Emergency traumatologists as partners in trauma care: the future is now.

BACKGROUND: Decreasing manpower available to care for trauma patients both in and out of the ICU has led to a number of proposed solutions, including increasing involvement of emergency medicine-trained physicians in the care of these patients. We performed a descriptive comparative study in an effort to define the role of fellowship-trained emergency medicine physicians as full-time traumatologists. STUDY DESIGN: We performed a retrospective review of concurrent and prospectively collected data comparing process of care and outcomes for the resuscitative phase of trauma patients cared for by full-time fellowship-trained trauma surgeons (TS), a fellowship-trained emergency medicine physician (ET), and a first-year fellowship-trained trauma surgeon (TS1). RESULTS: Patient age, Revised Trauma Score, and Injury Severity Score were similar between groups. Process of care, defined by transfusion of uncrossmatched blood, prevalence of hypotension in patients receiving uncrossmatched blood, time spent in the emergency department, frequency of ICU admission, severity of injury for ICU admission, and time between emergency department and operating room for patients requiring surgery, was equivalent between groups. Outcomes evaluated by mortality and length of stay in the hospital and ICU did not differ between groups, and provider group was not predictive of mortality in stepwise logistic regression. CONCLUSIONS: These data suggest that emergency traumatologists can provide trauma care effectively within a defined scope of practice and may provide an effective solution to manpower issues confronting trauma centers.

The global burden of non-conflict related firearm mortality.

OBJECTIVE: Understanding global firearm mortality is hindered by data availability, quality, and comparability. This study assesses the adequacy of publicly available data, examines populations for whom firearm mortality data are not publicly available, and estimates the global burden of non-conflict related firearm mortality. DESIGN: The design is a secondary analysis of existing data. A dataset of countries, populations, economic development, and geographic regions was created, using United Nations 2000 world population data and World Bank classifications of economic development and global regions. Firearm mortality data were obtained from governmental vital statistics reported by the World Health Organization and published survey data. A qualitative review of literature informed estimates for the 15 most populous countries without firearm death data. For countries without data, estimates of firearm deaths were made using quartiles of observed rates and peer reviewed literature. MAIN OUTCOME MEASURES: Non-conflict related firearm deaths. RESULTS: Global non-conflict related firearm deaths were estimated to fall between 196,000 and 229,000, adjusted to the year 2000. 162,800 firearm deaths adjusted for the year 2000 came from countries reporting data and represent 35% of the world's 186 countries. Public data are not available for 122 of these 186 countries, representing more than three billion (54%) of the world's population, predominately in lower and lower middle income countries. Estimates of firearm death for those countries without data range from 33,200 to 66,200. CONCLUSIONS: This study provides evidence that the burden of firearm related mortality poses a substantial threat to local and global health.

Strategies to improve compliance with evidence-based clinical management guidelines.

BACKGROUND: Clinical management guidelines (CMGs) have been developed to standardize physician practices and ensure safe and cost-effective patient care. In June 1996, evidence-based CMGs were initiated at our urban Level I trauma center. This study compares physician compliance with two such CMGs before (PRE) and after (POST) the institution of continuous surveillance by a clinical resource manager. STUDY DESIGN: For 2 months PRE resource manager surveillance hospital records were reviewed retrospectively for compliance with two CMGs. POST data were collected prospectively for 2 months by the resource manager, who alerted practitioners to deviance from CMGs to justify or document therapy alternatives. The CMGs studied addressed deep venous thrombosis and stress ulcer prophylaxis. "Under" or "over" therapy described that which fell short of or exceeded guidelines. Data were analyzed by chi-square; p < 0.05 defined statistical significance. RESULTS: Compliance with the CMGs was 48% PRE and 74% POST (p=0.001). All noncompliant instances POST (and none PRE) were altered or justified. Deep venous thrombosis and ulcer "over" therapy was significantly higher PRE (19% versus 2%, p=0.003; 49% versus 19%, p=0.001), resulting in $22,760.35 in costs. There was no difference in pulmonary embolism or gastrointestinal bleed rate (1%) PRE to POST. CONCLUSIONS: The use of a clinical resource manager empowered to monitor and coordinate physician behavior improves compliance with CMGs. Further study is warranted to validate resultant outcomes benefit, specifically cost-effectiveness and duration of the need for such a program.

