Correlation between prehospital and in-hospital hypotension and outcomes after traumatic brain injury.

BACKGROUND AND OBJECTIVE: Hypotension has a powerful effect on patient outcome after traumatic brain injury (TBI). The relative impact of hypotension occurring in the field versus during early hospital resuscitation is unknown. We evaluated the association between hypotension and mortality and non-mortality outcomes in four cohorts defined by where the hypotension occurred [neither prehospital nor hospital, prehospital only, hospital only, both prehospital and hospital]. METHODS: Subjects ≥10 years with major TBI were included. Standard statistics were used for unadjusted analyses. We used logistic regression, controlling for significant confounders, to determine the adjusted odds (aOR) for outcomes in each of the three cohorts. RESULTS: Included were 12,582 subjects (69.8% male; median age 44 (IQR 26-61). Mortality by hypotension status: No hypotension: 9.2% (95%CI: 8.7-9.8%); EMS hypotension only: 27.8% (24.6-31.2%); hospital hypotension only: 45.6% (39.1-52.1%); combined EMS/hospital hypotension 57.6% (50.0-65.0%); (p < 0.0001). The aOR for death reflected the same progression: 1.0 (reference-no hypotension), 1.8 (1.39-2.33), 2.61 (1.73-3.94), and 4.36 (2.78-6.84), respectively. The proportion of subjects having hospital hypotension was 19.0% (16.5-21.7%) in those with EMS hypotension compared to 2.0% (1.8-2.3%) for those without (p < 0.0001). Additionally, the proportion of patients with TC hypotension was increased even with EMS "near hypotension" up to an SBP of 120 mmHg [(aOR 3.78 (2.97, 4.82)]. CONCLUSION: While patients with hypotension in the field or on arrival at the trauma center had markedly increased risk of death compared to those with no hypotension, those with prehospital hypotension that was not resolved before hospital arrival had, by far, the highest odds of death. Furthermore, TBI patients who had prehospital hypotension were five times more likely to arrive hypotensive at the trauma center than those who did not. Finally, even "near-hypotension" in the field was strongly and independently associated the risk of a hypotensive hospital arrival (<90 mmHg). These findings are supportive of the prehospital guidelines that recommend aggressive prevention and treatment of hypotension in major TBI.

Optimal Out-of-Hospital Blood Pressure in Major Traumatic Brain Injury: A Challenge to the Current Understanding of Hypotension.

STUDY OBJECTIVE: Little is known about the out-of-hospital blood pressure ranges associated with optimal outcomes in traumatic brain injuries (TBI). Our objective was to evaluate the associations between out-of-hospital systolic blood pressure (SBP) and multiple hospital outcomes without assuming any predefined thresholds for hypotension, normotension, or hypertension. METHODS: This was a preplanned secondary analysis from the Excellence in Prehospital Injury Care (EPIC) TBI study. Among patients (age ≥10 years) with major TBIs (Barell Matrix type 1 and/or Abbreviated Injury Scale-head severity ≥3) and lowest out-of-hospital SBPs of 40 to 299 mmHg, we utilized generalized additive models to summarize the distributions of various outcomes as smoothed functions of SBP, adjusting for important and significant confounders. The subjects who were enrolled in the study phase after the out-of-hospital TBI guideline implementation were used to validate the models developed from the preimplementation cohort. RESULTS: Among 12,169 included cases, the mortality model revealed 3 distinct ranges: (1) a monotonically decreasing relationship between SBP and the adjusted probability of death from 40 to 130 mmHg, (2) lowest adjusted mortality from 130 to 180 mmHg, and (3) rapidly increasing mortality above 180 mmHg. A subanalysis of the cohorts with isolated TBIs and multisystem injuries with TBIs revealed SBP mortality patterns that were similar to each other and to that of the main analysis. While the specific SBP ranges varied somewhat for the nonmortality outcomes (hospital length of stay, ICU length of stay, discharge to skilled nursing/inpatient rehabilitation, and hospital charges), the patterns were very similar to that of mortality. In each model, validation was confirmed utilizing the postimplementation cohort. CONCLUSION: Optimal adjusted mortality was associated with a surprisingly high SBP range (130 to 180 mmHg). Below this level, there was no point or range of inflection that would indicate a physiologically meaningful threshold for defining hypotension. Nonmortality outcomes showed very similar patterns. These findings highlight how sensitive the injured brain is to compromised perfusion at SBP levels that, heretofore, have been considered adequate or even normal. While the study design does did not allow us to conclude that the currently recommended treatment threshold (<90 mmHg) should be increased, the findings imply that the definition of hypotension in the setting of TBI is too low. Randomized trials evaluating treatment levels significantly higher than 90 mmHg are needed.

