Does Practice Match Training? Consultation Practices in Surgical Critical Care.

INTRODUCTION: Intensive care unit (ICU) patient and provider attributes may prompt specialty consultation. We sought to determine practice patterns of surgical critical care (SCC) physicians for ICU consultation. METHODS: We surveyed American Association for the Surgery of Trauma members. Various diagnoses were listed under each of nine related specialties. Respondents were asked for which conditions they would consult a specialist. Conditions were cross-referenced with the SCC fellowship curriculum. Other perspectives on practice and consultation were queried. RESULTS: 314 physicians (18.6%) responded (68% male; 79% White; 96.2% surgical intensivist); 284 (16.8%) completed all questions. Percentage of clinical time practicing SCC was 26-50% in 57% and >50% in 14.5%. ICUs were closed (39%), open (25%), or hybrid (36%). Highest average confidence ratings (1 = least, 5 = most) for managing select conditions were ventilator, 4.64; palliative care, 4.51; infections, 4.44; organ donation, hemodynamics (tie), 4.31; lowest rating was myocardial ischemia, 3.85. Consults were more frequent for Cardiology, Hematology, and Neurology; less frequent for nephrology, palliative care, gastroenterology, infectious disease, and pulmonary; and low for curriculum topics (<25%) except for infectious diseases and palliative care. Attending staffing 24 h/day was associated with a lower mean number of topics for consultation (mean 24.03 versus 26.31, P = 0.015). CONCLUSIONS: ICU consultation practices vary based on consultant specialty and patient diagnosis. Consultation is most common for specialty-specific diseases and specialist interventions, but uncommon for topics found in the SCC curriculum, suggesting that respondents' scope of practice closely matched their training.

Palliative Care in the Trauma and Surgical Critical Care Settings: A Narrative Review.

BACKGROUND: We aimed to conduct a narrative review of available literature to understand the use of palliative care in the trauma and surgical critical care setting. METHODS: PubMed, EMBASE, and Google Scholar databases were searched for studies investigating the use of palliative care in the trauma and surgical critical care setting. The search included all studies published through January 9th, 2022. The risk of bias of included studies was assessed using the Joanna Briggs Institute Critical Appraisal Checklist tools. Outcomes were summarized in tables and synthesized qualitatively. RESULTS: A total of 22 studies were included in this review. Key elements of successful palliative care include communication, shared decision-making, family involvement, pain control, establishing a patient's prognosis, and end-of-life management. Approaches to implementation based upon these key elements include best-case/worst-case scenarios, consultation trigger systems, and integrated institutional palliative care programs. Palliative care may reduce hospital length of stay, improve symptom management, and increase patient satisfaction, but the impact on mortality is unclear. CONCLUSION: The core elements of palliative care have been identified and palliative care has been shown to improve outcomes in trauma and surgical critical care. However, the approaches for implementation still require development. The underutilization of palliative care for trauma patients reveals the need for refining criteria for use of palliative care and improvement in the education of surgical critical care teams to provide primary palliative care services.

Prevention of alcohol withdrawal syndrome in the surgical ICU: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document.

Alcohol withdrawal syndrome is a common and challenging clinical entity present in trauma and surgical intensive care unit (ICU) patients. The screening tools, assessment strategies, and pharmacological methods for preventing alcohol withdrawal have significantly changed during the past 20 years. This Clinical Consensus Document created by the American Association for the Surgery of Trauma Critical Care Committee reviews the best practices for screening, monitoring, and prophylactic treatment of alcohol withdrawal in the surgical ICU.

Management of Decompensated Cirrhosis in the Surgical ICU: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document.

Management of decompensated cirrhosis (DC) can be challenging for the surgical intensivist. Management of DC is often complicated by ascites, coagulopathy, hepatic encephalopathy, gastrointestinal bleeding, hepatorenal syndrome, and difficulty assessing volume status. This Clinical Consensus Document created by the American Association for the Surgery of Trauma Critical Care Committee reviews practical clinical questions about the critical care management of patients with DC to facilitate best practices by the bedside provider.

