Fall Risk Identification Throughout the Continuum of Care for Elderly Trauma Patients: An Injury Prevention Initiative.

INTRODUCTION: Falls are the second leading cause of trauma-related deaths worldwide. Identifying fall risk patients and initiating interventions reduces injuries and mortality, particularly in the elderly. The primary aim of this retrospective study was to identify missed opportunities for fall risk identification and intervention for geriatric trauma patients. PATIENTS AND METHODS: In this retrospective observational cohort study, the trauma registry was queried to identify geriatric patients admitted for a fall over 36 months. The electronic medical record (EMR) was reviewed to evaluate patients' fall risk in the 12 months prior to the index fall admission. The EMR was also queried for repeat falls within 12 months after discharge, and to determine if fall prevention education was provided at discharge. RESULTS: 597 patients met inclusion criteria; 68.3% were female. 64.7% were at risk for falling in the year before admission. 2% had documented fall prevention education at discharge. 32% of patients fell again within a year of discharge and 19.4% were readmitted for a repeat fall. Patients at high risk for falls (on the Hester-Davis scale) were significantly more likely to be readmitted (p = 0.005) and expire within six months (p = 0.033) than moderate risk patients. Mortality at 12 months post-admission for all patients was 19.4%. CONCLUSION: This large study demonstrated that geriatric trauma patients admitted for a fall were already at risk for falling in the 12 months prior to admission. This is a novel finding that presents a substantial prevention opportunity for healthcare systems. Education and implementation of proven techniques to prevent falls as soon as at-risk patients are identified has the potential to change the course for a patient who may not only fall, but also fall again. This proactive approach could significantly impact the fall epidemic in our elderly population.

Resuscitative Endovascular Balloon Occlusion of the Aorta Process Improvement: Examining a Novel Case Evaluation Tool and Standardized Simulations.

A quality improvement project was undertaken. The objectives of this study were to describe an original case evaluation tool, discuss barriers encountered, present a standardized simulation course, and evaluate the efficacy of this course. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an emerging adjunct in the trauma bay for patients with noncompressible subdiaphragmatic hemorrhage. Compared with the alternative (emergency department thoracotomy), it is less invasive and allows for continuation of chest compressions, and early studies suggest a positive effect on mortality. Infrequent utilization of REBOA limits provider and support staff exposure to its indications and technical skills required to deploy the device. Furthermore, there is no standardized evaluation tool for collecting and reporting REBOA-related data. The REBOA Review Tool was designed to easily evaluate all the steps involved in deploying the REBOA tool and was implemented at our institution without difficulty. This tool provided meaningful feedback for areas that required improvement including ease of information retrieval and documentation of sheath removal. Standardized simulation courses were performed to further improve provider and support staff confidence in using the REBOA tool. Analysis of pre- and postsimulation surveys showed significant improvement in participants' confidence in their understanding and utilization of the REBOA tool and its indications. REBOA placement is a low-volume but high-impact procedure. Therefore, simulations to prepare and a standardized tool to learn from prior experience are vital to improving patient care.

Redefining the Trauma Triage Matrix: The Role of Emergent Interventions.

BACKGROUND: A tiered trauma team activation (TTA) system aims to allocate resources proportional to the patient's need based upon injury burden. The current metrics used to evaluate appropriateness of TTA are the trauma triage matrix (TTM), need for trauma intervention (NFTI), and secondary triage assessment tool (STAT). MATERIALS AND METHODS: In this retrospective study, we compared the effectiveness of the need for an emergent intervention within 6 h (NEI-6) with existing definitions. Data from the Michigan Trauma Quality Improvement Program was utilized. The dataset contains information from 31 level 1 and 2 trauma centers from 2011 to 2017. Inclusion criteria were: adult patients (≥16 y) and ISS ≥5. RESULTS: 73,818 patients were included in the study. Thirty percentage of trauma patients met criteria for STAT, 21% for NFTI, 20% for TTM, and 13% for NEI-6. NEI-6 was associated with the lowest rate of undertriage at 6.5% (STAT 22.3%, NFTI 14.0%, TTM 14.3%). NEI-6 best predicted undertriage mortality, early mortality, in-hospital mortality, and late (>60 h) mortality. Most patients who met criteria for TTM (58%), NFTI (51%), and STAT (62%) did not require emergent intervention. All four methods had similar rates of early mortality for patients who did not meet criteria (0.3%-0.5%). CONCLUSIONS: NEI-6 performs better than TTM, NFTI, and STAT in terms of undertriage, mortality and need for resource utilization. Other methods resulted in significantly more full TTAs than NEI-6 without identifying patients at risk for early mortality. NEI-6 represents a novel tool to determine trauma activation appropriateness.

