Pilot Study of a Software Application to Identify Trauma Registry Inconsistencies.

BACKGROUND: Trauma registries are essential to the functioning of modern trauma centers, and high-quality data are necessary to identify patient care issues, develop evidence-based practice, and more. However, institutional experience suggested existing methods to evaluate data quality were insufficient. OBJECTIVE: This study aims to compare a new software application developed at our trauma center to our existing trauma registry platform on the ability to identify registry inconsistencies (i.e., potential data quality issues). METHODS: We conducted a pilot retrospective cohort study of patients from September 2019 to August 2020 who underwent chart review during a Level I verification visit and had been audited several times for accuracy. Registry records were processed by both validation systems, and registry inconsistencies were recorded. RESULTS: In registry data for 63 patients, the new software found 225 registry inconsistencies, and the registry systems found 153 inconsistencies. The most frequent inconsistencies identified by the new software were missing or unknown procedure start times, with 18/63 (28.6%) patients affected and prehospital supplemental oxygen being blank, with 29/53 (54.7%) patients with prehospital care affected. None of the 10 most common inconsistencies detected with the registry systems were true issues. CONCLUSIONS: This study found the new software application identified 47% more inconsistencies than the standard registry systems, and none of the most frequent inconsistencies detected with the registry systems were true issues pertinent to institutional practice. Centers should consider additional methods to identify registry inconsistencies as existing processes appear insufficient.

Safer neighborhoods? Violent crime and trauma volume pre/post targeted police interventions in Dallas, Texas.

BACKGROUND: Project Safe Neighborhoods: Dallas (PSND) is part of a national initiative that partners federal, state, and local stakeholders and law enforcement to reduce violent crime, especially firearm violence, in select communities. The authors' hospital is located centrally in PSND's target areas, and the trauma center's service area fully covers the target areas. This cohort study evaluated PSND's effectiveness by examining if PSND's April 2018 launch was associated with decreases in (1) violent crime or (2) the rate of patients presenting with firearm and assaultive injuries. METHODS: Data on violent crime (murder/non-negligent homicide, robbery, and aggravated assault) were obtained from all municipalities in the county for January 2015 - December 2020. Patient volume data were queried from the trauma registry for the same period. Nonlinear spatiotemporal models were used to calculate estimated rates and confidence intervals; derivatives were used to determine periods of significant change. Spatial point pattern tests assessed potential relocation of criminal activity. Given the importance of reducing violent crime, alpha was set at 0.05. RESULTS: The target areas' violent crime rate remained higher than the non-target areas' throughout the study period, and target area violent crime non-significantly increased after PSND's launch. Violent crime in the non-target area increased significantly between February 2018 and February 2019. Part of this increase was attributable to a 7-fold increase (odds ratio [95% confidence interval] = 7.32 [2.58, 30.65], p < 0.001) in one police patrol beat just outside of the target areas. After years of decreases, rates of patients presenting with assaultive injuries or firearm injuries began significantly increasing and nearly doubled within two years of PSND. CONCLUSIONS: Results suggest PSND was ineffective. Criminal activity in the target area was not reduced relative to its pre-intervention levels or relative to the non-target areas. Offenders may have moved outside the target areas to evade increased scrutiny. Additionally, rates of firearm and assaultive injuries increased. As trusted third parties, trauma centers should consider evaluating local crime and injury prevention programs for effectiveness.

Role of Serial Phlebotomy in the Management of Blunt Solid Organ Injury in Adults.

BACKGROUND: The management of blunt spleen and liver trauma has become increasingly nonoperative. There is no consensus on timing or duration of serial hemoglobin and hematocrit monitoring in this patient population. OBJECTIVE: This study examined the clinical utility of serial hemoglobin and hematocrit monitoring. We hypothesized that most interventions occur early in the hospital course, based on hemodynamic instability or physical examination findings rather than serial monitoring. METHODS: We conducted a retrospective cohort study of adult trauma patients with blunt spleen or liver injury from November 2014 through June 2019 at our Level II trauma center. Interventions were classified as no intervention, surgical intervention, angioembolization, or packed red blood cell transfusion. Demographics, length of stay, total blood draws, laboratory values, and clinical triggers preceding intervention were reviewed. RESULTS: A total of 143 patients were studied, of whom 73 (51%) received no intervention, 47 (33%) received an intervention within 4 hr of presentation, and 23 (16%) had interventions beyond 4 hr. Of these 23 patients, 13 received an intervention based on phlebotomy results alone. Most of these patients (n = 12, 92%) received blood transfusion without further intervention. Only one patient underwent operative intervention based on serial hemoglobin results on hospital day 2. CONCLUSION: The majority of patients with these injury patterns either require no intervention or declare themselves promptly after arrival. Serial phlebotomy after initial triage and intervention may add little value in the management of blunt solid organ injury.

