Prothrombin complex concentrate versus standard therapies for INR reversal in trauma patients receiving warfarin.

BACKGROUND: Prothrombin complex concentrate (PCC) is recommended as a therapy to be considered for the reversal of warfarin's effects. Few published data are available on the use of PCC for this indication in traumatically injured patients. OBJECTIVE: To determine whether the addition of PCC to standard approaches to warfarin reversal more rapidly corrects the international normalized ratio (INR) in injured patients. METHODS: A retrospective analysis was performed in trauma patients who were on warfarin preinjury from January 2007 to September 2009 at North Memorial Medical Center. Data were collected from medical records and the trauma registry. Patients were separated based on whether or not they received PCC. The groups were compared on the basis of demographics, units of fresh frozen plasma (FFP), vitamin K use, units of PCC, number of patients achieving an INR of 1.5 or less, time to an INR of 1.5 or less, mortality, intensive care unit (ICU) and hospital length of stay, and the incidence of thromboembolic events during hospitalization. RESULTS: Thirty-one patients were included in the analysis; 13 patients who received a total mean (SD) dose of 2281 (1053) units (25.6 [12.2] units/kg) of PCC (Profilnine SD) were compared to 18 patients who did not receive PCC. There was no significant difference between groups in FFP units received or the number of patients who received vitamin K. Most patients in both groups achieved an INR of 1.5 or less (92% PCC vs 89% no PCC). However, the mean time to achieve an INR of 1.5 or less was 16:59 (20:53) hours in the PCC group versus 30:03 (23:10) hours in the no PCC group (p = 0.048). There were 3 deaths in the PCC group and no deaths in the no PCC group (p = 0.06). ICU and hospital length of stay and number of thromboembolic events did not differ significantly between the 2 groups. CONCLUSIONS: PCC, when added to FFP and vitamin K, resulted in a more rapid time to reversal of the INR.

Incontinence-associated dermatitis in critically ill adults: time to development, severity, and risk factors.

PURPOSE: The purpose of this study was to determine the time to development, severity, and risk factors of incontinence-associated dermatitis (IAD) among critically ill patients with fecal incontinence. SUBJECTS AND SETTING: Forty-five patients with a mean age of 49.4 ± 18.5 years (mean ± SD) in the surgical/trauma critical care unit (ICU) of 1 of 3 urban hospitals who were free of any perineal skin damage at study start participated in the study. The majority (76%) were male. METHODS: Surveillance of skin for IAD and chart review of data initially and daily. RESULTS: Incontinence-associated dermatitis developed in 36% of patients. The median time to onset of IAD was 4 days (range, 1-6). Eighty-one percent of patients still had IAD at discharge from the ICU and at the end of their surveillance (median time = 7 days, range, 1-19 days). The severity of erythema associated with IAD was mild, moderate, or severe for 13%, 11%, or 4% (means) of the time patients were observed. Denudement occurred 9% of the observed time. Frequent incontinence of loose or liquid stools and diminished cognitive awareness were significant independent risk factors for development of IAD sooner. CONCLUSION: Incontinence-associated dermatitis develops in critically ill patients with fecal incontinence relatively quickly and does not resolve in most before their discharge from the ICU. Early monitoring and prevention of IAD, especially in patients with diminished cognition or with frequent leakage of loose or liquid feces, are recommended to promote skin health.

A trauma outreach program provided by a level I trauma center is an effective way to initiate peer review at referring hospitals and foster process improvements.

BACKGROUND: The initial care of critically injured patients has profound effects on ultimate outcomes. The "golden hour" of trauma care is often provided by rural hospitals before definitive transfer. There are, however, no standardized methods for providing educational feedback to these hospitals for the purposes of performance improvement. We hypothesized that an outreach program would stimulate peer review and identify systematic deficiencies in the care of patients with injuries. METHODS: We developed a quality improvement program aimed at providing educational feedback to hospitals that referred patients to our American College of Surgeons-verified level I trauma center. We traveled to each referral center to provide feedback on the initial treatment and ultimate outcome of patients that were transferred to us. These feedback sessions were presented in the format of case presentations and case discussions. RESULTS: The outreach program was presented at each hospital every 3 months to 6 months. Nine hospitals were included in our program. We received 334 patients in transfer from these hospitals during the study period. Formal peer review that focused on trauma patients increased from 14% of hospitals to 100% of hospitals after institution of the program. Eighty-five percent of hospitals thought that the care of patients with injuries was improved as a result of the program. Eighty-five percent of hospitals developed process improvement initiatives as a result of the program. CONCLUSIONS: A formal outreach program can stimulate peer review at rural hospitals, provide continuing education in the care of patients with injuries, and foster process improvements at referring hospitals.

Reducing complications in trauma patients: use of a standardized quality improvement approach.

Injured patients are especially prone to developing complications. Using a multidisciplinary standardized approach to complication review is an effective method of evaluating quality improvement in patients on the trauma service. Collaboration between trauma surgeons and nurse clinicians is instrumental in improving the care of patients in each of the areas we identified. Using this consistently, quality improvement strategies can be put in place and tracked for outcomes. This has allowed for better quantification of the problem as well as any change that may result from applying this formal review process and subsequent intervention.

Implementation of a Prophylactic Anticoagulation Guideline for Patients with Traumatic Brain Injury.

