 to January 1997. Toxicologic screening augmented in-person interviews. Main outcome measures were ED case disposition; frequency of physician office visits, ED visits, and hospitalizations in the past 12 months; and costs of excess service utilization. Covariates in the multivariate model were substance abuse treatment need status, age, sex, main reason for ED visit, perceived previous health status, history of tobacco use, and health care coverage. Unmet substance abuse treatment need was assessed using 13 overlapping criteria that incorporated use, dependence, denial, and treatment history. Target substances included ethanol and selected illegal and prescription drugs but not nicotine. RESULTS: Compared with patients without substance abuse treatment need (n=1,073), patients with unmet need (n=415) were 81% more likely to be admitted to the hospital during their current ED visit (odds ratio [OR] 1.81; 95% confidence interval [CI] 1.27 to 2.64) and 46% more likely to have reported making at least 1 ED visit in the previous 12 months (OR 1.46; 95% CI 1.12 to 1.84). Their utilization patterns accounted for an estimated 777.2 million US dollars in extra hospital charges for Tennessee in 2000 dollars, representing an additional 1,568 US dollars per ED patient with unmet substance abuse treatment need. CONCLUSION: ED patients with unmet substance abuse treatment need generated much higher hospital and ED charges than patients without such need. Given potential savings from avoidable health care costs, the future burden of substance-associated ED visits and hospitalizations may be reduced through programs that screen and, as appropriate, provide brief interventions or treatment options to these patients.

Occupational disability after hospitalization for the treatment of an injury of the anterior cruciate ligament.

BACKGROUND: To date, no large population-based studies have focused on permanent occupational disability after injury of the anterior cruciate ligament as far as we know. The purpose of our study was to determine the risk factors for occupational disability after an injury of the anterior cruciate ligament. METHODS: We identified a cohort of 2192 active-duty personnel in the Army who had been hospitalized between 1989 and 1997 because of an injury of the anterior cruciate ligament and had completed a health risk-assessment survey. With use of the Total Army Injury and Health Outcomes Database, we retrospectively followed these individuals for up to nine years and collected clinical, demographic, occupational, and psychosocial data. These data were then evaluated with bivariate and proportional-hazards regression analyses to identify risk factors for receiving a disability discharge related to an injury of the anterior cruciate ligament. RESULTS: Overall, 209 (9.5%) of 2192 initial anterior cruciate ligament injuries resulted in a permanent disability discharge. In bivariate analyses, the following factors were related to a disability discharge: lower job satisfaction (p < 0.0001), lower education level (p < 0.0001), shorter length of service (p < 0.0001), lower pay grade or rank (p < 0.0001), occupational classification (p < 0.0001), older age (p < 0.01), cigarette-smoking (p = 0.01), and greater mental stress at work (p = 0.02). Associated cartilage injury (p = 0.07) and occupational physical demands (p = 0.08) approached significance; however, with the numbers available, other variables that were hypothesized to contribute to the development of disability, such as gender (p = 0.85), reconstruction of the anterior cruciate ligament (p = 0.52), and other secondary comorbidities of the knee, demonstrated no significant association. Proportional-hazards regression analysis confirmed that pay grade or rank, occupational classification, job satisfaction, age, and length of service were independent predictors of disability discharge. CONCLUSIONS: In keeping with risk profiles of several other musculoskeletal disorders, such as low-back pain and carpal tunnel syndrome, the results revealed a multifactorial risk profile in which psychosocial factors were strongly associated with disability discharge from active military duty after injury of the anterior cruciate ligament.

The effect of cigarette smoking on musculoskeletal-related disability.

BACKGROUND: This study describes cigarette smoking's effect on development of physical disability following initial musculoskeletal-related hospitalization. METHODS: We followed 15,140 US Army personnel hospitalized for common musculoskeletal disorders between 1989-1996 for up to 8 years (1997) to assess risk for long-term physical disability. RESULTS: Trends between increased smoking level and long-term disability were identified for persons with knee injuries, rotator cuff injuries, and intervertebral disc displacement. In proportional hazards models, disability was significantly associated with heavy smoking among all subjects (relative hazard (RH) = 1.21). Both heavy smokers (RH = 1.49) and light to moderate smokers (RH = 1.44) were at greater risk for disability following meniscal injuries. Excess fraction due to smoking among subjects with meniscal injuries who currently smoke was 38%. CONCLUSIONS: Findings suggest an association between smoking and development of disability following meniscal injury. Given the high excess fraction of disability associated with smoking, other studies are needed to confirm this association.

The natural history and risk factors of musculoskeletal conditions resulting in disability among US Army personnel.

We describe the natural history of 13 musculoskeletal conditions requiring hospitalization and identify demographic, behavioral, psychosocial, occupational, and clinical characteristics most strongly associated with disability discharge from the Army. Subjects included 15,268 active-duty personnel hospitalized for a common musculoskeletal condition between the years 1989-1996 who were retrospectively followed through 1997. Back conditions had the greatest 5-year cumulative risk of disability (21%, 19%, and 17% for intervertebral disc displacement, intervertebral disc degeneration, and nonspecific low back pain, respectively). Cox proportional hazards models identified the following risk factors for disability among males: lower pay grade, musculoskeletal diagnosis, shorter length of service, older age, occupational category, lower job satisfaction, recurrent musculoskeletal hospitalizations, more cigarette smoking, greater work stress, and heavier physical demands. Among females, fewer covariates reached statistical significance, although lower education level was significant in more than one model. Modifiable risk factors related to work (job satisfaction, work stress, physical demands, occupation) and health behaviors (smoking) suggest possible targets for intervention.