Avoiding Cribari gridlock 2: The standardized triage assessment tool outperforms the Cribari matrix method in 38 adult and pediatric trauma centers.

OBJECTIVES: The Cribari Matrix Method (CMM) is the current standard to identify over/undertriage but requires manual trauma triage reviews to address its inadequacies. The Standardized Triage Assessment Tool (STAT) partially emulates triage review by combining CMM with the Need For Trauma Intervention, an indicator of major trauma. This study aimed to validate STAT in a multicenter sample. METHODS: Thirty-eight adult and pediatric US trauma centers submitted data for 97,282 encounters. Mixed models estimated the effects of overtriage and undertriage versus appropriate triage on the odds of complication, odds of discharge to a continuing care facility, and differences in length of stay for both CMM and STAT. Significance was assessed at p <0.005. RESULTS: Overtriage (53.49% vs. 30.79%) and undertriage (17.19% vs. 3.55%) rates were notably lower with STAT than with CMM. CMM and STAT had significant associations with all outcomes, with overtriages demonstrating lower injury burdens and undertriages showing higher injury burdens than appropriately triaged patients. STAT indicated significantly stronger associations with outcomes than CMM, except in odds of discharge to continuing care facility among patients who received a full trauma team activation where STAT and CMM were similar. CONCLUSIONS: This multicenter study strongly indicates STAT safely and accurately flags fewer cases for triage reviews, thereby reducing the subjectivity introduced by manual triage determinations. This may enable better refinement of activation criteria and reduced workload.

Relation of length of stay and other hospital variables to posttraumatic stress disorder and depression after orthopedic trauma.

Posttraumatic stress disorder (PTSD) and depression are common following orthopedic trauma. This study examined the relationship between injury- and hospital-related variables and PTSD and depression at baseline and 12 months after orthopedic trauma. This longitudinal, prospective cohort study examined adult orthopedic trauma patients admitted ≥24 hours to a level I trauma center. Non-English/Spanish-speaking and cognitively impaired patients were excluded. The Primary Care PTSD screen and PTSD Checklist-Civilian version assessed PTSD, and the Patient Health Questionnaire 8-Item assessed depression. Demographic and hospital-related variables were examined (e.g., hospital length of stay, Injury Severity Score, Glasgow Coma Scale). For 160 participants, PTSD prevalence was 23% at baseline and 21% at 12 months. Depression prevalence was 28% at baseline and 29% at 12 months. Ventilation (P = 0.023, P = 0.006) and prolonged length of stay (P = 0.008, P = 0.003) were correlated with baseline PTSD and depression. Injury etiology (P = 0.008) and Injury Severity Score (P = 0.013) were associated with baseline PTSD. Intensive care unit admission (P = 0.016, P = 0.043) was also correlated with PTSD at baseline and 12 months. Ventilation (P = 0.002, P = 0.040) and prolonged length of stay (P < 0.001, P = 0.001) were correlated with 12-month PTSD and depression. Early and continued screenings with potential interventions could benefit patients' physical and mental rehabilitation after orthopedic injury.

Secondary traumatic stress among physiatrists treating trauma patients.

Secondary traumatic stress is a form of posttraumatic stress disorder resulting from exposure to others' acute serious physical harm or death, regardless of mechanism. However, the incidence of secondary traumatic stress among physiatrists remains unexplored. This study examined relationships with secondary traumatic stress among physiatrists. Surveys were distributed to members of the Association of Academic Physiatry and local physiatrists. Surveys included measures of secondary traumatic stress, resilience, personality factors, demographics, and work-related factors. Of 102 surveys returned, 88 were complete and included for analysis. The sample was 42 ± 11 years and included 45 women (51%). Moderate to severe levels of secondary traumatic stress were found in 26 (30%) respondents, and 45% reported clinical levels of at least one symptom cluster. Higher resilience, higher extraversion, and higher emotional stability were associated with significantly lower odds of positive secondary traumatic stress screens and lower symptom severity (all P < 0.023). In conclusion, a third of responding physiatrists reported moderate to severe symptoms of secondary traumatic stress-a rate consistent with previous research among clinicians in a trauma setting and higher than the rate of posttraumatic stress disorder in the general population. Resilience-building interventions for secondary traumatic stress are likely to improve the well-being of physiatrists.

