The Fragmentation of Specialty Care. The Role of Referral Location, Type of Referral, and Demographic Factors in Determining Completion Rates for Uninsured Patients in a Student-Run Free Clinic.

Little is known about how location of specialty care affects accessibility for uninsured patients at free clinics. To address this gap, the specialty referral completion rate by location and role of demographic and referral-specific factors were analyzed at an urban-based free clinic. A retrospective review was performed at a single site, student-run free clinic exclusively serving uninsured patients. Referral completion rate and predictors of referral completion were examined including age, race, ethnicity, sex, referral type, and location of referral. Significant predictors (p < 0.05) were included in the adjusted model if the associated odds ratio (OR) was meaningful. A total of 351 referrals met criteria. Completion rate was 53.6%. Co-location of specialty services was associated with a higher completion rate (64.7%, p < 0.001) and counseling referral type had a lower completion rate (11.5%, p < 0.001). Significant predictors of referral completion included sex, ethnicity, location of referral, and referral type (p < 0.001). Hispanic patients had higher rates of completion (68.4%, p < 0.001). On multivariable analysis, non-co-located fee-for-service hospital referrals had lower odds of completion when compared to co-located referrals at the free clinic (OR = 0.25, CI 95% [0.12-0.54], p < 0.001). Also, when compared to other types of referrals, counseling referrals had a 25 times lower odds of referral completion (p < 0.001). There was a higher completion rate of co-located referrals suggesting that multiple locations and health systems may deter patients from seeking necessary care. The lower rate of counseling referral completion indicates that additional efforts are needed to make these services more accessible to uninsured patients.

The Impact of Surgical Boot Camp on Medical Student Confidence and Imposter Syndrome.

INTRODUCTION: Transitioning from medical student to surgical intern is accompanied by increased responsibility, stress, and clinical burden. This environment lends itself to imposter syndrome (IS), a psychological condition grounded in self-doubt causing fear of being discovered as fraud despite adequate abilities. We hypothesized a 2-week surgical boot camp for fourth year medical students would improve confidence in technical skills/knowledge and IS. METHODS: Thirty medical students matching into surgical specialties completed the boot-camp in February 2020. Presurveys/postsurveys assessed confidence levels using a 1-5 Likert scale regarding 32 technical skills and knowledge points. The Clance Impostor Phenomenon Scale (CIPS) assessed IS, where increasing scores correlate to greater IS. RESULTS: Median (interquartile range [IQR]) subject age was 27 y (26, 28), 20 (66.7%) were male, and 21 (70%) were Caucasian. Of the 30 students, 23 (76.7%) had a break in training with a median [IQR] of 2 [1, 3] y outside of medicine. Confidence scores were significantly improved in all five assessment categories (P < 0.05); however, there was no change in CIPS in median [IQR] presurveys versus postsurveys (65.5 [52, 75] versus 64 [52, 75], P = 0.70). Females had higher mean (standard deviation) pre-CIPS than males (68.4 [15.2] versus 61.6 [14.9], P = 0.02). There was no strong correlation between age and CIPS in the presurvey (Spearman Rank Correlation Coefficient [SRCC]: 0.29, P = 0.19) or postsurvey (SRCC: 0.31, P = 0.10). While subjects who worked outside of medicine had a stronger relationship with IS (SRCC: 0.37, P = 0.05), multivariable regression analysis did not reveal any significant differences. CONCLUSIONS: We advocate for surgical boot-camp training courses to improve trainee skill and confidence. As IS is not improved by boot camp, additional research is needed to identify opportunities to improve IS among surgical trainees.

Prevention of Firearm Violence Through Specific Types of Community-based Programming: An Eastern Association for the Surgery of Trauma Evidence-based Review.

