Value in Acute Care Surgery, Part 3: Defining Value in Acute Surgical Care - It Depends on the Perspective.

ABSTRACT: The prior articles in this series have focused on measuring cost and quality in acute care surgery. This third article in the series explains the current ways of defining value in acute care surgery, based on different stakeholders in the healthcare system - the patient, the healthcare organization, the payer and society. The heterogenous valuations of the different stakeholders require that the framework for determining high-value care in acute care surgery incorporates all viewpoints.

Establishing a core outcome set for blunt cerebrovascular injury: an EAST modified Delphi method consensus study.

Objectives: Our understanding of blunt cerebrovascular injury (BCVI) has changed significantly in recent decades, resulting in a heterogeneous description of diagnosis, treatment, and outcomes in the literature which is not suitable for data pooling. Therefore, we endeavored to develop a core outcome set (COS) to help guide future BCVI research and overcome the challenge of heterogeneous outcomes reporting. Methods: After a review of landmark BCVI publications, content experts were invited to participate in a modified Delphi study. For round 1, participants submitted a list of proposed core outcomes. In subsequent rounds, panelists used a 9-point Likert scale to score the proposed outcomes for importance. Core outcomes consensus was defined as >70% of scores receiving 7 to 9 and <15% of scores receiving 1 to 3. Feedback and aggregate data were shared between rounds, and four rounds of deliberation were performed to re-evaluate the variables not achieving predefined consensus criteria. Results: From an initial panel of 15 experts, 12 (80%) completed all rounds. A total of 22 items were considered, with 9 items achieving consensus for inclusion as core outcomes: incidence of postadmission symptom onset, overall stroke incidence, stroke incidence stratified by type and by treatment category, stroke incidence prior to treatment initiation, time to stroke, overall mortality, bleeding complications, and injury progression on radiographic follow-up. The panel further identified four non-outcome items of high importance for reporting: time to BCVI diagnosis, use of standardized screening tool, duration of treatment, and type of therapy used. Conclusion: Through a well-accepted iterative survey consensus process, content experts have defined a COS to guide future research on BCVI. This COS will be a valuable tool for researchers seeking to perform new BCVI research and will allow future projects to generate data suitable for pooled statistical analysis with enhanced statistical power. Level of evidence: Level IV.

Early surgical stabilization of rib fractures for flail chest is associated with improved patient outcomes: An ACS-TQIP review.

BACKGROUND: Rib fractures are a common in thoracic trauma. Increasingly, patients with flail chest are being treated with surgical stabilization of rib fractures (SSRF). We performed a retrospective review of the Trauma Quality Improvement Program database to determine if there was a difference in outcomes between patients undergoing early SSRF (≤3 days) versus late SSRF (>3 days). METHODS: Patients with flail chest in Trauma Quality Improvement Program were identified by CPT code, assessing those who underwent SSRF between 2017 and 2019. We excluded those younger than 18 years and Abbreviated Injury Scale head severity scores greater than 3. Patients were grouped based on SSRF before and after hospital Day 3. These patients were case matched based on age, Injury Severity Score, Abbreviated Injury Scale head and chest, body mass index, Glasgow Coma Scale, and five modified frailty index. All data were examined using χ2, one-way analysis of variance, and Fisher's exact test within SPSS version 28.0. RESULTS: For 3 years, 20,324 patients were noted to have flail chest, and 3,345 (16.46%) of these patients underwent SSRF. After case matching, 209 patients were found in each group. There were no significant differences between reported major comorbidities. Patients with early SSRF had fewer unplanned intubations (6.2% vs. 12.0%; p = 0.04), fewer median ventilator days (6 days Q1: 3 to Q3: 10.5 vs. 9 Q1: 4.25 to Q3: 14; p = 0.01), shorter intensive care unit length of stay (6 days Q1: 4 to Q3: 11 vs. 11 Q1: 6 to Q3: 17; p < 0.01), and hospital length of stay (15 days Q1: 11.75 to Q3: 22.25 vs. 20 Q1: 15.25 - Q3: 27, p < 0.01. Early plating was associated with lower rates of deep vein thrombosis and ventilator-acquired pneumonia. CONCLUSION: In trauma-accredited centers, patients with flail chest who underwent early SSRF (<3 days) had better outcomes, including fewer unplanned intubations, decreased ventilator days, shorter intensive care unit LOS and HLOS, and fewer DVTs, and ventilator-associated pneumonia. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Biological Effects of Intravenous Vitamin C on Neutrophil Extracellular Traps and the Endothelial Glycocalyx in Patients with Sepsis-Induced ARDS.

