Venous thromboembolism testing practices after orthopaedic trauma: prophylaxis regimen does not influence testing patterns.

Objectives: To determine venous thromboembolism (VTE) testing patterns in an orthopaedic trauma population and to evaluate for differences in VTE surveillance by prophylaxis regimen through a secondary analysis of the ADAPT trial. Design: Prospective randomized trial. Setting: Level I trauma center. Patients: Three hundred twenty-nine adult (18 years and older) trauma patients presenting with an operative extremity fracture proximal to the metatarsals/carpals or any pelvic or acetabular fracture requiring VTE prophylaxis. Intervention: VTE imaging studies recorded within 90 days post injury. Main Outcome Measurements: Percentage of patients tested for VTE were compared between treatment groups using Fisher's exact test. Subsequently, multivariable regression was used to determine patient factors significantly associated with risk of receiving a VTE imaging study. Results: Sixty-seven patients (20.4%) had VTE tests ordered during the study period. Twenty (29.9%) of these 67 patients with ordered VTE imaging tests had a positive finding. No difference in proportion of patients tested for VTE by prophylaxis regimen (18.8% on aspirin vs. 22.0% on LMWH, P = 0.50) was observed. Factors associated with increased likelihood of VTE testing included White race (adjusted odds ratio [aOR]: 2.61, 95% CI: 1.26-5.42), increased Injury Severity Score (aOR for every 1-point increase: 1.10, 95% CI: 1.05-1.15), and lower socioeconomic status based on the Area Deprivation Index (aOR for every 10-point increase: 1.14, 95% CI: 1.00-1.30). Conclusions: VTE surveillance did not significantly differ by prophylaxis regimen. Patient demographic factors including race, injury severity, and socioeconomic status were associated with differences in VTE surveillance. Level of Evidence: Level I, Therapeutic.

Inpatient compliance with venous thromboembolism prophylaxis after orthopaedic trauma: results from a randomized controlled trial of aspirin versus low molecular weight heparin.

OBJECTIVES: To compare inpatient compliance with venous thromboembolism prophylaxis regimens. DESIGN: A secondary analysis of patients enrolled in the ADAPT (A Different Approach to Preventing Thrombosis) randomized controlled trial. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: Patients with operative extremity or any pelvic or acetabular fracture requiring venous thromboembolism prophylaxis. INTERVENTION: We compared patients randomized to receive either low molecular weight heparin (LMWH) 30 mg or aspirin 81 mg BID during their inpatient admission. MAIN OUTCOME MEASUREMENTS: The primary outcome measure was the number of doses missed compared with prescribed number of doses. RESULTS: A total of 329 patients were randomized to receive either LMWH 30 mg BID (164 patients) or aspirin 81 mg BID (165 patients). No differences observed in percentage of patients who missed a dose (aspirin: 41.2% vs LMWH: 43.3%, P = .7) or mean number of missed doses (0.6 vs 0.7 doses, P = .4). The majority of patients (57.8%, n = 190) did not miss any doses. Missed doses were often associated with an operation. CONCLUSIONS: These data should reassure clinicians that inpatient compliance is similar for low molecular weight heparin and aspirin regimens.

PREVENTion of CLots in Orthopaedic Trauma (PREVENT CLOT): a randomised pragmatic trial protocol comparing aspirin versus low-molecular-weight heparin for blood clot prevention in orthopaedic trauma patients.

