Impact of emergency department boarding on patients outcomes in hip fractures.

BACKGROUND: Boarding time in the Emergency Department (ED) is an area of concern for all patients and potentially more problematic for the hip fracture population. Identifying patient outcomes impacted by ED boarding and improving emergent care to reduce surgical delay for this patient population is a recognized opportunity. The objective of this study is to examine the impact of ED boarding in relation to patient outcomes in the surgical hip fracture population. METHODS: This is a retrospective study of hip fracture patients who presented at the ED of a Level 1 trauma center between January 2020 and December 2021. Patients were categorized into four quartiles based on boarding time. Study outcomes-hospital length of stay, time to surgery, visit to ICU post-operative, total blood products, in-hospital complications, discharge disposition, in-hospital mortality, and 30-day readmission-were compared among these four quartiles. RESULTS: The outcome endpoints were comparable among the four quartiles except for time to surgery. Time to surgery significantly differed among the quartiles, increasing from 20.39 to 29.03 h (p < 0.001) from the first to fourth quartile. CONCLUSION: In contrast to the existing literature, ED boarding in our study was not associated with adverse outcomes except for time to surgery. By expediting the time to surgery in accordance with established guidelines, adverse outcomes were mitigated even when our patients boarded for a longer duration. System processes including a 24/7 trauma nurse practitioner model, availability of in-house orthopedic surgeons, and timely cardiac evaluation need to be considered in relation to time to surgery, in turn impacting ED boarding and patient outcomes.

Resilience in rural health system.

INTRODUCTION: Current literature emphasises the importance of resilience in health care. Studies have shown that lack of resilience not only leads to adverse clinical outcomes but is also associated with burnout and long-term stress in clinicians. Resource-limited rural settings in the United States often impose unique stressors, and thus, it is critical to examine resilience of health care providers practicing rural medicine. METHODS: An anonymous REDCap survey was completed by medical students, residents and attending physicians between 7 April 2021 and 18 May 2022. The primary outcome of resilience was measured by the Connor-Davidson Resilience Scale 10 (CD-RISC-10©). RESULTS: Survey takers scored moderately on the resilience scale (30.64 on a 40-point scale). The first quartile of respondents scored between 0 and 28; the second quartile scored between 29 and 30; the third quartile scored between 31 and 35; the fourth quartile scored between 36 and 40. Age and years of service were not correlated with resilience. However, survey takers who had been exposed to trauma informed care scored significantly higher on the resilience scale (32.37 vs. 28.85, p = 0.021). The level of resilience when compared by profession was found to be comparable among medical students, residents and attending physicians. CONCLUSION: Individuals scoring in the first two quartiles of the CD-RISC-10© perhaps indicate need for support as they are having difficulty coping with stress. Health care organisations should provide resilience training to support the wellness and mental health of their staff. Moreover, dedicated efforts should be made toward creating trauma-informed health care organisations as exposure to the topic of trauma informed care had a significant positive impact on resilience.

Ten-Year Review of Tracheostomy Techniques and Related Complications.

BACKGROUND: Tracheostomy is a frequently performed procedure that allows for definitive airway access in critically ill patients. Complications associated with tracheostomy have been well documented in the literature. This study aims to examine if different tracheostomy techniques were associated with specific complications. Secondary objectives were to determine the rate and commonality of post-tracheostomy complications. METHODS: This was a descriptive retrospective study of patients who underwent tracheostomy between June 2009 and June 2019. Patients included in the study were ≥18 years and were admitted to a rural tertiary care hospital system. RESULTS: Overall procedure complication rate was 34.3% with pneumonia (18.6%), obstruction (6.2%), bleeding (4.0%), and accidental tube decannulation (3.8%) being the most common. Rate of complications was not associated with the timing of the tracheostomy, the incision type, tube location, tracheostomy technique, and securing technique. However, tube size significantly differed between patients with or without complications (P = .016). Tube size 8 Shiley was most commonly used in both groups and was significantly associated with reduced complication rate (72.0% vs 78.8%, P = .002). CONCLUSION: Tracheostomy technique should be guided by proceduralist experience and patient clinical picture to determine the best approach. However, the association of post-tracheostomy complication with tube size perhaps will guide clinicians with tube size selection.