(1) Background: The disease-modifying mechanisms of high-dose intravenous vitamin C (HDIVC) in sepsis induced acute respiratory distress syndrome (ARDS) is unclear. (2) Methods: We performed a post hoc study of plasma biomarkers from subjects enrolled in the randomized placebo-controlled trial CITRIS-ALI. We explored the effects of HDIVC on cell-free DNA (cfDNA) and syndecan-1, surrogates for neutrophil extracellular trap (NET) formation and degradation of the endothelial glycocalyx, respectively. (3) Results: In 167 study subjects, baseline cfDNA levels in HDIVC (84 subjects) and placebo (83 subjects) were 2.18 ng/µL (SD 4.20 ng/µL) and 2.65 ng/µL (SD 3.87 ng/µL), respectively, p = 0.45. At 48-h, the cfDNA reduction was 1.02 ng/µL greater in HDIVC than placebo, p = 0.05. Mean baseline syndecan-1 levels in HDIVC and placebo were 9.49 ng/mL (SD 5.57 ng/mL) and 10.83 ng/mL (SD 5.95 ng/mL), respectively, p = 0.14. At 48 h, placebo subjects exhibited a 1.53 ng/mL (95% CI, 0.96 to 2.11) increase in syndecan-1 vs. 0.75 ng/mL (95% CI, 0.21 to 1.29, p = 0.05), in HDIVC subjects. (4) Conclusions: HDIVC infusion attenuated cell-free DNA and syndecan-1, biomarkers associated with sepsis-induced ARDS. Improvement of these biomarkers suggests amelioration of NETosis and shedding of the vascular endothelial glycocalyx, respectively.

Early video-assisted thoracoscopic surgery (VATS) for non-emergent thoracic trauma remains underutilized in trauma accredited centers despite evidence of improved patient outcomes.

PURPOSE: Thoracic injury is a major contributor to morbidity in trauma patients. There is limited data regarding practice patterns of video-assisted thoracoscopic surgery (VATS) across trauma-accredited hospitals in the United States. We hypothesized that early VATS remains underutilized affecting patient outcomes. METHOD: We evaluated a cohort of patients who underwent non-urgent thoracic surgical intervention for trauma from the ACS-TQIP database in 2017 excluding patients who were discharged within 48-h or died within 72-h. We selected patients who underwent partial lung resection and decortication to assess the effect of early (day 2-5) versus late VATS. Univariate followed by multivariate regression analyses were utilized to evaluate the independent impact of timing. RESULTS: Over 12 months, 997,970 patients were admitted to 850 trauma-accredited centers. Thoracic injury occurred in 23.5% of patients, 1% of whom had non-urgent thoracic procedures. A total of 406 patients underwent VATS for pulmonary decortication with/out partial resection, 39% were Early VATS (N = 159) compared to 61% late VATS (N = 247). Both groups had comparable demographics and comorbidities with exception of a higher ISS score in the late surgical group (17.9 ± 9.8 vs 14.9 ± 7.6, p < 0.01). The late VATS patients' group had higher rates of superficial site infection, unplanned intubation, and pneumonia. Early VATS was associated with shorter ICU stay and HLOS. Multivariate analysis confirmed the independent effect of surgical timing on postoperative complications and LOS. The conversion rate from VATS to thoracotomy was 1.9% in early group compared to 6.5%, p = 0.03. There was no difference in surgical pattern among participating facilities. CONCLUSION: Despite established practice guidelines supporting early VATS for thoracic trauma management, there is underutilization with less than half of patients undergoing early VATS. Early VATS is associated with improved patient outcomes.

