Benjamin D. Mosher

Chemical venous thromboembolic prophylaxis is safe and effective for patients with traumatic brain injury when started 24 hours after the absence of hemorrhage progression on head CT.

BACKGROUND Venous thromboembolism (VTE) continues to be an important complication for patients with trauma, including patients with intracranial hemorrhage. We implemented a protocol starting chemical prophylaxis 24 hours after the absence of progression of hemorrhage on computed tomography (CT) to increase consistency with the use of chemical venous thromboembolic prophylaxis in this population. The objective of this study was to review the protocol of VTE prophylaxis for patients with traumatic brain injury at our institution to determine whether it has been effective and safe in preventing VTE without increasing intracranial hemorrhage. METHODS A retrospective case series was conducted to study 205 patients with intracranial hemorrhage admitted to a Level I trauma center during a 24-month period. These patients were reviewed with respect to type of intracranial injury, need for surgery, injury severity, time to initiation of chemical prophylaxis, and progression of injury on brain CT. Patients with a hospital length of stay less than 3 days or nonstable CT were excluded in the analysis of administration of chemical prophylaxis. Time to chemical prophylaxis in relation to absence of progression on brain CT was examined as well as the subsequent risk of progression of hemorrhage and risk of VTE events. The overall rate of venous thromboembolism was compared with that of matched historical controls. RESULTS All patients received mechanical prophylaxis in the form of sequential compression devices. One hundred sixty-two intracranial hemorrhages were identified in 122 patients who met the study’s inclusion criteria. Of this group of patients who did not have progression of hemorrhage on follow-up CT, 76.2% received chemical prophylaxis during their hospitalization. No patients had progression of intracranial hemorrhage after initiation of chemical VTE prophylaxis, and no patients developed VTE. This represents a decrease of VTE from previous years. No other complications related to chemical VTE prophylaxis were identified. CONCLUSION A protocol based on an early use of chemical venous thromboembolic prophylaxis after the absence of progression of tramatic intracranial hemorrhage does not result in increased progression of intracranial hemorrhage and reduced the rate of venous thromboembolic events at our institution. LEVEL OF EVIDENCE Therapeutic study, level IV.

Aspiration Pneumonia After Stroke: Intervention and Prevention

Fifteen million strokes occur worldwide each year with 5 million associated deaths and an additional 5 million people left permanently disabled. In the United States, about 780 000 people suffer a new or recurrent stroke each year. There were an estimated total 5.8 million stroke survivors as of 2008. Mortality from stroke is the third leading cause of death in America following heart disease and cancer. Chest infection may affect up to as many as one-third of stroke patients. This increases the morbidity and mortality of this patient population. Pneumonia causes the highest attributable mortality of all medical complications following stroke. A comprehensive multidisciplinary team approach is required at the hospital level. This requires active administrative commitment and participation. Implementation of evidence-based management strategies can improve outcomes and reduce costs. We sought to review the problem of post-stroke pneumonia and discuss strategies for prevention and intervention.

Disorganized care: the findings of an iterative, in-depth analysis of surgical morbidity and mortality.

INTRODUCTION Performance improvement driven by the review of surgical morbidity and mortality is often limited to critiques of individual cases with a focus on individual errors. Little attention has been given to an analysis of why a decision seemed right at the time or to lower-level root causes. The application of scientific performance improvement has the potential to bring to light deeper levels of understanding of surgical decision-making, care processes, and physician psychology. METHODS A comprehensive retrospective chart review of previously discussed morbidity and mortality cases was performed with an attempt to identify areas where we could better understand or influence behavior or systems. We avoided focusing on traditional sources of human error such as lapses of vigilance or memory. An iterative process was used to refine the practical areas for possible intervention. Definitions were then created for the major categories and subcategories. RESULTS Of a sample of 152 presented cases, the root cause for 96 (63%) patient-related events was identified as uni-factorial in origin, with 51 (34%) cases strictly related to patient disease with no other contributing causes. Fifty-six cases (37%) had multiple causes. The remaining 101 cases (66%) were categorized into two areas where the ability to influence outcomes appeared possible. Technical issues were found in 27 (18%) of these cases and 74 (74%) were related to disorganized care problems. Of the 74 cases identified with disorganized care, 42 (42%) were related to failures in critical thinking, 18 (18%) to undisciplined treatment strategies, 8 (8%) to structural failures, and 6 (6%) were related to failures in situational awareness. CONCLUSIONS On a comprehensive review of cases presented at the morbidity and mortality conference, disorganized care played a large role in the cases presented and may have implications for future curriculum changes. The failure to think critically, to deliver disciplined treatment strategies, to recognize structural failures, and to achieve situational awareness contributed to the morbidities and mortalities. Future research may determine if focused training in these areas improves patient outcomes.

Whole body imaging in the diagnosis of blunt trauma, ionizing radiation hazards and residual risk.

Ever since the introduction of radiographic imaging, its utility in identifying injuries has been well documented and was incorporated in the workup of injured patients during advanced trauma life support algorithms [American College of Surgeons, 8th ed. Chicago, 2008]. More recently, computerized tomography (CT) has been shown to be more sensitive than radiography in the diagnosis of injury. Due to the increased use of CT scanning, concerns were raised regarding the associated exposure to ionizing radiation [N Engl J Med 357:2277–2284, 2007]. During the last several years, a significant amount of research has been published on this topic, most of it being incorporated in the BEIR VII Phase 2 report, published by the National Research Council of the National Academies [National Academy of Sciences, Washington DC, 2006]. The current review will analyze the scientific basis for the concerns over the ionizing radiation associated with the use of CT scanning and will examine the accuracy of the typical advanced trauma life support work-up for diagnosis of injuries.

Use of a Dog Visitation Program to Improve Patient Satisfaction in Trauma Patients

Clinical staff members all recognize the importance of attaining high patient satisfaction scores. Although there are many variables that contribute to patient satisfaction, implementation of a dog visitation program has been shown to have positive effects on patient satisfaction in total joint replacement patients. This innovative practice had not previously been studied in trauma patients. The purpose of this quasi-experimental study was to determine whether dog visitation to trauma inpatients increased patient satisfaction scores with the trauma physicians. A team consisting of a dog and handler visited 150 inpatients on the trauma service. Patient satisfaction was measured using a preexisting internal tool for patients who had received dog visitation and compared with other trauma patients who had not received a visit. This study demonstrated that patient satisfaction on four of the five measured scores was more positive for the patients who had received a dog visit.