Impact of Treatment Modalities on Discharge Disposition in Blunt Splenic Injuries.

BACKGROUND: Management of blunt splenic trauma has evolved over several decades, trending towards nonoperative management and splenic artery embolization. Extensive research has been conducted regarding the management of blunt splenic injuries, but there is little data on the association of treatment modality with discharge disposition. METHODS: This is an observational retrospective study conducted at a level-one trauma center with blunt splenic trauma patients of age ≥18 years between January 2010 and December 2021. The primary outcome of unfavorable discharge was defined as discharge to an acute care facility, intermediate care facility, long-term care facility, rehabilitation (inpatient) facility, or skilled nursing facility. RESULTS: Five hundred seventy-nine patients were included in the analysis, with 108 (18.7%) in the unfavorable group and 471 (81.3%) in the favorable group. Most patients were managed nonoperatively (69.3%), followed by splenectomy (25.0%) and embolization (5.7%). Due to the low number of embolizations performed during the study period, treatment modalities were grouped into two broad categories: intervention (embolization and splenectomies) and nonintervention. The treatment modality was found to have no significant impact on unfavorable discharge. Independent risk factors for unfavorable discharge included age >55 years, injury severity score (ISS) >15, hospital-acquired pneumonia, and in-hospital complications of sepsis. CONCLUSIONS: This study provides an understanding of specific demographic and clinical factors that may predispose blunt splenic injury trauma patients to an unfavorable discharge. Providers may apply these data to identify at-risk patients and subsequently adapt the care they provide in an effort to prevent the development of in-hospital pneumonia and sepsis.

Prehospital Active and Passive Warming in Trauma Patients.

OBJECTIVE: Hypothermia is common among trauma patients and can lead to a serious rise in morbidity and mortality. This study was performed to investigate the effect of active and passive warming measures implemented in the prehospital phase on the body temperature of trauma patients. METHODS: In a multicenter, multinational prospective observational design, the effect of active and passive warming measures on the incidence of hypothermia was investigated. Adult trauma patients who were transported by helicopter emergency medical services (HEMS) or ground emergency medical services with an HEMS physician directly from the scene of injury were included. Four HEMS/ground emergency medical services programs from Canada, the United States, and the Netherlands participated. RESULTS: A total of 80 patients (n = 20 per site) were included. Eleven percent had hypothermia on presentation, and the initial evaluation occurred predominantly within 60 minutes after injury. In-line fluid warmers and blankets were the most frequently used active and passive warming measures, respectively. Independent risk factors for a negative change in body temperature were transportation by ground ambulance (odds ratio = 3.20; 95% confidence interval, 1.06-11.49; P = .03) and being wet on initial presentation (odds ratio = 3.64; 95% confidence interval, 0.99-13.36; P = .05). CONCLUSION: For adult patients transported from the scene of injury to a trauma center, active and passive warming measures, most notably the removal of wet clothing, were associated with a favorable outcome, whereas wet patients and ground ambulance transport were associated with an unfavorable outcome with respect to temperature.

A 10-Year Epidemiologic Overview of Firearm Injuries in Southern West Virginia.

The firearm mortality rate in West Virginia (WV) increased over the past four years and is currently 50% higher than the national rate. These alarming statistics, combined with the urban-to-rural shift in firearm injuries, prompted this 10-year epidemiologic overview. To the best of the authors' knowledge, the current study stands alone as the only report of its kind on firearm injuries in the rural setting of southern WV. Firearm injuries were common in White males within the age range of 20-49 years. Assault, which is typically identified as an urban problem, was found to be the most common injury in the study population. In our data series, injury severity score was the strongest predictor of mortality, followed by self-inflicted cause of injury and trauma to the neck/head region.