Time and motion: a study of trauma surgeons' work at the bedside during the first 24 hours of blunt trauma care.

BACKGROUND: The current literature defines the costs of trauma care in terms of hospital costs and charges. We sought to define the qualitative and quantitative labor costs of trauma care by measuring the various components of bedside care provided by surgeons at a community hospital. METHODS: We conducted a prospective time-and-motion study during the initial 24 hours of blunt trauma patients' stay in the hospital at a Level II trauma center. The services provided by two surgeons and one nurse practitioner were examined. All patients were resuscitated and seen initially by one of the physicians. Ten service elements (SEs) were defined, and total time (TT) spent was the sum of time spent on all service elements for that patient. We defined labor cost as TT. Data on Injury Severity Score (ISS), alcohol intoxication, length of stay, operative procedures, and injury mechanism were also collected. Data are in minutes as means +/- SEM. Analysis of linear correlation was by Pearson correlation coefficient, and intergroup comparison of means was by two-tailed t test. RESULTS: Fifty-eight patients were studied. Mean ISS and length of stay were 11.8 +/- 3 and 4.6 +/- 3 days, respectively. A mean of seven SEs were provided per patient, and the number of SEs provided correlated directly with ISS (r = 0.75, p < 0.01). The mean TT spent was 171 +/- 9 minutes, and it correlated directly with ISS (r = 0.64, p < 0.01). For patients undergoing operative procedures by the trauma surgeon, the procedures consumed the greatest portion of TT: 73 +/- 6 minutes (24%). For patients not undergoing operative procedures, resuscitation and time spent in the radiology department consumed the majority of TT: 30 minutes for each SE (40% of TT). Serum ethanol was greater than 0.10 in 33 of 58 patients (57%), and these patients required significantly more TT (135 vs. 193 minutes; p < 0.05) than nonintoxicated patients. CONCLUSION: A significant labor cost (TT) was required for the care of blunt trauma patients, and the majority of that cost was not spent in the operating room but involved the performance of cognitive services. Significant correlation existed between ISS and labor cost. The presence of ethanol intoxication significantly increased this commitment. These data might be of use in creating provider reimbursement schemes for trauma care. This methodology may have applications in the design of hospital systems for trauma care.

Who pays for failed organ procurement and what is the cost of altruism?

Our objective was to define medical complications and financial charges generated during the care of potential solid organ donors who fail to donate after consent has been obtained. A retrospective review of financial and medical records of potential organ donors was done at an urban level 1 trauma center. Total hospital stay (T1+T2) for the group was broken down into the interval between admission and diagnosis of lethality (T1) and between diagnosis of lethality and death (T2). Medical complications occurring during the hospital stay and charges generated during each time interval were abstracted. After consent was obtained, 19 of 53 (36%) potential donors failed to donate: 9 of 19 (47%) expired prior to legal determination of brain death; 10 patients failed to progress to brain death and were made DNR. Of these, 9 died within 24 hr, 1 survived 16 days; 6 of the 10 patients did not meet brain death criteria, and 4 were rejected by the OPO for reasons of infectious risks. There were 3.1+/-1.3 medical complications per patient. T1 was less than 4 hr in 16/19 (84%) potential donors and constituted a small percentage of the mean total hospital stay (37+/-10 hr). Charges generated during T1+T2 (33,997+/-25,843) and specifically during T2 (17,385+/-9453) were considerable. These charges were passed on to patients' families or third party payers though care was directed solely at organ procurement after diagnosis of lethality. We conclude that multiple medical complications are encountered in the care of potential organ donors; total hospital stays are short but expensive; more than 50% of charges generated during the total hospital stay arise from care provided after determination of lethality; and the goodwill of families to consent to organ donations of their loved ones appears to carry potential for significant financial burden.

Comorbidity and the elderly trauma patient.

