Practice patterns in the use of retrievable inferior vena cava filters in a trauma population: a single-center experience.

BACKGROUND: The use of permanent inferior vena cava filters (IVCFs) offers protection against pulmonary embolism (PE) but increases the long-term risk of deep vein thrombosis (DVT) and does not affect long-term mortality. The use of retrievable IVCFs in trauma patients offers the dual advantage of protection against PE during the risk period and the option of filter removal thus avoiding complications of DVT. Despite the safety of removal, it is likely that many of these retrievable filters are not removed. METHODS: This was a retrospective, single-center, observational cohort study at a rural level I trauma center. We sought to investigate the number of patients and the circumstances under which retrievable IVCFs were placed and removed. RESULTS: During a 4-year period, 3,455 trauma patients were admitted and 125 patients had retrievable IVCFs placed (71 therapeutic and 54 prophylactic). The most common indications were traumatic brain and spinal cord injuries (66%). During in-hospital filter use, there were 36 new incidences (29%) of PE (1) and DVT (35). Nine patients died before removal. In 40 patients (32%), removal was attempted, and 32 (26%) retrievable IVCFs were successfully removed and in most patients (76%) within 180 days of insertion. Seventeen patients were transferred out of the area for extended care and lost to follow-up. In 55 patients, the filters were not removed. In 20 patients, the surgeon decided against removal. Thirty patients were transferred to extended care or rehabilitation within the community, but they did not return for removal. Thus, of 108/125 patients with follow-up, 76 patients (70%) did not have their IVCFs removed, and 50 patients did not have their IVCFs removed because of the choice of the surgeon, extended care, or rehabilitation. CONCLUSIONS: The use of retrievable IVCFs, when necessary, produced predictable protection against PE and DVT complications. Despite the opportunity for removal, most patients, in fact, did not have their filters removed, even when posthospital care could be tracked. The practices of the surgeon, the transfer to extended-care facilities, near or far, and the reluctance to remove long-standing IVCFs contributed to the high-retention rate.

Medication reconciliation in a rural trauma population.

STUDY OBJECTIVE: Medication errors during hospitalization can lead to adverse drug events. Because of preoccupation by health care providers with life-threatening injuries, trauma patients may be particularly prone to medication errors. Medication reconciliation on admission can result in decreased medication errors and adverse drug events in this patient population. The purpose of this study is to determine the accuracy of medication histories obtained on trauma patients by initial health care providers compared to a medication reconciliation process by a designated clinical pharmacist after the patient's admission and secondarily to determine whether trauma-associated factors affected medication accuracy. METHODS: This was a prospective enrollment study during 13 months in which trauma patients admitted to a Level I trauma center were enrolled in a stepwise medication reconciliation process by the clinical pharmacist. The setting was a rural Level I trauma center. Patients admitted to the trauma service were studied. The intervention was medication reconciliation by a clinical pharmacist. The main outcome measure was accuracy of medication history by initial trauma health care providers compared to a medication reconciliation process by a clinical pharmacist who compared all sources, including telephone calls to pharmacies. Patients taking no medications (whether correctly identified as such or not) were not analyzed in these results. Variables examined included admission medication list accuracy, age, trauma team activation mode, Injury Severity Score, and Glasgow Coma Scale (GCS) score. RESULTS: Two hundred thirty-four patients were enrolled. Eighty-four of 234 patients (36%) had an Injury Severity Score greater than 15. Medications were reconciled within an average of 3 days of admission (range 1 to 8) by the clinical pharmacist. Overall, medications as reconciled by the clinical pharmacist were recorded correctly for 15% of patients. Admission trauma team medication lists were inaccurate in 224 of 234 cases (96%). Admitting nurses' lists were more accurate than the trauma team's (11% versus 4%; 95% confidence interval 2.5% to 11.2%). Errors were found by the clinical pharmacist in medication name, strength, route, and frequency. No patients (0/20) with admission GCS less than 13 had accurate medication lists. Seventy of 84 patients (83%) with an Injury Severity Score greater than 15 had inaccurate medication lists. Ten of 234 patients (4%) were ordered wrong medications, and 1 adverse drug event (hypoglycemia) occurred. The median duration of the reconciliation process was 2 days. Only 12% of cases were completed in 1 day, and almost 25% required 3 or more (maximum 8) days. CONCLUSION: This study showed that medication history recorded on admission was inaccurate. This patient population overall was susceptible to medication inaccuracies from multiple sources, even with duplication of medication histories by initial health care providers. Medication reconciliation for trauma patients by a clinical pharmacist may improve safety and prevent adverse drug events but did not occur quickly in this setting.

Traumatic subarachnoid hemorrhage and QTc prolongation.

OBJECTIVE: Spontaneous subarachnoid hemorrhage (SAH) causes a prolonged corrected QT interval (QTc) in 25% to 90% of patients, but whether this occurs with traumatic SAH (tSAH) is unknown. This investigation was conducted to determine whether QTc prolongation occurs with tSAH and to evaluate QTc prolongation with respect to severity of tSAH. DESIGN: Records of 104 consecutive tSAH patients were reviewed. A QTc was calculated on posttrauma day (PTD) 0, 1, and 3. Cranial computed tomography (CT) scans were graded for severity using a previously validated scale. QTc intervals were compared based on CT scan severity. SETTING: Pennsylvania level II trauma center. PATIENTS: Trauma patients with tSAH. INTERVENTIONS: None MEASUREMENTS AND MAIN RESULTS: QTc prolongation occurred in 67% of those with tSAH. Mean QTc intervals for PTD0, PTD1, and PTD3 were 470 +/- 69 ms, 467 +/- 72 ms, and 465 +/- 50 ms, respectively. As the severity of the tSAH increased, the average QTc became more prolonged (Pearson's r = 0.855, P = 0.003). CONCLUSIONS: tSAH is a common cause of an acquired prolonged QTc syndrome. As the tSAH becomes more severe, the QTc becomes more prolonged.

When the bough breaks: a 10-year review of logging injuries treated at a rural trauma center in Pennsylvania.

The purpose of this study was to describe logging-related injuries at a Pennsylvania trauma center and evaluate the impact of helmets and profession. Charts of patients from 1990 through 1999 admitted after logging accidents were retrospectively reviewed. Most injuries were to the head (71 in 28 patients). Injury Severity Score was greater for helmeted loggers (21.0 vs 11.8; P = 0.02) but did not differ by profession. Mean hospital stay was not significantly different for helmeted loggers (9.6 vs 5.4 days, P = 0.499). Mean length of stay was 8.2 days and 3.5 days for professionals and nonprofessionals, respectively (P = 0.01). Professional loggers tended to remain hospitalized longer. Helmet use does not appear to affect injury severity; however, this could be a result of the catastrophic nature of many logging accidents. Most loggers in this study were not wearing helmets, which suggests that improved educational efforts are needed to improve safety in this dangerous occupation.