David Fleiszer

Trauma care regionalization: a process-outcome evaluation.

BACKGROUNDnRegionalization of trauma care services in our region was initiated in 1993 with the designation of four tertiary trauma centers. The process continued in 1995 with the implementation of patient triage and transfer protocols. Since 1995, the network of trauma care has been expanded with the designation of 33 secondary, 30 primary, and 32 stabilization trauma centers. In addition, during this period emergency medical personnel have been trained to assess and triage trauma victims within minimal prehospital time. The objective of the present study was to evaluate the impact of trauma care regionalization on the mortality of major trauma patients.nnnMETHODSnThis was a prospective study in which patients were entered at the time of injury and were followed to discharge from the acute-care hospital. The patients were identified from the Quebec Trauma Registry, a review of the records of acute-care hospitals that treat trauma, and records of the emergency medical services in the region. The study sample consisted of all patients fulfilling the criteria of a major trauma, defined as death, or Injury Severity Score (ISS) > 12, or Pre-Hospital Index > 3, or two or more injuries with Abbreviated Injury Scale scores > 2, or hospital stay of more than 3 days. Data collection took place between April 1, 1993, and March 31, 1998. During this period, four distinct phases of trauma care regionalization were defined: pre-regionalization (phase 0), initiation (phase I), intermediate (phase II), and advanced (phase III).nnnRESULTSnA total of 12,208 patients were entered into the study cohort, and they were approximately evenly distributed over the 6 years of the study. During the study period, there was a decline in the mean age of patients from 54 to 46 years, whereas the male/female ratio remained constant at 2:1. There was also an increase in the mean ISS, from 25.5 to 27.5. The proportion of patients injured in motor vehicle collisions increased from less than 45% to more than 50% (p < 0.001). The mortality rate during the phases of regionalization were: phase 0, 52%; phase I, 32%; phase II, 19%; and phase III, 18%. These differences were clinically important and statistically significant (p < 0.0001). Stratified analysis showed a significant decline in mortality among patients with ISS between 12 and 49. The change in mortality for patients with fatal injuries (ISS > or = 50) was not significant. During the study period, the mean prehospital time decreased significantly, from 62 to 44 minutes. The mean time to admission after arrival at the hospital decreased from 151 to 128 minutes (p < 0.001). The latter decrease was primarily attributable to changes at the tertiary centers. The proportion of patients with ISS between 12 and 24 and between 25 and 49 who were treated at tertiary centers increased from 56 to 82% and from 36 to 84%, respectively (p < 0.001). Compared with the secondary and primary centers, throughout the course of the study the mortality rate in the secondary and tertiary centers showed a consistent decline (p < 0.001). In addition, the mortality rate in the tertiary centers remained consistently lower (p < 0.001). The results of multivariate analyses showed that after adjusting for injury severity and patient age, the primary factors contributing to the reduced mortality were treatment at a tertiary center, reduced prehospital time, and direct transport from the scene to tertiary centers.nnnCONCLUSIONnThis study produced empirical evidence that the integration of trauma care services into a regionalized system reduces mortality. The results showed that tertiary trauma centers and reduced prehospital times are the essential components of an efficient trauma care system.

Direct transport to tertiary trauma centers versus transfer from lower level facilities: impact on mortality and morbidity among patients with major trauma