BACKGROUND: Patients with traumatic brain injury (TBI) are at an increased risk of developing complications from venous thromboembolisms (VTEs [blood clots]). Benchmarking by the American College of Surgeons Trauma Quality Improvement Program identified suboptimal use of prophylactic anticoagulation in patients with TBI. We hypothesized that institutional implementation of an anticoagulation protocol would improve clinical outcomes in such patients. METHODS: A new prophylactic anticoagulation protocol that incorporated education, weekly audits, and real-time adherence feedback was implemented in July 2015. The trauma registry identified patients with TBI before (PRE) and after (POST) implementation. Multivariable regression analysis with risk adjustment was used to compare use of prophylactic anticoagulation, VTE events, and mortality. RESULTS: A total of 681 patients with TBI (368 PRE, 313 POST) were identified. After implementation of the VTE protocol, more patients received anticoagulation (PRE: 39.4%, POST: 80.5%, p < 0.001), time to initiation was shorter (PRE: 140 hours, POST: 59 hours, p < 0.001), and there were fewer VTE events (PRE: 19 [5.2%], POST: 7 [2.2%], p = 0.047). Multivariable analysis showed that POST patients were more likely to receive anticoagulation (odds ratio [OR] = 10.8, 95% confidence interval [CI] = 6.9-16.7, p < 0.001) and less likely to develop VTE (OR = 0.33, 95% CI = 0.1-1.0, p = 0.05). CONCLUSION: Benchmarking can assist institutions to identity potential clinically relevant areas for quality improvement in real time. Combining education and multifaceted protocol implementation can help organizations to better focus limited quality resources and counteract barriers that have hindered adoption of best practices.

Re-examination of risk factors for non-Clostridium difficile-associated diarrhoea in hospitalized patients.

AIM: This paper is a report of a study to determine the incidence of non-Clostridium difficile-associated diarrhoea in hospitalized patients and to re-evaluate clinical characteristics and other risk factors related to non-C. difficile-associated diarrhoea. BACKGROUND: Numerous factors are thought to be responsible for diarrhoea in hospitalized patients. Reports about the diarrhoeal effects of some medications administered concomitantly with tube feeding have stimulated reappraisal of the influence of tube feeding as a potential cause. METHOD: This study was a secondary analysis of data of 154 hospitalized patients collected during a prospective epidemiological study from 1992 to 1993. The secondary analysis was completed in 2006 in order to investigate unanswered questions of current importance. FINDINGS: The sample was predominantly male and middle aged; approximately 50% were tube fed, and 25% were in an intensive care unit. The incidence of diarrhoea was 35%. Increased severity of illness as well as the combination of sorbitol-containing medication administration and tube feeding were found to be statistically significant factors in the development of diarrhoea. CONCLUSION: As diarrhoea in hospitalized patients appears to be multifactorial, use of an algorithm to systematically evaluate and manage related factors is recommended.

Society of Trauma Nurses position statement on the role of the clinical nurse specialist in trauma.

The clinical nurse specialist (CNS) is included in the collective term advanced practice nurse. Preparation of the CNS involves completion of a graduate program with a clinical focus, specialty certification, and state-defined requirements for licensure.The trauma CNS demonstrates advanced clinical knowledge based on an in-depth understanding of the pathophysiology of trauma combined with extensive practical experience observing human responses to injury. The trauma CNS assumes the traditional subroles as expert practitioner, educator, consultant, and researcher with the proportion of time spent in each subrole based on the needs of the trauma program. The CNS's ability to minimize variances in care and prevent adverse outcomes directly support performance improvement. The Society of Trauma Nurses recognizes and supports the utilization of CNSs in trauma programs.

Kinetic therapy beds are associated with more complications in patients with thoracolumbar spinal column injuries.

BACKGROUND AND PURPOSE: Traumatic spine injuries are an important cause of morbidity and mortality. Kinetic therapy (KT) beds were designed to minimize skin breakdown and enhance clearance of pulmonary secretions by rotating the patient from side to side. However, little evidence exists to suggest that fewer complications occur in patients with thoracolumbar spine injuries (TLSIs) treated preoperatively with a KT bed. We investigated the effect of KT bed use on infectious complications and respiratory failure in patients requiring surgery for TLSIs. METHODS: We queried the trauma registry of a Level 1 trauma center for patients who had surgery for a TLSI from January 1, 1994, through June 30, 2001, and performed a retrospective medical record review. Patients were divided into two groups according to whether they were treated with a KT bed preoperatively. Patient data included age, injury severity score (ISS), admission Glasgow Coma Scale score (GCS), time to surgery, narcotics administered in total and during the first 24 h after injury, the lowest recorded systolic blood pressure, and acute resuscitation volume requirement. Outcome data included infectious complications, neurologic deficits, respiratory failure, hospital length of stay (LOS), and number of days of ventilator support. Infectious complications included pneumonia, urinary tract infections, and surgical site infections. RESULTS: Patients treated with a KT bed and patients treated with a conventional bed were similar in age, ISS, admission GCS, time to surgery, total narcotics administered, lowest recorded systolic blood pressure, and resuscitation requirement during the first 24 h. However, patients with neurologic deficits were more frequently treated with a KT bed. Infectious complications were more common in patients receiving KT bed therapy than among those on conventional beds. The incidence of respiratory failure, the number of days of ventilator support, and hospital LOS also were significantly higher in patients treated with KT beds. The variables most predictive of infectious complications were the number of days of ventilator support, the amount of fluid administered during the first 24 h, and KT bed therapy (r2 = 0.459). CONCLUSIONS: Patients with TLSIs treated with a KT bed had a higher incidence of infectious complications and respiratory failure and more days of ventilator support than patients treated with a conventional bed despite similar ISS and time to surgical repair. The longer hospital LOS in patients treated with a KT bed may be secondary to the higher incidence of infectious complications and respiratory failure and the greater number of days of ventilator support.