The salutary effect of an integrated system on the rate of repeat CT scanning in transferred trauma patients: Improved costs and efficiencies.

BACKGROUND: Duplication of Computed Tomography (CT) scanning in trauma patients has been a source of quality waste in healthcare and potential harm for patients. Integrated and regional health systems have been shown to promote opportunities for efficiencies, cost savings and increased safety. METHODS: This study evaluated traumatically injured patients who required transfer to a Level One Trauma Center (TC) from either within a vertically integrated healthcare system (IN) or from an out-of-network (OON) hospital. RESULTS: We found the rate of repeat CT scanning, radiology costs and total costs for day one of hospitalization to be significantly lower for trauma patients transferred from an IN hospital as compared to those patients transferred from OON hospitals. CONCLUSION: The inefficiencies and waste often associated with transferred patients can be mitigated and strategies to do so are necessary to reduce costs in the current healthcare environment.

Epidemiology of Traumatic Brain Injury After Small-Wheeled Vehicle Trauma in Utah.

BACKGROUND: Recreational use of small-wheeled vehicles (SWVs), which include skateboards, longboards, nonmotorized scooters, ice skates, and roller skates or rollerblades, results in numerous injuries in the United States. OBJECTIVE: To describe the nature and severity of traumatic brain injuries (TBIs) that result from the use of SWVs in Utah. METHODS: Patients who were admitted to any Utah hospital after a SWV-related injury from 2001 through 2010 were identified from the Utah State Trauma Registry. Patients who sustained TBI were identified by International Classification of Diseases, Ninth Revision, codes. RESULTS: Of 907 patients admitted with SWV injury, 392 (43%) had a TBI (85% male). Their mean age was 19.8 ± 0.5 years, including 234 (60%) aged ≤18 and 119 (30%) aged 19 to 29. Most patients sustained TBI while using a skate- or longboard (87%). Mean Glasgow Coma Scale score in the emergency department was 12.8 ± 0.2. Thirty-nine percent were admitted to an intensive care unit, and 6% (23) underwent emergent neurosurgical intervention. Thirty-three (8.4%) patients had a concussion; the rest had nonoperative intracranial hemorrhage. Among patients for whom helmet use data were available, 8 out of 291 (2.7%) patients with TBI were wearing a helmet, whereas 24 out of 190 (12.6%) non-TBI patients were wearing helmets (P < .001). Overall mortality was higher in TBI patients than in non-TBI patients (2.3% vs 0.2%, P = .003). CONCLUSION: Young people, especially males, who ride SWVs in Utah are at risk for serious TBI, admission to the intensive care unit, neurosurgical intervention, and death. Helmet use in these patients is likely rare, but may reduce the risk of TBI and death. ABBREVIATIONS: ED, emergency departmentSWV, small-wheeled vehicleTBI, traumatic brain injury.

Protecting trauma patients from duplicated computed tomography scans: the relevance of integrated care systems.

BACKGROUND: Duplicated computed tomography (CT) scans in transferred trauma patients have been described in university-based trauma systems. This study compares CT utilization between a university-based nonintegrated system (NIS) and a vertically integrated regional healthcare system (IS). METHODS: Trauma patients transferred to 2 Level I trauma centers were prospectively identified at the time of transfer. Imaging obtained before and subsequent to transfer and the reason for CT imaging at the Level I center were captured by real-time reporting. RESULTS: Four hundred eighty-one patients were reviewed (207 at NIS and 274 at IS). Ninety-nine patients (48%) at NIS and 45 (16%) at IS underwent duplicate scanning of at least one body region. Inadequate scan quality and incomplete imaging were the most common reason category reported at NIS (54%) and IS (78%). CONCLUSIONS: Fewer patients received duplicated scans within the vertically IS as compared with a traditional university-based referral system. Our findings suggest that the adoption of features of a vertically IS, particularly improved transferability of radiographic studies, may improve patient care in other system types.