BACKGROUNDnThe purpose of the study was to compare the outcome of severely injured patients who were transported directly to a Level I, tertiary trauma center with those who were transferred after being first transported to less specialized hospitals.nnnMETHODSnThe data were based on all patients treated at three tertiary trauma centers in Quebec between April 1, 1993, and December 31, 1995. There were 1,608 patients (37%) transferred and 2,756 patients (63%) transported directly.nnnRESULTSnThe mean age of the patients was approximately 45 years, and more than 60% were males. The predominant mechanisms of injury were falls and motor vehicle crashes. The transfer and direct transport groups were similar with respect to age, gender, and mechanism of injury. Body regions injured were also similar with the exception of head or neck injuries (transfer, 56%; direct, 28%; p < 0.0001). The mean Injury Severity Score was 14, the mean Pre-Hospital Index score was 5.5, and the mean Revised Trauma Score was 7.5. The two groups were similar with respect to these injury severity measures. The primary outcome of interest was mortality described as overall death rate, death rate in the emergency room, and death rate after admission. Other outcomes studied were hospital length of stay and duration of treatment in an intensive care unit. When compared with the direct transport group, transferred patients were at increased risk for overall mortality (transfer, 8.9%; direct, 4.8%; odds ratio, 1.96; 95% confidence interval (CI) = 1.53-2.50), emergency room mortality (transfer, 3.4%; direct, 1.2%; odds ratio, 2.96; 95% CI = 1.90-4.6), and mortality after admission (transfer, 5.5%; direct, 3.6%; odds ratio, 1.57; 95% CI = 1.17-2.11). All of these differences were statistically significant (p < 0.003). Stratified and multiple logistic regression analysis did not alter these results and failed to identify a patient subgroup for which transfer was associated with a reduced risk of mortality. After adjusting for patient age, Injury Severity Score, and presence of injuries to the head or neck and extremities, transferred patients stayed significantly longer in the hospital and the intensive care unit as indicated by the mean length of stay (transfer, 16.0 days; direct, 13.2 days; p = 0.02) and the mean intensive care unit stay (transfer, 2.0 days; direct, 0.95 days; p = 0.001).nnnCONCLUSIONnThe results of this study have shown that transportation of severely injured patients from the scene directly to Level I trauma centers is associated with a reduction in mortality and morbidity. Further studies are required for the evaluation of transport protocols for rural trauma. Economic and cost-effectiveness considerations of patient triage are also essential.

Ineffectiveness of on-site intravenous lines: is prehospital time the culprit?

The purpose of the present study was to test the association between on-site intravenous fluid replacement and mortality in patients with severe trauma. The effect of prehospital time on this association was also evaluated. The design was that of an observational quasi-experimental study comparing 217 patients who had on-site intravenous fluid replacement (IV group) with an equal number of matched patients for whom this intervention was not performed (no-IV group). The patients were individually matched on their Prehospital Index obtained at the scene and were included in the study if they had an on-site Prehospital Index score > 3 and were transported alive to the hospital. The outcome measure of interest was mortality because of injury. The patients in the IV group had a significantly lower mean age (37 vs. 45 years; p < 0.001) and higher incidence of injuries to the head or neck (46 vs. 32%; p = 0.004), chest (34 vs. 17%; p < 0.001), and abdomen (28 vs. 12%; p < 0.001). The IV group also had a higher proportion of patients injured by motor vehicle crashes (41 vs. 27%; p = 0.003), firearms (9 vs. 2%; p = 0.001), and stabbing (20 vs. 9%; p = 0.001). The rate of extremity injuries (38 vs. 59%; p < 0.001) and falls (12 vs. 40%; p < 0.001) was lower for the IV group. In addition, the mean Injury Severity Score was significantly higher for the IV group (15 vs. 9; p < 0.001). The mortality rates for the IV and no-IV groups were 23 and 6% (p < 0.001). Logistic regression analysis showed that after adjusting for patient age, gender, Injury Severity Score, mechanism of injury, and prehospital time, the use of on-site intravenous fluid replacement was associated with a significant increase in the risk of mortality (adjusted odds ratio = 2.3; 95% confidence interval = 1.02-5.28; p = 0.04). To further evaluate the effect of prehospital time on the association between on-site IV use and mortality, the analysis was repeated separately for the following time strata: 0 to 30 minutes, 31 to 60 minutes, and >60 minutes. The adjusted odds ratios (95% confidence interval) for these strata were 1.05 (0.08-14.53; p = 0.97), 3.38 (0.84-13.62; p = 0.08), and 8.40 (1.27-54.69; p = 0.03). These results show that for prehospital times of less than 30 minutes, the use of on-site intravenous fluid replacement provides no benefit, and that for longer times, this intervention is associated with significant increases in the risk of mortality. The results of this observational study have shown that the use of on-site intravenous fluid replacement is associated with an increase in mortality risk and that this association is exacerbated by, but is not solely the result of, increased prehospital times. Our findings are consistent with the hypothesis that early intravenous fluid replacement is harmful because it disrupts the normal physiologic response to severe bleeding. Although this evidence is against the implementation of on-site intravenous fluid replacement for severely injured patients, further studies including randomized controlled trials are required to provide a definitive answer to this question.