The elderly are forming an increasingly larger proportion of the population in developed countries with increasingly active life styles. The injured elderly patient has a combination of decreased physiologic reserve and a high incidence of preexisting medical conditions that cause comparably worse outcome, complications, longer hospital stay, and high costs. Although the management of specific injuries is similar in the elderly, many benefit from an overall more aggressive approach to early resuscitation and optimization of cardiopulmonary dynamics. An awareness of the importance of preexisting medical conditions and a coordinated, directed approach to the management of the injuries and the concomitant diseases leads to the most effective care. Upon recovery from injury there is often a change of functional level that precipitates a change in social circumstance. Ethical dilemmas, both at individual and community levels, may arise more frequently in the older trauma patient population. Increased triage to a trauma center, particularly when concomitant disease is present, is justified on the basis of improving outcomes.

Bronchoscopic guidance makes percutaneous tracheostomy a safe, cost-effective, and easy-to-teach procedure.

BACKGROUND: We wanted to assess the efficiency of instituting a modified technique of percutaneous tracheostomy (PET) with bronchoscopic guidance. METHODS: During a 10-month period 48 consecutive trauma patients requiring tracheostomy were divided between a standard tracheostomy control group (ST) and a PET group. All patients were followed prospectively. The hospital charges were reviewed retrospectively. RESULTS: Age, gender, body habitus, and principal diagnosis were similar in the 21 ST patients and the 27 PET patients. All STs and 15 of the PETs were performed in the operating room (OR), and the 12 remaining PETs were done in the intensive care unit (ICU). Four patients in the ST group and six in the PET group died. One of these deaths occurred in a patient in the PET group with severe adult respiratory distress syndrome. Procedure time was shorter for PET (16 versus 45 minutes, p < 0.0001). Junior residents performed more PETs than STs (33% versus 10%), and PET was considered "easier" to perform than ST (81% versus 47%). Hospital charges for PET in the ICU were $3400 less per patient compared with ST or PET in the OR. CONCLUSIONS: PET was performed easily and safely in the OR and at the ICU bedside. PET required one-third the time of ST. Bronchoscopic supervision of PET may have contributed to the small number of complications and the educational experience of junior residents. PET in the ICU can reduce hospital charges significantly and avoids transport of patients to the OR. PET is as safe as ST and should be considered the procedure of choice for an ICU patient requiring an elective tracheostomy.

Penetrating neck trauma: sensitivity of clinical examination and cost-effectiveness of angiography.

PURPOSE: To evaluate penetrating neck trauma for (a) sensitivity of the clinical examination as an indicator of clinically significant vascular injury, and (b) cost-effectiveness of performing screening diagnostic angiography. METHODS: The medical records of all patients with penetrating neck trauma presenting at our institution over 4 years were retrospectively reviewed. Injuries were classified into one of three anatomic zones and classified into four mutually exclusive groups based on the extent of vascular injury; (a) no vascular injury; (b) minor vascular abnormality; (c) major vascular abnormality without a change in clinical management; or (d) any injury requiring a change in clinical management. Cost data were also obtained for each patient's hospitalization. RESULTS: There were 111 patients with penetrating neck trauma. No statistically significant difference between the sensitivities of the clinical examination or angiography for the detection of vascular injury were detected. Of the 48 patients who had vascular injuries, 45 had an abnormal clinical findings (93.7% sensitivity). None of the remaining 3 patients with vascular injury and normal clinical findings would have had their treatment altered by the results of angiography. The calculated cost of using angiography as a screening tool for vascular injury in patients with normal clinical findings was approximately $3.08 million per central nervous system event prevented. CONCLUSION: Our study suggests that in patients with zone II penetrating neck injuries the clinical examination is sufficient to detect significant vascular lesions and that screening angiography may not be indicated. Because our sample size was relatively small and the mean follow-up only 13.3 days, further investigation is needed to demonstrate definitively the lack of usefulness of screening angiography.

Trauma in the geriatric patient.

Elderly individuals are living longer, healthier, and more active lives, and, in the process, they are continually exposed to the risk of injury. Trauma is now the fifth most common cause of death in people over the age of 65 years, and the elderly suffer disproportionately high injury-related mortality rates compared with younger adults. They consume a vast portion of health care resources and their care precipitates some of the most difficult ethical and sociologic questions in modern medicine. Physiologically, the elderly present a unique and complex picture that requires an understanding of the process of aging and the concomitant effects of acquired diseases. As surgeons involved in the care of the injured, we find ourselves becoming more frequently involved with this national dilemma. This review provides some insights and guidelines for the care of the injured elderly, with the hope of improving our understanding and their outcome.