OBJECTIVE: The purpose of this review was to provide an evidence-based recommendation for community-based programs to mitigate gun violence, from the Eastern Association for the Surgery of Trauma (EAST). SUMMARY BACKGROUND DATA: Firearm Injury leads to >40,000 annual deaths and >115,000 injuries annually in the United States. Communities have adopted culturally relevant strategies to mitigate gun related injury and death. Two such strategies are gun buyback programs and community-based violence prevention programs. METHODS: The Injury Control and Violence Prevention Committee of EAST developed Population, Intervention, Comparator, Outcomes (PICO) questions and performed a comprehensive literature and gray web literature search. Using GRADE methodology, they reviewed and graded the literature and provided consensus recommendations informed by the literature. RESULTS: A total of 19 studies were included for analysis of gun buyback programs. Twenty-six studies were reviewed for analysis for community-based violence prevention programs. Gray literature was added to the discussion of PICO questions from selected websites. A conditional recommendation is made for the implementation of community-based gun buyback programs and a conditional recommendation for community-based violence prevention programs, with special emphasis on cultural appropriateness and community input. CONCLUSIONS: Gun violence may be mitigated by community-based efforts, such as gun buybacks or violence prevention programs. These programs come with caveats, notably community cultural relevance and proper support and funding from local leadership.Level of Evidence: Review, Decision, level III.

Fever in the ICU: A Predictor of Mortality in Mechanically Ventilated COVID-19 Patients.

PURPOSE: While fever may be a presenting symptom of COVID-19, fever at hospital admission has not been identified as a predictor of mortality. However, hyperthermia during critical illness among ventilated COVID-19 patients in the ICU has not yet been studied. We sought to determine mortality predictors among ventilated COVID-19 ICU patients and we hypothesized that fever in the ICU is predictive of mortality. MATERIALS AND METHODS: We conducted a retrospective cohort study of 103 ventilated COVID-19 patients admitted to the ICU between March 14 and May 27, 2020. Final follow-up was June 5, 2020. Patients discharged from the ICU or who died were included. Patients still admitted to the ICU at final follow-up were excluded. RESULTS: 103 patients were included, 40 survived and 63(61.1%) died. Deceased patients were older {66 years[IQR18] vs 62.5[IQR10], (p = 0.0237)}, more often male {48(68%) vs 22(55%), (p = 0.0247)}, had lower initial oxygen saturation {86.0%[IQR18] vs 91.5%[IQR11.5], (p = 0.0060)}, and had lower pH nadir than survivors {7.10[IQR0.2] vs 7.30[IQR0.2] (p < 0.0001)}. Patients had higher peak temperatures during ICU stay as compared to hospital presentation {103.3°F[IQR1.7] vs 100.0°F[IQR3.5], (p < 0.0001)}. Deceased patients had higher peak ICU temperatures than survivors {103.6°F[IQR2.0] vs 102.9°F[IQR1.4], (p = 0.0008)}. Increasing peak temperatures were linearly associated with mortality. Febrile patients who underwent targeted temperature management to achieve normothermia did not have different outcomes than those not actively cooled. Multivariable analysis revealed 60% and 75% higher risk of mortality with peak temperature greater than 103°F and 104°F respectively; it also confirmed hyperthermia, age, male sex, and acidosis to be predictors of mortality. CONCLUSIONS: This is one of the first studies to identify ICU hyperthermia as predictive of mortality in ventilated COVID-19 patients. Additional predictors included male sex, age, and acidosis. With COVID-19 cases increasing, identification of ICU mortality predictors is crucial to improve risk stratification, resource management, and patient outcomes.

Higher Fluid Balance Increases the Risk of Death From Sepsis: Results From a Large International Audit.

OBJECTIVES: Excessive fluid therapy in patients with sepsis may be associated with risks that outweigh any benefit. We investigated the possible influence of early fluid balance on outcome in a large international database of ICU patients with sepsis. DESIGN: Observational cohort study. SETTING: Seven hundred and thirty ICUs in 84 countries. PATIENTS: All adult patients admitted between May 8 and May 18, 2012, except admissions for routine postoperative surveillance. For this analysis, we included only the 1,808 patients with an admission diagnosis of sepsis. Patients were stratified according to quartiles of cumulative fluid balance 24 hours and 3 days after ICU admission. MEASUREMENTS AND MAIN RESULTS: ICU and hospital mortality rates were 27.6% and 37.3%, respectively. The cumulative fluid balance increased from 1,217 mL (-90 to 2,783 mL) in the first 24 hours after ICU admission to 1,794 mL (-951 to 5,108 mL) on day 3 and decreased thereafter. The cumulative fluid intake was similar in survivors and nonsurvivors, but fluid balance was less positive in survivors because of higher fluid output in these patients. Fluid balances became negative after the third ICU day in survivors but remained positive in nonsurvivors. After adjustment for possible confounders in multivariable analysis, the 24-hour cumulative fluid balance was not associated with an increased hazard of 28-day in-hospital death. However, there was a stepwise increase in the hazard of death with higher quartiles of 3-day cumulative fluid balance in the whole population and after stratification according to the presence of septic shock. CONCLUSIONS: In this large cohort of patients with sepsis, higher cumulative fluid balance at day 3 but not in the first 24 hours after ICU admission was independently associated with an increase in the hazard of death.