Blunt cardiac injury: is this diagnosis necessary?

The diagnosis of blunt cardiac injury in traumatized patients is problematic and the implications of such a diagnosis are not clear. Although cardiac selective creatine kinase (CK-MB) assays and electrocardiograms (EKG) are the most widely available laboratory investigations, they often correlate poorly with diagnoses made on clinical grounds, or by other laboratory methods. We therefore retrospectively studied the Montreal General Hospital experience with 342 consecutive blunt trauma patients admitted to our surgical intensive care/trauma unit. Using clinical criteria, cardiac injury was diagnosed in 44 patients (13%). Twenty-seven of these patients (61%) developed arrythmias or cardiogenic hypotension, half of which required treatment. Heart injuries contributed to six of the 12 deaths in this group. Many of the patients maintained normal CK-MB levels and/or had normal admission EKGs despite the clinical diagnosis of cardiac injury. However, using our criteria for CK-MB positivity, there was a strong correlation between CK-MB elevation and the development of cardiac complications, and very high CK-MB levels (greater than 200 mu/L) were associated with a 100% incidence of such complications. Focusing on patients who developed cardiac complications serious enough to require treatment, we found combined CK-MB/EKG positivity in all cases (100% sensitivity). This method also provided a negative predictive value of 100%. We conclude that although blunt cardiac injury is an important source of morbidity and mortality its diagnosis is not the issue. Rather, it is more important to recognize which of these clinically identified high-risk patients will actually develop cardiac complications. We feel our approach will enable clinicians to do this.

PROTECTIVE EFFECT OF DIETARY FIBRE AGAINST CHEMICALLY INDUCED BOWEL TUMOURS IN RATS

101 rats were fed one of four diets containing graded amounts of dietary fibre. Subcutaeous dimethylhydrazine (D.M.H.) was given to half the rats in each of the diet groups. Stool mass was found to be directly related to the amount of dietary fibre consumed, and the incidence of D.M.H.-induced colon carcinoma was reduced as dietary fibre increased.

Dietary Milk Proteins Inhibit the Development of Dimethylhydrazine-Induced Malignancy

This study investigated the influence of two formula diets containing 20 g/100 g diet of either whey protein concentrate or casein, or Purina mouse chow on 1,2-dimethylhydrazine (DMH)-induced colon carcinoma in A/J mice. Four weeks after the 24th DMH treatment the incidence of tumour and tumour area in the whey protein-fed mice was substantially less in comparison to either the casein or Purina groups. The Purina group exhibited the greatest tumour burden. At the end of the experiment all animals continuously fed the whey protein diet were found to be alive, whereas 33% of those on the casein or Purina diet had died. Animals fed Purina diet for 20 weeks and then switched to either milk protein diet for a further 8 weeks exhibited a decrease in tumour burden as compared to those animals fed the Purina diet continuously. Body weights were similar in all dietary groups. In conclusion, a whey protein diet appears to significantly influence the development of chemically induced colon tumours and the short-term survival of mice.

Preventable death evaluation of the appropriateness of the on-site trauma care provided by Urgences-Santé physicians.