The role of focused abdominal sonography for trauma (FAST) in pediatric trauma evaluation.

PURPOSE: With increasing concerns about radiation exposure, we questioned whether a structured program of FAST might decrease CT use. METHODS: All pediatric trauma surgeons in our level 1 pediatric trauma center underwent formal FAST training. Children with potential abdominal trauma and no prior imaging were prospectively evaluated from 10/2/09 to 7/31/11. After physical exam and FAST, the surgeon declared whether the CT could be eliminated. RESULTS: Of 536 children who arrived without imaging, 183 had potential abdominal trauma. FAST was performed in 128 cases and recorded completely in 88. In 48% (42/88) the surgeon would have elected to cancel the CT based on the FAST and physical exam. One of the 42 cases had a positive FAST and required emergent laparotomy; the others were negative. The sensitivity of FAST for injuries requiring operation or blood transfusion was 87.5%. The sensitivity, specificity, PPV, and NPV in detecting pathologic free fluid were 50%, 85%, 53.8%, and 87.9%. CONCLUSIONS: True positive FAST exams are uncommon and would rarely direct management. While the negative FAST would have potentially reduced CT use due to practitioner reassurance, this reassurance may be unwarranted given the test's sensitivity.

Process improvement in trauma: compliance with recommended imaging evaluation in the diagnosis of high-grade renal injuries.

BACKGROUND: Appropriate imaging in renal trauma can avoid delayed recognition of collecting system injuries, allowing for prompt intervention and less morbidity. Current recommendations include obtaining abdominal and pelvic computed tomographic scans with intravenous contrast, followed by excretory images for high-grade injury or perinephric fluid. The purpose of this study was to evaluate compliance with this recommendation among adult Level I trauma centers in Utah. METHODS: A retrospective review was performed on all renal trauma patients evaluated at adult Level I trauma centers in Utah from January 2005 to January 2011. For all American Association for Surgery of Trauma grade 3 to 5 renal injuries, injury characteristics and outcomes were reviewed. We defined compliance as obtaining delayed images for grade 3 injuries with perinephric fluid or any grade 4 to 5 injuries. Descriptive statistics and univariate comparisons were calculated using statistical software. RESULTS: A total of 147 patients were identified with injuries of grade 3 or higher, but only 126 had available images for review at the time of the study. Of the 102 patients with a perinephric fluid collection or grade 4 to 5 injuries, delayed images were obtained in 74 (73%). In these patients, 14 (19%) had a collecting system injury. In the 28 patients without delayed images, 7 (25%) were later identified to have a collecting system injury. Of the 21 collecting system injuries, 7 (33%) had a delay in diagnosis because of lack of excretory images obtained on initial evaluation. CONCLUSION: Our findings support obtaining excretory images in patients with grade 4 to 5 injuries or those with a perinephric fluid collection. Poor compliance led to delayed diagnosis, with several patients requiring intervention for persistent urinary leak. We have implemented trauma imaging guidelines within Utah Level I trauma hospitals, which seek to minimize these diagnostic problems. LEVEL OF EVIDENCE: Epidemiologic study, level III; therapeutic study, level IV.

High grade renal injuries: application of Parkland Hospital predictors of intervention for renal hemorrhage.