INTRODUCTION: Patients who sustain orthopaedic trauma are at an increased risk of venous thromboembolism (VTE), including fatal pulmonary embolism (PE). Current guidelines recommend low-molecular-weight heparin (LMWH) for VTE prophylaxis in orthopaedic trauma patients. However, emerging literature in total joint arthroplasty patients suggests the potential clinical benefits of VTE prophylaxis with aspirin. The primary aim of this trial is to compare aspirin with LMWH as a thromboprophylaxis in fracture patients. METHODS AND ANALYSIS: PREVENT CLOT is a multicentre, randomised, pragmatic trial that aims to enrol 12 200 adult patients admitted to 1 of 21 participating centres with an operative extremity fracture, or any pelvis or acetabular fracture. The primary outcome is all-cause mortality. We will evaluate non-inferiority by testing whether the intention-to-treat difference in the probability of dying within 90 days of randomisation between aspirin and LMWH is less than our non-inferiority margin of 0.75%. Secondary efficacy outcomes include cause-specific mortality, non-fatal PE and deep vein thrombosis. Safety outcomes include bleeding complications, wound complications and deep surgical site infections. ETHICS AND DISSEMINATION: The PREVENT CLOT trial has been approved by the ethics board at the coordinating centre (Johns Hopkins Bloomberg School of Public Health) and all participating sites. Recruitment began in April 2017 and will continue through 2021. As both study medications are currently in clinical use for VTE prophylaxis for orthopaedic trauma patients, the findings of this trial can be easily adopted into clinical practice. The results of this large, patient-centred pragmatic trial will help guide treatment choices to prevent VTE in fracture patients. TRIAL REGISTRATION NUMBER: NCT02984384.

Aspirin versus low-molecular-weight heparin for venous thromboembolism prophylaxis in orthopaedic trauma patients: A patient-centered randomized controlled trial.

BACKGROUND: Emerging evidence suggests aspirin may be an effective venous thromboembolism (VTE) prophylaxis for orthopaedic trauma patients, with fewer bleeding complications. We used a patient-centered weighted composite outcome to globally evaluate aspirin versus low-molecular-weight heparin (LMWH) for VTE prevention in fracture patients. METHODS: We conducted an open-label randomized clinical trial of adult patients admitted to an academic trauma center with an operative extremity fracture, or a pelvis or acetabular fracture. Patients were randomized to receive LMWH (enoxaparin 30-mg) twice daily (n = 164) or aspirin 81-mg twice daily (n = 165). The primary outcome was a composite endpoint of bleeding complications, deep surgical site infection, deep vein thrombosis, pulmonary embolism, and death within 90 days of injury. A Global Rank test and weighted time to event analysis were used to determine the probability of treatment superiority for LMWH, given a 9% patient preference margin for oral administration over skin injections. RESULTS: Overall, 18 different combinations of outcomes were experienced by patients in the study. Ninety-nine patients in the aspirin group (59.9%) and 98 patients in the LMWH group (59.4%) were event-free within 90 days of injury. Using a Global Rank test, the LMWH had a 50.4% (95% CI, 47.7-53.2%, p = 0.73) probability of treatment superiority over aspirin. In the time to event analysis, LMWH had a 60.5% probability of treatment superiority over aspirin with considerable uncertainty (95% CI, 24.3-88.0%, p = 0.59). CONCLUSION: The findings of the Global Rank test suggest no evidence of superiority between LMWH or aspirin for VTE prevention in fracture patients. LMWH demonstrated a 60.5% VTE prevention benefit in the weighted time to event analysis. However, this difference did not reach statistical significance and was similar to the elicited patient preferences for aspirin.

Factors associated with tracheostomy decannulation in patients with severe traumatic brain injury.

OBJECTIVE: To assess variables associated with decannulation in patients with traumatic brain injury (TBI). PARTICIPANTS: 79 patients with TBI requiring tracheostomy and ICU admission from January 1st to December 31st, 2014. DESIGN: Retrospective analysis. MEASURES: Patients decannulated prior to 90 days were compared with patients who remained cannulated. Two Cox Proportional Hazards models were used to predict decannulation using variables prior to tracheostomy and throughout hospitalization. RESULTS: Median time to decannulation was 37 days (Interquartile Range [IQR] 29-67). Variables prior to tracheostomy associated with decannulation included diabetes (HR, 0.15; 95% CI, 0.03-0.84; p =.03), craniotomy (HR, 0.25; 95% CI, 0.06-1.02; p =.05) and acute kidney injury (AKI) (HR, 0.06; 95% CI, 0.01-0.48; p =.01). Variables present throughout hospitalization included age (HR, 1.12; 95% CI, 1.01-1.21; p =.03), ventilator days (HR, 0.74; 95% CI, 0.57-0.95; p =.02), reintubation (HR, 0.07; 95% CI, 0.01-0.64; p =.02), aspiration (HR, 0.01; 95% CI, 0.0-0.29, p =.01), craniotomy (HR, 0.004; 95% CI, 0.0-0.39; p =.02) and AKI (HR, 0.0; 95% CI, 0.0-0.21; p =.01). CONCLUSION: The presence of diabetes, craniotomy and acute kidney injury may inform the conversation surrounding chances for decannulation prior to tracheostomy.

