Prediction of Time to Hemodynamic Stabilization of Unstable Injured Patient Encounters Using Electronic Medical Record Data.

BACKGROUND: This study sought to predict time to patient hemodynamic stabilization during trauma resuscitations of hypotensive patient encounters using electronic medical records (EMR) data. METHODS: This observational cohort study leveraged EMR data from a nine-hospital academic system composed of Level I, Level II and non-trauma centers. Injured, hemodynamically unstable (initial systolic blood pressure < 90 mmHg) emergency encounters from 2015-2020 were identified. Stabilization was defined as documented subsequent systolic blood pressure > 90 mmHg. We predicted time to stabilization testing random forests, gradient boosting and ensembles using patient, injury, treatment, EPIC Trauma Narrator and hospital features from the first four hours of care. RESULTS: Of 177,127 encounters, 1347 (0.8%) arrived hemodynamically unstable; 168 (12.5%) presented to Level I trauma centers, 853 (63.3%) to Level II, and 326 (24.2%) to non-trauma centers. Of those, 747 (55.5%) were stabilized with a median of 50 minutes (IQR 21-101 min). Stabilization was documented in 94.6% of unstable patient encounters at Level I, 57.6% at Level II and 29.8% at non-trauma centers (p < 0.001). Time to stabilization was predicted with a C-index of 0.80. The most predictive features were EPIC Trauma Narrator measures; documented patient arrival, provider exam, and disposition decision. In-hospital mortality was highest at Level I, 3.0% vs. 1.2% at Level II, and 0.3% at non-trauma centers (p < 0.001). Importantly, non-trauma centers had the highest re-triage rate to another acute care hospital (12.0%) compared to Level II centers (4.0%, p < 0.001). CONCLUSION: Time to stabilization of unstable injured patients can be predicted with EMR data.

Hospital variation in adoption of balanced transfusion practices among injured patients requiring blood transfusions.

BACKGROUND: This study sought to measure hospital variability in adoption of balanced transfusion following the Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) guidelines. We hypothesized hospital adoption rates of balanced transfusion would be low, and vary significantly among hospitals after controlling for patient, injury and hospital characteristics. STUDY DESIGN AND METHODS: This was an observational cohort study of injured adult patients (≥16 years) in Trauma Quality Improvement Program hospitals 2016-2021. Inclusion criteria were hypotensive patients receiving one transfusion of packed red blood cells, fresh frozen plasma, platelets, or cryoprecipitate. Balanced transfusion was defined as ≥1 ratio of plasma to packed red blood cells or platelets to packed red blood cells or whole blood use at 4 hours. Hierarchical multivariable logistic regression quantified residual hospital-level variability in balanced transfusion rates after adjusting for patient and hospital characteristics. RESULTS: Among 172,457 injured patients who received transfusions, 30,386 (17.6%) underwent balanced transfusion. Patient-level balanced transfusion rates were 11% in 2016, rose to 14.0% in 2019, and jumped up once whole blood transfusions were measured to 24.0% in 2020 and to 25.9% in 2021. Approximately 26% of the variability in balanced transfusion rates was attributable to the hospital. Verified level I hospitals had a 2.09 increased adjusted odds of balanced transfusion (95% CI 1.88-2.21) compared to nonverified hospitals. University teaching status had a 1.29 increased adjusted odds of balanced transfusion (95% CI 1.08-1.54) compared with community hospitals. Overall, 150 (23.5%) hospitals were high outliers (high performing) in balanced transfusion adoption and 124 (19.4%) hospitals were low outliers. CONCLUSION: There was significant variability in hospital adoption of balanced transfusion.

Investigating the 2016 surge in firearm violence in Illinois, USA, through community-based organisations: a qualitative study.