PURPOSE: Investigators from Parkland Hospital proposed substratification of the AAST (American Association for the Surgery of Trauma) grading scale based on 3 risk factors, including active vascular extravasation, a medial laceration and a perinephric hematoma of greater than 3.5 cm. We hypothesized that these characteristics would also be associated with intervention for renal hemorrhage in our large trauma series. MATERIALS AND METHODS: From January 2005 to January 2011 we retrospectively reviewed the renal trauma records at adult level 1 trauma centers in Utah. AAST grade 3 and 4 injuries were characterized based on the mentioned 3 risk factors. Our primary outcome was intervention to control renal hemorrhage. RESULTS: AAST grade 3 or greater injury was identified in 147 patients, including 115 who had grade 3 and 4 injuries as well as imaging available for review. There were 63 grade 3 (53%) and 52 grade 4 (43%) renal injuries. Eight patients (7%) underwent intervention for renal hemorrhage. Vascular extravasation (OR 16.4, 95% CI 2.6-179.8, p <0.001) and perinephric hematoma greater than 3.5 cm (OR 8.4, 95% CI 1.4-52.5, p = 0.0099) were associated with intervention, while a medial laceration was not (p = 0.454). Patients with 1 or fewer, 2 and 3 risk factors had an intervention rate of less than 2.9%, 18% and 50%, respectively (p <0.001). CONCLUSIONS: Vascular extravasation, a perinephric hematoma greater than 3.5 cm and the number of risk factors (0 to 3) were associated with intervention for renal hemorrhage. Our findings are similar to those at Parkland Hospital. These imaging features may serve as useful prognostic indicators for renal trauma.

Process improvement in trauma: traumatic bladder injuries and compliance with recommended imaging evaluation.

BACKGROUND: We hypothesized that our compliance was low with recommended imaging for evaluation of traumatic bladder injury, which includes either a computed tomographic (CT) cystogram or plain cystogram. We sought to determine if poor compliance impacted diagnosis, management, and outcome of patients with bladder injury. METHODS: Patients with bladder injury were identified from all Level 1 hospital trauma registries in Utah from 1996 to 2010. Details including presentation, management, and outcome of bladder injury were described using descriptive statistics and bivariate and logistic regression analysis. RESULTS: A total of 124 patients were identified from the trauma registries with bladder injury and adequate records for review. The mean age was 35 years. Blunt trauma occurred in 110 patients (88%). Mean Injury Severity Score was 26.3. The leading concomitant injury was pelvic fracture in 98 patients (79%). Bladder injury was extraperitoneal in 75 patients (60%), intraperitoneal in 39 (31%), and both or undetermined in 10 (8%). A higher risk of death was seen in intraperitoneal with or without concomitant extraperitoneal injury compared with extraperitoneal injury only (odds ratio, 12.4; 95% confidence interval, 2.37-99.2). Management was operative in 68 (55%) patients (95% intraperitoneal, 31% extraperitoneal). Of the 124 injuries, 100 were detected with imaging: standard CT scan in 70 (56%) and cystogram or CT cystogram in 30 (24%). The remaining injuries were discovered operatively or were undocumented (n = 24, 19%). Initial imaging missed or incorrectly diagnosed bladder injury in 13 (13%) patients (nine from standard CT scan and four from CT or plain cystogram). In five cases diagnosed by standard CT scan, extraperitoneal injuries were misdiagnosed as intraperitoneal and operatively explored. CONCLUSION: There was poor compliance with imaging recommendations for evaluation of suspected bladder injury by either CT cystogram or plain cystogram at Level 1 trauma centers in Utah. We have implemented a genitourinary trauma imaging algorithm designed to minimize errors in bladder injury diagnosis. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Treatment of chronic lead toxicity with succimer: a case series of 2 adults with retained lead shotgun fragments.

UNLABELLED: Few recommendations exist for management of chronic lead toxicity in instances when the source of lead exposure cannot be removed. CASES: We describe 2 patients who had shotgun wounds resulting in multiple retained lead pellets. They developed elevated blood lead levels and were treated with 2 weeks of high-dose oral succimer before being placed on maintenance oral succimer therapy with the goal of sustaining suppressed lead levels. DISCUSSION: Retained lead pellets have been associated with increasing blood lead levels over time. Chronic lead toxicity can cause significant morbidity. Few treatments for lead toxicity are available, and there is scarce data on maintenance therapy for patients who have large numbers of retained shotgun pellets. CONCLUSIONS: This case series documents 2 patients who continue on maintenance oral chelation therapy with succimer in an effort to prevent the sequelae of chronic lead toxicity by maintaining blood lead levels less than 20 µg/dL.