Trauma team size and task performance in adult trauma resuscitations.

BACKGROUND: The initial evaluation of a trauma patient involves multiple personnel from various disciplines. Whereas this approach can expedite care, an increasing number of personnel can also create chaos and hinder efficiency. We sought to determine the optimal number of persons associated with an expedient primary survey. METHODS: Audio and/or video recordings of all consecutive adult trauma evaluations at a level 1 trauma center were reviewed for a 1-month period. A 20-task checklist was developed based on Advanced Trauma Life Support principles. The number of practitioners present (TeamN) and tasks completed at 2 and 5 min (Task2, Task5) were recorded. The association between TeamN, demographics, presence of attending surgeon, and team leader engagement and Task2/Task5 was measured the using chi square test and Spearman correlation. A multivariate regression model was developed. RESULTS: A total of 170 cases were reviewed, 44 of which were top-tier activations. Average TeamN was 6 ± 2 persons. Task2 and Task5 were significantly positively correlated with TeamN (r = 0.34, P < 0.0001; r = 0.22, P = 0.004, respectively) and leader engagement (r = 0.27, P < 0.01; r = 0.16, P < 0.05, respectively). There was a significant positive correlation between TeamN and Task2 and Task5. Only TeamN had a significant, independent association with Task2 and Task5 (P = 0.005). We did not find a size that was negatively associated with task completion. Only assessment of breath sounds was negatively associated with increasing team size. CONCLUSIONS: TeamN is significantly associated with efficiency of trauma evaluation. Studies evaluating reasons for this and the effect of maximal team size are needed to determine optimal trauma team staffing.

A pilot project of a Post Discharge Care Team for firearm injury survivors decreases emergency department utilization, hospital readmission days, and cost.

BACKGROUND: Persons of low socioeconomic status are overrepresented in the firearm injury patient population and may experience challenges in accessing complex outpatient health systems. Consequently, outpatient care for these patients is plagued by poor follow-up and increased emergency department (ED) utilization. We developed a Post Discharge Care Team (PDCT) consisting of a dedicated trauma nurse navigator and medical social worker to bridge the gap between hospital discharge and outpatient care to improve recovery. METHODS: Adult firearm injury survivors admitted to the trauma service were randomized 1:1 to receive either PDCT services or standard of care (SOC) workflows. The PDCT nurse provided education and set expectations regarding injuries, wound care, and outpatient follow-up. The PDCT social worker performed a comprehensive assessment to identify concerns including housing and financial instability, food insecurity, or transportation issues. The primary outcome was ED utilization, with secondary outcomes including readmissions and overall health care costs compared between groups. RESULTS: In the first 6 months of the study, a total of 44 patients were randomized to PDCT and 47 to SOC. There were 10 patients who visited the ED in the PDCT group compared with 16 in the SOC group ( p = 0.23) for a total of 14 and 23 ED visits, respectively. There were 14 patients in the PDCT and 11 patients in the SOC groups who were readmitted ( p = 0.31), but the PDCT group was readmitted for 27.9 fewer hospital days. After accounting for programmatic costs, the PDCT had a hospital savings of $34,542.71. CONCLUSION: A collaborative, specialized PDCT for firearm injury survivors consisting of a dedicated trauma nurse navigator and medical social worker decreased outpatient ED utilization, readmission days, and was cost effective. Trauma centers with high volumes of penetrating trauma should consider a similar model to improve outpatient care for firearm injury survivors. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

A comparison of the psychometric properties of a person-administered vs. automated screening tool for posttraumatic stress disorder (PTSD) in traumatically injured patients.