Injury Characteristics and Outcomes of Patients With Inflammatory Bowel Disease After Trauma: A Propensity Score Matched Analysis.

BACKGROUND: The clinical course of patients with inflammatory bowel disease (IBD) after trauma is largely unknown. We sought to compare the clinical course of patients with IBD to those without. METHODS: We conducted a retrospective case-control study of adult patients admitted to a level-1 trauma center from January 1, 2008, through October 1, 2015. Seventy-five patients with IBD were identified. Cases were matched to controls by age, sex, injury severity, and mechanism using 4:1 propensity score-matching analysis. Injury characteristics, clinical course, and infectious and noninfectious complications were compared using bivariate and multivariate analysis. RESULTS: Participants had a mean age of 56 years and mean injury severity score of 15. Of the 75 cases, 44% had ulcerative colitis, 44% had Crohn's disease, and 12% had undetermined type. More cases were on an immunosuppressant (19% vs 2%, P < 0.01) or steroids (8% vs 2%, P = 0.02) on admission compared with controls. More cases had prior abdominal surgery (P = 0.01). Cases had fewer brain injuries (P = 0.02) and higher admission Glasgow Coma Scale (P < 0.01) but required more neurosurgical intervention (P = 0.03). Cases required more orthopedic surgeries (P < 0.01) and more pain management consultations (P = 0.04). In multivariable analysis, IBD was associated with increased odds of operative intervention, pain management consultation, venous thromboembolism, and longer hospital stay (P < 0.05). Patients on immunosuppressants had increased odds of requiring surgery (P = 0.04), particularly orthopedic surgery (P < 0.01). CONCLUSIONS: Baseline factors associated with inflammatory bowel disease may place patients at higher risk for surgery and complications after trauma.

A Distinct Gut Microbiota Exists Within Crohn's Disease-Related Perianal Fistulae.

BACKGROUND: Gut bacteria are strongly suspected to play a key role in the pathogenesis of Crohn's disease (CD). Studies have demonstrated alterations in the gut microbiota in this patient population. The purpose of this study was to characterize the gut microbiota of fistulizing perianal CD. MATERIALS AND METHODS: Stool and fistula samples were obtained from patients undergoing surgery for CD-related anorectal fistulae. Microbial compositions of matched stool and fistula samples were characterized using 16S rRNA gene profiling. The effect of sample type, patient gender, disease classification (Montreal A/B), disease activity (Harvey Bradshaw Index), antibiotic use, and presence of active proctitis on microbial composition was assessed. RESULTS: Samples were obtained from 18 patients. Bacteroides was the most abundant genera across all samples collected, followed by Streptococcus and Bifidobacterium. Bifidobacterium was present at significantly higher levels in fecal samples than fistula samples, whereas Achromobacter and Corynebacterium were present at significantly higher levels in fistula samples. Antibiotic, but not thiopurine or antitumor necrosis factor medication, exposure affected the gut microbial composition. Patient gender, disease classification, disease activity, and presence of active proctitis did not alter stool or fistula microbiota. CONCLUSIONS: Our data show that the gut microbiota within CD-related anorectal fistulae is distinct from that in stool samples obtained from the same patients. We also observe a dysbiosis in patients treated with antibiotics compared with those not treated with antibiotics.

Early Postoperative Anti-TNF Therapy Does Not Increase Complications Following Abdominal Surgery in Crohn's Disease.