Developing a National Trauma Research Action Plan: Results from the postadmission critical care research gap Delphi survey.

INTRODUCTION: The 2016 National Academies of Science, Engineering and Medicine report included a proposal to establish a National Trauma Research Action Plan. In response, the Department of Defense funded the Coalition for National Trauma Research to generate a comprehensive research agenda spanning the continuum of trauma and burn care from prehospital care to rehabilitation as part of an overall strategy to achieve zero preventable deaths and disability after injury. The Postadmission Critical Care Research panel was 1 of 11 panels constituted to develop this research agenda. METHODS: We recruited interdisciplinary experts in surgical critical care and recruited them to identify current gaps in clinical critical care research, generate research questions, and establish the priority of these questions using a consensus-driven Delphi survey approach. The first of four survey rounds asked participants to generate key research questions. On subsequent rounds, we asked survey participants to rank the priority of each research question on a 9-point Likert scale, categorized to represent low-, medium-, and high-priority items. Consensus was defined as ≥60% of panelists agreeing on the priority category. RESULTS: Twenty-five subject matter experts generated 595 questions. By Round 3, 249 questions reached ≥60% consensus. Of these, 22 questions were high, 185 were medium, and 42 were low priority. The clinical states of hypovolemic shock and delirium were most represented in the high-priority questions. Traumatic brain injury was the only specific injury pattern with a high-priority question. CONCLUSION: The National Trauma Research Action Plan critical care research panel identified 22 high-priority research questions, which, if answered, would reduce preventable death and disability after injury. LEVEL OF EVIDENCE: Diagnostic Tests or Criteria; Level IV.

Developing a National Trauma Research Action Plan: Results from the long-term outcomes research gap Delphi survey.

BACKGROUND: In the National Academies of Sciences, Engineering, and Medicine 2016 report on trauma care, the establishment of a National Trauma Research Action Plan to strengthen and guide future trauma research was recommended. To address this recommendation, the Department of Defense funded the Coalition for National Trauma Research to generate a comprehensive research agenda spanning the continuum of trauma and burn care. We describe the gap analysis and high-priority research questions generated from the National Trauma Research Action Plan panel on long-term outcomes. METHODS: Experts in long-term outcomes were recruited to identify current gaps in long-term trauma outcomes research, generate research questions, and establish the priority for these questions using a consensus-driven, Delphi survey approach from February 2021 to August 2021. Panelists were identified using established Delphi recruitment guidelines to ensure heterogeneity and generalizability including both military and civilian representation. Panelists were encouraged to use a PICO format to generate research questions: Patient/Population, Intervention, Compare/Control, and Outcome model. On subsequent surveys, panelists were asked to prioritize each research question on a 9-point Likert scale, categorized to represent low-, medium-, and high-priority items. Consensus was defined as ≥60% of panelists agreeing on the priority category. RESULTS: Thirty-two subject matter experts generated 482 questions in 17 long-term outcome topic areas. By Round 3 of the Delphi, 359 questions (75%) reached consensus, of which 107 (30%) were determined to be high priority, 252 (70%) medium priority, and 0 (0%) low priority. Substance abuse and pain was the topic area with the highest number of questions. Health services (not including mental health or rehabilitation) (64%), mental health (46%), and geriatric population (43%) were the topic areas with the highest proportion of high-priority questions. CONCLUSION: This Delphi gap analysis of long-term trauma outcomes research identified 107 high-priority research questions that will help guide investigators in future long-term outcomes research. LEVEL OF EVIDENCE: Diagnostic Tests or Criteria; Level IV.

Rhabdomyolysis: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document.

