A quality-improvement approach to effective trauma team activation

Background: Appropriate, timely trauma team activation (TTA) can directly affect outcomes for patients with trauma. A review of quality-performance indicators at our Canadian level 1 trauma centre showed a high level of undertriage, with TTA compliance rates less than 60% for major trauma. A quality-improvement project was undertaken, targeting a sustained goal of at least 90% TTA compliance based on Accreditation Canada guidelines. Methods: Quality-improvement action followed a well-defined process. Baseline data collection was performed, and, in keeping with the Donabedian approach, we brought together stakeholders to collectively review and understand the reasons behind poor TTA compliance; and root-cause analysis. This was followed by rapid change cycles that focused on structure and processes with ongoing audits to support and sustain change. Results: Trauma team activation compliance improved from 58.8% to more than 90% over 2 years. Quality indicators showed a statistically significant reduction in the time to computed tomography scanner, time in the acute care region of the emergency department and total time in the emergency department, with improved TTA compliance. Conclusion: Compliance with TTA protocols improved to more than 90% over a 2-year period, which shows the benefit of having a clearly outlined qualityimprovement process. This well-defined quality-improvement method provides a framework for use by other institutions that seek to improve their processes of trauma care, including activation rates.

Contexte: Le déploiement rapide et approprié de l'équipe de traumatologie (DÉT) peut avoir une influence directe sur les résultats chez les polytraumatisés. Une revue des indicateurs de qualité/performance dans notre centre de traumatologie canadien de niveau 1 a révélé une lacune importante au plan du triage, et des taux de conformité aux protocoles de DÉT atteignant moins de 60 % pour les traumatismes majeurs. Un projet d'amélioration de la qualité a donc été entrepris avec pour objectif une conformité soutenue d'au moins 90 % aux protocoles de DÉT selon les lignes directrices d'Agrément Canada. Méthodes: Les mesures d'amélioration de la qualité ont suivi un processus bien défini. Une collecte des données de référence a été effectuée, et conformément au modèle de Donabedian, nous avons réuni les différentes parties intéressées pour revoir et comprendre ensemble les raisons de la piètre conformité aux protocoles de DÉT et procéder à leur analyse en profondeur. On a ensuite appliqué des cycles de changements rapides axés sur la structure et les procédés, accompagnés de vérifications en continu pour les appuyer et les maintenir. Résultats: La conformité aux protocoles de déploiement de l'équipe de traumatologie s'est améliorée, passant de 58,8 % à plus de 90 % en l'espace de 2 ans. Les indicateurs de qualité ont montré des réductions statistiquement significatives du délai prétomographie, du temps passé dans la section de soins aigus du service des urgences et du temps total passé aux urgences, de même qu'une meilleure conformité aux protocoles de DÉT. Conclusion: La conformité aux protocoles de DÉT s'est améliorée pour dépasser les 90 % en l'espace de 2 ans, ce qui montre l'efficacité d'un processus d'amélioration de la qualité clairement défini. Cette méthode d'amélioration de la qualité bien définie fournit un cadre que d'autres établissements peuvent appliquer s'ils cherchent à améliorer leurs protocoles de traumatologie, y compris la vitesse de leur déploiement.

High-risk medications in older patients with trauma: a cross-sectional study of risk mitigation

Background: The Beers Criteria for Potentially Inappropriate Medication Use inOlder Adults is a framework that can assess the nature of high-risk medication use. The objective of this study was to use the Beers Criteria to assess the prevalence and nature of polypharmacy, the magnitude of medication changes during the hospital stay and the impact of Beers Criteria medications on outcomes in older patients with trauma. Methods: We used the Alberta Trauma Registry to conduct a retrospective review of patients aged 65 years or older with major trauma (Injury Severity Score ≥ 12) who were admitted to a level 1 trauma centre between January 2013 and December 2014. We analyzed changes in medication prescriptions during the hospital stay using descriptive statistics and assessed the association between Beers Criteria medications and relevant outcomes using multivariable regression analysis. Results: There was no significant change in the number of Beers Criteria medications prescribed before and after admission. The adjusted odds ratio for 30-day mortality for each additional Beers Criteria medication prescribed was 2.02 (95% confidence interval [CI] 1.16­3.51) versus 1.24 (95% CI 1.04­1.59) for each additional medication of any type. The corresponding adjusted incidence rate ratios for length of stay were 1.15 (95% CI 1.03­1.30) versus 1.05 (95% CI 1.01­1.10). Conclusion: Beers Criteria medications were not discontinued during trauma admissions. Using the Beers Criteria as a process indicator for quality improvement in trauma care may provide interdisciplinary trauma teams an opportunity to audit patient medications and stop potentially harmful medications in a vulnerable population.