Multi-center validation of the Bowel Injury Predictive Score (BIPS) for the early identification of need to operate in blunt bowel and mesenteric injuries.

INTRODUCTION: The Bowel Injury Prediction Score (BIPS) is a tool for identifying patients at risk for blunt bowel and mesenteric injury (BBMI) requiring surgery. BIPS is calculated by assigning one point for each of the following: (1) WBC ≥ 17,000, (2) abdominal tenderness, and (3) injury grade ≥ 4 (mesenteric contusion or hematoma with bowel wall thickening or adjacent interloop fluid collection) on CT scan. A total score ≥ 2 is associated with BBMI requiring surgery. We aimed to validate the BIPS as a predictor for patients with BBMIs requiring operative intervention in a multi-center prospective study. MATERIALS AND METHODS: Patients were prospectively enrolled at 15 U.S. trauma centers following blunt trauma with suspicion of BBMI on CT scan between July 1, 2018 and July 31, 2019. The BIPS was calculated for each patient enrolled in the study. RESULTS: Of 313 patients, 38% had BBMI requiring operative intervention. Patients were significantly more likely to require surgery in the presence of abdominal tenderness (OR, 3.6; 95% CI, 1.6-8.0) and CT grade ≥ 4 (OR, 11.7; 95% CI, 5.7-23.7). Patients with a BIPS ≥ 2 were more than ten times more likely to require laparotomy than those with a BIPS < 2 (OR, 10.1; 95% CI, 5.0-20.4). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of a BIPS ≥ 2 for BBMI requiring surgery was 72% (CI 0.6-0.8), 78% (CI 0.7-0.8), 67% (CI 0.6-0.8), and 82% (CI 0.8-0.9), respectively. The AUROC curve for BIPS ≥ 2 was 0.75. The sensitivity, specificity, PPV, and NPV of a BIPS ≥ 2 for BBMI requiring surgery in patients with severe alteration in mental status (GCS 3-8) was 70% (CI 0.5-0.9), 92% (CI 0.8-1.0), 82% (CI 0.6-1.0), and 86% (CI 0.7-1.0), respectively. CONCLUSION: This prospective multi-center trial validates BIPS as a predictor of BBMI requiring surgery. Calculation of BIPS during the initial evaluation of trauma patients is a useful adjunct to help general surgeons taking trauma call determine operative versus non-operative management of patients with BBMI including those with severe alteration in mental status.

Enhanced Recovery After Surgery, Lean, and claims-based quality databases: how does it all make sense?

PURPOSE OF REVIEW: Healthcare is rapidly evolving toward value-focused objectives, integrating outcomes and cost instead of simply volume. Concepts pertaining to Enhanced Recovery After Surgery (ERAS), Lean, and claims-based risk-adjusted databases can be used to optimize value, but the application of Lean principles and risk-adjusted outcomes is poorly described in perioperative medicine in perioperative medicine. RECENT FINDINGS: Lean management and process optimization tools allow the consistent application of a perioperative medical framework of ERAS to improve outcomes. Vizient risk-stratified outcomes are often used by hospitals to measure and compare quality. SUMMARY: Understanding administrative databases and Lean concepts for change management will allow the perioperative physician to better align medical concepts with health system tools for improving quality and reducing cost.

Anticoagulation therapy in patients with traumatic brain injury: An Eastern Association for the Surgery of Trauma multicenter prospective study.