Developing performance indicators for homeless outreach psychiatric services.

OBJECTIVE: Performance indicators (PIs) aim to improve services by measuring key activities in a way that allows comparison over time, between services and against benchmarks. This paper describes the development and implementation of Homeless Psychiatric Service PIs and explores their potential benefits and limitations. METHOD: We collected descripton of quality service from key stakeholders. We identified eight key parameters, from which PIs were developed and tested over a 12-month period. RESULTS: The use of the PIs led to increased awareness of the practice being measured. PIs were used to stimulate practice changes. They played a positive role in team dynamics and were useful in clarifying team aims and identity. The main challenge to their use was the burden of data collection and analysis. CONCLUSION: Homeless service PIs can assist in determining how well the programs are performing in activities that are relevant to clients and non clinical services for the homeless. With the movement of homeless clients away from inner urban areas, homeless performance measures may aid teams to develop the capacity to work effectively with homeless clients.

EMS Treatment Guidelines in Major Traumatic Brain Injury With Positive Pressure Ventilation.

Importance: The Excellence in Prehospital Injury Care (EPIC) study demonstrated improved survival in patients with severe traumatic brain injury (TBI) following implementation of the prehospital treatment guidelines. The impact of implementing these guidelines in the subgroup of patients who received positive pressure ventilation (PPV) is unknown. Objective: To evaluate the association of implementation of prehospital TBI evidence-based guidelines with survival among patients with prehospital PPV. Design, Setting, and Participants: The EPIC study was a multisystem, intention-to-treat study using a before/after controlled design. Evidence-based guidelines were implemented by emergency medical service agencies across Arizona. This subanalysis was planned a priori and included participants who received prehospital PPV. Outcomes were compared between the preimplementation and postimplementation cohorts using logistic regression, stratified by predetermined TBI severity categories (moderate, severe, or critical). Data were collected from January 2007 to June 2017, and data were analyzed from January to February 2023. Exposure: Implementation of the evidence-based guidelines for the prehospital care of patient with TBI. Main Outcomes and Measures: The primary outcome was survival to hospital discharge, and the secondary outcome was survival to admission. Results: Among the 21 852 participants in the main study, 5022 received prehospital PPV (preimplementation, 3531 participants; postimplementation, 1491 participants). Of 5022 included participants, 3720 (74.1%) were male, and the median (IQR) age was 36 (22-54) years. Across all severities combined, survival to admission improved (adjusted odds ratio [aOR], 1.59; 95% CI, 1.28-1.97), while survival to discharge did not (aOR, 0.94; 95% CI, 0.78-1.13). Within the cohort with severe TBI but not in the moderate or critical subgroups, survival to hospital admission increased (aOR, 6.44; 95% CI, 2.39-22.00), as did survival to discharge (aOR, 3.52; 95% CI, 1.96-6.34). Conclusions and Relevance: Among patients with severe TBI who received active airway interventions in the field, guideline implementation was independently associated with improved survival to hospital admission and discharge. This was true whether they received basic airway interventions or advanced airways. These findings support the current guideline recommendations for aggressive prevention/correction of hypoxia and hyperventilation in patients with severe TBI, regardless of which airway type is used.

Use of Long Spinal Board Post-Application of Protocol for Spinal Motion Restriction for Spinal Cord Injury.

