Implementing a domestic violence screening program.

The purpose of this study was to design and implement a domestic violence (DV) screening protocol. Trauma patients meeting inclusion criteria (hospitalized > 48 hours) were given a four question DV screen. If abuse was found, a comprehensive DV questionnaire followed. Barriers to screening and results were recorded. Compliance during the pilot test showed 23 of 157 (14.6%) admitted patients were screened. In the implementation year, 446 of 721 (61.9%) were screened. During the 10-month follow-up, 499 of 619 (80.6%) patients were screened. Lack of social work resources was the primary barrier to screening, but compliance increased and was maintained after the study period.

Red cell distribution width is predictive of mortality in trauma patients.

BACKGROUND: Red blood cell distribution width (RDW) is a component of the complete blood count (CBC) that is traditionally used to identify iron-deficiency anemia. RDW has been shown to predict mortality in patients with multiple different medical conditions and in general populations. It is unknown whether RDW predicts outcomes in trauma patients. This study tested whether RDW predicts mortality in a trauma population at a Level I trauma center. METHODS: Trauma patients with a CBC from October 2005 to December 2011 were evaluated. Sex-specific 30-day and 1-year all-cause mortality and RDW were studied using Cox regression adjusted for age, Injury Severity Score (ISS), hospital length of stay, blunt versus penetrating trauma, and other CBC parameters. RESULTS: A total of 3,637 females and 5,901 males were evaluated at 30 days and 1 year. With full adjustment, RDW predicted 30-day mortality in males (for RDW quintiles 1-5: 2.2%, 1.8%, 3.6%, 4.8%, 10.1%, respectively; p < 0.001) but not in females (3.4%, 1.9%, 3.0%, 3.9%, 6.2%; p = 0.036). At 1 year, RDW predicted mortality in both males (p < 0.001; 0.5%, 0.4%, 0.8%, 1.7%, and 8.3%) and females (p < 0.001; 0.5%, 2.1%, 3.0%, 4.2%, and 8.8%). Receiver operating characteristic analysis found c = 0.705 in males and c = 0.625 in females at 30 days and c = 0.820 in males and c = 0.723 in females at 1 year. CONCLUSION: RDW independently predicted mortality in trauma patients at this single Level I trauma center. RDW may reveal underlying health status and be clinically useful for prognostication. The mechanistic relationship between RDW and mortality in trauma remains unknown and should be further evaluated. LEVEL OF EVIDENCE: Prognostic and epidemiological study, level III.

A survey of trauma registrars: job requirements, responsibilities, recruitment, and retention.

Study purpose was to describe trauma registrar job requirements, responsibilities, and recruitment/retention practices. An online survey was used. One-third required a high school diploma; two-thirds required a college degree. Most required skills were medical terminology (66%), database management (65%), anatomy (64%), Word (63%). Data responsibilities included abstracting, entry, coding, and validating. Few employers required certification. Twenty-six percent reported problems with recruitment, and 35% with retention. Salary and lack of advancement were primary reasons for employee turnover. Certifications were less relevant than skills; the primary focus was data management. Recommendations for recruitment/retention include job flexibility, educational opportunities, and recognition as a profession.

Research and quality improvement experience and knowledge: a nursing survey.

AIM: To assess nursing staff's background and research and quality improvement (QI) experience. BACKGROUND: In this corporation, participation in research and QI is encouraged, but little is known about nurses' experiences. METHODS: A web-based survey was distributed. Nursing staffs from an academic/teaching medical centre and other intra-corporation non-academic facilities were compared. RESULTS: Respondents included: 148 (52.9%) medical centre and 132 (47.1%) non-medical centre subjects. Medical centre respondents had a higher proportion previously engaged in research, currently engaged in research and previously engaged in QI. Productivity (grant, published and presented) was low for both groups but statistically lower for the non-medical centre group. Medical centre employees used research resources more often than the non-medical centre. Time was the most frequently mentioned barrier to participation in research and QI initiatives. CONCLUSIONS: A moderate proportion of respondents had research and QI experience, yet productivity and use of resources was low. Nurses at non-academically focused facilities were in most need of assistance. Familiarizing nurses with resources and providing protected time may increase productivity. IMPLICATIONS FOR NURSING MANAGEMENT: Developing an infrastructure to support nursing research is a worthy goal. Information about interest and experience of nurses can aid management in determining how to focus financial resources.