Contexte: Les critères de Beers sur les médicaments potentiellement inappropriés chez les adultes âgés constituent un cadre qui permet d'évaluer la nature d'une pharmacothérapie à risque élevé. L'objectif de cette étude était d'utiliser les critères de Beers pour évaluer la prévalence et la nature de la polypharmacologie, l'ampleur des changements de prescriptions en cours d'hospitalisation et l'impact des médicaments potentiellement inappropriés sur l'évolution de l'état de personnes âgées victimes de traumatismes. Méthodes: Nous avons utilisé le Registre albertain des traumatismes pour procéder à une revue rétrospective des patients de 65 ans et plus victimes d'un traumatisme grave (indice de gravité des blessures ≥ 12) admis dans un centre de traumatologie entre janvier 2013 et décembre 2014. Nous avons analysé les changements de médicaments prescrits durant le séjour hospitalier au moyen de statistiques descriptives et nous avons évalué le lien entre les médicaments potentiellement inappropriés et les variables pertinentes au moyen d'une analyse de régression multivariée. Résultats: On n'a noté aucun changement significatif entre les médicaments potentiellement inappropriés prescrits avant et après l'admission. Le rapport des cotes ajusté pour la mortalité à 30 jours pour chaque médicament potentiellement inapproprié prescrit a été de 2,02 (intervalle de confiance [IC] à 95 % 1,16­3,51) contre 1,24 (IC à 95 % 1,04­1,59) pour chaque médicament additionnel, de tout type. Les rapports des taux d'incidence ajustés correspondants pour la durée de l'hospitalisation ont été de 1,15 (IC à 95 % 1,03­1,30) contre 1,05 (IC à 95 % 1,01­1,10). Conclusion: Les médicaments potentiellement inappropriés (selon les critères de Beers) n'ont pas été cessés durant les admissions pour traumatisme. L'utilisation des critères de Beers comme indicateur de processus pour l'amélioration de la qualité des soins en traumatologie pourrait fournir aux équipes interdisciplinaires une occasion de vérifier les médicaments prescrits et de cesser ceux qui sont nuisibles à une population vulnérable.

Unusual osseous metaplasia following hernia repair with Prolene mesh: a case report.

The use of Prolene mesh for repair of various hernias is very common. As with any surgical procedure, it can be associated with complications such as seroma, hematoma and wound infection. However, it is uncommon to develop heterotopic ossification following incisional hernia repair with Prolene mesh. Herein, we report a case with chronic abdominal pain secondary to heterotopic ossification occurring after incisional hernia repair with Prolene mesh. It is crucial to report uncommon reactions to the mesh in order to aid in diagnosis of unexplained abdominal pain post hernia repair, after common etiologies are ruled out.

Ensuring adequate vascular access in patients with major trauma: a quality improvement initiative.

Ensuring adequate vascular access in major trauma patients prior to decompensative physiological processes is crucial to patient outcomes. Most protocols suggest achieving two 18-gauge or larger intravenous lines immediately in patients with major trauma. We discuss a quality improvement approach to ensure that >90% of patients with major trauma (as defined by an injury severity score ≥12) at a level one trauma centre receive timely and adequate fluid access. Applying Donabedian principles for process improvement, we used the Alberta Trauma Registry to perform a 4-month chart audit on patients with major trauma at the University of Alberta Hospital. Background data were supported with a formal root cause analysis to outline the problems and generate plan, do, study and act (PDSA) rapid change cycles. These PDSA cycles were then implemented over the course of 2 months to alter system and personnel barriers to care, thereby ensuring that patients with major trauma received adequate vascular access for fluid resuscitation. This was followed by a 6-month sustainability assessment. The percentage of patients with major trauma who received adequate fluid access went from a mean of 55.5% to >90% in 2 months and was sustained at or greater than 90% for 6 consecutive months. The formal application of quality improvement processes is uncommon in trauma care but is much needed to ensure success and sustainability of quality initiatives. Planning including engagement and prechange awareness is crucial to staff engagement, change, and sustainment. Formal quality improvement and change management techniques can elicit rapid and sustainable changes in trauma care. We provide a framework for change to increase compliance with fluid access in patients with major trauma.