Retrospective analysis of locked versus non-locked plating of distal fibula fractures.

INTRODUCTION: Unstable distal fibular fractures have traditionally been treated with open reduction internal fixation using a 1/3 tubular non-locked plate (compression plating). Locked plating is a newer technique that has become more popular despite the lack of clinical data supporting improved outcomes. The cost of locked plating is almost four times that of compression plating. We compared rates of reoperation due to implant failure, infection, and symptomatic device between compression and locked plating in open reduction internal fixation of distal fibular fractures METHODS: A retrospective study was performed at a level one trauma center over a ten-year period (2008-2017). Patients who were 18 and older and treated for unstable ankle fractures with locking or non-locking plate were included in this study. Patient charts were reviewed by orthopedic trauma surgeons to identify whether patients were treated with a 1/3 tubular non-locking or pre-contoured locked plate and to determine the cause of reoperation. RESULTS: In total, 442 patients were identified with 203 in the non-locked 1/3 tubular plate group and 239 in the pre-contoured locked plate group. A total of 38 patients (8.6%) underwent device removal with a higher proportion of patients in the non-locked 1/3 tubular plate cohort (11.3% vs. 6.3%, p = 0.059). Statistically significant differences in reasons for reoperation were found for symptomatic implant (78.3% vs. 46.7%, p = 0.045) and infection (8.7% vs 53.3%., p < 0.01). Of patients who had device removal for symptomatic implant in the compression plating cohort, 13 (72.2%) had lateral positioning and 5 (27.8%) had posterior positioning (p < 0.01) whereas there was no statistical difference in plate positioning in the locked cohort. Of all medical comorbidities identified, only diabetes was associated with a higher rate of infection-related reoperations (83.3% vs. 15.6%, p < 0.01). CONCLUSIONS: Both compression and locked plate techniques demonstrated low reoperation rates. Compression plating with 1/3 tubular plates placed laterally more often resulted in reoperation due to symptomatic implant but had fewer complications of infection. Given that the cost is significantly less, 1/3 tubular plating placed posteriorly may be preferred to decrease the risks of symptomatic implant and infection.

Impact of the 24/7 nurse practitioner model on emergency department stay at a level 1 trauma center: A retrospective study.

AIMS: The aim of the study was to assess the impact of 24/7 trauma nurse practitioner service model on the emergency department patient flow. BACKGROUND: Seamless transition of trauma patients through the emergency department to inpatient hospital care is crucial for coordination of care, clinical safety and positive health outcomes. A level 1 trauma centre located in Southern West Virginia, USA expanded their trauma nurse practitioner service covering the emergency department 24/7. DESIGN: Retrospective cohort study conducted in accordance with the Strengthening the Reporting of Observational studies in Epidemiology guidelines. METHODS: Patients admitted to the trauma centre between March 2019 and February 2020 were divided into two groups: trauma patients managed by trauma nurse practitioners versus the hospitalist service. The hospital service group was chosen as the comparator group because any admission prior to night coverage by the trauma nurse practitioners were managed by the hospitalist service. RESULTS: The emergency department length of stay was significantly lower in trauma nurse practitioners' patients by an average of 300 min (772.25 ± 831.91 vs. 471.44 ± 336.65, p = <.001). Similarly, time to place emergency department discharge order was shorter by 49 min (277.76 ± 159.69 vs. 228.27 ± 116.04, p = .001) for this group. Moreover, trauma nurse practitioners on an average placed one less consultation (1.06 ± 0.23 vs. 1.46 ± 0.74, p < .001). CONCLUSION: The patient care provided by trauma nurse practitioners aided in the reduction of strain felt by their emergency department. They were able to help facilitate patient flow thus lessening the pressure of boarding in an overcrowded emergency department. The study institution hopes to sustain the current service model and continue to review outcomes and processes managed by trauma nurse practitioners to ensure consistency and quality. RELEVANCE TO CLINICAL PRACTICE: Similar trauma centres should evaluate the structure of their trauma service that includes the role of trauma nurse practitioner service and work towards allowing them to manage patient care from the emergency department 24/7.