BACKGROUND: The American College of Surgeons Committee on Trauma (ACS-CoT) mandated that trauma centers have mental health screening and referral protocols in place by 2023. This study compares the Injured Trauma Survivor Screen (ITSS) and the Automated Electronic Medical Record (EMR) Screen to assess their performance in predicting risk for posttraumatic stress disorder (PTSD) within the same sample of trauma patients to inform trauma centers' decision when selecting a tool to best fit their current clinical practice. METHODS: This was a secondary analysis of three prospective cohort studies of traumatically injured patients (N = 255). The ITSS and Automated EMR Screen were compared using receiver operating characteristic curves to predict risk of subsequent PTSD development. PTSD diagnosis at 6-month follow-up was assessed using the Clinician Administered PTSD Scale for DSM-5. RESULTS: Just over half the sample screened positive on the ITSS (57.7%), while 67.8% screened positive on the Automated EMR Screen. The area under the curve (AUC) for the two screens was not significantly different (ITSS AUC = 0.745 versus Automated EMR Screen AUC = 0.694, p = 0.21), similar performance in PTSD risk predication within the same general trauma population. The ITSS and Automated EMR Screen had similar sensitivities (86.5%, 89.2%), and specificities (52.5%, 40.9%) respectively at their recommended cut-off points. CONCLUSION: Both screens are psychometrically comparable. Therefore, trauma centers considering screening tools for PTSD risk to comply with the ACS-CoT 2023 mandate should consider their local resources and patient population. Regardless of screen selection, screening must be accompanied by a referral process to address the identified risk.

Analysis of social determinants of health on emergency department utilization by gunshot wound survivors after level 1 trauma center discharge.

Background: This project analyzed risk factors for emergency department (ED) utilization without readmission within 2 weeks post-discharge for survivors of gun violence. Methods: A hundred gun violence survivors admitted to a Level 1 trauma center were surveyed. Descriptive analyses and group comparisons were conducted between patients who did and did not use the ED. Factors analyzed are rooted in social determinants of health and clinical care related to the index hospitalization. Results: Of the 100 patients, 31 had an ED visit within 6 weeks, although most (87.1%) returned within 2 weeks of discharge. Factors significantly associated (p≤0.05) with a return ED visit included: not having an identified primary care provider, not having friends or family to count on for help, not having enough money to support themselves before return to work, and not feeling able to read discharge instructions. Conclusion: Lack of a primary care provider, low health literacy and social support were associated with increased ED visits without readmission post-discharge. Level of Evidence: Level III, Prognostic and Epidemiological.

Improved follow-up care for gun violence survivors in the Trauma Quality of Life Clinic.

Background: Outpatient follow-up represents a crucial opportunity to re-engage with gun violence survivors (GVS) and to facilitate positive health outcomes. Current outpatient models for firearm-related injuries and trauma care are inconsistent and unstandardized across trauma centers. This project describes the patient population served by the multidisciplinary Trauma Quality of Life (TQoL) Clinic for GVS. Also of primary interest was the outpatient follow-up services used by patients prior to their clinic appointment. Subsequent referrals placed during Clinic, as well as rate of attendance, was a secondary aim. Methods: This was a descriptive retrospective analysis of a quality improvement project of the TQoL Clinic. Data were extracted from the electronic medical record and were supplemented with information from the trauma registry and the hospital-based violence intervention program database. Descriptive statistics characterized the patient population served. A Χ2 analysis was used to compare no-show rates for the TQoL Clinic against two historical cohorts of trauma clinic attendees. Results: Most attendees were young (M=32.0, SD=1.8, range=15-88 years), Black (80.1%), and male (82.0%). Of the 306 total TQoL Clinic attendees, 82.3% attended their initial scheduled appointment. Most non-attendee patients rescheduled their appointments (92.1%), and 89.5% attended the rescheduled appointment. TQoL Clinic demonstrated a significantly lower no-show rate than the traditional trauma clinic model, including after the implementation of the hospital's inpatient violence intervention program (χ2(2)=75.52, p<0.001). Conclusion: The TQoL Clinic has demonstrated improved outpatient follow-up to address the comprehensive needs of GVS. Trauma centers with high gunshot wound volume should consider the implementation of the multidisciplinary TQoL Clinic model to increase access to care and to continue partnership with violence intervention programs to address health outcomes in those most at risk of future morbidity and mortality. Level of evidence: Therapeutic/care management, level III.

Addressing the educational gap in the role of law enforcement personnel in the resuscitation bay.