BACKGROUND: The impact of postoperative anti-TNF therapy on infectious complications following Crohn's disease surgery remains controversial. Use of anti-TNF therapy 2-4 weeks postoperatively appears safe, but safety of use within 2 weeks is unknown. AIMS: We sought to evaluate the effect of anti-TNF therapy initiated within 2 weeks of abdominal surgery in patients with Crohn's disease. METHODS: We conducted a retrospective review of adult Crohn's disease patients undergoing abdominal surgery between 2004 and 2011. Infectious and non-infectious complications were compared between patients exposed to anti-TNF therapy within 2 weeks or between 2 and 4 weeks postoperatively and to those without exposure using chi-squared and regression analysis. RESULTS: Three hundred thirty-one abdominal surgeries were included; 241 were without anti-TNF exposure, 46 received postoperative anti-TNF within 2 weeks of surgery, and 44 received anti-TNF therapy 2-4 weeks after surgery. Patients who received anti-TNF therapy within 2 weeks of surgery, those initiated between 2 and 4 weeks of surgery, and those who did not receive anti-TNF therapy within 4 weeks of surgery had no significant difference in rates of infectious complications (22%, 32%, 33%, p = 0.332). Rates of non-infectious complications (4%, 9%, 14%, p = 0.143), mortality (0%, 0%, 3%, p = 0.105), hospital readmission (17%, 16%, 15%, p = 0.940), and reoperation (11%, 11%, 16%, p = 0.563) were also similar between groups. CONCLUSIONS: Use of early anti-TNF therapy within 2 weeks or between 2 and 4 weeks following abdominal surgery did not increase risk of postoperative surgical infections in Crohn's patients.

Inpatient Complications Predict Tracheostomy Better than Admission Variables After Traumatic Brain Injury.

BACKGROUND: Data regarding who will require tracheostomy are lacking which may limit investigations into therapeutic effects of early tracheostomy. METHODS: We performed an observational study of adult traumatic brain injury (TBI) patients requiring intensive care unit (ICU) admission for ≥ 72 h and mechanical ventilation for ≥ 24 h between January 2014 and December 2014 at a level 1 trauma center. Patients who had life-sustaining measures withdrawn were excluded. Multivariable logistic regression analyses were used to assess admission and inpatient factors associated with receiving a tracheostomy and to develop predictive models. Inpatient complications prior to day 7 were used to standardize data collection for patients with and without tracheostomy. Patients who received tracheostomy prior to day 7 were excluded from analysis. RESULTS: In total, 209 patients (78% men, mean 48 years old, median Glasgow Coma Scale score (GCS) 8) met study criteria with tracheostomy performed in 94 (45%). Admission predictors of tracheostomy included GCS, chest tube, Injury Severity Score, and Marshall score. Inpatient factors associated with tracheostomy included the requirement for an external ventricular drain (EVD), number of operations, inpatient dialysis, aspiration, GCS on day 5, and reintubation. Multiple logistic regression analysis demonstrated that the number of operation room trips (adjusted odds ratio [AOR], 1.75; 95% CI, 1.04-2.97; P = 0.036), reintubation (AOR, 8.45; 95% CI, 1.91-37.44; P = .005), and placement of an EVD (AOR, 3.48; 95% CI, 1.27-9.58; P = .016) were independently associated with patients undergoing tracheostomy. Higher GCS on hospital day 5 (AOR, 0.52; 95% CI, 0.40-0.68; P < 0.001) was protective against tracheostomy. A model of inpatient variables only had a stronger association with tracheostomy than one with admission variables only (ROC AUC 0.93 vs 0.72, P < 0.001) and did not benefit from the addition of admission variables (ROC AUC 0.93 vs 0.92, P = 0.78). CONCLUSION: Potentially modifiable inpatient factors have a stronger association with tracheostomy than do admission characteristics. Multicenter studies are needed to validate the results.

Early Enteral Nutrition Is Associated with Reduced Morbidity in Critically Ill Soft Tissue Patients.