Air medical transport personnel experiences with and opinions about research.

INTRODUCTION: This study examined air medical transport (AMT) personnel's experiences with and opinions about prehospital and AMT research. METHODS: A Web-based questionnaire was sent to eight randomly selected AMT programs from each of six Association of Air Medical Services (AAMS) regions. Responders were defined by university association (UA) and AMT professional role. RESULTS: Forty-eight of 54 (89%) contacted programs and 536 of 1,282 (42%) individuals responded. Non-UA responders (74%) had significantly more work experience in emergency medical services (EMS) (13.5 +/- 8.5 vs. 10.8 +/- 8.3 years, P = .002) and AMT (8.3 +/- 6.3 vs. 6.8 +/- 5.7 years, P = .008), whereas UA responders (26%) had more research training (51% vs. 37%, P = .006), experience (79% vs. 59%, P < .001), and grants (7% vs. 2%, P = .006). By AMT role, administrators had the most work experience, and physicians had the most research experience. Research productivity of responders was low, with only 9% having presented and 10% having published research; and UA made no difference in productivity. A majority of responders advocated research: EMS (66%) and AMT (68%), program (53%). Willingness to participate in research was high for both EMS research (87%) and AMT research (92%). CONCLUSIONS: Although AMT personnel were strong advocates of and willing to participate in research, few had research knowledge. For AMT personnel, disparity exists between advocating for and producing research.

Quantifying the value of AMPA membership services.

INTRODUCTION: The purpose of this study was to quantify the value of current and future Air Medical Physician Association (AMPA) membership services. METHODS: Three-hundred-ninety-eight AMPA members were contacted by e-mail to participate in ranking AMPA membership services by a perceived numeric value (10 = highest to 1 = lowest), using a web-based survey. RESULTS: One-hundred-eighteen AMPA members completed the survey. The percentage of respondents having attended the conference and their AMPA-related Conference ranked-value scores were as follows: Air Medical Transport Conference (AMTC), 43%, 9.6 +/- 1.9; AirMed International Conference, 9%, 7.8 +/- 4.2; AMTC Pre-conference, 65%, 7.6 +/- 2.5; Critical Care Transport Medicine Conference (CCTMC), 47%, 6.6 +/- 2.6; CCTMC Pre-conference, 37%, 6.6 +/- 2.6; the Association of Air Medical Services (AAMS) Mid-Year Conference, 6%, 6.4 +/- 4.9; and General Membership meeting, 63%, 5.6 +/- 2.4. Current AMPA Benefit/Service ranked-value scores were as follows: textbook, 8.4 +/- 1.8; voice for physicians, 8.0 +/- 2.3; position papers, 7.9 +/- 1.8; Air Medical Journal subscription, 7.8 +/- 2.1; networking with others, 7.7 +/- 2.4; newsletter, 7.3 +/- 1.9; means to enhance professional credibility, 7.1 +/- 2.5; web site, 7.0 +/- 2.1; voice on Commission on Accreditation of Medical Transport Systems (CAMTS), 7.0 +/- 2.7; continuing medical education (CME) credits, 6.6 +/- 3.0; conference discounts, 6.4 +/- 2.9; and curriculum vitae builder, 4.9 +/- 2.9. Future AMPA Benefits/Services ranked-value scores were as follows: evidence-based guidelines, 8.6 +/- 1.7; transport database, 7.7 +/- 2.1; malpractice repository, 7.6 +/- 2.2; DVD lectures, 7.4 +/- 2.0; medical director certification, 7.2 +/- 2.9; lobbying, 7.1 +/- 2.4; photo library, 6.4 +/- 2.3; salary and benefits surveys, 6.4 +/- 2.6; speaker's bureau, 6.2 +/- 2.4; and consulting service list, 6.2 +/- 2.4. CONCLUSION: This AMPA survey was useful in prioritizing membership services.

Utilization of failure mode effects analysis in trauma patient registration.