A role in trauma care for advanced practice clinicians.

Advanced practice clinicians (APCs) are increasingly being utilized to care for patients on trauma services, but the quality of care provided by these alternate delivery models has been questioned. We hypothesized that APCs could safely administer trauma care that had traditionally been provided by surgical residents. Outcomes from an APC trauma-care delivery model were compared with those reported in the National Trauma Data Bank (NTDB). Parameters included in the comparison were mechanism of injury (MOI), length of hospital stay (LOS), injury severity score (ISS), and mortality. When MOI was used as the basis of comparison, the percentage of patients treated at the trauma center and the percentage of patients with information in the NTDB were similar. Despite having more seriously injured patients, the APC-staffed trauma center demonstrated a shorter LOS for all ISS categories; comparisons of patients with ISS >24 did not reach statistical significance. In addition, the APC-staffed trauma center had a statistically lower overall combined mortality rate when categorized by ISS. We conclude that an APC trauma-care delivery model provides outcomes at least as good as those reported by the NTDB.

A six-year descriptive study of hospital-associated infection in trauma patients: demographics, injury features, and infection patterns.

BACKGROUND AND PURPOSE: Hospital-associated infection (HAI) is of concern to surgeons providing care for traumatized patients, as such patients have a higher rate of infection than other patients. Infection surveillance programs often study trauma patients within other populations (e.g., intensive care unit [ICU], surgery), and important issues may be missed. Information identifying trauma patients at risk, most frequent infection sites, and pathogens is of importance for surveillance and infection control. Measurement is essential to improving care. METHODS: We evaluated the HAI rate, demographics, injury characteristics, and HAI patterns (microorganisms, sites, antibiotics) in trauma patients (1996-2001). We used two-tailed Mann-Whitney and Fisher exact tests for univariate analysis and a stepwise multivariable logistic regression model for association of multiple variables with the development of HAI. RESULTS: The incidence of HAI was 501 (9.1%) in 5,537 patients. Trauma patients with HAI were older (p < 0.001), more severely injured (p < 0.001), and more likely to have multi-system trauma (p = 0.027). Development of HAI was associated with all injury sites except the face. The most common pathogens were gram-positive cocci, and the most common infection sites were urinary and respiratory, with 157 of 501 (31%) being ventilator-associated pneumonia. The antibiotics most commonly used were cephalosporins and fluoroquinolones. Of 5,537 trauma patients, 19 (0.3%) had Staphylococcus aureus resistant to methicillin, which was higher (p < 0.001) than in the non-trauma patients (176 in 146,727 [0.1%]). CONCLUSIONS: Hospital-associated infections occur frequently in trauma patients. This paper identifies populations to target for surveillance and HAI control initiatives. With increased interest in adverse event prevention and continuing quality of care improvement, these data provide a benchmark for this institution and others.

Trauma patient hospital-associated infections: risks and outcomes.

BACKGROUND: Trauma patients with surgical procedures, acute lung injury (ALI), systemic inflammatory response syndrome (SIRS), and longer exposure to invasive devices may be at increased risk for hospital-associated infection (HAI). HAIs have been shown to affect outcome measures, but the extent is not well studied. METHODS: An infection control team identified HAIs in trauma patients from 1996 through 2001. The authors evaluated the relation of HAI to surgical procedures, ALI, SIRS, and device exposure time by comparing groups with and without HAI using Fisher's exact and Mann-Whitney tests. Using multiple linear and logistic regressions, the authors evaluated associations of HAI, age, and Injury Severity Score (ISS) with length of stay (LOS), cost of care, and mortality. They used Cox proportional hazard regression to further explore the relations of HAI, age, and ISS to LOS. RESULTS: In 501 of 5,537 trauma patients with HAI (9.1%), the percent having surgical procedures, ALI, and SIRS was significantly higher (p < 0.001). Exposure to all devices studied was significantly longer (p < 0.001) in HAI patients. When the population was controlled for age and ISS, HAI patients had longer lengths of stay (LOSs) and higher costs. Age had less effect than ISS on LOS, and the effect of increases in age was greater as ISS increased. ISS had a greater effect than HAIs on LOS. HAIs increased LOS more in patients less severely injured. When comparing patients with and without HAI, no difference in mortality rates was detected. CONCLUSION: In this study of trauma patients, ISS had the greatest effect on LOS, but increased age and presence of HAI did increase LOS and cost of care. HAI increased LOS more in the less severely injured patients.