Driver see, driver crash: Associations between televised stock car races' audience size and the incidence of speed-related motor vehicle collisions in the United States.

Several studies have examined road rage, but few studies have examined other psychosocial factors that may contribute to the number of motor vehicle collisions (MVCs). One study found increases in MVCs in West Virginia following televised NASCAR races but did not account for audience size. This study examined associations between NASCAR's television viewership ratings and the incidence of speed-related MVCs in the USA using generalized estimating equations that controlled for seasonal effects, intoxication, road surface conditions, and lighting conditions. A 1% increase in the number of US households watching NASCAR races per month was associated with a 6.3% (95% confidence interval [CI], 3.0% to 9.7%; P < 0.001) increase in the incidence of speed-related MVCs-approximately 4911 (95% CI, 2353 to 7470) speed-related MVCs per month or one speed-related MVC per 595 (95% CI, 382 to 1354) viewers. As expected, similar results were not found for the total number of MVCs. These data suggest that televised NASCAR races may be associated with substantial increases in the incidence of speed-related MVCs. Making drivers aware of psychological factors that may increase risky driving behaviors could prove beneficial because self-monitoring can result in safer driving.

A meta-analytic review of cognitive processing therapy for adults with posttraumatic stress disorder.

Numerous studies have demonstrated the efficacy of cognitive processing therapy (CPT) for treating posttraumatic stress disorder (PTSD). Two prior meta-analyses of studies are available but used approaches that limit conclusions that can be drawn regarding the impact of CPT on PTSD outcomes. The current meta-analysis reviewed outcomes of trials that tested the efficacy of CPT for PTSD in adults and evaluated potential moderators of outcomes. All published trials comparing CPT against an inactive control condition (i.e. psychological placebo or wait-list) or other active treatment for PTSD in adults were included, resulting in 11 studies with a total of 1130 participants. CPT outperformed inactive control conditions on PTSD outcome measures at posttreatment (mean Hedges' g = 1.24) and follow-up (mean Hedges' g = 0.90). The average CPT-treated participant fared better than 89% of those in inactive control conditions at posttreatment and 82% at follow-up. Results also showed that CPT outperformed inactive control conditions on non-PTSD outcome measures at posttreatment and follow-up and that CPT outperformed other active treatments at posttreatment but not at follow-up. Effect sizes of CPT on PTSD symptoms were not significantly moderated by participant age, number of treatment sessions, total sample size, length of follow-up, or group versus individual treatment; but, older studies had larger effect sizes and percent female sex moderated the effect of CPT on non-PTSD outcomes. These meta-analytic findings indicate that CPT is an effective PTSD treatment with lasting benefits across a range of outcomes.

Better with age? A comparison of geriatric and non-geriatric trauma patients' psychological outcomes 6 months post-injury.

This is the first study to compare both physical and psychological outcomes in geriatric and non-geriatric patients (n = 268) at baseline and 6 months post-trauma. Demographic, clinical, and psychological data, including screens for alcohol use, depressive symptoms, and post-traumatic stress symptoms (PTSS) were collected from 67 geriatric patients (70.7 ± 8.0 years) and 201 non-geriatric patients (40.2 ± 12.8 years) admitted to a Level I trauma center for ≥ 24 h. Geriatric patients were significantly less likely to screen positive for alcohol use at baseline, and depression, PTSS, and alcohol use at follow-up. When not controlling for discharge to rehabilitation or nursing facility, geriatric patients had significantly lower odds of alcohol use at follow-up. There was no significant difference in injury severity, resilience, or pre-trauma psychological status between the two groups. Results indicate that geriatric trauma patients fare better than their younger counterparts at 6 months post-trauma on measures of alcohol use, depression, and PTSS. Screenings and interventions for both age groups could improve psychological health post-trauma, but younger patients may require additional attention.

The role of depression and social support on readmission rates within one year of traumatic injury.