Supplemental emergent chest computed tomography in the management of blunt torso trauma.

The efficacy of conventional chest X-ray (CXR) in comparison to chest computed tomography (CCT) in acutely injured blunt trauma patients was examined. Over a 21-month period, 50 patients underwent CXR and CCT according to a standard protocol, and their films and records were reviewed retrospectively. Hemo- and/or pneumothorax (HPTX) was noted in 12 patients (five by CXR, 12 by CCT). Pulmonary contusion (PC) was identified in ten patients (four by CXR, ten by CCT). Three additional false positive PC were diagnosed by CXR. Therapy changes based upon CCT findings occurred in seven of seven HPTX and five of six PC. The two imaging techniques were complementary in detecting fractures. Atelectasis was a common CCT finding (58% incidence). Chest X-ray is less sensitive than chest computed tomography in the detection of HPTX (42% vs. 100%) and PC (40% vs. 100%). Emergent chest computed tomography is recommended in stable patients with: 1) blunt high-energy torso trauma, 2) "cross-body" injury pattern, and/or 3) a mechanism of injury suggestive of chest trauma.

Clinical prospective injury severity scoring: when is it accurate?

The development of Condensed Abbreviated Injury Scaling (CAIS) charts (based on AIS-85) has allowed the development of a method to perform early prospective clinical injury scoring (ISS). This information, when available within hours of admission, has allowed an awareness of the magnitude of injuries and creates an appropriate atmosphere for clinical management. In addition, ISS may be used as a rough guide to length of stay and the cost of care for the trauma patient. Three hundred thirty-seven patients entering a Level I Trauma Center were prospectively scored on a daily basis to determine the relationship between time following admission and accuracy. Overall, 18 patients (4.9%) required subsequent changes in their Injury Severity Scores after 24 hours. Patients having severe injury (ISS greater than 16) from blunt trauma had a higher likelihood of having "delayed" diagnosis that resulted in a slightly higher ISS. Overall, the accuracy of this scoring technique was 95% at 24 hours, 98% at 72 hours, and 99% at 5 days.

DRG reimbursement for trauma: the demise of the trauma center (the use of ISS grouping as an early predictor of total hospital cost).

All institutional reimbursement for inpatient care in the State of New Jersey is administered by the DRG methodology (Prospective Payment System). This system is essentially identical to federal Medicare. In 1983 our hospital was designated the Level I trauma center for southern New Jersey (population, 2.6 million). Prehospital triage guidelines based on anatomic injury were implemented, and, as a result, an annual 30% increase in severe trauma cases (ISS greater than 16) was realized. In late 1984 serious financial shortfalls were noticed, especially in the higher ISS cases. A 1-year study (1985) of all patients admitted through the Trauma Center to an intensive care unit was completed (523 patients; mean ISS, 15.16; ISS greater than 16, 37.8%). All patients were stratified to one of five ISS groups (A: ISS 1-8; B: ISS 9-15; C: ISS 16-24; D: ISS 25-40; E: ISS greater than 40). Average cost, reimbursement, ISS, LOS, and mortality were reviewed for the entire aggregate and each severity group. The system of ISS grouping was an accurate method of cost analysis, and prospectively, ISS grouping allowed prediction of length of stay and total hospital cost. In addition, these data allowed early fiscal management decisions and resource allocation. As a reimbursement system, DRG falls short of the cost of care for all ISS levels and groups. As severity of injury rose, costs increased in a linear manner, but reimbursement did not, resulting in a substantial financial loss. The net loss to the hospital in 1 year was $1.86 million.(ABSTRACT TRUNCATED AT 250 WORDS)

Injury severity scoring: influence of timing and nurse raters on accuracy.

