Accelerated Biologic Aging, Chronic Stress, and Risk for Sepsis and Organ Failure Following Trauma.

Chronic stress and accelerated aging have been shown to impact the inflammatory response and related outcomes like sepsis and organ failure, but data are lacking in the trauma literature. The purpose of this study was to investigate potential relationships between pretrauma stress and posttrauma outcomes. The hypothesis was that pretrauma chronic stress accelerates aging, which increases susceptibility to posttrauma sepsis and organ failure. In this prospective, correlational study, chronic stress and accelerated biologic aging were compared to the occurrence of systemic inflammatory response syndrome, sepsis, and organ failure in trauma patients aged 18-44 years. Results supported the hypothesis with significant overall associations between susceptibility to sepsis and accelerated biologic aging (n = 142). There were also significant negative associations between mean cytokine levels and chronic stress. The strongest association was found between mean interleukin-1ß (IL-1ß) and human telomerase reverse transcriptase (hTERT), r(101) = -0.28), p = .004. Significant negative associations were found between mean cytokine levels, IL-12p70, r(108) = -0.20, p = .034; and tumor necrosis factor-α (TNF-α), r(108) = -0.20, p = .033, and positive life events via the behavioral measure of chronic stress. Results may help identify individuals at increased risk for poor outcomes of trauma and inform interventions that may reduce the risk for sepsis and organ failure.

The Social Determinants of Trauma: A Trauma Disparities Scoping Review and Framework.

The drivers of trauma disparities are multiple and complex; yet, understanding the causes will direct needed interventions. The aims of this article are to (1) explore how the injured patient, his or her social environment, and the health care system interact to contribute to trauma disparities and examine the evidence in support of interventions and (2) develop a conceptual framework that captures the socioecological context of trauma disparities. Using a scoping review methodology, articles were identified through PubMed and CINAHL between 2000 and 2015. Data were extracted on the patient population, social determinants of health, and interventions targeting trauma disparities and violence. Based on the scoping review of 663 relevant articles, we inductively developed a conceptual model, The Social Determinants of Trauma: A Trauma Disparities Framework, based on the categorization of articles by: institutional power (n = 9), social context-place (n = 117), discrimination experiences (n = 59), behaviors and comorbidities (n = 57), disparities research (n = 18), and trauma outcomes (n = 85). Intervention groupings included social services investment (n = 54), patient factors (n = 88), hospital factors (n = 27), workforce factors (n = 31), and performance improvement (n = 118). This scoping review produced a needed taxonomy scheme of the drivers of trauma disparities and known interventions that in turn informed the development of The Social Determinants of Trauma: A Trauma Disparities Framework. This study adds to the trauma disparities literature by establishing social context as a key contributor to disparities in trauma outcomes and provides a road map for future trauma disparities research.

Descriptive Analysis of Venous Thromboembolism in Georgia Trauma Centers Compared with National Trauma Centers Participating in the Trauma Quality Improvement Program.

This study was designed to compare the incidence of venous thromboembolism (VTE) in Georgia trauma centers with other national trauma centers participating in the Trauma Quality Improvement Program (TQIP). The use of chemoprophylaxis and characteristics of patients who developed VTE were also examined. We conducted a retrospective observational study of 325,703 trauma admissions to 245 trauma centers from 2013 to 2014. Patient demographics, rate of VTE, as well as the use, type, and timing of chemoprophylaxis were compared between patients admitted to Georgia and non-Georgia trauma centers. The rate of VTE in Georgia trauma centers was 1.9 per cent compared with 2.1 per cent in other national trauma centers. Overall, 49.6 per cent of Georgia patients and 45.5 per cent of patients in other trauma centers had documented chemoprophylaxis. Low molecular weight heparin was the most commonly used medication. Most patients who developed VTE did so despite receiving prophylaxis. The rate of VTE despite prophylaxis was 3.2 per cent in Georgia and 3.1 per cent in non-Georgia trauma centers. Mortality associated with VTE was higher in Georgia trauma centers compared with national TQIP benchmarks. The incidence of VTE and use of chemoprophylaxis within Georgia trauma centers were similar to national TQIP data. Interestingly, most patients who developed VTE in both populations received VTE prophylaxis. Further research is needed to develop best-practice guidelines for prevention, early detection, and treatment in high-risk populations.