Computed tomography without oral contrast solution for blunt diaphragmatic injuries in abdominal trauma.

OBJECTIVE: The aim of this study was to estimate the sensitivity, specificity, and positive predictive value (PPV) of computed tomography (CT) without oral contrast for diaphragm injuries (DIs) in blunt abdominal trauma. METHODS: We prospectively enrolled 500 consecutive "trauma-one" patients who received CT imaging and interpretation (CT-Read1) of the abdomen within 45 minutes of their arrival from July 2000 to December 2001. All patients were imaged without oral contrast but with intravenous contrast. Computed tomographic images were reviewed within 24 hours of admission by research radiologists (CT-Read2) blinded to CT-Read1. True DIs were determined hierarchically by either laparotomy or autopsy. RESULTS: There were 9 patients with laparotomy or autopsy-proven blunt DIs; 8 of these injuries involved the left hemidiaphragm. The CT-Read1 correctly detected only 6 of 9 blunt DIs, thus missing 3 DIs. One of these involved the right hemidiaphragm, whereas the other 2 were left sided. There were no false-positive findings with CT-Read1 for blunt DI. The sensitivity and specificity of CT imaging with respect to DI were 66.7% (95% CI, 29.9%-92.5%) and 100% (95% CI, 99.2%-100%), respectively. The PPV for the test was 1.00 (95% CI, 0.65-1.00). CONCLUSION: Although the low number of blunt DIs in this study limits its general applicability, CT imaging of the diaphragm without oral contrast appears to perform within the range of reported imaging techniques using oral contrast. Still, CT scanning appears to have an unsatisfactorily low sensitivity to be reliably used in eliminating the diagnosis of blunt DI.

Retrievable vena cava filters in trauma patients for high-risk prophylaxis and prevention of pulmonary embolism.

BACKGROUND: Venous thromboembolic (VTE) disease remains a significant cause of morbidity for trauma patients because many patients have injuries that may preclude effective VTE prevention and treatment. Retrievable vena cava filters may prove beneficial in this subset of trauma patients. METHODS: Trauma patients at risk for VTE were identified and managed by institutional protocol. Patients who required a vena cava filter were managed with a device that could be retrieved or left in situ. A retrospective review of medical records was used to identify the use, indications, and complications associated with a retrievable filter. RESULTS: Fifty-three retrievable filters were placed in 51 patients. Two of these patients received a second filter, and 1 received a filter in the superior vena cava. Thirty-two filters were placed prophylactically, whereas 21 were placed for demonstrated venous thromboembolism (VTE). Retrieval was successful in 24 of 25 attempts. Twenty-nine filters became permanent: 10 for continued contraindications to anticoagulation without known VTE, 12 for known VTE and continued contraindications to anticoagulation, 1 for technical reasons, and 6 because of patient death. There were no complications of bleeding, device migration or thrombosis, infection, or pulmonary embolism. CONCLUSIONS: A retrievable vena cava filter appears safe and effective for the prevention of pulmonary embolism in the high-risk trauma patient who cannot receive anticoagulation.

Computed tomographic scanning without oral contrast solution for blunt bowel and mesenteric injuries in abdominal trauma.

