Medical Information During Trauma Resuscitations: Are Smartphones the Contemporary Medical ID Bracelet?

INTRODUCTION: Smartphone emergency medical identification (SEMID) applications are built-in health information-storing functions that are accessible without a passcode. The utility of these applications in the real-time resuscitation of trauma patients is unknown. METHODS: We prospectively evaluated all trauma activation patients ≥16 y and unable to provide a medical history for any reason for the presence of a smartphone at our urban level I center between October 2020 and September 2021. Available smartphones were queried for SEMID utilization, categories of information contained, and real-time clinical relevance. RESULTS: One hundred and forty three patients with a median age of 39 y [interquartile range 28-59] and Injury Severity Score of 16 [2-29] were included. 30 (21%) patients arrived with a smartphone, 27 (90%) of which were accessible. 8 (30%) of those individuals utilized a SEMID application, and SEMID information was relevant for patient care in 6 cases (75%). The extracted information included: identifiers (75%), emergency contacts (50%), height/weight (38%), allergies (38%), age (38%), medications (25%), medical history (13%), and blood type (13%). CONCLUSIONS: Approximately one in five altered trauma patients have smartphones present at arrival, some of which contain medical information pertinent for immediate care. There is a pressing need for education and our institution has developed a publicly-facing campaign with shareable materials to improve SEMID awareness and utilization. Other centers are likely to find similar benefit.

Reduction of anti-A and anti-B isoagglutinin titers of group O whole blood units employing an ABO antibody immune adsorption column.

BACKGROUND: Massive hemorrhage is a leading cause of death from trauma. There is growing interest in group O whole blood transfusions to mitigate coagulopathy and hemorrhagic shock. Insufficient availability of low-titer group O whole blood is a barrier to routine use. We tested the efficacy of the Glycosorb® ABO immunoadsorption column to reduce anti-A/B titers in group O whole blood. METHODS: Six group O whole blood units were collected from healthy volunteers, and centrifuged to separate platelet poor plasma. Platelet-poor plasma was filtered through a Glycosorb® ABO antibody immunoabsorption column, then reconstituted to prepare post-filtration whole blood. Anti-A/B titers, CBC, free hemoglobin, and thromboelastography (TEG) assays were performed on pre-and post-filtration whole blood. RESULTS: Mean( ± SEM) anti-A (224 ± 65 pre vs 13 ± 4 post) and anti-B (138 ± 38 pre vs 11 ± 4 post) titers were significantly reduced (p = 0.004) in post-filtration whole blood. No significant changes were detected in CBC, free hemoglobin, and TEG parameters on day 0. Free hemoglobin increased throughout storage (48 mg/dl ± 24 Day 0 vs 73 ± 35 Day 7 vs 96 ± 44 Day 14; p = 0.14). CONCLUSIONS: The Glycosorb® ABO column can significantly reduce anti-A/B isoagglutinin titers of group O whole blood units. Glycosorb® ABO could be employed to provide whole blood with lower risk of hemolysis and other consequences of infusing ABO incompatible plasma. Preparation of group O whole blood with substantially reduced anti-A/B would also increase the supply of low-titer group O whole blood for transfusion.

Under the Lens: Team Perception of Trauma Video Review.

BACKGROUND: Video-based assessment and review are becoming increasingly common, and trauma video review (TVR) has been shown to be an effective educational, quality improvement, and research tool. Yet, trauma team perception of TVR remains incompletely understood. OBJECTIVE: We evaluated positive and negative perceptions of TVR across multiple team member groups. We hypothesized that members of the trauma team would find TVR educational and that anxiety would be low across all groups. METHODS: An anonymous electronic survey was provided to nurses, trainees, and faculty during weekly multidisciplinary trauma performance improvement conference following each TVR activity. Surveys assessed perception of performance improvement and anxiety or apprehension (Likert scale: 1 "strongly disagree" to 5 "strongly agree"). We report individual and normalized cumulative scores (average of responses for each positive [n = 6] and negative [n = 4] question stem). RESULTS: We analyzed 146 surveys over 8 months, with 100% completion rate. Respondents were trainees (58%), faculty (29%), and nurses (13%). Of the trainees, 73% were postgraduate year (PGY) 1-3 and 27% were PGY 4-9. Of all respondents, 84% had participated previously in a TVR conference. Respondents reported an improved perception of resuscitation education quality and personal leadership skills development. Participants found TVR to be more educational than punitive overall. Analysis of team member types showed lower scores for faculty for all positive stemmed questions. Trainees were more likely to agree with negative stemmed questions if they were a lower PGY, and nurses were least likely to agree with negative stemmed questions. CONCLUSIONS: TVR improves trauma resuscitation education in a conference setting, with trainees and nurses reporting the greatest benefit. Nurses were noted to be the least apprehensive about TVR.