BACKGROUND: Health care workers are often uncertain of the role of law enforcement personnel in the resuscitation bay. A cross-sectional, quality improvement project was designed with an educational intervention to address the knowledge gaps. METHODS: There were 2 sessions for trauma surgery and emergency medicine faculty, residents, and staff. The first was a formal presentation by hospital risk management and security focused on answering questions generated by real-life scenarios. After reviewing feedback from the first session, the second session was designed as a panel discussion led by attending physicians who reviewed various clinical scenarios. A pre/postsurvey was administered, including potential clinical scenarios with multiple-choice answers and open feedback. RESULTS: There were 64 presurvey and 31 postsurvey respondents from the first session (48.4%). Significantly more questions were answered correctly from pre to postsurvey (5.5 vs 6.7/16 questions; U = 798.0, P = .048). Of the 14 (45.2%) respondents who provided open-ended feedback, 50% indicated confusion, and 21.4% expressed strong, negative emotions. In the second session, there were 39 presurvey and 18 postsurvey respondents (46.2%). Again, significantly more questions were answered correctly after the second session (2.2 vs 4.5/7 questions; U = 115.0, P ≤ .001). Feedback highlighted that the panel format was considered more helpful than the formal didactic of the first session. CONCLUSION: Confusion about the role of law enforcement personnel in the clinical environment can be partially addressed using multidisciplinary joint conferences that should be led by clinicians to ensure real-life clinical applicability. Further education and law enforcement personnel role clarification for health care workers are critical to protect patient rights.

Comprehensive Framework of Firearm Violence Survivor Care: A Review.

Importance: Firearm violence is a public health crisis placing significant burden on individuals, communities, and health care systems. After firearm injury, there is increased risk of poor health, disability, and psychopathology. The newest 2022 guidelines from the American College of Surgeons Committee on Trauma require that all trauma centers screen for risk of psychopathology and provide referral to intervention. Yet, implementing these guidelines in ways that are responsive to the unique needs of communities and specific patient populations, such as after firearm violence, is challenging. Observations: The current review highlights important considerations and presents a model for trauma centers to provide comprehensive care to survivors of firearm injury. This model highlights the need to enhance standard practice to provide patient-centered, trauma-informed care, as well as integrate inpatient and outpatient psychological services to address psychosocial needs. Further, incorporation of violence prevention programming better addresses firearm injury as a public health concern. Conclusions and Relevance: Using research to guide a framework for trauma centers in comprehensive care after firearm violence, we can prevent complications to physical and psychological recovery for this population. Health systems must acknowledge the socioecological context of firearm violence and provide more comprehensive care in the hospital and after discharge, to improve long-term recovery and serve as a means of tertiary prevention of firearm violence.

Disparities in disposition from trauma centers to inpatient psychiatric treatment in a national sample of patients with self-inflicted injury.

BACKGROUND: Surgery providers are integral to the treatment of patients with self-inflicted injuries. Patient disposition (eg, home, inpatient psychiatric treatment, rehabilitation) is important to long-term outcomes, but little is known about factors influencing disposition after discharge following traumatic self-inflicted injury. We tested whether patient or injury characteristics were associated with disposition after treatment for self-inflicted injury. METHODS: National Trauma Data Bank query for self-inflicted injuries from 2010 to 2018. RESULTS: There were 77,731 patients treated for self-inflicted injuries during the study period. Discharge home was the most common disposition (45%), and those without insurance were less likely to discharge to inpatient psychiatric treatment than those with insurance. Racial minority patients were less likely to discharge to inpatient psychiatric treatment (18.9%) than nonminority patients (23.8%, P < .001). Additionally, patients discharged to inpatient psychiatric treatment had significantly lower injury severity score (7.24 ± 7.5) than those who did not (8.69 ± 9.1, P < .001). CONCLUSION: Racial/ethnic minority patients and those without insurance were significantly less likely to discharge to an inpatient psychiatric facility after treatment at a trauma center for self-inflicted injury. Future research is needed to evaluate the internal factors (eg, trauma center practices) and external factors (eg, inpatient psychiatric facilities not accepting patients with wound care needs) driving disposition variability.

Trauma video review outperforms prospective real-time data collection for study of resuscitative thoracotomy.