The study is based on 44 preventable deaths occurring in a cohort of 360 patients with major trauma. These cases were reviewed by a committee of nine experts. The mean Injury Severity Score (ISS) was 28, and most cases had injuries to the head/neck (68%) and chest (64%). The mean (+/- SD) observed prehospital times, and those considered the maximum allowable by the committee, were 40.6 +/- 12.0 minutes for head/neck injuries and 23.9 +/- 12.2 minutes for chest injuries (p < 0.05). Intravenous (i.v.) lines were started in 38 (86%) of the patients. The committee classified this procedure as harmful for 16 (42%) and neutral for 19 (50%). Among the 18 (46%) that were intubated, this intervention was considered harmful for 17% and neutral for 39%. In two of the three patients for whom a pneumatic antishock garment was applied, this procedure was considered harmful. Of the 34 patients that required direct transport at a level I trauma center, 50% were transferred to such a hospital. These results show significant prehospital delays and high rates of inappropriate IV line initiation and intubation in trauma patients receiving on-site care by physicians. We conclude that prehospital care protocols for trauma patients should emphasize prompt transport and specific on-site care algorithms.

Increased incidence of experimental colon cancer associated with long-term metronidazole therapy

Using the well-established DMH model for colon neoplasia, we demonstrated that a high-fiber diet pair-fed to animals was associated both with certain changes in bacterial profile and with protection against experimental colon neoplasia. The addition of metronidazole on a long-term basis to both high- and low-fiber diets did not alter stool bacteroides counts as expected and was associated with an apparent cocarcinogenic effect. Concern exists among surgeons and gastroenterologists as to whether metronidazole places their patients at risk. The status of long-term metronidazole therapy for patients with Crohns disease is a pertinent example. In view of our findings, it is important to further elucidate the metabolism of metronidazole in both the rat and human gut.

Effect of dietary fiber on intestinal mucosal sodium-potassium-activated ATPase.

Abstract The effect of dietary fiber on rat intestinal weight, intestinal mucosal Na-K-ATPase, and alkaline phosphatase, and on fecal excretion of water and cations was studied. Rats were fed, for 28 weeks, diets containing 0% (elemental), 5%, or 28% fiber. The fiber-free diet was associated with atrophy, and the high-fiber diet with hypertrophy of the large intestine (79 and 155%, respectively of weights in rats fed the 5% fiber diet). Increased levels of alkaline phosphatase were found in the small intestine of rats fed the elemental diet (200% of levels in rats fed the 5% fiber diet), an effect which appears to confirm the finding observed previously of hypertrophy of enterocyte microvilli in animals fed the elemental diet. Rats fed the high-fiber diet had increased levels of mucosal Na-K-ATPase in the ileum, cecum, and colon (220% of total cecal activity in rats fed the 5% fiber diet). The high-fiber diet was also associated with increased fecal excretion of water, sodium, and potassium (178, 620, and 150%, respectively of levels in rats fed the 5% fiber diet). This effect probably reflects intraluminal trapping of water and cations by fiber with a compensatory rise in mucosal Na-K-ATPase.

Doughnut Rounds: A self-directed learning approach to teaching critical care in surgery

In light of medical students and residents becoming more knowledgeable and vocal in their evaluation of traditional clinical teaching methods, a number of innovative approaches have been tried in our program. We examined a self-directed learning approach to teaching critical care in surgery, known locally as Doughnut Rounds, which involve four to seven medical students and or residents during their surgical intensive care unit (SICU) rotation. They choose the reading material as a group and are expected to formulate 12 questions based on the weeks readings. They pose these questions to their colleagues in a game show format. In this scenario, the attending surgeon has only to bring the doughnuts and to act as a moderator during the session. Several weeks following the end of their three-month ICU rotation, 25 students were sent a questionnaire. It was designed to reflect their degree of satisfaction with Doughnut Rounds and their perception of the importance of various components of these teaching se...