Team Assessment and Decision Making Is Associated With Outcomes: A Trauma Video Review Analysis.

BACKGROUND: Teamwork is a critical element of trauma resuscitation. Assessment tools such as T-NOTECHS (Trauma NOn-TECHnical Skills) exist, but correlation with patient outcomes is unclear. Using emergency department thoracotomy (EDT), we sought to describe T-NOTECHS scores during resuscitations. We hypothesized that patients undergoing EDT whose resuscitations had better scores would be more likely to have return of spontaneous circulation (ROSC). METHODS: Continuously recording video was used to review all captured EDTs over a 24-mo period. We used a modification of the validated T-NOTECHS instrument to measure five domains on a 3-point scale (1 = best, 2 = average, 3 = worst). A total T-NOTECHS score was calculated by one of three reviewers. The primary outcome was ROSC. ROSC was defined as an organized rhythm no longer requiring internal cardiac compressions. Associations between variables and ROSC were examined using univariate regression. RESULTS: Sixty-one EDTs were captured. Nineteen patients had ROSC (31%) and 42 (69%) did not. The median T-NOTECHS score for all resuscitations was 8 [IQR 6-10]. As demographic and injury data (age, gender, mechanism, signs of life) were not associated with ROSC in univariate analysis, they were not considered for inclusion in a multivariable regression model. The association between overall T-NOTECHS score and ROSC did not reach statistical significance, but examination of the individual components of the T-NOTECHS score demonstrated that, compared to resuscitations that had "average" (2) or "worst" (3) scores on "Assessment and Decision Making," resuscitations with a "best" score were 5 times more likely to lead to ROSC. CONCLUSIONS: Although the association between overall T-NOTECHS scores and ROSC did not reach statistical significance, better scores in the domain of assessment and decision making are associated with improved rates of ROSC in patients arriving in cardiac arrest who undergo EDT. LEVEL OF EVIDENCE: Level IV Therapeutic/Care Management.

Epidural catheters are associated with an increased risk of venous thromboembolism in trauma.

Little is known about the association between epidural catheters (EC) and venous thromboembolism (VTE) in trauma. We sought to study this association and hypothesized that trauma patients with EC were more likely to develop VTE. Using the Pennsylvania Trauma Outcomes Study (PTOS) registry, we identified all adult trauma patients (age ≥ 18) admitted for at least 2 days between 1/2013 and 12/2017. Baseline characteristics and outcome variables were compared between patients who underwent EC placement and those who did not. The primary outcome was development of VTE. 147,721 patients met inclusion criteria; 2247 (1.5%) developed a VTE. Patients were mostly white (85%), male (56%), with blunt trauma (94%). 776 (0.5%) had an EC placed. Patients who underwent EC placement were more likely to develop a VTE (2.8% vs. 1.5%, p = 0.003). After adjusting for covariates, patients with EC were 1.6 times more likely to develop VTE (95% CI 1.1-2.5). The overall rate of VTE was low and associated with the use of EC. Future work should focus on determining the underlying mechanisms.

Getting out of the bay faster: Assessing trauma team performance using trauma video review.