A 10-Year Review of Spatio-Temporal Patterns of Firearm Injury in a Rural Setting.

INTRODUCTION: West Virginia (WV) had the ninth highest rate of firearm mortality of all states in the United States according to the CDC in 2018. Gun violence in WV has been a steady problem over the last decade. The rural population is more vulnerable to unintentional firearm injuries and suicides. Previously published literature from urban settings has demonstrated a link between firearm injuries and modifiable situational variables such as crime, unemployment, low income, and low education. There are very few studies that have utilized geospatial analytic techniques as a tool for injury mapping, surveillance, and primary prevention in rural and frontier zones of the United States. METHODS: We performed a 10-year retrospective single-institution review of firearm injuries at a rural WV level 1 trauma center between January 2010 and December 2019. The AIS World Geocoding Service was then used to identify specific areas of emerging firearm-related injuries within the service area. RESULTS: Specific hot spots of emerging firearm injury were identified in both intentional and unintentional populations. These were located in geographically distinct areas of the WV unincorporated rural and frontier population. These rural WV hotspots were associated with the modifiable variables of crime, unemployment, lower income, and lower education level. CONCLUSIONS: Emerging hot spots of firearm injury in rural and frontier locations were associated with modifiable social determinants. These areas represent an opportunity for targeted injury prevention efforts addressing these disparities. Further prospective study of these findings is warranted.

Change in Medication-Associated Fall Risk Among Older Adults After Admission for Fall-Related Trauma.

BACKGROUND: As the population ages, it is predicted that approximately 40% of all patients who experience fall-related trauma will be 65 years of age and older. Most injuries in older adults are caused by falls that are the result of multiple contributing factors including home hazards, comorbidities, frailty, and medications. A variety of medications have been associated with falls, specifically those with sedating and anticholinergic effects. The drug burden index can be used to quantify sedating and anticholinergic drug burden, with higher scores being associated with reduced psychomotor function. OBJECTIVE: Assess the medication-associated fall risk on admission and discharge for older patients admitted to a trauma nurse practitioner service. METHODS: Retrospective, observational study of patients managed by trauma nurse practitioners at a Level 1 trauma center between January 1, 2018, and December 31, 2019. Patients were included if they were at least 65 years of age, the primary diagnosis for the admission was fall-related trauma, and length of stay was at least 7 days. RESULTS: A total of 172 patients were included in the study. The drug burden index was significantly higher at discharge than admission (M = 1.4, SD = 0.9 vs. M = 1.9, SD = 0.9) as was the total number of medications (M = 11.0, SD = 5.2 vs. M = 15.1, SD = 5.8). CONCLUSIONS: Medication-related fall risk was increased during admission due to fall-related trauma. Patients were discharged with a higher sedating and anticholinergic burden than on admission, which increases risk for future falls.

Trauma Bay Time Clocks: Influence on Emergency Department Length of Stay.

BACKGROUND: To monitor the time elapsed since patient arrival in the emergency department, Trauma Services at the study institution installed a large digital stopwatch timer placed at the head of each trauma bay on June 5, 2017. This quality improvement endeavor became an essential component of performance evaluation. OBJECTIVE: The purpose of the study is to measure the impact of trauma bay time clocks on emergency department length of stay. METHODS: This is a retrospective before-and-after study of trauma activation patients between June 2015 and May 2019. Two 24-month intervals were compared before and after installation of time clocks. RESULTS: In full activation patients, outcomes of emergency department length of stay ≤50 min (39.2% vs. 61.7%, p < .001) and time to transfer to intensive care unit ≤56 min (45.3% vs. 55.1%, p = .002) were significantly favorable in the postimplementation phase. Time to first computed tomography scan and time to first operating room from arrival to the emergency department were comparable between both phases. For limited activation patients, positive changes were noted in emergency department length of stay ≤87 min (41.4% vs. 60.6%, p < .001), time to first computed tomography scan ≤32 min (47.7% vs. 53.0%, p = .015), and time to transfer to intensive care unit ≤74 min (50.2% vs. 57.2%, p = .008). Time to first operating room remained comparable between two periods. CONCLUSIONS: The study institution improved their provision of immediate care by using time clocks in trauma bays. This is a simple and cost-effective intervention and may benefit similar institutions.