BACKGROUND: A major challenge in the study of high-impact, low-frequency procedures in trauma is the lack of accurate data for time-sensitive processes of care. Trauma video review offers a possible solution, allowing investigators to collect extremely granular time-stamped data. Using resuscitative thoracotomy as a model, we compared data collected using review of audiovisual recordings to data prospectively collected in real time with the hypothesis that data collected using video review would be subject to less missingness and bias. METHODS: We conducted a prospective cohort study of patients undergoing resuscitative thoracotomy at a single urban academic level 1 trauma center. Key data on the timing and completion of procedural milestones of resuscitative thoracotomy were collected using video review and prospective collection. We used McNemar's test to compare proportions of missing data between the 2 methods and calculated bias in time measurements for prospective collection with respect to video review. Statistical analyses were performed using Stata v. 15.0 (College Station, TX). RESULTS: We included 51 subjects (88% Black, 82% male, 90% injured by gunshot wounds) over the study period. Missingness in resuscitative thoracotomy procedural milestone time measurements ranged from 34% to 63% for prospective collection and 0 to 8% for video review and was less missing for video review for all key variables (P < .001). When not missing, bias in data collected by prospective collection was 10% to 43% compared with data collected by video review. CONCLUSIONS: The data collected using video review have less missingness and bias than prospective collection data collected by trained research assistants. Audiovisual recording should be the gold standard for data collection for the study of time-sensitive processes of care in resuscitation.

Coaching for impact: successful implementation of a multi-national, multi-institutional synchronous research course in Ethiopia.

Purpose: Under the American College of Surgeons' Operation Giving Back, several US institutions collaborated with a teaching and regional referral hospital in Ethiopia to develop a surgical research curriculum. Methods: A virtual, interactive, introductory research course which utilized a web-based classroom platform and live educational sessions via an online teleconferencing application was implemented. Surgical and public health faculty from the US and Ethiopia taught webinars and led breakout coaching sessions to facilitate participants' project development. Both a pre-course needs assessment survey and a post-course participation survey were used to examine the impact of the course. Results: Twenty participants were invited to participate in the course. Despite the majority of participants having connection issues (88%), 11 participants completed the course with an 83% average attendance rate. Ten participants successfully developed structured research proposals based on their local clinical needs. Conclusion: This novel multi-institutional and multi-national research course design was successfully implemented and could serve as a template for greater development of research capacity building in the low- and middle-income country (LMIC) setting.

Large Gathering Attendance is Associated with Increased Odds of Contracting COVID-19: A Survey Based Study.

We used a telephone survey to determine risk factors associated with a positive polymerase chain reaction test of a nasopharyngeal swab for severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2) at a community hospital in Central New Jersey during the early stages of the pandemic. We compared survey responses of 176 patients in March 2020. Respondents were asked about their living situation, work environment, use of public transportation and attendance at one or more large gatherings (more than 10 people) in the 3 weeks prior to undergoing COVID testing. We found that those who attended a large gathering in the 3 weeks prior to their COVID test had a 2.50 odds ratio (95% CI 1.19, 5.22) of testing positive after controlling for age, sex, race/ethnicity, occupation, living situation and recent visit to a nursing home. The total number of gatherings attended or the number of people in attendance was not associated with a positive test. An association was also seen for specific job types such as factory workers, construction workers, and facilities managers. Attendance at a gathering of more than ten people was associated with testing positive for COVID-19.

The Prognostic Value of Brain Dysfunction in Critically Ill Patients with and without Sepsis: A Post Hoc Analysis of the ICON Audit.

Brain dysfunction is associated with poor outcome in critically ill patients. In a post hoc analysis of the Intensive Care over Nations (ICON) database, we investigated the effect of brain dysfunction on hospital mortality in critically ill patients. Brain failure was defined as a neurological sequential organ failure assessment (nSOFA) score of 3-4, based on the assumed Glasgow Coma Scale (GCS) score. Multivariable analyses were performed to assess the independent roles of nSOFA and change in nSOFA from admission to day 3 (ΔnSOFA) for predicting hospital mortality. Data from 7192 (2096 septic and 5096 non-septic) patients were analyzed. Septic patients were more likely than non-septic patients to have brain failure on admission (434/2095 (21%) vs. 617/4665 (13%), p < 0.001) and during the ICU stay (625/2063 (30%) vs. 736/4665 (16%), p < 0.001). The presence of sepsis (RR 1.66 (1.31-2.09)), brain failure (RR 4.85 (3.33-7.07)), and both together (RR 5.61 (3.93-8.00)) were associated with an increased risk of in-hospital death, but nSOFA was not. In the 3280 (46%) patients in whom ΔnSOFA was available, sepsis (RR 2.42 (1.62-3.60)), brain function deterioration (RR 6.97 (3.71-13.08)), and the two together (RR 10.24 (5.93-17.67)) were associated with an increased risk of in-hospital death, whereas improvement in brain function was not.