Soft tissue diseases including necrotizing soft tissue infections are associated with high mortality and morbidity with hospital-acquired infection rates up to 76 per cent. Critically ill patients with soft tissue infections have increased metabolic requirements; however, the effect of early nutrition on inhospital morbidity including nosocomial infection rates remains unclear. We hypothesized that enteral nutrition within 48 hours of intensive care unit admission would be associated with fewer hospital-acquired infections. We conducted a retrospective review of patients with soft tissue infection requiring intensive care unit admission for >72 hours from January 2013 through December 2014 to a high-volume, dedicated soft tissue service. Variables were compared using chi-squared, Student's t test, linear regression, and binary logistic regression analysis. Eighty-five patients met inclusion criteria; 80 per cent started enteral nutrition within 48 hours. Twenty-six per cent had a hospital-acquired infection postadmission requiring treatment. Patients started on enteral nutrition within 48 hours had fewer ventilator days (mean 5 vs 12) and shorter hospital length of stay (mean 18 vs 40 days) when adjusted for age, gender, and confounding variables present on admission. Patients receiving early nutrition also had fewer hospital-acquired infections (18 vs 59%) when adjusted for confounding factors (aOR 0.15, P = 0.045). No significant difference in mortality (13.2% early vs 5.9% late, P = 0.4) or for inhospital morbidity when evaluating percentage of goal calories or protein received or time to goal tube feed rate was found. Early enteral feeding is associated with reduced inhospital morbidity in critically ill soft tissue patients, including fewer hospital-acquired infections and ventilator days, and shorter total length of stay.

EAST Multicenter Trial on targeted temperature management for hanging-induced cardiac arrest.

BACKGROUND: We sought to determine the outcome of suicidal hanging and the impact of targeted temperature management (TTM) on hanging-induced cardiac arrest (CA) through an Eastern Association for the Surgery of Trauma (EAST) multicenter retrospective study. METHODS: We analyzed hanging patient data and TTM variables from January 1992 to December 2015. Cerebral performance category score of 1 or 2 was considered good neurologic outcome, while cerebral performance category score of 3 or 4 was considered poor outcome. Classification and Regression Trees recursive partitioning was used to develop multivariate predictive models for survival and neurologic outcome. RESULTS: A total of 692 hanging patients from 17 centers were analyzed for this study. Their overall survival rate was 77%, and the CA survival rate was 28.6%. The CA patients had significantly higher severity of illness and worse outcome than the non-CA patients. Of the 175 CA patients who survived to hospital admission, 81 patients (46.3%) received post-CA TTM. The unadjusted survival of TTM CA patients (24.7% vs 39.4%, p < 0.05) and good neurologic outcome (19.8% vs 37.2%, p < 0.05) were worse than non-TTM CA patients. However, when subgroup analyses were performed between those with an admission Glasgow Coma Scale score of 3 to 8, the differences between TTM and non-TTM CA survival (23.8% vs 30.0%, p = 0.37) and good neurologic outcome (18.8% vs 28.7%, p = 0.14) were not significant. Targeted temperature management implementation and post-CA management varied between the participating centers. Classification and Regression Trees models identified variables predictive of favorable and poor outcome for hanging and TTM patients with excellent accuracy. CONCLUSION: Cardiac arrest hanging patients had worse outcome than non-CA patients. Targeted temperature management CA patients had worse unadjusted survival and neurologic outcome than non-TTM patients. These findings may be explained by their higher severity of illness, variable TTM implementation, and differences in post-CA management. Future prospective studies are necessary to ascertain the effect of TTM on hanging outcome and to validate our Classification and Regression Trees models. LEVEL OF EVIDENCE: Therapeutic study, level IV; prognostic study, level III.

Inpatient mortality rates during an era of increased access to HIV testing and ART: A prospective observational study in Lilongwe, Malawi.