The Abbreviated Injury Scale (AIS) and its incorporation into the Injury Severity Score (ISS) have become accepted as objective ways to quantitate the severity of trauma. To examine the practicality of using critical care nurses to initiate injury scoring within the first 24 hours of admission, a prospective study was undertaken. Nurses on the trauma intensive care unit were asked to calculate the ISS in patients admitted to the unit over a 4-month period. Scoring was completed within 24 hours of admission and recorded on an edited single-page chart constructed from the 1980 revision of the AIS. All patients were followed up until discharge, and the ISS was reviewed in the light of discharge diagnoses. One hundred four patients were studied, and accurate scores were calculated in 54 patients (51.9%). In three patients (2.9%) the single-page chart did not allow accurate scoring, and in 18 patients (17.3%) the diagnoses noted subsequent to the scoring time frame resulted in inaccuracy. Human errors resulted in inaccuracy in 28% of patients. In comparison with a concurrent study involving surgical residents, human error rates were similar. However, scoring within 24 hours, as opposed to 72 hours, resulted in significantly more errors related to diagnostic uncertainty. Initiation of the scoring process soon after admission, with subsequent correction during the hospital course, allows important information to be available at the earliest time.

Clearing the cervical spine: initial radiologic evaluation.

The identification of unstable cervical spine injury (UCSI) in blunt high-energy transfer injury (BHETI) patients is critical to management. In a prospective study of BHETI patients identified to be at high risk for UCSI, the use of lateral cervical spine view (LCV), three-view cervical spine series (FCS), and limited computerized tomography (CT) in the initial evaluation of these patients was analyzed. Thirteen of 204 patients sustained UCSI. Sensitivity of the LCV alone was 0.85 and the predictive value of the negative test was 0.97. Sensitivity and predictive value of a negative study were maximized by the use of FCS combined with CT when plain X-rays were inadequate. We conclude that technically adequate, normal FCS can be safely used to eliminate the presence of UCSI. If these studies are technically inadequate, the addition of a limited CT can be used to "clear" the spine.

The mangled extremity syndrome (M.E.S.): a severity grading system for multisystem injury of the extremity.

The severely mangled extremity presents a challenge in appropriate surgical management. Very few objective data were found about this problem. To clarify the situation, criteria for a "mangled extremity' were defined, a multidisciplined approach employed, and a retrospective graduated grading system developed. Sixty consecutive trauma patients with severely injured extremities during the past 3 years were reviewed. Seventeen patients fit the category of Mangled Extremity Syndrome (M.E.S.). Injuries were retrospectively classified using a graduated grading system directed at four major tissue systems of the extremity involved (integument, nerve, artery, and bone). Additional scoring items were included to define the significance of trauma sustained outside the extremities. Patients who ultimately came to amputation could have been identified preoperatively at initial emergency evaluation utilizing this graduated grading system. Retrospective data suggest that a Mangled Extremity Syndrome Index (M.E.S.I.) of 20 is the dividing line below which functional limb salvage can be expected and above which limb salvage is improbable. Prospective application of this system, as well as an organized multidisciplined approach, could be useful in the identification of functionally retrievable versus probably irretrievable extremities, thus identifying and helping define the indications for amputation. The grading system criteria and results in these 17 patients form the basis of this report.

The impact of an air ambulance system on an established trauma center.

Hospital competition for air ambulance business has resulted in implementation of a helicopter service before the medical staff can prepare for the increased patient load. We reviewed the effect of an air ambulance on an already established trauma center (TC) by analyzing the impact of the helicopter trauma patient load during the initial year of operation. The helicopter carried a three-member flight crew consisting of a pilot, paramedic, and critical care nurse. Admission data of all flights from February 1982 through February 1983 were reviewed. Of the 325 air missions launched, 192 (59%) were for the transport of trauma victims. One hundred forty (73.6%) patients were transported from local hospitals, the remaining 52 (26.4%) from the accident scene. Ninety per cent of the injuries were due to motor vehicle accidents. Forty-nine per cent of the flights occurred on weekends and 68.8% were launched between 7:00 P.M. and 3:00 A.M. The average flight times from hospital and accident scenes were 37 min 30 sec and 13 min 30 sec, respectively. Of all trauma missions flown, 126 (65.8%) were considered new or 'captured' by the air ambulance system and brought to the TC. Thirty-seven (19.3%) patients died in flight, were DOA, or died within 1 hour of TC arrival. Eighty per cent of the deaths were from massive head injuries. The average injury severity score was 35.58 (all patients), 32.9 (survivors), and 45.80 (deaths).(ABSTRACT TRUNCATED AT 250 WORDS)