BACKGROUND: Trauma care providers often face a dilemma regarding anticoagulation therapy initiation in patients with traumatic brain injury owing to the associated risks of traumatic brain injury progression. The aims of this study were the following: (1) to describe the current practice of anticoagulation therapy in traumatic brain injury patients and their outcomes and (2) to identify factors associated with the progression of traumatic brain injury after anticoagulation therapy. METHODS: In this multicenter prospective observational study, we included computed tomography-proven traumatic brain injury patients who received anticoagulation therapy within 30 days of hospital admission. Our primary outcome was the incidence of clinically significant progression of traumatic brain injury after anticoagulation therapy initiation. RESULTS: A total of 168 patients were enrolled more than 22 months. Atrial fibrillation and venous thromboembolism were the most common pre-injury and postinjury anticoagulation therapy indications, respectively. Overall, 16 patients (9.6%) experienced clinically significant traumatic brain injury progression after anticoagulation therapy, out of which 9 (5.4%) patients subsequently required neurosurgical interventions. Between patients with clinical progression of traumatic brain injury and patients who showed no such progression, there were no significant differences in the baseline demographics and severity of traumatic brain injury. However, anticoagulation therapy was initiated significantly earlier in patients of the deterioration group than those of the no-deterioration group (4.5 days vs 11 days, P = .015). In a multiple logistic regression model, patients who received anticoagulation therapy later after injury had significantly lower risk of clinically significant traumatic brain injury progression (odds ratio: 0.915 for each day, 95% confidence interval: 0.841-0.995, P = .037). CONCLUSION: Our results suggest that early anticoagulation therapy is associated with higher risk of traumatic brain injury progression, thus a balance between bleeding and thromboembolic risks should be carefully evaluated in each case before initiating anticoagulation therapy.

The influence of a statewide "Stay-at-Home" order on trauma volume and patterns at a level 1 trauma center in the united states.

The COVID pandemic of 2020 resulted in unprecedented restrictions of public life in most countries around the world, and many hospital systems experienced dramatic decreases in non-COVID related patient admissions. We aimed to compare trauma volumes, patient characteristics, and trauma mechanisms at a large, urban Level 1 trauma center in the United States during a state-wide "State of Emergency" and "stay-at-home" order to corresponding historic dates. All adult trauma activations from March 1 through April 30, 2020 and a historic control from March 1 through April 30, 2018 and 2019 were reviewed in the institution's trauma registry. Trauma volumes, patient characteristics, and trauma mechanisms were compared over time as increasingly stricter COVID-related restrictions were enacted in the Commonwealth of Virginia. After declaration of a state-wide "Public Health Emergency" on March 17, 2020, the daily number of trauma activations significantly declined to a mean of 4.7 (standard deviation, SD = 2.6), a decrease by 43% from a mean of 8.2 (SD = 0.3) for the same dates in 2018 and 2019. Trauma activations during COVID restrictions vs. historic control were characterized by significantly higher prevalence of chronic alcohol use (15.5% vs. 6.8%, p < 0.01), higher median (25th - 75th percentile) Injury Severity Score of 9 (5 - 16) vs. 6 (4 - 14), p = 0.01, and shorter median (25th - 75th percentile) length of hospital stay of 2 (1 - 6) days vs. 3 (1 - 7) days, p = 0.03. The COVID-related Public Health Emergency and "stay-at-home" order in the Commonwealth of Virginia dramatically reduced overall trauma volumes with minor but interesting changes in trauma patterns.

Triage of Patients With Rib Fractures : Patient's Age and Number Don't Tell the Whole Story.

BACKGROUND: Most triage guidelines for blunt chest wall trauma focus on advanced age and multiple fractured ribs to indicate a high-risk patient population that should be admitted to an intensive care unit (ICU). Overly sensitive ICU admission criteria, however, may result in overutilization of resources. We revised our rib fracture triage guideline to de-emphasize age and number of rib fractures, hypothesizing that we could lower ICU admission rates without compromising outcomes. METHODS: Patients admitted to our level 1 trauma center over 9 months after the institution of the revised guideline (N = 248) were compared with those admitted over 6 months following the original guideline (N = 207) using Fisher's exact and Wilcoxon-Mann-Whitney tests, as appropriate. Univariate followed by multivariate analyses were performed to determine risk factors for complications. RESULTS: The ICU admission rate significantly decreased from 73% to 63% (P = .02) after the institution of the revised guideline, despite an increase in the patient's age and injury acuity of the cohort. There was no significant difference in respiratory complications, unplanned ICU admission rates, and overall mortality. Poor incentive spirometer effort (750 mL or less) and dyspnea in the trauma bay were the strongest predictors of an adverse composite outcome and prolonged hospital length of stay. DISCUSSION: A revised rib fracture triage guideline with less emphasis on the patient's age and the number of fractured ribs safely lowered ICU admission rates. Poor functional status rather than age and anatomy was the strongest predictor of complications and prolonged hospital stay.