Protracted myelin clearance hinders central primary afferent regeneration following dorsal rhizotomy and delayed neurotrophin-3 treatment.

Regeneration within or into the CNS is thwarted by glial inhibition at the site of a spinal cord injury and at the dorsal root entry zone (DREZ), respectively. At the DREZ, injured axons and their distal targets are separated by degenerating myelin and an astrocytic glia limitans. The different glial barriers to regeneration following dorsal rhizotomy are temporally and spatially distinct. The more peripheral astrocytic barrier develops first, and is surmountable by neurotrophin-3 (NT-3) treatment; the more central myelin-derived barrier, which prevents dorsal horn re-innervation by NT-3-treated axons, becomes significant only after the onset of myelin degeneration. Here we test the hypothesis that in the presence of NT-3, axonal regeneration is hindered by myelin degeneration products. To do so, we used the Long Evans Shaker (LES) rat, in which oligodendrocytes do not make CNS myelin, but do produce myelin-derived inhibitory proteins. We show that delaying NT-3 treatment for 1 week in normal (LE) rats, while allowing axonal penetration of the glia limitans and growth within degenerating myelin, results in misdirected regeneration with axons curling around presumptive degenerating myelin ovoids within the CNS compartment of the dorsal root. In contrast, delaying NT-3 treatment in LES rats resulted in straighter, centrally-directed regenerating axons. These results indicate that regeneration may be best optimized through a combination of neurotrophin treatment plus complete clearance of myelin debris.

Compliance to advanced trauma life support protocols in adult trauma patients in the acute setting.

INTRODUCTION: Advanced Trauma Life Support (ATLS) protocols provide a common approach for trauma resuscitations. This was a quality review assessing compliance with ATLS protocols at a Level I trauma center; specifically whether the presence or absence of a trauma team leader (TTL) influenced adherence. METHODS: This retrospective study was conducted on adult major trauma patients with acute injuries over a one-year period in a Level I Canadian trauma center. Data were collected from the Alberta Trauma Registry, and adherence to ATLS protocols was determined by chart review. RESULTS: The study identified 508 patients with a mean Injury Severity Score of 24.5 (SD 10.7), mean age 39.7 (SD 17.6), 73.8% were male and 91.9% were involved in blunt trauma. The overall compliance rate was 81.8% for primary survey and 75% for secondary survey. The TTL group compared to non-TTL group was more likely to complete the primary survey (90.9% vs. 81.8%, p = 0.003), and the secondary survey (100% vs. 75%, p = 0.004). The TTL group was more likely than the non-TTL group to complete the following tasks: insertion of two large bore IVs (68.2% vs. 57.7%, p = 0.014), digital rectal exam (64.6% vs. 54.7%, p = 0.023), and head to toe exam (77% vs. 67.1%, p = 0.013). Mean times from emergency department arrival to diagnostic imaging were also significantly shorter in the TTL group compared to the non-TTL group, including times to pelvis xray (mean 68min vs. 107min, p = 0.007), CT chest (mean 133min vs. 172min, p = 0.005), and CT abdomen and pelvis (mean 136min vs. 173min, p = 0.013). Readmission rates were not significantly different between the TTL and non-TTL groups (3.5% vs. 4.5%, p = 0.642). CONCLUSIONS: While many studies have demonstrated the effectiveness of trauma systems on outcomes, few have explored the direct influence of the TTL on ATLS compliance. This study demonstrated that TTL involvement during resuscitations was associated with improved adherence to ATLS protocols, and increased efficiency (compared to non TTL involvement) to diagnostic imaging. Findings from this study will guide future quality improvement and education for early trauma management.