BACKGROUND: In the era of increased access to HIV testing and antiretroviral treatment (ART), the impact of HIV and ART status on inpatient mortality in Malawi is unknown. METHODS: We prospectively followed adult inpatients at Kamuzu Central Hospital medical wards in Lilongwe, Malawi, between 2011 and 2012, to evaluate causes of mortality, and the impact of HIV and ART status on mortality. We divided the study population into five categories: HIV-negative, new HIV-positive, ART-naïve patients, new ART-initiators, and ART-experienced. We used multivariate binomial regression models to compare risk of death between categories. RESULTS: Among 2911 admitted patients the mean age was 38.5 years, and 50% were women. Eighty-one percent (81%) of patients had a known HIV status at the time of discharge or death. Mortality was 19.4% and varied between 13.9% (HIV-negative patients) and 32.9% (HIV-positive patients on ART ≤1 year). In multivariable analyses adjusted for age, sex and leading causes of mortality, being new HIV-positive (RR = 1.64 95% CI: 1.16-2.32), ART-naive (RR = 2.28 95% CI: 1.66-2.32) or being a new ART-initiator (RR = 2.41 95% CI: 1.85-3.14) were associated with elevated risk of mortality compared to HIV-negative patients. ART-experienced patients had comparable mortality (RR = 1.33 95% CI: 0.94-1.88) to HIV-negative patients. CONCLUSION: HIV related mortality remains high among medical inpatients, especially among HIV-positive patients who recently initiated ART or have not started ART yet.

Post-discharge adherence with venous thromboembolism prophylaxis after orthopedic trauma: Results from a randomized controlled trial of aspirin versus low molecular weight heparin.

BACKGROUND: Orthopedic trauma patients are often treated with venous thromboembolism (VTE) chemoprophylaxis with aspirin or low molecular weight heparin (LMWH) after discharge from their index admission, but adherence patterns are not known. We hypothesized that overall adherence would be moderate and greater with aspirin compared to LMWH. METHODS: We conducted a randomized controlled trial of adult trauma patients with an operative extremity fracture or any pelvic/acetabular fracture requiring VTE prophylaxis. Patients were randomized to receive either LMWH 30 mg BID or aspirin 81 mg BID. Patients prescribed outpatient prophylaxis were contacted between 10 and 21 days after discharge to assess adherence measured by the validated Morisky Medication Adherence Scale (MMAS-8). Adherence scores were compared between the two treatment arms with similar results for intention-to-treat and as-treated analyses. As-treated multivariable logistic regression was performed to determine factors associated with low-medium adherence scores. RESULTS: One hundred fifty patients (64 on LMWH, 86 on aspirin) on chemoprophylaxis at time of follow-up completed the questionnaire. As-treated analysis showed that adherence was high overall (mean MMAS 7.2 out of 8, SD 1.5) and similar for the two regimens (LMWH: 7.4 vs. aspirin: 7.0, p = 0.13). However, patients on LMWH were more likely to feel hassled by their regimen (23% vs. 9%, p = 0.02). In a multivariable model, low-medium adherence was associated with taking LMWH as the prophylaxis medication (aOR 2.34, CI 1.06-5.18, p = 0.04), having to self-administer the prophylaxis (aOR 4.44, CI 1.45-13.61, p < 0.01), being of male sex (aOR 2.46, CI 1.10-5.49, p = 0.03), and of younger age (aOR 0.72 per additional 10 years of age, CI 0.57-0.91, p < 0.01). CONCLUSIONS: Overall post-discharge adherence with VTE prophylaxis was high. Several factors, including prophylaxis by LMWH, were associated with decreased adherence. These factors should be considered when managing patients and designing efficacy trials. LEVEL OF EVIDENCE: Therapeutic, level II.

Patient preferences for venous thromboembolism prophylaxis after injury: a discrete choice experiment.