A Decade Evaluation of a State Trauma System: Has Access to Inpatient Trauma Care at Designated Trauma Centers Improved?

Recently, the trauma center component of the Georgia trauma system was evaluated demonstrating a 10 per cent probability of increased survival for severely injured patients treated at designated trauma centers (DTCs) versus nontrauma centers. The purpose of this study was to determine the effectiveness of a state trauma system to provide access to inpatient trauma care at DTCs for its residents. We reviewed 371,786 patients from the state's discharge database and identified 255,657 treated at either a DTC or a nontrauma center between 2003 and 2012. Injury severity was assigned using the International Classification Injury Severity Score method. Injury was categorized as mild, moderate, or severe. Patients were also categorized by age and injury type. Access improved over time in all severity levels, age groups, and injury types. Although elderly had the largest improvement in access, still only 70 per cent were treated at a DTC. During the study period, increases were noted for all age groups, injury severity levels, and types of injury. A closer examination of the injured elderly population is needed to determine the cause of lower utilization by this age group. Overall, the state's trauma system continues to mature by providing patients with increased access to treatment at DTCs.

The Association of Race, Socioeconomic Status, and Insurance on Trauma Mortality.

BACKGROUND: Although race, socioeconomic status, and insurance individually are associated with trauma mortality, their complex interactions remain ill defined. METHODS: This retrospective cross-sectional study from a single Level I center in a racially diverse community was linked by socioeconomic status, insurance, and race from 2000 to 2009 for trauma patients aged 18-64 years with an injury severity score more than 9. The outcome measure was inpatient mortality. Multiple logistic regression analyses were performed to investigate confounding variables known to predict trauma mortality. RESULTS: A total of 4,007 patients met inclusion criteria. Individually, race, socioeconomic status, and insurance were associated with increased mortality rate; however, in multivariate analysis, only insurance remained statistically significant and varied by insurance type with age. Odds of death were higher for Medicare (odds ratio [OR] = 3.63, p = .006) and other insurance (OR = 3.02, p = .007) than for Private Insurance. However, when grouped into ages 18-40 years versus 41-64 years, the insurance influences changed with Uninsured and Other insurance (driven by Tricare) predicting mortality in the younger age group, while Medicare remained predictive in the older age group. CONCLUSIONS: Insurance type, not race or socioeconomic status, is associated with trauma mortality and varies with age. Both Uninsured and Tricare insurance were associated with mortality in younger age trauma patients, whereas Medicare was associated with mortality in older age trauma patients. The lethality of the Tricare group warrants further investigation.

An analysis of the effectiveness of a state trauma system: treatment at designated trauma centers is associated with an increased probability of survival.

BACKGROUND: States struggle to continue support for recruitment, funding and development of designated trauma centers (DTCs). The purpose of this study was to evaluate the probability of survival for injured patients treated at DTCs versus nontrauma centers. METHODS: We reviewed 188,348 patients from the state's hospital discharge database and identified 13,953 severely injured patients admitted to either a DTC or a nontrauma center between 2008 and 2012. DRG International Classification of Diseases-9th Rev. Injury Severity Scores (ICISS), an accepted indicator of injury severity, was assigned to each patient. Severe injury was defined as an ICISS less than 0.85 (indicating ≥15% probability of mortality). Three subgroups of the severely injured patients were defined as most critical, intermediate critical, and least critical. A full information maximum likelihood bivariate probit model was used to determine the differences in the probability of survival for matched cohorts. RESULTS: After controlling for injury severity, injury type, patient demographics, the presence of comorbidities, as well as insurance type and status, severely injured patients treated at a DTC have a 10% increased probability of survival. The largest improvement was seen in the intermediate subgroup. CONCLUSION: Treatment of severely injured patients at a DTC is associated with an improved probability of survival. This argues for continued resources in support of DTCs within a defined statewide network. LEVEL OF EVIDENCE: Epidemiologic study, level III.