Introduction: Historically, prehospital care of trauma patients has included nearly universal use of a cervical collar (C-collar) and long spine board (LSB). Due to recent evidence demonstrating harm in using LSBs, implementation of new spinal motion restriction (SMR) protocols in the prehospital setting should reduce LSB use, even among patients with spinal cord injury. Our goal in this study was to evaluate the rates of and reasons for LSB use in high-risk patients-those with hospital-diagnosed spinal cord injury (SCI)-after statewide implementation of SMR protocols. Methods: Applying data from a state emergency medical services (EMS) registry to a state hospital discharge database, we identified cases in which a participating EMS agency provided care for a patient later diagnosed in the hospital with a SCI. Cases were then retrospectively reviewed to determine the prevalence of both LSB and C-collar use before and after agency adoption of a SMR protocol. We reviewed cases with LSB use after SMR protocol implementation to determine the motivations driving continued LSB use. We used simple descriptive statistics, odds ratios (OR) with 95% confidence intervals (CI) to describe the results. Results: We identified 52 EMS agencies in the state of Arizona with 417,979 encounters. There were 225 patients with SCI, of whom 74 were excluded. The LSBs were used in 52 pre-SMR (81%) and 49 post-SMR (56%) cases. The odds of LSB use after SMR protocol implementation was 70% lower than it had been before implementation (OR 0.297, 95% CI 0.139-0.643; P = 0.002). Use of a C-collar after SMR implementation was not significantly changed (OR 0.51, 95% CI 0.23-1.143; P = 0.10). In the 49 cases of LSB use after agency SMR implementation, the most common reasons for LSB placement were ease of lifting (63%), placement by non-transporting agency (18%), and extrication (16.3%). High suspicion of SCI was determined as the primary or secondary reason for not removing LSB after assessment in 63% of those with LSB placement, followed by multiple transfers required (20%), and critical illness (10%). Conclusion: Implementation of selective spinal motion restriction protocols was associated with a statistically significant decrease in the utilization of long spine boards among prehospital patients with acute traumatic spinal cord injury.

Haboob Dust Storms and Motor Vehicle Collision-related Trauma in Phoenix, Arizona.

BACKGROUND: The Sonoran Desert region, encompassing most of southern Arizona, has an extreme climate that is famous for dust storms known as haboobs. These storms lead to decreased visibility and potentially hazardous driving conditions. In this study we evaluate the relationship between haboob events and emergency department (ED) visits due to motor vehicle collisions (MVCs) in Phoenix, Arizona. METHODS: This study is a retrospective analysis of MVC-related trauma presentations to Phoenix, AZ, hospitals before and following haboob dust storms. These events were identified from 2009-2017 primarily using Phoenix International Airport weather data. De-identified trauma data were obtained from the Arizona Department of Health Services (ADHS) Arizona State Trauma Registry (ASTR) from seven trauma centers within a 10-mile radius of the airport. We compared MVC-related trauma using six- and 24-hour windows before and following the onset of haboob events. RESULTS: There were 31,133 MVC-related trauma encounters included from 2009-2017 and 111 haboob events meeting meteorological criteria during that period. There was a 17% decrease in MVC-related ED encounters in the six hours following haboob onset compared to before onset (235 vs 283, P = 0.04), with proportionally more injuries among males (P < 0.001) and higher mortality (P = 0.02). There was no difference in frequency of presentations (P = 0.82), demographics, or outcomes among the 24-hour pre-and post-haboob groups. CONCLUSION: Haboob dust storms in Phoenix, Arizona, are associated with a decrease in MVC-related injuries during the six-hour period following storm onset, likely indicating the success of public safety messaging efforts. Males made up a higher proportion of those injured during the storms, suggesting a target for future interventions. Future public-targeted weather-safety initiatives should be accompanied more closely by monitoring and evaluation efforts to assess for effectiveness.

Identified themes of interactive visualizations overlayed onto EHR data: an example of improving birth center operating room efficiency.