Authorized Agent-Controlled Analgesia for Pain Management in Critically Ill Adult Patients.

BACKGROUND: Patient-controlled analgesia is commonly used for adult patients requiring parenteral opioid analgesia in the postoperative setting. However, many patients are unable to use patient-controlled analgesia because of physical or cognitive limitations. Authorized agent-controlled analgesia, in which a nurse or family member activates the patient-controlled analgesia device, has been studied in the pediatric population but has received little attention in adults. OBJECTIVE: To evaluate the efficacy of authorized agent-controlled analgesia in critically ill adult patients. METHODS: A retrospective pilot study was conducted involving 46 patients who were placed on an authorized agent-controlled analgesia protocol in a mixed medical/surgical adult intensive care unit. Critical-Care Pain Observation Tool scores were abstracted for the 24 hours before and after initiation of authorized agent-controlled analgesia. Authorized agent-controlled analgesia was administered by nurses only. RESULTS: The mean (SD) change in pain score was -3.4 (2.0) (95% CI, -4.0 to -2.7), representing a 69% decrease in the mean (SD) pain score from before to after initiation of authorized agent-controlled analgesia (4.8 [1.8] vs 1.5 [1.6]; P < .001). When the results were controlled for time, sedative administration, and opioid medication administration, the effect of authorized agent-controlled analgesia initiation on pain scores remained significant (P < .001). CONCLUSIONS: Use of authorized agent-controlled analgesia is associated with a reduction in pain in critically ill patients. Larger studies are warranted to confirm these findings.

Assessment and Resuscitation in Trauma Management.

The golden hour of trauma represents a crucial period in the management of acute injury. In an efficient trauma resuscitation, the primary survey is viewed as more than simple ABCs with multiple processes running in parallel. Resuscitation efforts should be goal oriented with defined endpoints for airway management, access, and hemodynamic parameters. In tandem with resuscitation, early identification of life-threatening injuries is critical for determining the disposition of patients when they leave the trauma bay. Salvage strategies for profoundly hypotensive or pulseless patients include retrograde balloon occlusion of the aorta and resuscitative thoracotomy, with differing populations benefiting from each.

Use of four-factor prothrombin complex concentrate in the reversal of warfarin-induced and nonvitamin K antagonist-related coagulopathy.

: To evaluate the efficacy of international normalized ratio (INR) reversal using four-factor prothrombin complex concentrate (4F-PCC) in nonmedication-induced coagulopathy. We performed a single-site, retrospective cohort study of patients receiving off-label use of 4F-PCC. Cohorts included liver dysfunction if they had acute liver decompensation or cirrhosis without other causative factors of liver failure such as sepsis, coagulopathy of acute sepsis (CAS) if they had documentation of sepsis and no underlying liver disorder, known factor deficiencies, or medication-induced coagulopathy, or warfarin if they were taking warfarin. Patients with unknown medication or direct oral anticoagulant usage were excluded. 4F-PCC was administered 32 times in 26 patients for nonvitamin-K antagonist related coagulopathy (11 CAS and 21 liver dysfunction) and 47 administrations were in warfarin patients. Liver dysfunction patients had a mean model for end-stage liver disease score of 28 ±â€Š10. CAS and warfarin patients had significant INR reductions (ΔINR 1.9, P < 0.01; ΔINR 3.9, P < 0.01, respectively). Liver dysfunction patients mean change in INR trended toward significance (ΔINR 0.7, P = 0.09). Patients who received 4F-PCC based upon previously established dosing guidelines for moderate elevations in INR (20-30 IU/kg) doing demonstrated similar reductions in INR between CAS and warfarin patients (ΔINR 1.3, P = 0.03, ΔINR 1.0 P < 0.01, respectively). 4F-PCC significantly reduces the INR in CAS patients and trended toward significant reductions in liver dysfunction patients. Adequately powered, prospective trials are needed to demonstrate 4F-PCC efficacy in reversal of these coagulopathies.