Rhabdomyolysis is a clinical condition characterized by destruction of skeletal muscle with release of intracellular contents into the bloodstream. Intracellular contents released include electrolytes, enzymes, and myoglobin, resulting in systemic complications. Muscle necrosis is the common factor for traumatic and non-traumatic rhabdomyolysis. The systemic impact of rhabdomyolysis ranges from asymptomatic elevations in bloodstream muscle enzymes to life-threatening acute kidney injury and electrolyte abnormalities. The purpose of this clinical consensus statement is to review the present-day diagnosis, management, and prognosis of patients who develop rhabdomyolysis.

Factors associated with receipt of intracranial pressure monitoring in older adults with traumatic brain injury.

BACKGROUND: The Brain Trauma Foundation (BTF) Guidelines for the Management of Severe Traumatic Brain Injury (TBI) include intracranial pressure monitoring (ICPM), yet very little is known about ICPM in older adults. Our objectives were to characterize the utilization of ICPM in older adults and identify factors associated with ICPM in those who met the BTF guidelines. METHODS: We analyzed data from the American Association for the Surgery of Trauma Geriatric TBI Study, a registry study conducted among individuals with isolated, CT-confirmed TBI across 45 trauma centers. The analysis was restricted to those aged ≥60. Independent factors associated with ICPM for those who did and did not meet the BTF guidelines were identified using logistic regression. RESULTS: Our sample was composed of 2303 patients, of whom 66 (2.9%) underwent ICPM. Relative to Glasgow Coma Scale (GCS) score of 13 to 15, GCS score of 9 to 12 (OR 10.2; 95% CI 4.3 to 24.4) and GCS score of <9 (OR 15.0; 95% CI 7.2 to 31.1), intraventricular hemorrhage (OR 2.4; 95% CI 1.2 to 4.83), skull fractures (OR 3.6; 95% CI 2.0 to 6.6), CT worsening (OR 3.3; 95% CI 1.8 to 5.9), and neurosurgical interventions (OR 3.8; 95% CI 2.1 to 7.0) were significantly associated with ICPM. Restricting to those who met the BTF guidelines, only 43 of 240 (18%) underwent ICPM. Factors independently associated with ICPM included intraparenchymal hemorrhage (OR 2.2; 95% CI 1.0 to 4.7), skull fractures (OR 3.9; 95% CI 1.9 to 8.2), and neurosurgical interventions (OR 3.5; 95% CI 1.7 to 7.2). DISCUSSION: Worsening GCS, intraparenchymal/intraventricular hemorrhage, and skull fractures were associated with ICPM among older adults with TBI, yet utilization of ICPM remains low, especially among those meeting the BTF guidelines, and potential benefits remain unclear. This study highlights the need for better understanding of factors that influence compliance with BTF guidelines and the risks versus benefits of ICPM in this population. LEVEL OF EVIDENCE: Prognostic and epidemiological, level III.

Impact of COVID-19 pandemic on injury prevalence and pattern in the Washington, DC Metropolitan Region: a multicenter study by the American College of Surgeons Committee on Trauma, Washington, DC.

BACKGROUND: The COVID-19 pandemic has had far-reaching effects on healthcare systems and society with resultant impact on trauma systems worldwide. This study evaluates the impact the pandemic has had in the Washington, DC Metropolitan Region as compared with similar months in 2019. DESIGN: A retrospective multicenter study of all adult trauma centers in the Washington, DC region was conducted using trauma registry data between January 1, 2019 and May 31, 2020. March 1, 2020 through May 31, 2020 was defined as COVID-19, and January 1, 2019 through February 28, 2020 was defined as pre-COVID-19. Variables examined include number of trauma contacts, trauma admissions, mechanism of injury, Injury Severity Score, trauma center location (urban vs. suburban), and patient demographics. RESULTS: There was a 22.4% decrease in the overall incidence of trauma during COVID-19 compared with a 3.4% increase in trauma during pre-COVID-19. Blunt mechanism of injury decreased significantly during COVID-19 (77.4% vs. 84.9%, p<0.001). There was no change in the specific mechanisms of fall from standing, blunt assault, and motor vehicle crash. The proportion of trauma evaluations for penetrating trauma increased significantly during COVID-19 (22.6% vs. 15.1%, p<0.001). Firearm-related and stabbing injury mechanisms both increased significantly during COVID-19 (11.8% vs. 6.8%, p<0.001; 9.2%, 6.9%, p=0.002, respectively). CONCLUSIONS AND RELEVANCE: The overall incidence of trauma has decreased since the arrival of COVID-19. However, there has been a significant rise in penetrating trauma. Preparation for future pandemic response should include planning for an increase in trauma center resource utilization from penetrating trauma. LEVEL OF EVIDENCE: Epidemiological, level III.