BACKGROUND: Illinois experienced a historic firearm violence surge in 2016 with a decline to baseline rates in 2018. This study aimed to understand this 2016 surge through the direct accounts of violence prevention community-based organisations (CBOs) in Illinois. METHODS: We conducted semistructured interviews with 20 representatives from 13 CBOs from the south and west sides of greater Chicago metropolitan area. Interviews were audio recorded, coded and analysed thematically. RESULTS: We identified lack of government-derived infrastructure and systemic poverty as the central themes of Illinois's 2016 firearm violence surge. Participants highlighted the Illinois Budget Impasse halted funding for violence prevention efforts, leading to 2016's violence. This occurred in the context of a strained relationship with the criminal justice system, where disengagement from police and mistrust in the justice system led victims and families to seek justice outside of the judicial system. Participants emphasised that systemic poverty and the obliteration of community support structures led to overwhelming desperation, which, in turn, increased risky behaviours perceived as necessary for survival. Participants disproportionately identified that this impacted the young people in their communities. CONCLUSIONS: Lack of government-derived infrastructure and systemic poverty were the central themes of the 2016 firearm violence surge. The insights gained from the 2016 surge are applicable to understanding both current and future surges. CBOs focused on violence prevention offer insights into the context and conditions fuelling surges in the epidemic of violence.

Barriers and Facilitators to End-of-Life Care Delivery in ICUs: A Qualitative Study.

OBJECTIVES: To understand frontline ICU clinician's perceptions of end-of-life care delivery in the ICU. DESIGN: Qualitative observational cross-sectional study. SETTING: Seven ICUs across three hospitals in an integrated academic health system. SUBJECTS: ICU clinicians (physicians [critical care, palliative care], advanced practice providers, nurses, social workers, chaplains). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: In total, 27 semi-structured interviews were conducted, recorded, and transcribed. The research team reviewed all transcripts inductively to develop a codebook. Thematic analysis was conducted through coding, category formulation, and sorting for data reduction to identify central themes. Deductive reasoning facilitated data category formulation and thematic structuring anchored on the Systems Engineering Initiative for Patient Safety model identified that work systems (people, environment, tools, tasks) lead to processes and outcomes. Four themes were barriers or facilitators to end-of-life care. First, work system barriers delayed end-of-life care communication among clinicians as well as between clinicians and families. For example, over-reliance on palliative care people in handling end-of-life discussions prevented timely end-of-life care discussions with families. Second, clinician-level variability existed in end-of-life communication tasks. For example, end-of-life care discussions varied greatly in process and outcomes depending on the clinician leading the conversation. Third, clinician-family-patient priorities or treatment goals were misaligned. Conversely, regular discussion and joint decisions facilitated higher familial confidence in end-of-life care delivery process. These detailed discussions between care teams aligned priorities and led to fewer situations where patients/families received conflicting information. Fourth, clinician moral distress occurred from providing nonbeneficial care. Interviewees reported standardized end-of-life care discussion process incorporated by the people in the work system including patient, family, and clinicians were foundational to delivering end-of-life care that reduced both patient and family suffering, as well as clinician moral distress. CONCLUSIONS: Standardized work system communication tasks may improve end-of life discussion processes between clinicians and families.

Characterizing re-triage guidelines: A scoping review of states' rules and regulations.

BACKGROUND: State guidelines for re-triage, or emergency inter-facility transfer, have never been characterized across the United States. METHODS: All 50 states' Department of Health and/or Trauma System websites were reviewed for publicly available re-triage guidelines within their rules and regulations. Communication was made via phone or email to state agencies or trauma advisory committees to obtain or confirm the absence of guidelines where public data was unavailable. Guideline criteria were abstracted and grouped into domains of Center for Disease Control Field Triage Criteria: pattern/anatomy of injury, vital signs, special populations, and mechanisms of injury. Re-triage criteria were summarized across states using median and interquartile ranges for continuous data and frequencies for categorical data. Demographic data of states with and without re-triage guidelines were compared using the Wilcoxon rank sum test. RESULTS: Re-triage guidelines were identified for 22 of 50 states (44%). Common anatomy of injury criteria included head trauma (91% of states with guidelines), spinal cord injury (82%), chest injury (77%), and pelvic injury (73%). Common vital signs criteria included Glasgow Coma Score (91% of states) ranging from 8 to 14, systolic blood pressure (36%) ranging from 90 to 100 mm Hg, and respiratory rate (23%) with all using 10 respirations/minute. Common special populations criteria included mechanical ventilation (73% of states), age (68%) ranging from <2 or >60 years, cardiac disease (59%), and pregnancy (55%). No significant demographic differences were found between states with versus without re-triage guidelines. CONCLUSION: A minority of US states have re-triage guidelines. Characterizing existing criteria can inform future guideline development.