Methods used by critical care nurses to verify feeding tube placement in clinical practice.

BACKGROUND: The American Association of Critical-Care Nurses practice alert on verification of feeding tube placement makes evidence-based practice recommendations to guide nursing management of adult patients with blindly inserted feeding tubes. Many bedside verification methods do not allow detection of improper positioning of a feeding tube within the gastrointestinal tract, thereby increasing aspiration risk. OBJECTIVES: To determine how the expected practices from the American Association of Critical-Care Nurses practice alert were implemented by critical care nurses. METHODS: This study was part of a larger national, online survey that was completed by 370 critical care nurses. Descriptive statistics were used to analyze the data. RESULTS: Seventy-eight percent of nurses used a variety of methods to verify initial placement of feeding tubes, although 14% were unaware that tube position should be confirmed every 4 hours. Despite the inaccuracy of auscultation methods, only 12% of nurses avoided this practice all of the time. CONCLUSIONS: Implementation of expected clinical practices from this guideline varied. Nurses are encouraged to implement expected practices from this evidence-based, peer reviewed practice alert to minimize risk for patient harm.

Factors influencing critical care nurses' adoption of the AACN practice alert on verification of feeding tube placement.

BACKGROUND: Clinical practice guidelines are intended to bridge the research-practice gap, yet little is known about how critical care nurses adopt guidelines. Feeding tube verification practices remain variable and have led to patient harm and death. OBJECTIVES: To examine factors influencing critical care nurses' adoption of the American Association of Critical-Care Nurses (AACN) practice alert on verification of feeding tube placement and its 4 recommended clinical practices. METHODS: Critical care nurses were invited to participate in a national, online questionnaire, guided by Rogers' diffusion of innovation framework. Descriptive statistics and logistic regression were used for data analysis. Alpha level was set at 0.05. RESULTS: Fifty-five percent of the 370 participating nurses were aware of the practice alert, and 45% had adopted it in practice. Only 29% of the adopters had also implemented all 4 clinical practices. Significant predictors of adoption included BSN or higher nursing education and guideline characteristics of observability and trialability. Predictors of implementation of the clinical practices included staff nurse/charge nurse role, academic medical center, research/web-based information sources, and perception of a policy. Policy was the only significant predictor of implementation of all 4 practices. Adoption of the practice alert was also a predictor for 2 of 4 clinical practices. CONCLUSIONS: Personal and organizational factors influenced implementation of practices associated with an AACN practice alert. Although a research-practice gap exists, the practice alert was a significant source of information for 2 of the clinical practices.

"It takes a village" to raise research productivity: Impact of a Trauma Interdisciplinary Group for Research (TIGR) at an urban, Level 1 trauma center.

BACKGROUND: Few interdisciplinary research groups include basic scientists, pharmacists, therapists, nutritionists, lab technicians, as well as trauma patients and families, in addition to clinicians. Increasing interprofessional diversity within scientific teams working to improve trauma care is a goal of national organizations and federal funding agencies like the National Institutes of Health (NIH). This paper describes the design, implementation, and outcomes of a Trauma Interdisciplinary Group for Research (TIGR) at a Level 1 trauma center as it relates to increasing research productivity, with specific examples excerpted from an on-going NIH-funded study. METHODS: We utilized a pre-test/post-test design with objectives aimed at measuring increases in research productivity following a targeted intervention. A SWOT (strengths, weaknesses, opportunities, threats) analysis was used to develop the intervention which included research skill-building activities, accomplished by adding multidisciplinary investigators to an existing NIH-funded project. The NIH project aimed to test the hypothesis that accelerated biologic aging from chronic stress increases baseline inflammation and reduces inflammatory response to trauma (projected N=150). Pre/Post-TIGR data related to participant screening, recruitment, consent, and research processes were compared. Research productivity was measured through abstracts, publications, and investigator-initiated projects. RESULTS: Research products increased from N =12 to N=42; (~ 400%). Research proposals for federal funding increased from N=0 to N=3, with success rate of 66%. Participant screenings for the NIH-funded study increased from N=40 to N=313. Consents increased from N=14 to N=70. Lab service fees were reduced from $300/participant to $5/participant. CONCLUSIONS: Adding diversity to our scientific team via TIGR was exponentially successful in 1) improving research productivity, 2) reducing research costs, and 3) increasing research products and mentoring activities that the team prior to TIGR had not entertained. The team is now well-positioned to apply for more federally funded projects and more trauma clinicians are considering research careers than before.