Blunt cerebrovascular injury: The case for universal screening.

BACKGROUND: Current evidence-based screening algorithms for blunt cerebrovascular injury (BCVI) may miss more than 30% of carotid or vertebral artery injuries. We implemented universal screening for BCVI with computed tomography angiography of the neck at our level 1 trauma center, hypothesizing that only universal screening would identify all clinically relevant BCVIs. METHODS: Adult blunt trauma activations from July 2017 to August 2019 underwent full-body computed tomography scan including computed tomography angiography neck with a 128-slice computed tomography scanner. We calculated sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of common screening criteria. We determined independent risk factors for BCVI using multivariate analyses. RESULTS: A total of 4,659 patients fulfilled the inclusion criteria, 2.7% (n = 126) of which had 158 BCVIs. For the criteria outlined in the American College of Surgeons Trauma Quality Improvement Program Best Practices Guidelines, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 72.2%, 64.9%, 6.8%, 98.5%, and 65.2%, respectively; for the risk factors suggested in the more extensive expanded Denver criteria, they were 82.5%, 50.4%, 5.3%, 98.9%, and 51.4%, respectively. Twenty-three percent (n = 14) of patients with BCVI grade 3 or higher would not have been captured by any screening criteria. Cervical spine, facial, and skull base fractures were the strongest predictors of BCVI with odds ratios and 95% confidence intervals of 8.1 (5.4-12.1), 5.7 (2.2-15.1), and 2.7 (1.5-4.7), respectively. Eighty-three percent (n = 105) of patients with BCVI received antiplatelet agents or therapeutic anticoagulation, with 4% (n = 5) experiencing a bleeding complication, 3% (n = 4) a BCVI progression, and 8% (n = 10) a stroke. CONCLUSION: Almost 20% of patients with BCVI, including a quarter of those with BCVI grade 3 or higher, would have gone undiagnosed by even the most extensive and sensitive BCVI screening criteria. Implementation of universal screening should strongly be considered to ensure the detection of all clinically relevant BCVIs. LEVEL OF EVIDENCE: Diagnostic study, level III.

The Emerging Role of Vitamin C as a Treatment for Sepsis.

Sepsis, a life-threatening organ dysfunction due to a dysregulated host response to infection, is a leading cause of morbidity and mortality worldwide. Decades of research have failed to identify any specific therapeutic targets outside of antibiotics, infectious source elimination, and supportive care. More recently, vitamin C has emerged as a potential therapeutic agent to treat sepsis. Vitamin C has been shown to be deficient in septic patients and the administration of high dose intravenous as opposed to oral vitamin C leads to markedly improved and elevated serum levels. Its physiologic role in sepsis includes attenuating oxidative stress and inflammation, improving vasopressor synthesis, enhancing immune cell function, improving endovascular function, and epigenetic immunologic modifications. Multiple clinical trials have demonstrated the safety of vitamin C and two recent studies have shown promising data on mortality improvement. Currently, larger randomized controlled studies are underway to validate these findings. With further study, vitamin C may become standard of care for the treatment of sepsis, but given its safety profile, current treatment can be justified with compassionate use.

Medication Reconciliation and Patient Safety in Trauma: Applicability of Existing Strategies.

The Joint Commission has established medication reconciliation as a National Patient Safety Goal, but it has not been studied much in trauma even though it is integral to safe patient care. This article reviews the existing medication reconciliation strategies and their applicability to the trauma setting. To perform medication reconciliation, hospitals use a variety of strategies including pharmacists or pharmacy technicians, electronic medical record tools, and patient-centered strategies. All of these strategies are limited in trauma. Subpopulations such as injured children, the elderly, and those with brain trauma are particularly challenging and are at risk for suboptimal care from inaccurate medication reconciliation. Further research is necessary to create a safe and efficient system for trauma patients.