AIM: Our goal was to identify strategies that would reduce risks and improve patient safety during registration of trauma patients and subsequent electronic data linkage. Recently, the health care industry and the Joint Commission on Accreditation of Healthcare Organizations have supported failure mode effects analysis (FMEA) as a tool for proactively reducing risk to patients. METHODS: We utilized FEMA for a comprehensive evaluation of our trauma patient registration process for system weaknesses. RESULTS: We found several areas of our processes that placed patients at risk. On the basis of our findings, we implemented changes that included education of staff, role clarification, task reallocation, and established a list of personnel authorized to request the electronic data linkage process. Further recommendations were made for information system changes, which are under review. CONCLUSIONS: FMEA helped us to systematically identify and prioritize risks to patient safety. Our findings directed changes, which, in turn, reduced potential errors. We recommend this method of evaluation to other health care personnel interested in improving patient safety.

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.

Failure mode and effects analysis as a performance improvement tool in trauma.

INTRODUCTION: Performance improvement (PI) in the multiple systems injured patient frequently highlights areas for improvement in overall hospital care processes. Failure mode effects analysis (FMEA) is an effective tool to assess and prioritize areas of risk in clinical practice. Failure mode effects analysis is often initiated by a "near-miss" or concern for risk as opposed to a root cause analysis that is initiated solely after a sentinel event. In contrast to a root cause analysis, the FMEA looks more broadly at processes involved in the delivery of care. The purpose of this abstract was to demonstrate the usefulness of FMEA as a PI tool by describing an event and following the event through the healthcare delivery PI processes involved. DESCRIPTION: During routine chart abstraction, a trauma registrar found that an elderly trauma patient admitted with a subdural hematoma inadvertently received heparin during the course of a dialysis treatment. Although heparin use was contraindicated in this patient, there were no sequelae as a result of the error. This case was reviewed by the trauma service PI committee and the quality improvement team, which initiated FMEA. EVALUATION: An FMEA of inpatient dialysis process was conducted following this incident. The process included physician, nursing, and allied health representatives involved in dialysis. As part of the process, observations of dialysis treatments and staff interviews were conducted. Observation revealed that nurses generally left the patient's room and did not involve themselves in the dialysis process. A formal patient "pass-off" report was not done. Nurses did not review dialysis orders or reevaluate the treatment plan before treatment. We found that several areas of our current practice placed our patients at risk. 1. The nephrology consult/dialysis communication process was inconsistent. 2. Scheduling of treatments for chronic dialysis patients could occur without a formal consult or order. 3. RNs were not consistently involved in dialysis scheduling, setup, or treatment. 4. Dialysis technicians may exceed scope of practice (taking telephone orders) when scheduling of treatment occurred before consult and written orders. OUTCOMES: Near-miss events may be overlooked as opportunities for improvement in cases where no harm has come to the patient. As a result of our FMEA investigation, the following recommendations were made to improve hospital care delivery in those trauma patients who require inpatient dialysis: 1. Education of RNs about the dialysis process. 2. Implementation of a formal reporting process between the RN and the dialysis technician before the procedure is initiated. 3. RN supervision of dialysis treatments. 4. Use of a preprinted inpatient dialysis form. 5. Education of dialysis technicians regarding their scope of practice. 6. Improve notification process for scheduling dialysis procedures between units and dialysis coordinator (similar to x-ray scheduling). Our performance improvement focus has broadened to include all reported "near-miss" events in order to improve our healthcare delivery process before an event with sequelae occurs. We have found that using FMEA has greatly increased our ability to facilitate change across all services and departments within the hospital.

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.

Sciatic nerve injuries associated with traumatic posterior hip dislocations.

This study was undertaken to test the hypothesis that patients transferred between hospitals with a dislocated hip have a greater incidence of sciatic nerve injury than patients who have their hip reduced at the first facility. One hundred six dislocated hips were included in this 12-year retrospective study. Sixty-nine hips were relocated at the first hospital and 36 patients were transferred with the hip still dislocated to LDS Hospital. There was a higher incidence of major sciatic nerve injury (complete sciatic or peroneal motor deficit) in patients transferred with the hip still dislocated (P =.0453). Time to relocation was significantly longer in patients with major motor nerve injury (P =.016). The presence of an associated fracture had no influence on sciatic nerve injury rates. The length of time a hip remains dislocated influences the incidence and severity of major sciatic nerve injury.

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.