BACKGROUND: Minutes matter for trauma patients in hemorrhagic shock. How trauma team function impacts time to the next phase of care has not been rigorously evaluated. We hypothesized better team performance scores to be associated with decreased time to the next phase of trauma care. METHODS: This retrospective secondary analysis of a prospective multicenter observational study included hypotensive trauma patients at 19 centers. Using trauma video review, we analyzed team performance with the validated Non-Technical Skills for Trauma scale: leadership, cooperation and resource management, communication, assessment/decision making, and situational awareness. The primary outcome was minutes from patient arrival to next phase of care; deaths in the bay were excluded. Secondary outcomes included time to initiation and completion of first unit of blood and inpatient mortality. Associations between team dynamics and outcomes were assessed with a linear mixed-effects model adjusting for Injury Severity Score, mechanism, initial blood pressure and heart rate, number of team members, and trauma team lead training level and sex. RESULTS: A total of 441 patients were included. The median Injury Severity Score was 22 (interquartile range, 10-34), and most (61%) sustained blunt trauma. The median time to next phase of care was 23.5 minutes (interquartile range, 17-35 minutes). Better leadership, communication, assessment/decision making, and situational awareness scores were associated with faster times to next phase of care (all p < 0.05). Each 1-point worsening in the Non-Technical Skills for Trauma scale score (scale, 5-15) was associated with 1.6 minutes more in the bay. The median resuscitation team size was 12 (interquartile range, 10-15), and larger teams were slower ( p < 0.05). Better situational awareness was associated with faster completion of first unit of blood by 4 to 5 minutes ( p < 0.05). CONCLUSION: Better team performance is associated with faster transitions to next phase of care in hypotensive trauma patients, and larger teams are slower. Trauma team training should focus on optimizing team performance to facilitate faster hemorrhage control. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Percutaneous thoracostomy with thoracic lavage for traumatic hemothorax: a performance improvement initiative.

Objectives: Percutaneously placed small-bore (14 Fr) catheters and pleural lavage have emerged independently as innovative approaches to hemothorax management. This report describes techniques for combining percutaneous thoracostomy with pleural lavage and presents results from a performance improvement series of patients managed with percutaneous thoracostomy with immediate lavage. Methods: This was a prospective performance improvement series of patients treated at a level 1 trauma center with percutaneous thoracostomy and immediate lavage between April 2021 and May 2023. Results: Percutaneous thoracostomy with immediate lavage was used to treat nine hemodynamically normal patients with acute hemothorax. Injuries included both blunt and penetrating mechanisms. 56% of patients presented immediately after injury, and 44% presented in a delayed fashion ranging from 2 to 26 days after injury. Median length of stay was 6 days (IQR 6, 9). Seven patients were discharged home in stable condition, one was discharged to an acute rehabilitation facility, and one was discharged to a skilled nursing facility. Conclusions: Percutaneous thoracostomy with pleural lavage is clinically feasible and effective and warrants further evaluation with a multicenter clinical trial. Level of evidence: Therapeutic/care management, level V.

Teamwork matters: The association between nontechnical skills and cardiac arrest in trauma patients presenting with hypotension.

BACKGROUND: The impact of trauma team dynamics on outcomes in injured patients is not completely understood. We sought to evaluate the association between trauma team function, as measured by a modified Trauma Non-Technical Skills assessment, and cardiac arrest in hypotensive trauma patients. We hypothesized that better team function is associated with a decreased probability of developing cardiac arrest. METHODS: Trauma video review was used to collect data from resuscitations of adult hypotensive trauma patients at 19 centers. Hypotension at emergency department presentation was defined as an initial systolic blood pressure <90 mm Hg or an initial systolic blood pressure ≥90 mm Hg followed by a systolic blood pressure <90 mm Hg within the first 5 minutes. Team dynamics were scored using a modified Trauma Non-Technical Skills assessment composed of 5 domains with combined scores ranging from 5 (best) to 15 (worst). Scores were compared between cardiac arrest/noncardiac arrest cases in the trauma bay. Logistic regression was used to evaluate the independent association between the Trauma Non-Technical Skills assessment and cardiac arrest. RESULTS: A total of 430 patients were included (median age 43 years [interquartile range: 29-61]; 71.8% male; 36% penetrating mechanism; median Injury Severity Score 20 [10-33]; 11% experienced cardiac arrest in trauma bay). The median total Trauma Non-Technical Skills assessment score was 7 (6-9), higher in patients who experienced cardiac arrest in the trauma bay (9 [6-10] vs 7 [6-9]; P = .016). This association persisted after controlling for age, sex, mechanism, injury severity, initial systolic blood pressure, and initial Glasgow Coma Scale score (adjusted odds ratio: 1.28; 95% confidence interval:1.11-1.48; P < .001), indicating a ∼3% higher predicted probability of cardiac arrest per Trauma Non-Technical Skills point. CONCLUSION: Better team function is independently associated with a decreased probability of cardiac arrest in trauma patients presenting with hypotension. This suggests that trauma team training may improve outcomes in peri-arrest patients.