OBJECTIVE: Limited evidence for the optimal venous thromboembolism (VTE) prophylaxis regimen in orthopaedic trauma leads to variability in regimens. We sought to delineate patient preferences towards cost, complication profile, and administration route (oral tablet vs. subcutaneous injection). DESIGN: Discrete choice experiment (DCE). SETTING: Level 1 trauma center in Baltimore, USA. PARTICIPANTS: 232 adult trauma patients (mean age 47.9 years) with pelvic or acetabular fractures or operative extremity fractures. PRIMARY AND SECONDARY OUTCOME MEASURES: Relative preferences and trade-off estimates for a 1% reduction in complications were estimated using multinomial logit modelling. Interaction terms were added to the model to assess heterogeneity in preferences. RESULTS: Patients preferred oral tablets over subcutaneous injections (marginal utility, 0.16; 95% CI: 0.11 - 0.21, P<0.0001). Preferences changed in favor of subcutaneous injections with an absolute risk reduction of 6.98% in bleeding, 4.53% in wound complications requiring reoperation, 1.27% in VTE, and 0.07% in death from pulmonary embolism (PE). Patient characteristics (sex, race, type of injury, time since injury) affected patient preferences (P<0.01). CONCLUSIONS: Patients preferred oral prophylaxis and were most concerned about risk of death from PE. Furthermore, the findings estimated the trade-offs acceptable to patients and heterogeneity in preferences for VTE prophylaxis.

Task Shifting: The Use of Laypersons for Acquisition of Vital Signs Data for Clinical Decision Making in the Emergency Room Following Traumatic Injury.

IMPORTANCE: In resource-limited settings, identification of successful and sustainable task-shifting interventions is important for improving care. OBJECTIVE: To determine whether the training of lay people to take vital signs as trauma clerks is an effective and sustainable method to increase availability of vital signs in the initial evaluation of trauma patients. DESIGN: We conducted a quasi-experimental study of patients presenting with traumatic injury pre- and post-intervention. SETTING: The study was conducted at Kamuzu Central Hospital, a tertiary care referral hospital, in Lilongwe, Malawi. PARTICIPANTS: All adult (age ≥ 18 years) trauma patients presenting to emergency department over a six-month period from January to June prior to intervention (2011), immediately post-intervention (2012), 1 year post-intervention (2013) and 2 years post-intervention (2014). INTERVENTION: Lay people were trained to take and record vital signs. MAIN OUTCOMES AND MEASURES: The number of patients with recorded vital signs pre- and post-intervention and sustainability of the intervention as determined by time-series analysis. RESULTS: Availability of vital signs on initial evaluation of trauma patients increased significantly post-intervention. The percentage of patients with at least one vital sign recorded increased from 23.5 to 92.1%, and the percentage of patients with all vital signs recorded increased from 4.1 to 91.4%. Availability of Glasgow Coma Scale also increased from 40.3 to 88.6%. Increased documentation of vital signs continued at 1 year and 2 years post-intervention. However, the percentage of documented vital signs did decrease slightly after the US-trained medical student and surgeon who trained the trauma clerks were no longer available in country, except for Glasgow Coma Scale. Patients who died during emergency department evaluation were significantly less likely to have vital signs recorded. CONCLUSIONS AND RELEVANCE: The training of lay people to collect vital signs and Glasgow Coma Scale is an effective and sustainable method of task shifting in a resource-limited setting.

Hand Hygiene Compliance in the Setting of Trauma Resuscitation.

INTRODUCTION: Healthcare-associated infections are a significant health burden, and hand hygiene (HH) is an essential prevention strategy. World Health Organization (WHO) 2009 guidelines recommend washing hands during five moments of patient care; 1)before touching a patient; 2)before a clean procedure; 3)after body fluid exposure; and 4)after touching a patient or 5)patient surroundings. HH opportunities at these 5 moments are frequent and compliance is low (22-60%). Infection risk is particularly high in trauma patients, and HH compliance during active trauma resuscitation has yet to be evaluated. MATERIALS AND METHODS: Using video surveillance, all healthcare worker (HCW)-patient interactions for 30 patients were retrospectively reviewed for HH compliance according to WHO guidelines and glove use during initial resuscitation at a level-1 trauma center. RESULTS: 342 HCW-patient interactions and 1034 HH opportunities were observed. HH compliance with the WHO moments was 7% (71/1034) overall; 3% (10/375) before patient contact, 0% (0/178) before a clean procedure, 11% (2/19) after body fluid contact, 15% (57/376) after patient contact and 2% (2/86) after contact with the environment. Glove use was more common, particularly before (69%) and after (47%) patient contact and after body fluid contact (58%). No HH was observed before clean procedures, but HCW donned new gloves 75% of the time before bedside procedures. If donning/removing gloves was included with HH as compliant, compliance was 57% overall. CONCLUSION: HH opportunities are frequent and compliance with WHO HH guidelines may be infeasible, requiring significant amounts of time that may be better spent with the patient during the golden hour of trauma resuscitation. In an era where more scrutiny is being applied to patient safety, particularly the prevention of inpatient infections, more research is needed to identify alternative strategies (e.g. glove use, prioritizing moments) that may more effectively promote compliance in this setting.