OBJECTIVE: Hospital readmission rates have become a quality metric-particularly in trauma and acute care, where up to one third of individuals with traumatic injury return to the hospital. Thus, identifying predictors of readmission is a priority in an effort to reduce readmissions. Based on previous theoretical work, this study tests the utility of social support and depression in predicting readmissions up to one year after initial injury. METHOD: Data from 180 injured individuals admitted to a large, urban Level 1 trauma center were matched to a regional readmissions database. Logistic regression was used to assess whether social support levels or positive depression screens during initial trauma visit predicted unplanned (a) readmissions or (b) emergency/urgent outpatient visits. RESULTS: Within the sample, there were 32 total readmissions and 50 total emergency outpatient encounters following initial injury. Depression continued to be a risk factor for emergency outpatient visits only (OR = 2.75). Patients with greater social integration (OR = 0.78), more guidance (advice or information; OR = 0.72) and more reliable alliance (OR = 0.72) as forms of social support were less likely to readmit. CONCLUSIONS: This study demonstrates the utility of screening for depression and social support in predicting readmission within one year after traumatic injury. Future efforts should continue emphasizing the impact of initial depression and the need for patients to have trusted individuals in their lives to whom they can turn during recovery; doing so may lower the probability that patients return to hospital. (PsycINFO Database Record

Avoiding Cribari gridlock: The standardized triage assessment tool improves the accuracy of the Cribari matrix method in identifying potential overtriage and undertriage.

BACKGROUND: The Cribari matrix method (CMM) is the standard to identify potential overtriage and undertriage but requires case reviews to correct for the fact that Injury Severity Score does not account for physiology or comorbidities, nor is it well correlated with resource consumption. Further, the secondary reviews introduce undesirable subjectivity. This study assessed if the Standardized Triage Assessment Tool (STAT)-a combination of the CMM and the Need For Trauma Intervention-could more accurately determine overtriage and undertriage than the CMM alone. METHODS: The registry of an American College of Surgeons verified Level I adult trauma center in Texas was queried for all new emergency department traumas 2013 to 2016 (n = 11,110). Binary logistic regressions were used to test the associations between the triage determinations of each metric against indicators of injury severity (risk factors, complications, and mortality) and resource consumption (number of procedures in 3 days and total length of stay). RESULTS: Both metrics were associated with the indicators of injury severity and resource consumption in the expected directions, but STAT had stronger or equivalent associations with all variables tested. Using the CMM, there was 50.4% overtriage and 9.1% undertriage. Using STAT, overtriage was reduced to 30.8% (relative reduction = 38.9%) and undertriage was reduced to 3.3% (relative reduction = 63.7%). CONCLUSION: Using the CMM with secondary case reviews makes valid multi-institutional triage rate comparisons impossible because of the subjective and unstandardized nature of these reviews. STAT's out-of-box triage determinations (i.e., without manual case review) outperformed CMM in almost every tested variable for both over- and undertriage. STAT, an automatic, standardized method offers significant improvements compared to the current subjective system. Further, by accounting for both anatomic injury severity and resource consumption, STAT may allow trauma centers to better allocate resources and predict patient needs with fewer cases requiring manual review. LEVEL OF EVIDENCE: Prognostic, level III.

Prospective Evaluation of Posttraumatic Stress Disorder and Depression in Orthopaedic Injury Patients With and Without Concomitant Traumatic Brain Injury.

OBJECTIVES: Psychological morbidities after injury [eg, posttraumatic stress disorder (PTSD) and depression] are increasingly recognized as a significant determinant of overall outcome. Traumatic brain injury (TBI) negatively impacts outcomes of patients with orthopaedic injury, but the association of concurrent TBI, orthopaedic injury, and symptoms of PTSD and depression has not been examined. This study's objective was to examine symptoms of PTSD and depression in patients with orthopaedic trauma with and without TBI. DESIGN: Longitudinal prospective cohort study. SETTING: Urban Level I Trauma Center in the Southwest United States. PATIENTS/PARTICIPANTS: Orthopaedic trauma patients older than 18 years admitted for ≥24 hours. MAIN OUTCOME MEASUREMENTS: Questionnaires examining demographics, injury-related variables, PTSD, and depression were administered during hospitalization and 3, 6, and 12 months later. Orthopaedic injury and TBI were determined based on ICD-9 codes. Generalized linear models determined whether PTSD and depression at follow-up were associated with TBI. RESULTS: Of the total sample (N = 214), 44 (21%) sustained a TBI. Those with TBI had higher rates of PTSD symptoms, 12 months postinjury (P = 0.04). The TBI group also had higher rates of depressive symptoms, 6 months postinjury (P = 0.038). CONCLUSIONS: Having a TBI in addition to orthopaedic injury was associated with significantly higher rates of PTSD at 12 months and depression at 6 months postinjury. This suggests that sustaining a TBI in addition to orthopaedic injury places patients at a higher risk for negative psychological outcomes. The findings of this study may help clinicians to identify patients who are in need for psychological screening and could potentially benefit from intervention. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Alcohol and drug toxicology screens at time of hospitalization do not predict PTSD or depression after traumatic injury.