Long-term functional, psychological, emotional, and social outcomes in pediatric victims of violence.

BACKGROUND: To evaluate the long-term functional, psychological, and emotional outcomes in individuals who survived violence-related injuries as children. METHODS: We retrospectively identified all pediatric patients (age <18y at time of injury) treated for a violent traumatic injury (gun-shot wound, stab, or assault) at our institution (1/2011-12/2020). We then prospectively attempted to contact and survey, via telephone, all patients that had reached adulthood (age ≥18y at time of study) using 7 Patient-Reported Outcomes Measurement Information System (PROMIS) instruments and the Primary Care Post Traumatic Stress Disorder (PTSD) screen. RESULTS: Of the 270 patients identified, we attempted to contact 218, successfully contacted 68, and 24 participated in the study. Of participants, 15 (62.5%) sustained gunshot wounds, 8 (33.3%) were stabbed, and 1 (4.2%) was assaulted with a median time from injury of 6.7(3.4) years. Based on PROMIS metrics, Global Physical Health (55.0 vs. 50.0, p = 0.013) and Emotional Support (55.4 vs. 50.0, p = 0.004) were better in participants compared to reference populations. However, a disproportionate number of participants reported substance use in the past 30 days (45.8 vs 13.0%; p < 0.001), 41.7% screened positive for PTSD, and 62.5% requested resources and/or referral for medical care. CONCLUSIONS: Many individuals who survive violent injuries as children continued to experience negative physical and mental outcomes extending into adulthood that required ongoing medical and psychological support. Further resources are needed to better understand the long-term effects of violent injury and to care for the complex needs of this population.

Evaluating emergency department tube thoracostomy: A single-center use of trauma video review to assess efficiency and technique.

BACKGROUND: Emergency department tube thoracostomy is a common procedure; however, assessing procedural skills is difficult. We sought to describe procedural variability and technical complications of emergency department tube thoracostomy using trauma video review. We hypothesized that factors such as hemodynamic abnormality lead to increased technical difficulty and malpositioning. METHODS: Using trauma video review, we reviewed all emergency department tube thoracostomy from 2020 to 2022. Patients were stratified into hemodynamically abnormal (systolic blood pressure <90 or heart rate >120) and hemodynamically normal (systolic blood pressure ≥90 or heart rate ≤120). Emergency department tube thoracostomies outside of video-capable rooms, with incomplete visualization, or in patients undergoing cardiopulmonary resuscitation or resuscitative thoracotomy were excluded. The primary outcome was a procedure score modified from the validated tool ranging from 0 to 11 (higher score indicating better performance). Also measured were procedural times to (1) decision to place, (2) pleural entry, and (3) procedure completion. Postprocedure x-ray and chart review were used to determine accuracy. RESULTS: In total, 51 videos met the inclusion criteria. The median age was 34 [interquartile range 24-40] years, body mass index 25.8 [interquartile range 21.8-30.7], predominately male (75%), blunt injury (57%), with Injury Severity Score of 22 [14.5-41]. The median procedure score was 9 [7-10]. Emergency department tube thoracostomies in patients with abnormal hemodynamics had significantly lower procedure scores (8 vs 10, P < .05). Hemodynamically abnormal patients had significantly shorter times from decision to proceed to pleural entry (4.05 vs 8.25 minutes, P < .001), and to completion (6.31 vs 14.23 minutes, P < .001). The most common complication was malpositioning (35.1%), with no significant difference noted when comparing hemodynamically normal and abnormal patients (P = .41). CONCLUSION: Using trauma video review we identified significant procedural variability in emergency department tube thoracostomy, mainly that hemodynamic abnormality led to lower proficiency scores and increased malpositioning. Efforts are needed to define procedural benchmarks and evaluation in the context of patient outcomes. Using this technology and methodology can help establish procedural norms.