OBJECTIVE: While electronic health record (EHR) systems store copious amounts of patient data, aggregating those data across patients can be challenging. Visual analytic tools that integrate with EHR systems allow clinicians to gain better insight and understanding into clinical care and management. We report on our experience building Tableau-based visualizations and integrating them into our EHR system. MATERIALS AND METHODS: Visual analytic tools were created as part of 12 clinician-initiated quality improvement projects. We built the visual analytic tools in Tableau and linked it within our EPIC environment. We identified 5 visual themes that spanned the various projects. To illustrate these themes, we choose 1 exemplary project which aimed to improve obstetric operating room efficiency. RESULTS: Across our 12 projects, we identified 5 visual themes that are integral to project success: scheduling & optimization (in 11/12 projects); provider assessment (10/12); executive assessment (8/12); patient outcomes (7/12); and control and goal charts (2/12). DISCUSSION: Many visualizations share common themes. Identification of these themes has allowed our internal team to be more efficient and directed in developing visualizations for future projects. CONCLUSION: Organizing visual analytics into themes can allow informatics teams to more efficiently provide visual products to clinical collaborators.

Are Australian men with psychosis spending more time homeless?

OBJECTIVE: The objective of this study was to determine if homeless men with psychosis using emergency accommodation services are spending more time homeless. METHOD: A 12-month accommodation history was collected from all men with psychosis referred to mental health services using two emergency accommodation services in inner Melbourne over a 5-year period. RESULTS: Of the 241 men referred with psychosis, 200 (81%) were able to provide a full accommodation history. In 2001 the mean total days spent in crisis accommodation was 27.0 days and in 2005 the mean number of days was 60.9. Over the 5 years, increasing time was spent homeless in the 12 months prior to assessment, most commonly in emergency accommodations. CONCLUSIONS: Australian men with psychosis using emergency accommodation are spending an increasing amount of time homeless.

Multiple-family group treatment for English- and Vietnamese-speaking families living with schizophrenia.

OBJECTIVE: This study, which was the first evaluation in Australia of multiple-family group treatment, explored the effectiveness of this approach for a newly arrived non-English speaking migrant group, first-generation Vietnamese families, and for English-speaking families. METHODS: Thirty-four pairs of English-speaking consumers and family members and 25 Vietnamese-speaking pairs were randomly assigned to a multiple-family group or a control group. All consumers had a diagnosis of schizophrenia. The multiple-family group intervention (26 sessions over 12 months) was delivered as an adjunct to case management services, which all consumers received. Outcomes, which were measured immediately after treatment and 18 months later, included the number of relapse episodes; the presence and severity of symptoms, as measured by the Brief Psychiatric Rating Scale (BPRS) and the Scale for the Assessment of Negative Symptoms; and social functioning, as measured by the Family Burden Scale, the Health of the Nation Outcome Scale, and the Quality of Life Scale. RESULTS: Relapse rates immediately after treatment were significantly lower for the multiple-family group than for the control group (12 and 36 percent), and relapse rates were also lower during the follow-up period (25 and 63 percent). BPRS ratings were significantly lower for participants in the multiple-family group, and vocational outcomes also improved. The reductions in relapse and symptoms were similar for the English-speaking and the Vietnamese-speaking family groups; sample size precluded statistical analysis of differences. CONCLUSIONS: Multiple-family group treatment is an effective cognitive-behavioral intervention in the treatment of schizophrenia. The findings suggest continued application of and research on family interventions for non-English speaking migrant populations.

The need for the development and evaluation of preventive psychosocial forensic interventions in mainstream adult community mental health services.

OBJECTIVE: This paper provides a selective review of forensic research with the aim of making recommendations for the development and evaluation of psychosocial interventions for the mainstream community mental health setting to address the needs of patients with a history of offending. CONCLUSION: Mainstream community mental health services can be guided by existing findings in the design of psychosocial intervention and prevention programmes. There is growing need to develop and evaluate such interventions.

Chronic mental illness and community treatment resistance.

OBJECTIVES: The movement from institutional to community care has been a key component of national mental health reform in Australia. In Victoria, where a model of community care has been fully implemented, a specialized forensic hospital is the sole remaining stand-alone psychiatric inpatient facility and access to long-term inpatient beds is severely limited. Clinical experience suggests that some high-needs patients are not well serviced by this structure. These patients are placing an increasing burden on a wide range of community services outside mental health. This paper aims to define more clearly this patient group, explore the limitations of their management and outline potential pathways for service development. CONCLUSIONS: A population of complex patients with chronic mental illness are not effectively contained within a 'good enough' community-based mental health system. Active debate is required regarding the community's willingness to tolerate the risks and challenges that arise from the current approach. A collaborative care model involving case-based and incentive funding in combination with community-integrated complex care units may improve the care of these patients.