Protocol Use in Surgical Intensive Care Units.

BACKGROUND: Protocols are common in intensive care, however the association between protocol prevalence and outcomes in surgical ICU patients is unclear. We hypothesized that ICUs in a multicenter database using more protocols had better outcomes. MATERIAL AND METHODS: This is a retrospective analysis of prospectively collected data from a 2-d prevalence study with 30-d follow up, on surgical and trauma patients in ICUs at 42 trauma centers. Use of forty clinical protocols was queried. Protocol prevalence was categorized by quartile into Low (first), Moderate (second and third), or High (fourth) use ICUs. The primary outcome was in-hospital mortality; secondary outcomes were ventilator, ICU, and hospital days, mechanical ventilation, tracheostomy, renal replacement, transfusion, and hospital-acquired infections. RESULTS: Data from 1044 surgical and trauma patients were analyzed. Protocol use was not different for "closed" (n = 20), "open" (n = 9), or "semi-open" (n = 13) ICUs (P= 0.20). Thirty-day in-hospital mortality was 8.4%, and not associated with number of protocols (OR 1.01 [95% CI 0.98-1.03], P= 0.65). There was no statistically significant difference between High and Low use ICUs for ventilator days (OR 0.86; 0.52-1.43), tracheostomy (OR 0.8; 0.47-1.38), renal replacement therapy (OR 0.66; 0.04-9.82), transfusion (OR 0.95; 0.58-1.57), or hospital-acquired infections (OR 1.07; 0.67-1.7). Higher mortality was seen in open (versusclosed; OR 1.74 [1.05-2.89], P= 0.033), and surgical/trauma (versustrauma; OR 1.86 [1.33-2.61]; P< 0.001). CONCLUSIONS: In this multicenter observational study of surgical ICU patients, no association was found between the number of protocols used and patient outcomes.

Venous thromboembolism prophylaxis in the trauma intensive care unit: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document.

Venous thromboembolism (VTE) is a potential sequela of injury, surgery, and critical illness. Patients in the Trauma Intensive Care Unit are at risk for this condition, prompting daily discussions during patient care rounds and routine use of mechanical and/or pharmacologic prophylaxis measures. While VTE rightfully garners much attention in clinical patient care and in the medical literature, optimal strategies for VTE prevention are still evolving. Furthermore, trauma and surgical patients often have real or perceived contraindications to prophylaxis that affect the timing of preventive measures and the consistency with which they can be applied. In this Clinical Consensus Document, the American Association for the Surgery of Trauma Critical Care Committee addresses several practical clinical questions pertaining to specific or unique aspects of VTE prophylaxis in critically ill and injured patients.

Patient-centered practices in organ donation.

The opportunity for a critically ill patient to be an organ donor depends on a complex interplay of factors (the Donation Process), one of which is the treating medical team's perspective of the importance and priority of donation during end-of-life care. Medical providers frequently are hesitant to administer treatments to preserve organ function in patients whose death is imminent for fear of invoking a conflict of interest. The basis of the perceived conflict is that organ donation is a process done for the sole benefit of organ transplant recipients and not for the donor, and therefore care directed toward donation prior to death is not for the donor patient's benefit. In this report, it is argued that the Donation Process is indeed a patient-centered process for the potential organ donor and that organ donation serves the donor's best interests. In addition, key elements of the Donation Process are described.