The History and Evolution of the Trauma Program Manager/Coordinator.

The role of the trauma program manager (TPM) has evolved since the early 1980s. Duties of TPM historically included broad responsibilities such as education, data collection, system, EMS, clinical activities, research, and quality assurance. The purpose of this study was to use survey sampling to evaluate self-perceived functions and scope of work of TPMs in the United States. Results show that TPMs from higher volume centers spend more time on program administration duties whereas TPMs from lower volume centers focus more on registry and clinical duties. Across time, the role has been expanded, refined, and customized, but much role variability remains.

Inpatient hospitalization and intimate partner violence: who are we treating?

BACKGROUND: The majority of research into health care use of intimate partner violence (IPV) has focused on female victims and primarily their emergency department use. There are limited data on injury-related hospitalization rates for female victims and even less for male victims and perpetrators. The goal of this study was to determine the annualized rates of inpatient injury-related hospitalization among individuals involved as either victims or defendants in IPV. METHODS: This was an observational retrospective study linking data from two Level 1 trauma centers and the county prosecutor's office from 2000 to 2010 in Kalamazoo County, Michigan. (1) Hospital data included injury-related admissions (DRG International Classification of Diseases-9th Rev. codes 800-959.9 excluding 905-909.9). (2) Prosecutor data contained all charging requests for crimes between intimate partners. Annualized rates were calculated for the year before the IPV crime and for the year after, using the following algorithm: (number of hospitalizations) / (total population) × (per 10,000). Confidence intervals and two-sided statistical significance were calculated at the 95% confidence level. RESULTS: During the study period, 21,179 IPV crimes were committed, involving 12,913 individual defendants and 14,797 victims. There were 30,301 injury-related hospitalizations by this group during this period. Compared with national hospitalization rates of 3.2 per 10,000 people for injury/poisoning (DRG International Classification of Diseases-9th Rev. 800-959.9 and 990-995), IPV victim annual admission rates were 31.9, defendants at 90.4, and bidirectional individuals at 339.1 per 10,000 people, in the 2 years surrounding the crime. Males, regardless of crime role, have higher injury-related hospitalization rates in this period compared with females (male, 115.6; female, 41.8). Males (victims or defendants) and bidirectional participants of either sex had rates that were significantly higher the year after than the year before the crime. CONCLUSION: Individuals involved in IPV have a 10-fold higher injury-related hospitalization rate as compared with age-matched national rates. Admission rates vary by sex, crime role, and time frame, with males and bidirectional participants having the highest rates. LEVEL OF EVIDENCE: Epidemiological study, level III.

What are barriers to nurses screening for intimate partner violence?

Intimate partner violence (IPV) causes serious injury and death each year in the United States. Estimates show that up to 16% of patients are current victims of IPV. The Joint Commission requires patients admitted to the hospital be screened for IPV. Nurses play a pivotal role in this screening process. The goal of this study was to identify nurses' attitudes and perceived barriers to screening. A survey was distributed to clinical nurses caring for inpatients at a level I trauma center. A total of 82.6% of nurses reported taking care of 2 or less victims of IPV in the last year, and 45.8% reported not caring for a single IPV victim in the last year. Most nurses in this study have reported that screening for IPV is important, that it is their responsibility to screen their patients, and that they experience few work environment barriers to screening. Among study respondents, the most common identified barrier to screening is the lack of training.