Outcome of suicidal hanging patients and the role of targeted temperature management in hanging-induced cardiac arrest.

BACKGROUND: No specific treatment is available for hanging-induced cardiac arrest (CA). We hypothesized that targeted temperature management (TTM) may improve the outcome of hanging-induced CA patients at hospital discharge. METHODS: A retrospective chart review of our trauma registry from January 1999 to September 2015 was conducted to identify patients 18 years or older with hanging as their injury type. All TTMs were performed to achieve 32°C to 34°C for 24 hours. The survival and Cerebral Performance Category scores at hospital discharge were determined. RESULTS: We identified 138 patients. Their average age was 32.1 ± 10.0 years; 81.3% were men, and 69.8% were white. The mortality rate was 15.2% (21 of 138). Overall, 79.7% (110 of 138) of the near-hanging patients did not sustain out-of-hospital CA (non-CA), and 1.8% of them (2 of 110) received TTM. All 110 non-CA patients survived to hospital discharge and 99.1% (109 of 110) had good neurologic outcome. The remaining 20.3% (28 of 138) of hanging patients suffered out-of-hospital CA; six of these patients were dead on arrival and thus excluded from further analysis. TTM was performed for 40.9% (9 of 22) of the remaining CA patients; 44.4% (4 of 9) of TTM CA patients survived to hospital discharge versus 23.1% (3 of 13) of non-TTM CA patients. There were no significant differences between the overall survival and patients discharged with good neurologic outcome between the TTM and non-TTM CA groups. CONCLUSION: Non-CA near-hanging patients are more likely to have favorable outcome than the CA patients. Our study was not large enough to detect survival and neurologic outcome differences between the TTM and non-TTM CA groups. A multicenter retrospective study is underway to determine the impact of TTM on the outcome of hanging-induced CA patients. LEVEL OF EVIDENCE: Therapeutic study, level IV; prognostic study, level IV.

Injury Characteristics and Outcomes in Elderly Trauma Patients in Sub-Saharan Africa.

BACKGROUND: Traumatic injury in the elderly is an emerging global problem with an associated increase in morbidity and mortality. This study sought to describe the epidemiology of elderly injury and outcomes in sub-Saharan Africa. METHODS: We conducted a retrospective analysis of adult patients (≥ 18 years) with traumatic injuries presenting to the Kamuzu Central Hospital (KCH) in Lilongwe, Malawi, over 5 years (2009-2013). Elderly patients were defined as adults aged ≥65 years and compared to adults aged 18-44 and 45-64 years. We used propensity score matching and logistic regression to compare the odds of mortality between age groups using the youngest age group as the reference. RESULTS: 42,816 Adult patients with traumatic injuries presented to KCH during the study period. 1253 patients (2.9 %) were aged ≥65 years with a male preponderance (77.4 %). Injuries occurred more often at home as age increased (25.3, 29.5, 41.1 %, p < 0.001) and falls were more common (14.1, 23.8, 36.3 %, p < 0.001) for elderly patients. Elderly age was associated with a higher proportion of hospital admissions (10.6, 21.3, 35.2 %, p < 0.001). Upon propensity score matching and logistic regression analysis, the odds ratio of mortality for patients aged ≥65 was 3.15 (95 % CI 1.45, 6.82, p = 0.0037) compared to the youngest age group (18-44 years). CONCLUSIONS: Elderly trauma in a resource-poor area in sub-Saharan Africa is associated with a significant increase in hospital admissions and mortality. Significant improvements in trauma systems, pre-hospital care, and hospital capacity for older, critically ill patients are imperative.