"It takes a village" to raise research productivity: impact of a Trauma Interdisciplinary Group for Research at an urban, Level 1 trauma center.

BACKGROUND: Few interdisciplinary research groups include basic scientists, pharmacists, therapists, nutritionists, laboratory technicians, as well as trauma patients and families, in addition to clinicians. Increasing interprofessional diversity within scientific teams working to improve trauma care is a goal of national organizations and federal funding agencies such as the National Institutes of Health (NIH). This article describes the design, implementation, and outcomes of a Trauma Interdisciplinary Group for Research (TIGR) at a Level 1 trauma center as it relates to increasing research productivity, with specific examples excerpted from an ongoing NIH-funded study. METHODS: We used a pretest/posttest design with objectives aimed at measuring increases in research productivity following a targeted intervention. A SWOT (strengths, weaknesses, opportunities, and threats) analysis was used to develop the intervention, which included research skill-building activities, accomplished by adding multidisciplinary investigators to an existing NIH-funded project. The NIH project aimed to test the hypothesis that accelerated biologic aging from chronic stress increases baseline inflammation and reduces inflammatory response to trauma (projected n = 150). Pre-TIGR/post-TIGR data related to participant screening, recruitment, consent, and research processes were compared. Research productivity was measured through abstracts, publications, and investigator-initiated projects. RESULTS: Research products increased from 12 to 42 (approximately 400%). Research proposals for federal funding increased from 0 to 3, with success rate of 66%. Participant screenings for the NIH-funded study increased from 40 to 313. Consents increased from 14 to 70. Laboratory service fees were reduced from $300 per participant to $5 per participant. CONCLUSION: Adding diversity to our scientific team via TIGR was exponentially successful in (1) improving research productivity, (2) reducing research costs, and (3) increasing research products and mentoring activities that the team before TIGR had not entertained. The team is now well positioned to apply for more federally funded projects, and more trauma clinicians are considering research careers than before.

Demographic differences in systemic inflammatory response syndrome score after trauma.

BACKGROUND: Demographic differences in health outcomes have been reported for chronic diseases, but few data exist on these differences in trauma (defined as acute, life-threatening injuries). OBJECTIVE: To investigate the relationship between the systemic inflammatory response syndrome score after trauma and race/ethnicity and socioeconomic status. METHODS: A retrospective chart review of 600 patients from a level I trauma center (1997-2007) was conducted. Inclusion criteria were age 18 to 44 years, Injury Severity Score 15 or greater, and admission to an intensive care unit. Exclusion criteria were use of transfusions, spinal cord injuries, comorbid conditions affecting the inflammatory response, use of nonsteroidal anti-inflammatory medications, and missing data (final sample, 246 charts/patients). Systemic inflammatory response syndrome was measured by using the systemic inflammatory response syndrome score. Race was self-reported. Socioeconomic status was defined by insurance and employment. Descriptive statistics, Wilcoxon rank sum, Kruskal-Wallis, and χ(2) tests were used for analysis. RESULTS: Compared with whites, African Americans (n = 94) had fewer occurrences of the syndrome (P = .04) and a 14% lower white blood cell count on admission to the intensive care unit (mean, 15,200/µL; 95% CI, 14,400/µL to 16,000/µL vs mean 17,700/µL; 95% CI, 16,700/µL to 18,700/µL; P < .001). CONCLUSIONS: Demographic differences exist in the systemic inflammatory response syndrome score after trauma. Additional studies in larger populations of patients are needed as well as basic science and translational research to determine potential mechanisms that may explain the differences.