The Impact of Under-triage on Trauma Outcomes in Older Populations ≥65 Years.

BACKGROUND: Undertriage of older trauma patients is implicated as a cause for outcome disparities. Undertriage is defined by an Injury Severity Score (ISS) ≥16 without full trauma activation. We hypothesized that in patients ≥65 years, undertriage is associated with unfavorable discharge. METHODS: This is a retrospective study of patients ≥65 years admitted at a Level 1 Trauma Center between July 2016 and June 2018 with blunt trauma. The Matrix method was used to determine the undertriage rate, and outcomes were compared between undertriaged and fully activated patients with ISS ≥16. Favorable outcomes in undertriaged patients instigated further analyses to determine factors that predicted unfavorable discharge condition, defined by discharge from the hospital with severe disability, persistent vegetative state, and in-hospital death. RESULTS: The undertriage rate was 7.9%. When compared to fully activated patients with ISS ≥16, a lower percentage of undertriaged patients were discharged in an unfavorable condition (16.6% vs 64.7%, P < .001). On the multivariate analysis, male sex (OR = 1.52), preexisting coronary artery disease (OR = 1.86), age >90 years (OR = 2.31), ISS 16-25 (OR = 3.50), Glasgow Coma Score (GCS) ≤14 (OR = 6.34), and ISS >25 (OR = 9.64) were significant independent risk factors for unfavorable discharge. DISCUSSION: The undertriage rate in patients ≥65 years was higher than the accepted standard (5%). However, undertriaged patients had better outcomes than those fully activated with ISS ≥16. Factors more predictive of unfavorable discharge condition were GCS ≤14 and ISS >25. These data suggest that ISS alone is a poor marker for assessing undertriage in older patients. Additional parameters established in this study should be considered as potential markers for better predicting outcomes in older trauma patients.

Development of a Prediction Model for Trauma Registry Chart Abstraction Time.

INTRODUCTION: A Level I trauma center routinely faced challenges with meeting data submission deadlines and frequently struggled with a backlog of cases that limited opportunities for concurrent performance improvement. To provide a validated algorithm through which registry workload could be evaluated, the study institution designed a scientific model that predicted the amount of time required for chart abstraction on a patient-by-patient basis. METHODS: As part of this quality improvement endeavor, registrars documented the amount of time required to complete each chart. A total of 600 patients' data were included by randomly selecting 150 patients from each of the 4 trauma registrars. Given that no previous study has examined the association of patient-related factors with chart abstraction time, study variables utilized to construct this predictive model were determined by the trauma program manager and the lead trauma registrar. RESULTS: Multiple linear regression demonstrated that inhospital mortality; transfer from a referring facility; hospital stay; ventilator days; and number of complications, specialty consults, injuries, blood products, and procedures were significant predictors of chart abstraction time. The equation for the regression line for the multivariate regression was as follows: Y = 38.95 + 31.28 × mortality + 15.33 × referring facility + 4.68 × complications+3.55 × hospital stay + 3.33 × consults + 2.83 × diagnoses + 2.00 × ventilator days + 1.78 × blood products + 1.09 × procedures. CONCLUSIONS: The merit of this prediction model is that it is based on patient-related variables and predicts time on a patient-by-patient basis. This innovative tool can be utilized by other trauma centers to evaluate registry productivity and identify opportunities for improvement retrospectively.

Evaluation of Burnout and Work-Life in Surgical Trauma Acute Care Units.