Chest Tube Management Practices by Trauma Surgeons.

BACKGROUND: Chest tube (CT) placement is among the most common procedures performed by trauma surgeons; evidence guiding CT management is limited and tends toward thoracic surgery patients. The study goal was to identify current CT management practices among trauma providers. MATERIALS AND METHODS: We designed a Web-based multiple-choice survey to assess CT management practices of trauma providers who were active, senior, or provisional members (n = 1890) of the Eastern Association for the Surgery of Trauma and distributed via e-mail. Descriptive statistics were used. RESULTS: The response rate was 39% (n = 734). Ninety-one percent of respondents were attending surgeons, the remainder fellows or residents. Regarding experience, 36% of respondents had five or fewer years of practice, 54% 10 y or fewer, and 79% 20 y or fewer. Attendings were more likely than trainees to place pigtail catheters for stable patients with pneumothorax (PTX). Attendings with experience of <5 y were more likely to choose a pigtail than more experienced surgeons for elderly patients with PTX. Respondents preferred standard size CTs for hemothorax and unstable patients with PTX, and larger tubes for unstable patients with hemothorax. Most respondents (53%) perceived the quality of evidence for trauma CT management to be low and cited personal experience and training as the main factors driving their practice. CONCLUSIONS: Trauma CT management is variable and nonstandardized, depending mostly on clinician training and personal experience. Few surgeons identify their practice as evidence based. We offer compelling justification for the need for trauma CT management research to determine best practices.

Trauma ICU Prevalence Project: the diversity of surgical critical care.

BACKGROUND: Surgical critical care is crucial to the care of trauma and surgical patients. This study was designed to provide a contemporary assessment of patient types, injuries, and conditions in intensive care units (ICU) caring for trauma patients. METHODS: This was a multicenter prevalence study of the American Association for the Surgery of Trauma; data were collected on all patients present in participating centers' trauma ICU (TICU) on November 2, 2017 and April 10, 2018. RESULTS: Forty-nine centers submitted data on 1416 patients. Median age was 58 years (IQR 41-70). Patient types included trauma (n=665, 46.9%), non-trauma surgical (n=536, 37.8%), medical (n=204, 14.4% overall), or unspecified (n=11). Surgical intensivists managed 73.1% of patients. Of ICU-specific diagnoses, 57% were pulmonary related. Multiple high-intensity diagnoses were represented (septic shock, 10.2%; multiple organ failure, 5.58%; adult respiratory distress syndrome, 4.38%). Hemorrhagic shock was seen in 11.6% of trauma patients and 6.55% of all patients. The most common traumatic injuries were rib fractures (41.6%), brain (38.8%), hemothorax/pneumothorax (30.8%), and facial fractures (23.7%). Forty-four percent were on mechanical ventilation, and 17.6% had a tracheostomy. One-third (33%) had an infection, and over half (54.3%) were on antibiotics. Operations were performed in 70.2%, with 23.7% having abdominal surgery. At 30 days, 5.4% were still in the ICU. Median ICU length of stay was 9 days (IQR 4-20). 30-day mortality was 11.2%. CONCLUSIONS: Patient acuity in TICUs in the USA is very high, as is the breadth of pathology and the interventions provided. Non-trauma patients constitute a significant proportion of TICU care. Further assessment of the global predictors of outcome is needed to inform the education, research, clinical practice, and staffing of surgical critical care providers. LEVEL OF EVIDENCE: IV, prospective observational study.

Structure and function of a trauma intensive care unit: A report from the Trauma Intensive Care Unit Prevalence Project.

