Dawn Brand

Outcomes of patients using a tiered trauma response protocol.

OBJECTIVES This study evaluated processes of care and outcome for injured patients at a Level I trauma center who had been either treated as a full trauma team activation (FULL) or managed with a modified trauma team activation (MOD). METHODS A retrospective methodology was used to evaluate all patients entered into the regional trauma system and transported from the scene to a Level I trauma center. Patients treated during a 2-year period of exclusively FULL trauma team protocols were compared with patients managed during a subsequent 2-year period after implementation of a two-tiered response. In the later era, trauma system patients were designated before hospital arrival as either FULL or MOD trauma team responses. An additional case-control analysis was conducted on a subset of MOD trauma team response patients who were undertriaged; that is, in retrospect, they met criteria for a FULL response. The outcomes in the case-control group were compared by chi2 tests and Mann-Whitney U tests. Statistical significance was assumed for p < 0.05. RESULTS During the presystem period, 1,740 patients were transported as trauma system entries to Oregon Health Sciences University. During the postsystem period, 2,333 patients were transported to Oregon Health Sciences University as either MOD trauma system entries (1,272 [55%]) or as FULL trauma system entries (1,061 [45%]). Postsystem patients had longer time intervals in the emergency department compared with presystem patients. Death rates for patients who died in the emergency department or before hospital discharge were similar. Among patients who were designated as MOD trauma system entries and were subsequently categorized as meeting FULL trauma team criteria, mortality rate was low. CONCLUSION Implementation of the tiered response protocol led to a substantial change in the operational response in the emergency department. Although processes of care were nominally prolonged, adverse consequences were not identified. We concluded from this quality improvement review that implementation of a tiered response protocol was satisfactory and improved efficiency. Further work is required to improve accuracy of the categorization of trauma system patients as either MOD or FULL trauma codes.

A comparison of patient characteristics and survival in two trauma centres located in different countries

INTRODUCTION The aim of the study was to compare patient characteristics and mortality in severely injured patients in two trauma centres located in different countries, allowing for differences in case-mix. It represents a direct bench-marking exercise between the trauma centres at the North Staffordshire Hospital (NSH), Stoke-on-Trent, UK and the Oregon Health Sciences University (OHSU) Hospital, Portland, Oregon, USA. METHODS Patients of all ages admitted to the two hospitals during 1995 and 1996 with an Injury Severity Score >15 were included, except for those who died in the emergency departments. Twenty-three factors were studied, including the Injury Severity Score, Glasgow Coma Score, mechanism of injury and anatomical site of injury. Outcome analysis was based on mortality at discharge. RESULTS The pattern of trauma differed significantly between Stoke and Portland. Patients from Stoke tended to be older, presented with a lower conscious level and a lower systolic blood pressure and were intubated less frequently before arriving at hospital. Mortality depended on similar factors in both centres, especially age, highest AIS score, systolic blood pressure and Glasgow Coma Score.The crude analysis of mortality showed a highly significant odds-ratio of 1.64 in Stoke compared with Portland. Single-factor adjustments were made for the above four factors, which had a similar influence on mortality in both centres. Adjusting for the first three factors individually did not alter the odds-ratio, which stayed in the range 1.53-1.59 and remained highly significant. Adjusting for the Glasgow Coma Score reduced the odds-ratio to 0.82 and rendered it non-significant. In a multi-factor logistic regression model incorporating all of the factors shown to influence mortality in either centre, the odds-ratio was 1.7 but was not significant. CONCLUSION The analysis illustrates the limitations and pitfalls of making crude outcome comparisons between centres. Highly significant differences in crude mortality were rendered non-significant by case-mix adjustments, supporting the null hypothesis that the two centres were equally effective in terms of this short-term indicator of outcome. To achieve a meaningful comparison between centres, adjustments must be made for the factors which affect mortality.

Weaning injured patients with prolonged pulmonary failure from mechanical ventilation in a non-intensive care unit setting.