BACKGROUND: Computed tomographic (CT) scanning using intravenous and oral contrast material has traditionally been advocated for the evaluation of intra-abdominal injury, including blunt bowel and mesenteric injuries (BBMIs). The necessity of oral contrast in detecting these injuries has recently been called into question. The purpose of this study was to determine the sensitivity and specificity of CT scanning without oral contrast for BBMIs. METHODS: We prospectively enrolled 500 consecutive blunt trauma patients who received CT imaging and interpretation (CT-Read1) of the abdomen from July 2000 to November 2001. All patients were imaged without oral contrast, but with intravenous contrast. CT images were reviewed within 24 hours of admission by a research radiologist (CT-Read2) blinded to CT-Read1. For study purposes, true BBMI was determined to be present if either laparotomy or autopsy identified bowel or mesenteric injury, or both CT-Read2 and the hospital discharge summary described bowel or mesenteric injury. Three-month telephone follow-up was also completed. RESULTS: CT-Read1 detected 19 of 20 bowel and mesenteric injuries. CT-Read1 missed one duodenal perforation. There were two patients with false-positive interpretations of CT-Read1 for bowel injury. The sensitivity and specificity of CT imaging for the detection of BBMIs were 95.0% and 99.6%, respectively. CONCLUSION: CT imaging of the abdomen without oral contrast for detection of BBMIs compares favorably with CT imaging using oral contrast.

Blunt chest trauma: an experimental model for heart and lung contusion.

BACKGROUND: Blunt chest trauma is an important clinical problem leading to injury of the heart and lungs that may be fatal. Experimental models in large animals have been developed previously. This study was aimed at developing a small-animal (rat) model for the purpose of evaluating blunt chest trauma. METHODS: Blunt trauma was delivered to the left side of the chest in rats by a captive bolt handgun. The gun was modified so that the amount of energy delivered to the chest wall could be adjusted. The injury energy varied from 1.7 to 6.8 J. Thirty-eight experiments in adult rats were performed. Electrocardiographic monitoring was performed continuously to determine cardiac rhythm. Gross and histologic examination of lungs and heart was performed at the time of death resulting from injury or euthanasia up to 13 days after injury. RESULTS: Some form of cardiac arrhythmia accompanied blunt chest trauma in every case. Serious ventricular arrhythmia (tachycardia or fibrillation) was nearly always fatal (15 of 16 cases), but gross or histologic evidence of cardiac injury was present in only 31% of fatal cases. Lung injury (often bilateral) as shown by atelectasis and hemorrhage into the parenchyma or airway was found in 93% of the experiments when medium range energy force was applied. CONCLUSION: This study has established a useful model for the study of blunt chest trauma in a small animal (rat). Blunt chest trauma is associated with cardiac arrhythmia, which may be fatal. Injury to the heart may not correlate with serious cardiac arrhythmia resulting in death, lending credence to the concept of cardiac concussion or commotio cordis. Lung contusion is always more obvious than morphologic injury to the heart.

Adverse drug events in trauma patients.

BACKGROUND: Adverse drug events (ADEs) are noxious and unintended results of drug therapy. ADEs have been shown to be a risk to hospitalized patients. The purpose of this study was to determine the rate and nature of ADEs in trauma patients and to characterize the population at risk. METHODS: An electronic medical record, a hospital wide computerized surveillance program, and a clinical pharmacist prospectively investigated ADEs in 4,320 trauma patients from 1996 through 1999. RESULTS: The rate of ADEs in trauma patients (98/4320, 2.3%) was twice that of non-trauma hospital patients (1,111/96,218, 1.2%, p < 0.001). Traumatized females had ADEs 1.5 times more often than traumatized males (2.7% versus 1.8%, p = 0.052). The medication class most often associated with ADEs was analgesics with 54% involving morphine and 20% involving meperidine. The most common ADEs were nausea, vomiting, and itching. Only one ADE was directly attributed to a medical error. CONCLUSIONS: Trauma patients are at double the risk for ADEs. Analgesics are particularly associated with ADEs and use should be carefully monitored.