High-Dose Intravenous Ascorbic Acid: Ready for Prime Time in Traumatic Brain Injury?

Traumatic brain injury (TBI) is one of the leading public health problems in the USA and worldwide. It is the number one cause of death and disability in children and adults between ages 1-44. Despite efforts to prevent TBIs, the incidence continues to rise. Secondary brain injury occurs in the first hours and days after the initial impact and is the most effective target for intervention. Inflammatory processes and oxidative stress play an important role in the pathomechanism of TBI and are exacerbated by impaired endogenous defense mechanisms, including depletion of antioxidants. As a reducing agent, free radical scavenger, and co-factor in numerous biosynthetic reactions, ascorbic acid (AA, vitamin C) is an essential nutrient that rapidly becomes depleted in states of critical illness. The administration of high-dose intravenous (IV) AA has demonstrated benefits in numerous preclinical models in the areas of trauma, critical care, wound healing, and hematology. A safe and inexpensive treatment, high-dose IV AA administration gained recent attention in studies demonstrating an associated mortality reduction in septic shock patients. High-quality data on the effects of high-dose IV AA on TBI are lacking. Historic data in a small number of patients demonstrate acute and profound AA deficiency in patients with central nervous system pathology, particularly TBI, and a strong correlation between low AA concentrations and poor outcomes. While replenishing deficient AA stores in TBI patients should improve the brain's ability to tolerate oxidative stress, high-dose IV AA may prove an effective strategy to prevent or mitigate secondary brain injury due to its ability to impede lipid peroxidation, scavenge reactive oxygen species, suppress inflammatory mediators, stabilize the endothelium, and reduce brain edema. The existing preclinical data and limited clinical data suggest that high-dose IV AA may be effective in lowering oxidative stress and decreasing cerebral edema. Whether this translates into improved clinical outcomes will depend on identifying the ideal target patient population and possible treatment combinations, factors that need to be evaluated in future clinical studies. With its excellent safety profile and low cost, high-dose IV AA is ready to be evaluated in the early treatment of TBI patients to mitigate secondary brain injury and improve outcomes.

Detecting direct oral anticoagulants in trauma patients using liquid chromatography-mass spectrometry: A novel approach to medication reconciliation.

BACKGROUND: Accurate medication reconciliation in trauma patients is essential but difficult. Currently, there is no established clinical method of detecting direct oral anticoagulants (DOACs) in trauma patients. We hypothesized that a liquid chromatography-mass spectrometry (LCMS)-based assay can be used to accurately detect DOACs in trauma patients upon hospital arrival. METHODS: Plasma samples were collected from 356 patients who provided informed consent including 10 healthy controls, 19 known positive or negative controls, and 327 trauma patients older than 65 years who were evaluated at our large, urban level 1 trauma center. The assay methodology was developed in healthy and known controls to detect apixaban, rivaroxaban, and dabigatran using LCMS and then applied to 327 samples from trauma patients. Standard medication reconciliation processes in the electronic medical record documenting DOAC usage were compared with LCMS results to determine overall accuracy, sensitivity, specificity, and positive and negative predictive values (PPV, NPV) of the assay. RESULTS: Of 356 patients, 39 (10.96%) were on DOACs: 21 were on apixaban, 14 on rivaroxaban, and 4 on dabigatran. The overall accuracy of the assay for detecting any DOAC was 98.60%, with a sensitivity of 94.87% and specificity of 99.05% (PPV, 92.50%; NPV, 99.37%). The assay detected apixaban with a sensitivity of 90.48% and specificity of 99.10% (PPV, 86.36%; NPV 99.40%). There were three false-positive results and two false-negative LCMS results for apixaban. Dabigatran and rivaroxaban were detected with 100% sensitivity and specificity. CONCLUSION: This LCMS-based assay was highly accurate in detecting DOACs in trauma patients. Further studies need to confirm the clinical efficacy of this LCMS assay and its value for medication reconciliation in trauma patients. LEVEL OF EVIDENCE: Diagnostic Test, level III.