Systemic inflammatory response syndrome score and race as predictors of length of stay in the intensive care unit.

BACKGROUND: Identifying predictors of length of stay in the intensive care unit can help critical care clinicians prioritize care in patients with acute, life-threatening injuries. OBJECTIVE: To determine if systemic inflammatory response syndrome scores are predictive of length of stay in the intensive care unit in patients with acute, life-threatening injuries. METHODS: Retrospective chart reviews were completed on patients with acute, life-threatening injuries admitted to the intensive care unit at a level I trauma center in the southeastern United States. All 246 eligible charts from the trauma registry database from 1998 to 2007 were included. Systemic inflammatory response syndrome scores measured on admission were correlated with length of stay in the intensive care unit. Data on race, sex, age, smoking status, and injury severity score also were collected. Univariate and multivariate regression modeling was used to analyze data. RESULTS: Severe systemic inflammatory response syndrome scores on admission to the intensive care unit were predictive of length of stay in the unit (F=15.83; P<.001), as was white race (F=9.7; P=.002), and injury severity score (F=20.23; P<.001). CONCLUSIONS: Systemic inflammatory response syndrome scores can be measured quickly and easily at the bedside. Data support use of the score to predict length of stay in the intensive care unit.

Impact of pretest on posttest knowledge scores with a Solomon Four research design.

There is a paucity of research on the effects of pretest measurement with prostate cancer screening. What effect does a pretest measurement have on posttest outcomes? This research reports knowledge of prostate cancer screening among men randomized to an Enhanced decision aid versus an Usual Care decision aid. Using a Solomon Four research design, there were a total of 198 men in 4 groups. Most of the sample was African American (78%), with a mean age of 52 years. The greatest posttest knowledge occurred with the Enhanced decision aid in contrast to the Usual Care. The Enhanced/Usual Care groups that had both a pretest and posttest and had received a previous digital rectal examination had the highest means (P = .015), with means of 9.1 and 7.0, respectively. Among men who had a previous digital rectal examination, the greatest increase in score occurred among men randomized to the Enhanced decision aid in contrast to the Usual Care decision aid, 2.9 versus 0.4 (P = .008). The outcome varied based on the status of (1) random group assignment of the Solomon Four design and (2) status of previous digital rectal examination. Implications for nurses include consideration 1 of a pretest to increase posttest knowledge scores.

Racial disparities in acute outcomes of life-threatening injury.

PURPOSE: To critically analyze racial and ethnic disparities in acute outcomes of life-threatening injury in the United States (US). DESIGN: Integrative review of literature. METHODS: A search of Medline (1966-2005) and CINAHL (Cumulative Index to Nursing and Allied Health Literature; 1982-2002) scientific literature databases was undertaken to identify research aimed at correlating minority race and ethnicity to acute outcomes of life-threatening injury in the US. RESULTS: Although injury is the leading cause of death for adults 15 to 44 years of age, racial and ethnic health disparities in acute outcomes of life-threatening injury have been relatively unexplored: only seven of 352 (2%) studies. The findings from these studies were mixed. Four studies indicated significant relationships between race or ethnicity to acute outcomes in injury morbidity and mortality, but three studies showed no significant relationships between these variables. Other variables associated with health disparities, such as income and education, were rarely (income) or not (education) addressed. CONCLUSIONS: These inconclusive results indicate the need for more research aimed at investigating racial and ethnic disparities in acute outcomes of life-threatening injury.

Defining "disasters" with implications for nursing scholarship and practice.

Nurses have long been a part of disaster care, yet the nurses' unique approaches to disaster victims have not been reported in the nursing literature. This situation raises the questions, "How does disaster nursing differ than general nursing?" and "What defines the specialty care of disaster nursing?" An analysis of the term "disaster" and the concepts that have been used to build a theoretic base for disaster nursing are presented.