Bias in the trauma bay: A multicenter qualitative study on team communication.

BACKGROUND: Team communication and bias in and out of the operating room have been shown to impact patient outcomes. Limited data exist regarding the impact of communication bias during trauma resuscitation and multidisciplinary team performance on patient outcomes. We sought to characterize bias in communication among health care clinicians during trauma resuscitations. METHODS: Participation from multidisciplinary trauma team members (emergency medicine and surgery faculty, residents, nurses, medical students, emergency medical services personnel) was solicited from verified level 1 trauma centers. Comprehensive semistructured interviews were conducted and recorded for analysis; sample size was determined by saturation. Interviews were led by a team of doctorate communications experts. Central themes regarding bias were identified using Leximancer analytic software (Leximancer Pty Ltd., Brisbane, Australia). RESULTS: Interviews with 40 team members (54% female, 82% White) from 5 geographically diverse Level 1 trauma centers were conducted. More than 14,000 words were analyzed. Statements regarding bias were analyzed and revealed a consensus that multiple forms of communication bias are present in the trauma bay. The presence of bias is primarily related to sex but was also influenced by race, experience, and occasionally the leader's age, weight, and height. The most commonly described targets of bias were females and non-White providers unfamiliar to the rest of the trauma team. Most common sources of bias were White male surgeons, female nurses, and nonhospital staff. Participants perceived bias being unconscious but affecting patient care. CONCLUSION: Bias in the trauma bay is a barrier to effective team communication. Identification of common targets and sources of biases may lead to more effective communication and workflow in the trauma bay. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Rethinking protocolized completion angiography following extremity vascular trauma: A prospective observational multicenter trial.

BACKGROUND: Completion angiography (CA) is commonly used following repair of extremity vascular injury and is recommended by the Eastern Association for the Surgery of Trauma practice management guidelines for extremity trauma. However, it remains unclear which patients benefit from CA because only level 3 evidence exists. METHODS: This prospective observational multicenter (18LI, 2LII) analysis included patients 15 years or older with extremity vascular injuries requiring operative management. Clinical variables and outcomes were analyzed with respect to with our primary study endpoint, which is need for secondary vascular intervention. RESULTS: Of 438 patients, 296 patients required arterial repair, and 90 patients (30.4%) underwent CA following arterial repair. Institutional protocol (70.9%) was cited as the most common reason to perform CA compared with concern for inadequate repair (29.1%). No patients required a redo extremity vascular surgery if a CA was performed per institutional protocol; however, 26.7% required redo vascular surgery if the CA was performed because of a concern for inadequate repair. No differences were observed in hospital mortality, length of stay, extremity ischemia, or need for amputation between those who did and did not undergo CA. CONCLUSION: Completion angiogram following major extremity injury should be considered in a case-by-case basis. Limiting completion angiograms to those patients with concern for an inadequate vascular repair may limit unnecessary surgery and morbidity. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Open versus percutaneous tube thoracostomy with and without thoracic lavage for traumatic hemothorax: a novel randomized controlled simulation trial.