BACKGROUND: Specialized trauma intensive care unit (TICU) care impacts patient outcomes. Few studies describe where and how TICU care is delivered. We performed an assessment of TICU structure and function at a sample of US trauma center TICUs. METHODS: This was a multicenter study in which participants supplied information about their trauma centers, staff, clinical protocols, processes of care, and study TICU (the ICU admitting the majority of trauma patients). RESULTS: Forty-five Level I trauma centers trauma centers enrolled through the American Association for the Surgery of Trauma multi-institutional trials platform; 71.1% had less than 750 beds and 55.5% treated 1,000 to 2,999 trauma activations/year. The median number of hospital ICU beds was 109 [66-185]. 46.7% were "closed" ICUs, 20% were "open," and 82.2% had mandatory intensivist consultation. 42.2% ICUs were classified as trauma (≥80% of patients were trauma), 46.7% surgical/trauma, and 11.1% medical-surgical. Trauma ICUs had a median 10 [7-12] intensivists. Intensivists were present 24 hours/day in 80% of TICUs. Centers reported a median of 8 (interquartile range [IQR], 6-10) full-time trauma surgeons, whose ICU duties comprised 25% (IQR, 20%-40%) of their clinical time and 20% (IQR, 20-33) of total work time. A median 16 (IQR, 12-23) ICU beds in use were staffed by 10 (IQR, 7-14) nurses. There was considerable variation in the number and type of protocols used and in diagnostic methods for ventilator-associated pneumonia. Daily patient care checklists were used by 80% of ICUs. While inclusion of families on rounds was performed in 91.1% of ICUs, patient- and family-centered support programs were less common. CONCLUSION: A study of structure and function of TICUs at a sample of Level I trauma centers revealed that presence of nontrauma patients was common, critical care is a significant component of trauma surgeons' professional practice, and significant variation exists in care delivery models and protocol use. Opportunities may exist to improve care through sharing of best practices. LEVEL OF EVIDENCE: Therapeutic/Care management, level IV.

Blunt small bowel perforation (SBP): An Eastern Association for the Surgery of Trauma multicenter update 15 years later.

BACKGROUND: Previous work demonstrated diagnostic delays in blunt small bowel perforation (SBP) with increased mortality and inability of scans to reliably exclude the diagnosis. We conducted a follow-up multicenter study to determine if these challenges persist 15 years later. METHODS: We selected adult cases with blunt injury, International Classification of Diseases, Ninth Revision or current procedural terminology (CPT) indicating small bowel surgery, no other major injury and at least one abdominal computed tomography (CT) within initial 6 hours. Controls had blunt trauma with abdominal CT but not SBP. After institutional review board approval, data from each center were collected and analyzed. RESULTS: Data from 39 centers (from October 2013 to September 2015) showed 127,919 trauma admissions and 94,743 activations. Twenty-five centers were Level 1. Centers submitted 77 patients (mean age, 39; male, 68%; mean length of stay, 11.3 days) and 131 controls (mean age, 44; male, 64.9%; length of stay, 3.6 days). Small bowel perforation cases were 0.06% of admissions and 0.08% of activations. Mean time to surgery was 8.7 hours (median, 3.7 hours). Initial CT showed free air in 31 cases (43%) and none in controls. Initial CT was within normal in three cases (4.2%) and 84 controls (64%). Five cases had a second scan; two showed free air (one had an initial normal scan). One death occurred among the patients (mortality, 1.4%; and time to surgery, 16.9 hours). Regression analysis showed sex, abdominal tenderness, distention, peritonitis, bowel wall thickening, free fluid, and contrast extravasation were significantly associated with SBP. CONCLUSIONS: Blunt SBP remains relatively uncommon and continues to present a diagnostic challenge. Trauma centers have shortened time to surgery with decreased case mortality. Initial CT scans continue to miss a small number of cases with potentially serious consequences. We recommend (1) intraperitoneal abnormalities on CT scan should always evoke high suspicion and (2) strong consideration of additional diagnostic/therapeutic intervention by 8 hours after arrival in patients who continue to pose a clinical challenge. LEVEL OF EVIDENCE: Observational study, level III.