INTRODUCTION: Stressors unique to trauma patients may potentiate burnout in the trauma care team. Among health care workers, nurses historically demonstrate high rates of burnout and are often the first caregivers in which patients interact. There is limited research, however, investigating burnout in trauma nurses. This study aims to evaluate levels of burnout and perceptions of work-life in nurses and ancillary staff at a Level 1 trauma center. METHODS: An anonymous, cross-sectional, online survey was administered utilizing the Maslach Burnout Toolkit to investigate levels of burnout and work-life. Supplemental questions developed by investigators were included to gather additional details about the work environment. RESULTS: A total of 126 trauma staff completed the survey yielding a response rate of 73%. Trauma staff exhibited low degrees of emotional exhaustion (M = 2.53, SD = 1.29) and depersonalization (M = 1.83, SD = 1.33). Staff with 4 to less than 9 years of tenure at the study institution experienced these emotions at the highest level. Overall, staff cited documentation requirements and patient-to-staff ratios as prominent concerns with their work-life. There were significant negative associations between manageable workload with emotional exhaustion (r = -0.68) and depersonalization (r = -0.56). CONCLUSIONS: Overall, low degrees of emotional exhaustion and depersonalization were exhibited, but significant increases were noted in staff with increasing tenure. These findings suggest that cited aspects of work-life may impact the development of emotional exhaustion and depersonalization over time. Pilot interventions are underway to identify an acuity-adjusted staffing process and a user-friendly electronic documentation platform to improve the institution's work environment.

Rate of Nonsurgical Admissions at a Level 1 Trauma Center: Impact of a Trauma Nurse Practitioner Model.

The American College of Surgeons (ACS) mandates all trauma centers conduct individual case reviews of nonsurgical admissions when rates of allocation to this service exceed 10% of all inpatient traumas. Nonsurgical admission rates at the study institution, which is a Level I trauma center, historically exceeded this ACS criterion. In an effort to decrease nonsurgical admissions, the study institution recruited trauma nurse practitioners (TNPs) who began managing low acuity patients with oversight from trauma attending physicians. This study examines the impact of TNPs on the rate of nonsurgical admissions. A retrospective cohort study was conducted with 1,400 patients between January 2017 and October 2018. Two cohorts examined in this study included trauma patients whose care was managed by the TNPs versus those admitted under the care of hospitalists. The rate of admission to nonsurgical services (NSS) was 19.6% in 2017 and 13.9% in 2018, which yielded a significant decrease from previous years' percentages (p < .001). The average hospital length of stay was 1.17 days shorter in the TNP group, which translated into a savings of approximately $876,330 in hospital charges for the study period. Additional significant findings noted in favor of the TNP cohort were for discharge orders placed prior to noon, discharge location, and reduced time to the operating room. This TNP model proved to be successful in significantly reducing admissions to NSS and substantiated the quality of patient care provided by TNPs. Hospitals struggling to meet the ACS criterion for NSS admissions may consider implementing a similar TNP model.

Dog-Bite Injuries to the Craniofacial Region: An Epidemiologic and Pattern-of-Injury Review at a Level 1 Trauma Center.