Objective: To quantify and assess the relative performance parameters of thoracic lavage and percutaneous thoracostomy (PT) using a novel, basic science 2×2 randomized controlled simulation trial. Summary background data: Treatment of traumatic hemothorax (HTX) with open tube thoracostomy (TT) is painful and retained HTX is common. PT is potentially less painful whereas thoracic lavage may reduce retained HTX. Yet, procedural time and the feasibility of combining PT with lavage remain undefined. Methods: A simulated partially clotted HTX (2%-gelatin-saline mixture) was loaded into a TT trainer and then evacuated after randomization to one of four protocols: TT+/-lavage or PT+/-lavage. Standardized inserts with fixed 28-Fr TT or 14-Fr PT positioning were used to minimize tube positioning variability. Lavage consisted of two 500 mL aliquots of warm saline after initial HTX evacuation. The primary outcome was HTX volume evacuated. The secondary outcome was additional procedural time required for the addition of the lavage. Results: A total of 40 simulated HTX trials were randomized. TT alone evacuated a median of 1236 mL (IQR 1168, 1294) leaving a residual volume of 265 mL (IQR 206, 333). PT alone resulted in a significantly greater median residual volume of 588 mL (IQR 497, 646) (p=0.002). Adding lavage resulted in similar residual volumes for TT compared with TT alone but significantly less for PT compared with PT alone (p=0.002). Lavage increased procedural time for TT by a median of 7.0 min (IQR 6.5, 8.0) vs 11.7 min (IQR 10.2, 12.0) for PT (p<0.001). Conclusion: This simulation trial characterized HTX evacuation in a standardized fashion. Adding lavage to thoracostomy placement may improve evacuation, particularly for small-diameter tubes, with little added procedural time. Further prospective clinical study is warranted. Level of evidence: NA.

Moving the needle on time to resuscitation: An EAST prospective multicenter study of vascular access in hypotensive injured patients using trauma video review.

BACKGROUND: Vascular access in hypotensive trauma patients is challenging. Little evidence exists on the time required and success rates of vascular access types. We hypothesized that intraosseous (IO) access would be faster and more successful than peripheral intravenous (PIV) and central venous catheter (CVC) access in hypotensive patients. METHODS: An EAST prospective multicenter trial was performed; 19 centers provided data. Trauma video review was used to evaluate the resuscitations of hypotensive (systolic blood pressure ≤90 mm Hg) trauma patients. Highly granular data from video recordings were abstracted. Data collected included vascular access attempt type, location, success rate, and procedural time. Demographic and injury-specific variables were obtained from the medical record. Success rates, procedural durations, and time to resuscitation were compared among access strategies (IO vs. PIV vs. CVC). RESULTS: There were 1,410 access attempts that occurred in 581 patients with a median age of 40 years (27-59 years) and an Injury Severity Score of 22 [10-34]. Nine hundred thirty-two PIV, 204 IO, and 249 CVC were attempted. Seventy percent of access attempts were successful but were significantly less likely to be successful in females (64% vs. 71%, p = 0.01). Median time to any access was 5.0 minutes (3.2-8.0 minutes). Intraosseous had higher success rates than PIV or CVC (93% vs. 67% vs. 59%, p < 0.001) and remained higher after subsequent failures (second attempt, 85% vs. 59% vs. 69%, p = 0.08; third attempt, 100% vs. 33% vs. 67%, p = 0.002). Duration varied by access type (IO, 36 [23-60] seconds; PIV, 44 [31-61] seconds; CVC 171 [105-298]seconds) and was significantly different between IO versus CVC ( p < 0.001) and PIV versus CVC ( p < 0.001) but not PIV versus IO. Time to resuscitation initiation was shorter in patients whose initial access attempt was IO, 5.8 minutes versus 6.7 minutes ( p = 0.015). This was more pronounced in patients arriving to the hospital with no established access (5.7 minutes vs. 7.5 minutes, p = 0.001). CONCLUSION: Intraosseous is as fast as PIV and more likely to be successful compared with other access strategies in hypotensive trauma patients. Patients whose initial access attempt was IO were resuscitated more expeditiously. Intraosseous access should be considered a first line therapy in hypotensive trauma patients. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level II.

Roll the Tape: Implementing and Harnessing the Power of Trauma Video Review.

Trauma video review (TVR) is a powerful technology with a rapidly expanding role in trauma performance improvement, education, and research. Video review is particularly well suited for evaluating elements not found in the medical record such as rapid changes in patient condition, medical decision making, resuscitation tempo, and team leadership. As such, TVR is an ideal tool for general surgery trainee education and as a means to evaluate multiple ACGME Core Competencies and entrustable professional activities. This article describes the development of a TVR program and the novel way in which we have integrated TVR into our resident trauma curriculum.