Boehler's angle and the critical angle of Gissane are of limited use in diagnosing calcaneus fractures in the ED.

STUDY OBJECTIVES: The aim of this study was to determine the use of Boehler's angle (BA) and the critical angle of Gissane (CAG) in diagnosing calcaneus fractures in the ED. DESIGN: The study was conducted as a randomized, blinded, case-control trial. CASES: One hundred thirty-three patients older than 15 years were included in the study. Sixty-five patients with computed tomography-verified calcaneus fractures (gold standard) and 68 ED patients with lateral foot or ankle x-rays without calcaneus fractures were included in the study. METHODS: One second-year emergency medicine resident, 1 third-year emergency medicine resident, 2 board-certified emergency medicine attending physicians, and 1 board-certified radiologist prospectively reviewed all films using the Picture Archival and Communication System digital radiology system. Cases and controls were randomized and the participants were blinded to final radiographic diagnoses. Participants determined whether there was a fracture on each x-ray and measured BA and the CAG using the digital angle tool in the Picture Archival and Communication System. RESULTS: Emergency physicians were 97.9% accurate in diagnosing calcaneus fractures (range, 97% to 99%). The mean kappa value for emergency physicians was 0.96 (range, 0.94-0.985). Receiver operating characteristic curves were constructed for BA and the CAG. When compared with the gold standard, the area under the curve for BA ranged from 0.82 to 0.88. The area under the curve for the CAG ranged from 0.45 to 0.67. BA had an interclass correlation coefficient of 0.84 (95% confidence interval, 0.79-0.87). The CAG interclass correlation was 0.52 (95% confidence interval, 0.43-0.60). One fracture was missed by the radiologist and all of the emergency physicians because it was only visible on computed tomography. CONCLUSION: BA is somewhat helpful and the CAG is not useful in diagnosing calcaneus fractures in the ED. Interrater reliability for BA is excellent, but for the CAG, it is poor. Emergency physicians were 97.9% accurate in making the diagnosis by reviewing the plain films without "assistance" of the angle measurements.

Development of an inner urban homeless mental health service.

OBJECTIVES: The aim is to describe the development, principles and practices of the Waratah Area Homeless Outreach Psychiatric Service (WAHOPS) and place these in the context of international developments in homeless psychiatric services. METHODS: Information on the development of the service was collected from current and past staff. Reference is made to the relevant literature. RESULTS: WAHOPS has developed a unique model of practice based on local and international experience. CONCLUSIONS: Specialized mental health services for the homeless, by working in close collaboration with existing homeless services, can successfully engage and manage patients. The application of homeless practices may need to become more widespread in public mental health services as patterns of accommodation change within the Australian population.

Accommodation history and continuity of care in patients with psychosis.

OBJECTIVES: The objective of this study was to determine the relationship between accommodation history and management outcome in patients with psychosis. METHOD: Demographic information, diagnosis and an accommodation history were taken from patients with psychosis accepted for case management by the Inner West Area Mental Health Service over a 12-month period. The patients were followed up 2 years later to determine their continuity of care and discharge outcome. RESULTS: One hundred 42 patients completed the assessments. Forty-eight percent of patients had spent at least 1 day in a homeless setting in the previous 12 months. Twenty-two percent of patients had long-term (between 2 and 12 months) and six percent chronic (more than 12 months) homelessness. The duration of previous homelessness was significantly inversely correlated with the length of engagement with the service, continuity of psychiatric care at discharge or likelihood of transfer to primary care. Previous interstate mobility was significantly associated with discontinuity of care at discharge. CONCLUSIONS: A history of homelessness is common in patients with psychosis using inner urban mental health services and is associated with poorer engagement with psychiatric services.