PURPOSE: The purpose was to determine the incidence, etiologic factors leading to injury, and demographic composition of patients sustaining dog-bite injuries of the craniofacial region at a regional referral level 1 trauma center. These findings may assist primary and affiliated health care providers, educators, and policy makers in developing and implementing strategies to prevent serious dog-bite injuries, particularly in the individuals most vulnerable-children and elderly persons. PATIENTS AND METHODS: We performed a retrospective observational and descriptive review of dog bite-related injuries solely managed by the Section of Maxillofacial Surgery at Charleston Area Medical Center in West Virginia. Patient information was derived from an existing database on dog-bite injuries of the craniofacial region, electronic health records, and animal encounter records. RESULTS: We reviewed 182 patient records distributed among several breed categories. The results showed a disturbing trend toward more severe injuries, especially in younger children, and a reversal in gender, with girls bitten more than boys. Young children incurred more extensive facial injuries, including fractures. The data showed that compared with other dog breeds, pit bull terriers inflicted more complex wounds, were often unprovoked, and went off property to attack. Other top-biting breeds resulting in more unprovoked and complex wounds included German shepherds, Rottweilers, and huskies. Management of facial wounds took place more often in the operating room, especially in younger children, with increased hospital stays. Of the patients, 19 (10.4%) had fractures and 22 (12%) underwent a rabies vaccination protocol. CONCLUSIONS: This study showed a disturbing trend toward more severe dog-bite injuries in young children and a greater incidence of bites in girls than in boys among several biting breeds of dogs. The public health implications of aggressive biting breeds and risks of severe injury in the home environment were discussed.

The impact of burnout syndrome on practitioners working within rural healthcare systems.

INTRODUCTION: Burnout syndrome (BOS) affects up to 50% of healthcare practitioners. Limited data exist on BOS in paramedics/firstresponders, or others whose practice involves trauma. We sought to assess the impact of BOS in practitioners of rural healthcare systems involved in the provision of trauma care within West Virginia. METHODS: A 3-part survey was distributed at two regional trauma conferences in 2018. The survey consisted of 1) Demographic/occupational items, 2) The Mini Z Burnout Survey, and 3) elements measuring the impact, and supportive infrastructure to prevent and/or manage BOS. RESULTS: Response rate was 74.7% (127/170 attendees). Respondents included emergency medical services (EMS) (44.9%), nurses (37.8%), and physicians (9.4%). Overall, 31% reported BOS - physicians (45.5%), EMS (35.1%), and nurses (25.0%). Most agreed that BOS impacts the health of medical professionals (99.2%) and presents a barrier to patient care (97.6%). Those with BOS reported higher stress (p < 0.001), chaos at work (p < 0.001), and excessive documentation time at home (p < 0.001). Fewer respondents with BOS reported job satisfaction (p < 0.001), control over workload (p = 0.001), sufficient time for documentation (p ≤0.001), value alignment with institutional leadership (p = 0.001), and team efficiency (p = 0.004). Unique factors for BOS in EMS included: lack of control over workload (p = 0.032), poor value alignment with employer (p = 0.002), lack of efficient teamwork (p = 0.006), and excessive time documenting at home (p = 0.003). CONCLUSIONS: Burnout syndrome impacts rural healthcare practitioners, regardless of discipline. These data highlight a need to address the entire team and implement occupation-specific approaches for prevention and treatment. Further prospective study of these findings is warranted.

Nurse Practitioners' Role in Improving Service for Elderly Trauma Patients.

Preexisting conditions and decreased physiological reserve in the elderly frequently complicate the provision of health care in this population. A Level 1 trauma center expanded its nurse practitioner (NP) model to facilitate admission of low-acuity patients, including the elderly, to trauma services. This model enabled NPs to initiate admissions and coordinate day-to-day care for low-acuity patients under the supervision of a trauma attending. The complexity of elderly trauma care and the need to evaluate the efficacy of management provided by NPs led to the development of the current study. Accordingly, this study endeavored to compare outcomes in elderly patients whose care was coordinated by trauma NP (TNP) versus nontrauma NP (NTNP) services. Patients under the care of TNPs had a 1.22-day shorter duration of hospitalization compared with that of the NTNP cohort (4.38 ± 3.54 vs. 5.60 ± 3.98, p = .048). Decreased length of stay in the TNP cohort resulted in an average decrease in hospital charges of $13,000 per admission ($38,053 ± $29,640.76 vs. $51,317.79 ± $34,756.83, p = .016). A significantly higher percentage of patients admitted to the TNP service were discharged home (67.1% vs. 36.0%, p = .002), and a significantly lower percentage of patients were discharged to skilled nursing facilities (25.7% vs. 51.9%, p = .040). These clinical and economic outcomes have proven beneficial in substantiating the care provided by TNPs at the study institution. Future research will focus on examining the association of positive outcomes with specific care elements routinely performed by the TNPs in the current practice model.