Defining conditions for effective interdisciplinary care team communication in an open surgical intensive care unit: a qualitative study.

OBJECTIVE: Poor interdisciplinary care team communication has been associated with increased mortality. The study aimed to define conditions for effective interdisciplinary care team communication. DESIGN: An observational cross-sectional qualitative study. SETTING: A surgical intensive care unit in a large, urban, academic referral medical centre. PARTICIPANTS: A total 6 interviews and 10 focus groups from February to June 2021 (N=33) were performed. Interdisciplinary clinicians who cared for critically ill patients were interviewed. Participants included intensivist, transplant, colorectal, vascular, surgical oncology, trauma faculty surgeons (n=10); emergency medicine, surgery, gynaecology, radiology physicians-in-training (n=6), advanced practice providers (n=5), nurses (n=7), fellows (n=1) and subspecialist clinicians such as respiratory therapists, pharmacists and dieticians (n=4). Audiorecorded content of interviews and focus groups were deidentified and transcribed verbatim. The study team iteratively generated the codebook. All transcripts were independently coded by two team members. PRIMARY OUTCOME: Conditions for effective interdisciplinary care team communication. RESULTS: We identified five themes relating to conditions for effective interdisciplinary care team communication in our surgical intensive care unit setting: role definition, formal processes, informal communication pathways, hierarchical influences and psychological safety. Participants reported that clear role definition and standardised formal communication processes empowered clinicians to engage in discussions that mitigated hierarchy and facilitated psychological safety. CONCLUSIONS: Standardising communication and creating defined roles in formal processes can promote effective interdisciplinary care team communication by fostering psychological safety.

Mixed Methods Assessment of Incivility During Surgical Mortality and Morbidity Conference.

OBJECTIVE: This study assessed incivility during Mortality and Morbidity (M&M) Conference. BACKGROUND: A psychologically safe environment at M&M Conference enables generative discussions to improve care. Incivility and exclusion demonstrated by "shame and blame" undermine generative discussion. METHODS: We used a convergent mixed-methods design to collect qualitative data through non-participant observations of M&M conference and quantitative data through standardized survey instruments of M&M participants. The M&M conference was attended by attending surgeons (all academic ranks), fellows, residents, medical students on surgery rotation, advanced practice providers, and administrators from the department of surgery. A standardized observation guide was developed, piloted and adapted based on expert non-participant feedback. The Positive and Negative Affect Schedule Short-Form (PANAS) and the Uncivil Behavior in Clinical Nursing Education (UBCNE) survey instruments were distributed to the Department of Surgery clinical faculty and categorical general surgery residents in an academic medical center. RESULTS: We observed 11 M&M discussions of 30 cases, over six months with four different moderators. Case presentations (virtual format) included clinical scenario, decision-making, operative management, complications, and management of the complications. Discussion was free form, without a standard structure. The central theme that limited discussion participation from attending surgeon of record, as well as absence of a systems-approach discussion led to blame and blame then set the stage for incivility. Among 147 eligible to participate in the survey, 54 (36.7%) responded. Assistant professors had a 2.60 higher Negative Affect score (p-value=0.02), a 4.13 higher Exclusion Behavior score (p-value=0.03), and a 7.6 higher UBCNE score (p-value=0.04) compared to associate and full professors. Females had a 2.7 higher Negative Affect Score compared to males (p-value=0.04). CONCLUSION: Free-form M&M discussions led to incivility. Structuring discussion to focus upon improving care may create inclusion and more generative discussions to improve care.

Transitional care programs for trauma patients: A scoping review.