Outcomes after Child Physical Abuse and Association with Community-Level Social Determinants of Health.

BACKGROUND: Child physical abuse is a significant cause of pediatric injury and death. Previous studies have described disparities in outcomes for physically abused children according to insurance status. We hypothesized that children treated for physical abuse would be more likely to live in neighborhoods with increased socioeconomic deprivation. STUDY DESIGN: We performed a retrospective review of children who were admitted with suspected physical abuse from 2011 to 2021. Home addresses at the time of admission were used to assign an Area Deprivation Index (ADI) of the neighborhood. Clinicopathologic and outcome variables were compared between children from neighborhoods in the top 10th and bottom 90th national neighborhood ADI percentile. Univariate and multivariate logistic models were constructed. RESULTS: One hundred eighty-four children were included for analysis. Children from the top 10th (more impoverished) ADI percentile presented with more severe injuries, had higher area injury scores in the abdomen and extremities, and required admission to the intensive care unit more often, compared with children from the bottom 90th ADI percentile (all p Values <0.05). Children from high ADI neighborhoods were more likely to be discharged to a different caretaker than children from low ADI neighborhoods (71% caretaker change vs 49% caretaker change, p = 0.005). Univariate and multivariate logistic regression demonstrated statistically significant association between the ADI score and the need for caretaker change at the time of discharge (p = 0.004). CONCLUSIONS: Community-level social determinants of health are closely associated with child physical abuse. Child abuse reduction strategies might consider increased support for families with fewer resources and social support systems.

Trauma video review outperforms prospective real-time data collection for study of resuscitative thoracotomy.

BACKGROUND: A major challenge in the study of high-impact, low-frequency procedures in trauma is the lack of accurate data for time-sensitive processes of care. Trauma video review offers a possible solution, allowing investigators to collect extremely granular time-stamped data. Using resuscitative thoracotomy as a model, we compared data collected using review of audiovisual recordings to data prospectively collected in real time with the hypothesis that data collected using video review would be subject to less missingness and bias. METHODS: We conducted a prospective cohort study of patients undergoing resuscitative thoracotomy at a single urban academic level 1 trauma center. Key data on the timing and completion of procedural milestones of resuscitative thoracotomy were collected using video review and prospective collection. We used McNemar's test to compare proportions of missing data between the 2 methods and calculated bias in time measurements for prospective collection with respect to video review. Statistical analyses were performed using Stata v. 15.0 (College Station, TX). RESULTS: We included 51 subjects (88% Black, 82% male, 90% injured by gunshot wounds) over the study period. Missingness in resuscitative thoracotomy procedural milestone time measurements ranged from 34% to 63% for prospective collection and 0 to 8% for video review and was less missing for video review for all key variables (P < .001). When not missing, bias in data collected by prospective collection was 10% to 43% compared with data collected by video review. CONCLUSIONS: The data collected using video review have less missingness and bias than prospective collection data collected by trained research assistants. Audiovisual recording should be the gold standard for data collection for the study of time-sensitive processes of care in resuscitation.

Short simulation training improves objective skills in established advanced practitioners managing emergencies on the ward and surgical intensive care unit.

BACKGROUND: Several studies evaluating simulation training in intensive care unit (ICU) physicians have demonstrated improvement in leadership and management skills. No study to date has evaluated whether such training is useful in established ICU advanced practitioners (APs). We hypothesized that human patient simulator-based training would improve surgical ICU APs' skills at managing medical crises. METHODS: After institutional review board approval, 12 APs completed ½ day of simulation training on the SimMan, Laerdal system. Each subject participated in five scenarios, first as team leader (pretraining scenario), then as observer for three scenarios, and finally, again as team leader (posttraining). Faculty teaching accompanied each scenario and preceded a debriefing session with video replay. Three experts scored emergency care skills (Airway-Breathing-Circulation [ABCs] sequence, recognition of shock, pneumothorax, etc.) and teamwork leadership/interpersonal skills. A multiple choice question examination and training effectiveness questionnaire were completed before and after training. Fellows underwent the same curriculum and served to validate the study. Pre- and postscores were compared using the Wilcoxon signed rank test with two-tailed significance of 0.05. RESULTS: Improvement was seen in participants' scores combining all parameters (73% ± 13% vs. 80% ± 11%, p = 0.018). AP leadership/interpersonal skills (+12%), multiple choice question examination (+4%), and training effectiveness questionnaire (+6%) scores improved significantly (p < 0.05). Fellows teamwork leadership/interpersonal skills scores were higher than APs (p < 0.001) but training brought AP scores to fellow levels. Interrater reliability was high (r = 0.77, 95% confidence interval 0.71-0.82; p < 0.001). CONCLUSIONS: Human patient simulator training in established surgical ICU APs improves leadership, teamwork, and self-confidence skills in managing medical emergencies. Such a validated curriculum may be useful as an AP continuing education resource.