Determination of Optimal Weight-Based Enoxaparin Dosing and Associated Clinical Factors for Achieving Therapeutic Anti-Xa Assays for Deep Venous Thrombosis Prophylaxis.

BACKGROUND: Previous studies have evaluated dose-to-weight ratios to define best practices for obtaining therapeutic anti-Xa assays for enoxaparin venous thromboembolism (VTE) prophylaxis. These studies have not examined relationships among dosing, patient characteristics, and therapeutic assays. This study examines factors associated with therapeutic assays and enoxaparin prophylaxis. STUDY DESIGN: This is a retrospective review of patients admitted to a Level 1 trauma center between March 2016 and June 2018. Prophylaxis was managed according to the trauma service's enoxaparin VTE prophylaxis protocol, which targets anti-Xa concentrations of 0.2 to 0.5 IU/mL. Assays were divided into sub-therapeutic, therapeutic, and super-therapeutic groups to determine factors associated with therapeutic concentrations. RESULTS: Overall, 623 patients (634 total anti-Xa assays) were identified during the study period. Patients with sub-therapeutic (n = 35) and therapeutic (n = 536) assays did not differ. Significant differences were identified between patients with therapeutic and super-therapeutic assays (n = 63). Receiver operating characteristic curve analysis was used to determine that the optimal cutoff for the dose-to-weight ratio was 0.4 mg/kg/dose (area under the curve 0.78; 95% CI 0.73 to 0.84; p < 0.001) differentiating therapeutic and super-therapeutic assays. Logistic regression revealed male sex, doses of 0.31 to 0.4 mg/kg, and creatinine clearance > 90 mL/min were independently associated with therapeutic assays. The combined effect of these 3 variables showed that therapeutic assays were 13.76 times more likely to occur (OR 13.76; 95% CI 3.43 to 56.96; p < 0.001). CONCLUSIONS: These data demonstrate that a dose of 0.4 mg/kg predicts a therapeutic anti-Xa level. When regimens of 0.31 to 0.4 mg/kg/dose are administered in males with a creatinine clearance >90 mL/min therapeutic results are 13.76 times more likely, suggesting that monitoring with anti-Xa assays might be unnecessary in this subgroup. Additional prospective study of these findings is warranted.

Improving Pharmacologic Prevention of VTE in Trauma: IMPACT-IT QI Project.

Enoxaparin regimens commonly used for prophylaxis fail to achieve optimal anti-factor Xa levels in up to 70 per cent of trauma patients. Accordingly, trauma services at the study institution endeavored to develop a standardized approach to optimize pharmacologic prevention with enoxaparin. An enoxaparin venous thromboembolism (VTE) prophylaxis protocol implemented in October 2015 provided weight-adjusted initial dosing parameters with subsequent dose titration to achieve targeted anti-factor Xa levels. Symptomatic VTE rate was evaluated 12 months pre- and post-implementation. Data were obtained from the trauma registry and charts were reviewed from electronic medical records. The rate of symptomatic VTE significantly declined post-implementation (2.0% vs 0.9%, P = 0.009). Enoxaparin use was comparable in these two phases validating that the decline in symptomatic VTEs was not due to an increase in enoxaparin use. Symptomatic VTE rate for patients who received enoxaparin in the post-implementation cohort decreased from 3.2 to 1.0 per cent (P = 0.023, 95% confidence interval = 0.124-0.856). There was also a significant decrease in the rate of symptomatic deep vein thrombosis (2.8% vs 0.9%, P = 0.040, 95% confidence interval = 0.117-0.950). This approach to VTE prophylaxis with enoxaparin resulted in a significant reduction in symptomatic VTE rates. Implementation of similar practices may be equally impactful in other institutions that use enoxaparin.