A novel, evidence-based, comprehensive clinical decision support system improves outcomes for patients with traumatic rib fractures.

BACKGROUND: Traumatic rib fractures are associated with high morbidity and mortality. Clinical decision support systems (CDSS) have been shown to improve adherence to evidence-based (EB) practice and improve clinical outcomes. The objective of this study was to investigate if a rib fracture CDSS reduced hospital length of stay (LOS), 90-day and 1-year mortality, unplanned ICU transfer, and the need for mechanical ventilation. The independent association of two process measures, an admission EB order set and a pain-inspiratory-cough score early warning system, with LOS were investigated. METHODS: The CDSS was scaled across nine US trauma centers. Following multiple imputation, multivariable regression models were fit to evaluate the association of the CDSS on primary and secondary outcomes. As a sensitivity analysis, propensity score matching was also performed to confirm regression findings. RESULTS: Overall, 3,279 patients met inclusion criteria. Rates of EB practices increased following implementation. On risk-adjusted analysis, in-hospital LOS preintervention versus postintervention was unchanged (incidence rate ratio [IRR], 1.06; 95% confidence interval [CI], 0.97-1.15, p = 0.2) but unplanned transfer to the ICU was reduced (odds ratio, 0.28; 95% CI, 0.09-0.84, p = 0.024), as was 1-year mortality (hazard ratio, 0.6; 95% CI, 0.4-0.89, p = 0.01). Provider utilization of the admission order bundle was 45.3%. Utilization was associated with significantly reduced LOS (IRR, 0.87; 95% CI, 0.77-0.98; p = 0.019). The early warning system triggered on 34.4% of patients; however, was not associated with a significant reduction in hospital LOS (IRR, 0.76; 95% CI, 0.55-1.06; p = 0.1). CONCLUSION: A novel, user-centered, comprehensive CDSS improves adherence to EB practice and is associated with a significant reduction in unplanned ICU admissions and possibly mortality, but not hospital LOS. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Should they stay or should they go? Who benefits from interfacility transfer to a higher-level trauma center following initial presentation at a lower-level trauma center.

BACKGROUND: Interfacility transfer of patients from Level III/IV to Level I/II (tertiary) trauma centers has been associated with improved outcomes. However, little data are available classifying the specific subsets of patients that derive maximal benefit from transfer to a tertiary trauma center. Drawbacks to transfer include increased secondary overtriage. Here, we ask which injury patterns are associated with improved survival following interfacility transfer. METHODS: Data from the National Trauma Data Bank was utilized. Inclusion criteria were adults (≥16 years). Patients with Injury Severity Score of 10 or less or those who arrived with no signs of life were excluded. Patients were divided into two cohorts: those admitted to a Level III/IV trauma center versus those transferred into a tertiary trauma center. Multiple imputation was performed for missing values, and propensity scores were generated based on demographics, injury patterns, and disease severity. Using propensity score-stratified Cox proportional hazards regression, the hazard ratio for time to death was estimated. RESULTS: Twelve thousand five hundred thirty-four (5.2%) were admitted to Level III/IV trauma centers, and 227,315 (94.8%) were transferred to a tertiary trauma center. Patients transferred to a tertiary trauma center had reduced mortality (hazard ratio, 0.69; p < 0.001). We identified that patients with traumatic brain injury with Glasgow Coma Scale score less than 13, pelvic fracture, penetrating mechanism, solid organ injury, great vessel injury, respiratory distress, and tachycardia benefited from interfacility transfer to a tertiary trauma center. In this sample, 56.8% of the patients benefitted from transfer. Among those not transferred, 49.5% would have benefited from being transferred. CONCLUSION: Interfacility transfer is associated with a survival benefit for specific patients. These data support implementation of minimum evidence-based criteria for interfacility transfer. LEVEL OF EVIDENCE: Therapeutic/Care Management, Level IV.

Pneumonia: challenges in the definition, diagnosis, and management of disease.

Defining health care-associated pneumonia, which includes both hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), is problematic and controversial. Aspiration pneumonia is often included as a subtype of HAP but may be related to community-acquired aspiration events. Scoring systems exist and new surveillance guidelines have been implemented to make early recognition of pneumonia more precise and objective. Management and prevention should follow recommendations, including early empirical therapy, targeted therapy, and limited duration of treatment. Patients with trauma present a challenge to the diagnosis and management of pneumonia, because of increased risk for aspiration and underlying chest and pulmonary injury.

Effect of high advanced glycation end-product diet on pulmonary inflammatory response and pulmonary function following gastric aspiration.

It is not clear why some patients with aspiration advance to acute lung injury or acute respiratory distress syndrome, whereas others do not. The Western diet is high in advanced glycation end-products (AGEs), which have been found to be proinflammatory. We hypothesize that dietary AGEs exaggerate the pulmonary inflammatory response following gastric aspiration. CD-1 mice were randomized to receive either a low-AGE (LAGE) or a high-AGE (HAGE) diet for 4 weeks. Five hours after intratracheal instillation of acidified small gastric particles, pulmonary function was determined. Polymorphonuclear neutrophil counts, albumin, cytokine/chemokine, and tumor necrosis factor soluble receptor II concentrations in the bronchoalveolar lavage and lung myeloperoxidase activity were measured. Compared with LAGE-fed animals, those fed a HAGE diet had increased lung tissue resistance (P = 0.017), bronchoalveolar lavage albumin concentration (P < 0.05), pulmonary polymorphonuclear neutrophil counts (P = 0.0045), and lung myeloperoxidase activity (P = 0.002) following aspiration. In addition, the plasma levels of tumor necrosis factor soluble receptor II were significantly elevated (P < 0.05), whereas paradoxically levels of keratinocyte chemoattractant and monocyte chemoattractant protein 1 were decreased in mice with HAGE diet. In conclusion, a diet high in AGEs exacerbates acute lung injury following gastric aspiration as evidenced by increases in neutrophil infiltration, airway albumin leakage, and decreased pulmonary compliance. This is the first evidence implicating exacerbation of acute inflammatory lung injury by dietary AGEs. Targeting AGEs in the circulatory system may offer a therapeutic strategy for limiting lung injury following gastric aspiration.