Unlocked yet untapped: The ubiquitous smartphone and utilization of emergency medical identification technology in the care of the injured patient.

BACKGROUND: Smartphones allow users to store health and identification information that is accessible without a passcode-conceivably invaluable information for care of unresponsive trauma patients. We sought to characterize the use of smartphone emergency medical identification applications and hypothesized that these are infrequently used but positively perceived. METHODS: We surveyed a convenience sample of adult trauma patients/family members (nonproviders) and providers from an urban Level I trauma center during July 2018 on their demographics and smartphone emergency medical identification application usage. Descriptive and chi-square/Fisher exact analyses were performed to characterize the use of smartphone emergency medical identification applications and compare groups. RESULTS: 338 subjects participated; most were female (52%) with median age of 36 (29-48). 182 (54%) were providers and 306 (91%) owned smartphones. 157 (51%) owners were aware smartphone emergency medical identification existed, but only 94 (31%) used it. 123 providers encountered unresponsive patients with smartphones, but only 26 (21%) queried smartphone emergency medical identification, with 19 (73%) finding smartphone emergency medical identification helpful. All 8 (100%) nonproviders who reported to have had their smartphone emergency medical identification queried believed it was beneficial. There were no differences between groups in smartphone emergency medical identification awareness and utilization. CONCLUSION: Smartphone emergency medical identification technology is underused despite its potential benefits. Future work should focus on improving education to use this technology in trauma care.

The REBOA Dissipation Curve: Training Starts to Wane at 6 Months in the Absence of Clinical REBOA Cases.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a low-frequency, high-acuity intervention. We hypothesized that REBOA-specific knowledge and comfort deteriorate significantly within 6 months of a formal training course if REBOA is not performed in the interim. METHODS: A comprehensive REBOA course was developed including didactics and hands-on practical simulation training. Baseline knowledge and comfort were assessed with a precourse objective test and a subjective self-assessment. REBOA knowledge and comfort were then re-assessed immediately postcourse and again at 6 months and 1 year. Performance trends were measured using paired Student's t and Wilcoxon signed-rank tests. RESULTS: Thirteen participants were evaluated including trauma faculty (n = 10) and fellows (n = 3). Test scores improved significantly from precourse (72% ± 10% correct) to postcourse (88% ± 8%, p < 0.001). At 6 months, scores remained no different from postcourse (p = 0.126); at 1 year, scores decreased back to baseline (p = 0.024 from postcourse; 0.285 from precourse). Subjective comfort with femoral arterial line placement and REBOA improved with training (p = 0.044 and 0.003, respectively). Femoral arterial line comfort remained unchanged from postcourse at 6 months (p = 0.898) and 1 year (p = 0.158). However, subjective comfort with REBOA decreased relative to postcourse levels at 6 months (p = 0.009), driven primarily by participants with no clinical REBOA cases in the interim. CONCLUSIONS: A formal REBOA curriculum improves knowledge and comfort with critical aspects of this procedure. This knowledge persists at 6 months, though subjective comfort deteriorated among those without REBOA placement in the interim. REBOA refresher training should be considered at 6-month intervals in the absence of clinical REBOA cases. LEVEL OF EVIDENCE/STUDY TYPE: Level III, prognostic.