Thinkfirst for teens: finding an injury-prevention approach for teenagers.

Teenagers are a vulnerable population for devastating injuries. The ThinkFirst for Teens injury-prevention program, which includes scientific information and real-life stories, was presented to high school freshman students and Web-based preprogram and postprogram surveys were used to evaluate injury knowledge and safety behaviors and influences. No statistically significant difference was found in the students' answers on the preprogram and postprogram surveys. After the program, student-reported seat belt and bicycle helmet compliance had improved from that reported in the preprogram survey. Other safety behaviors that did not improve remained better than the national trends reported in the 2009 Youth Risk Behavior Surveillance data. The study supports the literature reporting that parents influence their teenagers' safety behaviors.

Factors influencing emergency medicine physicians' management of sports-related concussions: a community-wide study.

BACKGROUND: Numerous guidelines to grade and manage sports-related concussions have been published. However, little is known about how frequently they are implemented in the emergency department. This study evaluates the current practices of emergency physicians (EPs) in managing sports-related concussions. OBJECTIVES: To evaluate the current practice of EP evaluation and management of sports-related concussions. METHODS: All EPs and emergency medicine residents in Kalamazoo County were surveyed regarding their management of sports-related concussions. The surveys obtained demographic data, participants' use of guidelines, and the importance of clinical and non-clinical factors in deciding when to allow a player to return to play. RESULTS: Of the 73 EP respondents, only 23% used a nationally recognized guideline, with no significant difference between attending and resident EPs. The symptomatic complaints of loss of consciousness, amnesia of the event, and difficulty concentrating were ranked most important by EPs in assessing patients with sports-related concussions. Among non-clinical factors, residents were significantly more likely than attendings to report that medical-legal, parental, and players' concerns were more likely to influence their decision in allowing a patient to return to play. CONCLUSION: EPs take into consideration important clinical factors in assessing patients with sports-related concussion. However, almost 75% do not use any nationally recognized guideline in their evaluation. Residents are more likely than attendings to be influenced by non-clinical factors.

Senior lifestyles and injury prevention: evaluating the effectiveness of an injury prevention program for older adults.

The purpose of this multicenter, before-and-after observational study was to determine whether a short educational intervention was associated with improvement in self-reported safety behavior in older adults. We developed 4 original injury prevention presentations with companion testing materials: Motor Vehicle Safety, Fall Prevention, Pedestrian Safety, and Home Safety. Participants also completed pre-post Short Form Health Survey Instrument (SF-12) quality-of-life surveys. Of 414 participants, 226 completed follow-up testing and SF-12 surveys, for a 54.6% response rate. Those who completed either Pedestrian or Home Safety program showed no significant changes (P > .05) in either test scores or SF-12, and they comprised 61.9% of the final sample. Participants in the Motor Vehicle Safety and Fall Prevention programs accounted for 38.1% of the final sample and did show significant improvements between pre-post test scores. Only Fall Prevention participants showed significant differences in pre-post SF-12 scores. In the Fall Prevention group, numerous SF-12 subscores from the initial survey were significantly inversely correlated with pretest scores, and improvements in some SF-12 subscores correlated with improvements in test scores. Findings from the Fall Prevention group suggest that seniors with quality-of-life limitations may be aware of their increased risk and more willing to make changes to enhance safety. Further study is needed because many questions regarding optimal approaches to injury prevention in the aging demographic remain unanswered.

Advanced trauma life support, 8th edition, the evidence for change.

The American College of Surgeons Committee on Trauma's Advanced Trauma Life Support Course is currently taught in 50 countries. The 8th edition has been revised following broad input by the International ATLS subcommittee. Graded levels of evidence were used to evaluate and approve changes to the course content. New materials related to principles of disaster management have been added. ATLS is a common language teaching one safe way of initial trauma assessment and management.