Decreasing Accuracy of the eFAST Examination-Another Challenge Due to Morbid Obesity.

The extended focused assessment with sonography for trauma (eFAST) ultrasound examination is an essential step in the initial assessment of trauma patients. Its accuracy depends on the ability to acquire high-quality ultrasound images, and we hypothesized that increasing BMI was associated with increased odds for incorrect eFAST. All adult blunt trauma activations at a high-volume urban trauma center in 2016 that underwent eFAST and CT chest, abdomen, and pelvis were included (n = 446). Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the eFAST were calculated with CT results as reference. The association of BMI and eFAST accuracy was determined using univariate analyses. Sensitivity and specificity of the eFAST examination were 27.1 per cent and 91.7 per cent, respectively, with an overall 76.2 per cent accuracy. At BMI 36 kg/m², the odds of having incorrect eFAST results increased to odds ratio (OR) = 1.85 (95% confidence interval, 1.03-3.32; P = 0.05). For those with BMI > 40 kg/m², the OR increased to OR = 3.12 (95% confidence interval, 1.45-6.69; P = 0.01). One-third of patients in this study were obese or morbidly obese. The latter was associated with increased odds for incorrect eFAST results, particularly the abdominal examination component.

Field Triage of Motor Vehicle Crashes: Which Factors Predict High Injury Severity?

Patient physiology and crash characteristics are essential components of field triage for motor vehicle crashes. We aimed to identify prehospital information that predicted high injury severity or critical patient condition on hospital arrival. The association of demographics, shock index (SI), Glasgow Coma Scale, and 10 crash characteristics of trauma activations for motor vehicle crashes with injury severity score (ISS) ≥ 16 and a composite of hypotension, need for blood transfusions, or immediate operation was determined using univariate and multivariate analyses. A total of 133 of 498 patients (27%) had ISS ≥ 16; SI ≥ 0.9, Glasgow Coma Scale ≤ 8, speed ≥ 55 mph, seatbelt use, airbag deployment, ambulatory patient, severe vehicle damage, ejection, and extrication were associated with ISS ≥ 16. Only abnormal SI and high speed remained independent predictors for ISS ≥ 16 with Odds Ratio (OR) = 10.76 (95% confidence interval (CI), 1.14-101, P = 0.04) and OR = 10.37 (95% CI, 1.48-72.93, P = 0.02), respectively. SI ≥ 0.9 predicted the composite outcome with OR = 5.92 (95% CI, 2.32-15.08, P < 0.01). Many commonly reported crash characteristics did not predict clinically important outcomes. Improvements in road and vehicle safety may be resulting in lower injury severity despite major crash mechanisms.

Medications and patient safety in the trauma setting: a systematic review.

Background: Medication errors account for the most common adverse events and a significant cause of mortality in the USA. The Joint Commission has required medication reconciliation since 2006. We aimed to survey the literature and determine the challenges and effectiveness of medication reconciliation in the trauma patient population. Materials and methods: We conducted a systematic review of the literature to determine the effectiveness of medication reconciliation in trauma patients. English language articles were retrieved from PubMed/Medline, CINAHL, and Cochrane Review databases with search terms "trauma OR injury, AND medication reconciliation OR med rec OR med rek, AND effectiveness OR errors OR intervention OR improvements." Results: The search resulted in 82 articles. After screening for relevance and duplicates, the 43 remaining were further reviewed, and only four articles, which presented results on medication reconciliation in 3041 trauma patients, were included. Two were retrospective and two were prospective. Two showed only 4% accuracy at time of admission with 48% of medication reconciliations having at least one medication discrepancy. There were major differences across the studies prohibiting comparative statistical analysis. Conclusions: Trauma medication reconciliation is important because of the potential for adverse outcomes given the emergent nature of the illness. The few articles published at this time on medication reconciliation in trauma suggest poor accuracy. Numerous strategies have been implemented in general medicine to improve its accuracy, but these have not yet been studied in trauma. This topic is an important but unrecognized area of research in this field.