BACKGROUND: Transitional care programs establish comprehensive outpatient care after hospitalization. This scoping review aimed to define participant characteristics and structure of transitional care programs for injured adults as well as associated readmission rates, cost of care, and follow-up adherence. METHODS: We conducted a scoping review in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews standard. Information sources searched were Medline, the Cochrane Library, CINAHL, and Scopus Plus with Full Text. Eligibility criteria were systematic reviews, clinical trials, and observational studies of transitional care programs for injured adults in the United States, published in English since 2000. Two independent reviewers screened all full texts. A data charting process extracted patient characteristics, program structure, readmission rates, cost of care, and follow-up adherence for each study. RESULTS: A total of 10 studies described 9 transitional care programs. Most programs (60%) were nurse/social-worker-led post-discharge phone call programs that provided follow-up reminders and inquired regarding patient concerns. The remaining 40% of programs were comprehensive interdisciplinary case-coordination transitional care programs. Readmissions were reduced by 5% and emergency department visits by 13% among participants of both types of programs compared to historic data. Both programs improved follow-up adherence by 75% compared to historic data. CONCLUSION: Transitional care programs targeted at injured patients vary in structure and may reduce overall health care use.

The gap between hospital-based violence intervention services and client needs: A systematic review.

BACKGROUND: Survivors of intentional interpersonal violence face social challenges related to social determinants of health that led to their initial injury. Hospital-based violence intervention programs reduce reinjury. It is unclear how well they meet clients' reported needs. This systematic review aimed to quantify how well hospital-based violence intervention program services addressed clients' reported needs. METHODS: Medline, The Cochrane Library, CINAHL Plus with Full Text, and PsycInfo were queried for studies addressing hospital-based violence intervention programs services and intentional injury survivors' needs in the United States. Case reports, reviews, editorials, theses, and studies focusing on pediatric patients, victims of intimate partner violence, or sexual assault were excluded. Data extracted included program structure, hospital-based violence intervention program services, and client needs assessments before and after receiving hospital-based violence intervention program services. RESULTS: Of the 3,339 citations identified, 13 articles were selected for inclusion. Hospital-based violence intervention programs clients' most reported needs included mental health (10 studies), employment (7), and education (5) before receiving hospital-based violence intervention programs services. Only 4 studies conducted quantitative client needs assessments before and after receiving hospital-based violence intervention program services. All 4 studies were able to meet at least 50% of each of the clients' reported needs. The success rate depended on the need and program location: success in meeting mental health needs ranged from 65% to 90% of clients. Conversely, time-intensive long-term needs were least met, including employment 60% to 86% of clients, education 47% to 73%, and housing 50% to 71%. CONCLUSION: Few hospital-based violence intervention programs studies considered clients' reported needs. Employment, education, and housing must be a stronger focus of hospital-based violence intervention programs.

Defining obstacles to emergency transfer of trauma patients: An evaluation of retriage processes from nontrauma and lower-level Illinois trauma centers.

BACKGROUND: Retriage is the emergency transfer of severely injured patients from nontrauma and lower-level trauma centers to higher-level trauma centers. We identified the barriers to retriage at sending centers in a single health system. METHODS: We conducted a failure modes effects and criticality analysis at 4 nontrauma centers and 5 lower-level trauma centers in a single health system. Clinicians from each center described the steps in the trauma assessment and retriage process to create a process map. We used standardized scoring to characterize each failure based on frequency, impact on retriage, and prevention safeguards. We ranked each failure using the scores to calculate a risk priority number. RESULTS: We identified 26 steps and 93 failures. The highest-risk failure was refusal by higher-level trauma centers (receiving hospitals) to accept a patient. The most critical failures in the retriage process based on total risk, frequency, and safeguard scores were (1) refusal from a receiving higher-level trauma center to accept a patient (risk priority number = 191), (2) delay in a sending center's consultant examination of a patient in the emergency department (risk priority number = 177), and (3) delay in receiving hospital's consultant calling back (risk priority number = 177). CONCLUSION: We identified (1) addressing obstacles to determining clinical indications for retriage and (2) identifying receiving level I trauma centers who would accept the patient as opportunities to increase timely retriage. Establishing clear clinical indications for retriage that sending and receiving hospitals agree on represents an opportunity for intervention that could improve the retriage of injured patients.