BACKGROUND: Identifying risk factors for the development of PTSD and depression is critical for intervention and recovery after injury. Given research linking toxicology screens and substance use and the evidenced relationship between substance misuse and distress, the current study aimed to gauge the predictive value of toxicology testing on PTSD and depression. METHODS: Patients admitted to a Level I Trauma Center (N = 379) completed the PC-PTSD, PCL-C, and PHQ-8 at baseline, 3, 6, and 12 months. RESULTS: Results showed 52% of tested patients had a positive toxicology test, 51% screened for PTSD, and 54% screened for depression. Positive drug or alcohol toxicology tests were not significantly associated with PTSD or depression. CONCLUSIONS: Toxicology testing may not meaningful predict depression or PTSD in traumatic injury patients. Future research using validated measures of problematic substance use is needed to better understand how misuse may influence the development of psychological distress.

Asking a Better Question: Development and Evaluation of the Need For Trauma Intervention (NFTI) Metric as a Novel Indicator of Major Trauma.

Many existing metrics, such as Injury Severity Score (ISS), cannot fully describe many trauma patients because of comorbidities. This study developed and evaluated the Need For Trauma Intervention (NFTI) metric as a novel indicator of major trauma. The NFTI metric was developed from an analysis of 2,396 trauma patients at a Level I trauma center. Six commonly recorded registry variables were found to be indicative of major trauma and comprised the NFTI criteria: receiving packed red blood cells within 4 hr; discharge from the emergency department (ED) to the operating room within 90 min; discharge from the ED to interventional radiology; discharge from the ED to the intensive care unit (ICU) with an ICU length of stay (LOS) of 3 or more days; mechanical ventilation outside of procedural anesthesia within 3 days; or death within 60 hr. Patients meeting any NFTI criteria are classified as having major traumas and, therefore, needing trauma activations (NFTI+). Need For Trauma Intervention was tested in an overlapping sample of 9,737 patients. Being NFTI+ was associated with higher trauma activation levels, older age, higher ISS, worse ED vitals, longer hospital LOS, and mortality. Only 13 of 561 deaths were not NFTI+ and all were in patients with do not resuscitate (DNR) orders; using ISS greater than 15 missed 73 mortalities, 46 with DNR orders. Results suggest that NFTI provides a comprehensive view of both anatomy and physiology in a manner that self-adjusts for age, frailty, and comorbidities as long as care teams adjust their treatments. Need For Trauma Intervention appears to be a unique, simple, and effective tool to retrospectively identify major trauma, regardless of ISS.

Secondary traumatic stress in emergency medicine clinicians.

Previously called Secondary Traumatic Stress (STS), secondary exposure to trauma is now considered a valid DSM-5 Criterion A stressor for posttraumatic stress disorder (PTSD). Previous studies have found high rates of STS in clinicians who treat traumatically injured patients. However, little research has examined STS among Emergency Medicine (EM) physicians and advanced practice providers (APPs). The current study enrolled EM providers (N = 118) working in one of 10 hospitals to examine risk factors, protective factors, and the prevalence of STS in this understudied population. Most of the participants were physicians (72.9%), Caucasian (85.6%), and male (70.3%) with mean age of 39.7 (SD = 8.9). Overall, 12.7% of the sample screened positive for STS with clinical levels of intrusion, arousal, and avoidance symptom clusters, and 33.9% had at least one symptom cluster at clinical levels. Low resilience and a history of personal trauma were positively associated with positive STS screens and STS severity scores. Borderline significance suggested that female gender and spending ≥10% of one's time with trauma patients could be additional risk factors. Findings suggest that resilience-building interventions may be beneficial.

Recurrent hospitalization for self-injuries and suicide attempts: case study of a super-utilizer.

Super-utilizers, patients who amass disproportionately large occurrences of emergency department visits and hospital admissions, are increasingly recognized as a significant and potentially preventable resource consumer. A comprehensive understanding of these individuals and their situations may prove useful in preventing unnecessary admissions and improving patient care and outcomes. While most super-utilizers suffer from chronic medical issues, this patient is an unusual variant, as his super-utilization stemmed from mental health problems leading to serial self-injury. Between January 2010 and October 2014, the patient performed 49 acts of self-harm resulting in 27 acute hospital admissions and 17 additional admissions secondary to complications. In addition to documented injuries, he and his family reported up to 50 additional self-injuries since his first episode 34 years earlier. It was concluded that the patient's pattern of self-injury resulted from a combination of factors, including underlying psychiatric conditions, chronic noncompliance with medications, and potentially unavoidable behavioral reinforcement from health care professionals.