BACKGROUND Injured patients with pulmonary failure often require prolonged length of stay in an intensive care unit (ICU), which includes weaning from ventilatory support. In the last decade, noninvasive ventilation modes have been established as safe and effective. One method for accomplishing this mode of ventilation uses a simple bilevel ventilator. Because this ventilator has been successfully used in hospital wards, we postulated that bilevel ventilators could provide sufficient support during weaning from mechanical ventilation of injured patients in a non-ICU setting. METHODS A retrospective review of trauma patients (August 1996-January 1999) undergoing bilevel positive pressure ventilation as the final phase of weaning was conducted. Before ward transfer with bilevel ventilation, conventionally ventilated ICU patients were changed to bilevel ventilation and were required to tolerate this mode for at least 24 hours. All patients had a tracheostomy as a secure airway. Outcomes analyzed included ICU length of stay, hospital length of stay, duration of mechanical ventilation, weaning success, complications, and survival. RESULTS Fifty-one patients (39 men, 12 women) with a mean age of 53 received more than 24 hours of bilevel positive pressure ventilation. Mean Injury Severity Score was 29, with blunt mechanisms of injury occurring in 90%. Chest or spinal cord injuries that affected pulmonary mechanics were present in 75% of patients. Ventilator-associated pneumonia was treated in 43% of patients. Mean ICU length of stay and hospital length of stay were 21 and 34 days, respectively. Weaning was successful in 89% of patients, whereas 11% were discharged to skilled nursing facilities still receiving bilevel positive pressure ventilation. Two patients died, neither from a pulmonary nor airway complication. Of the remaining 49 patients, 12 were weaned in the ICU and 37 were transferred to the ward with bilevel ventilatory support. The average length of ward ventilation was 6.5 +/- 5.4 days (n = 37). CONCLUSIONS Implementation of a program using bilevel ventilation to support the terminal phase of weaning seriously injured patients from mechanical ventilation was successful. After initiating this mode in the ICU, it was satisfactorily continued in standard surgical wards. Because this method enabled the withdrawal of ventilatory support in a non-ICU setting, its major advantage was reducing ICU length of stay.

A statewide teleradiology system reduces radiation exposure and charges in transferred trauma patients

BACKGROUND Trauma transfer patients routinely undergo repeat imaging because of inefficiencies within the radiology system. In 2009, the virtual private network (VPN) telemedicine system was adopted throughout Oregon allowing virtual image transfer between hospitals. The startup cost was a nominal

Surveyed opinion of American trauma surgeons on the prevention of the abdominal compartment syndrome.

3,000 per hospital. METHODS A retrospective review from 2007 to 2012 included 400 randomly selected adult trauma transfer patients based on a power analysis (200 pre/200 post). The primary outcome evaluated was reduction in repeat computed tomography (CT) scans. Secondary outcomes included cost savings, emergency department (ED) length of stay (LOS), and spared radiation. All data were analyzed using Mann-Whitney U and chi-square tests. P less than .05 indicated significance. Spared radiation was calculated as a weighted average per body region, and savings was calculated using charges obtained from Oregon Health and Science University radiology current procedural terminology codes. RESULTS Four-hundred patients were included. Injury Severity Score, age, ED and overall LOS, mortality, trauma type, and gender were not statistically different between groups. The percentage of patients with repeat CT scans decreased after VPN implementation: CT abdomen (13.2% vs 2.8%, P < .01) and cervical spine (34.4% vs 18.2%, P < .01). Post-VPN, the total charges saved in 2012 for trauma transfer patients was

Enterocutaneous fistula and ventral hernia after absorbable mesh prosthesis closure for trauma: the plain truth.

333,500, whereas the average radiation dose spared per person was 1.8 mSV. Length of stay in the ED for patients with Injury Severity Score less than 15 transferring to the ICU was decreased (P < .05). CONCLUSIONS Implementation of a statewide teleradiology network resulted in fewer total repeat CT scans, significant savings, decrease in radiation exposure, and decreased LOS in the ED for patients with less complex injuries. The potential for health care savings by widespread adoption of a VPN is significant.