Frank Thomas

The risk of infection related to radial vs femoral sites for arterial catheterization.

To evaluate risk factors for infections associated with indwelling arterial catheters, 186 catheters were randomly allocated for either femoral or radial insertion in 155 critically ill patients. Femoral catheters were easier to insert and it was easier to obtain blood specimens from them. Rates of

Calf-thigh sequential pneumatic compression compared with plantar venous pneumatic compression to prevent deep-vein thrombosis after non-lower extremity trauma.

OBJECTIVE To compare the effectiveness of calf-thigh sequential pneumatic compression devices with the effectiveness of plantar venous intermittent pneumatic compression devices in prevention of venous thrombosis after major trauma. SUBJECTS AND METHODS We evaluated 181 consecutive patients after major trauma without lower extremity injuries that precluded the use of pneumatic compression devices. We randomly assigned 149 patients to either calf-thigh sequential pneumatic compression or plantar venous pneumatic compression. After blinding the observers to the method of prophylaxis against deep-vein thrombosis, we performed bilateral compression ultrasonography on or before day 8 after randomization. RESULTS Among 149 randomized patients, 62 who received calf-thigh sequential pneumatic compression and 62 who received plantar venous intermittent pneumatic compression devices completed the trial. Thirteen patients randomized to plantar venous intermittent pneumatic compression (21.0%) and 4 patients randomized to calf-thigh sequential pneumatic compression (6.5%) had deep-vein thrombosis (p = 0.009). Seven of 13 patients with deep-vein thrombosis after prophylaxis with plantar venous intermittent pneumatic compression had bilateral deep-vein thromboses, whereas all 4 patients with deep-vein thrombosis after prophylaxis with calf-thigh sequential pneumatic compression had unilateral deep-vein thrombosis. CONCLUSION Calf-thigh sequential pneumatic compression prevents deep-vein thrombosis more effectively than plantar venous intermittent pneumatic compression after major trauma without lower extremity injuries.

Outcome of critically injured patients treated at Level I trauma centers versus full-service community hospitals.

Critically injured patients were identified by a CRAMS (circulation, respiration, abdomen, motor, speech) score of 6 or less while still in the field. They were prospectively followed as they received their care at the nearest medical facility according to the then-existing district Emergency Medical Services protocols. Those cared for by Level I trauma centers had a significantly reduced mortality rate compared to those treated at the other large full-service community hospitals. The commitment to Level I trauma care improves outcome of the critically injured, and field triage of the critically injured patient to these centers is indicated.

Prospective evaluation of the CRAMS scale for triaging major trauma.

In order to effectively implement a community-wide trauma system, a mechanism of field triage is required. This process of triage should be simple to use and should accurately identify patients who are in need of level I trauma facility care. It should also allow the less critically injured to be cared for at the local hospital of their choice or at the nearest community hospital. The CRAMS (Circulation, Respiration, Abdomen, Motor, Speech) scale was prospectively studied as a potential triage tool by using it to score patients in the field and then comparing their scores to their emergency room dispositions and final outcomes. The CRAMS scale was easy to apply and accurately identified both the critically injured who should be triaged to a Level I center and the less critically injured who can be adequately cared for by Level II and III centers.

Impact of prospective payments on a tertiary care center receiving large numbers of critically ill patients by aeromedical transport.

To determine the economic impact of federal prospective payments and the potential effect if private insurance payers were to implement similar prospective payments, we examined payments under Medicare diagnosis-related grouping (DRG) reimbursement policies for 105 Medicare and 357 non-Medicare patients admitted to a tertiary care center via air transport. Among the 105 Medicare patients, the average length of stay was 11.4 days and the mortality rate was 24%. Hospital charges exceeded DRG reimbursement for 74% of Medicare patients. A comparison of previous Medicare payment policies to current federal DRG reimbursement resulted in a revenue loss to the hospital of

Effectiveness of the kinetic treatment table for preventing and treating pulmonary complications in severely head-injured patients

667,229 (

Effectiveness of implementing a trauma triage system on outcome: a prospective evaluation.

6335 per patient). For the 357 non-Medicare patients, the average length of stay was 10.8 days, the mortality rate was 10%, and hospital charges exceeded Medicare DRG reimbursement for 78% of the patients. Implementation of DRG-like payments by non-Medicare insurers would create a hospital revenue loss of

The economic impact of DRG payment policies on air-evacuated trauma patients.

2,493,048 (

A prospective comparison of arterial catheter blood and catheter-tip cultures in critically ill patients

6983 per patient). We conclude that unless current and planned prospective payment policies are modified, the use of aeromedical transport services to recruit large numbers of critically ill patients to tertiary care centers is economically prohibitive.

Outcomes of pediatric trauma patients transported from rural and urban scenes

The efficacy of using the Kinetic Treatment Table (KTT) to prevent or reduce pulmonary complications in severely head-injured patients is unclear. This study is a prospective, randomized trial using the KTT vs. conventional bed care in severely head-injured patients. Outcome measures were hospital length of stay (LOS), mortality, CNS morbidity at hospital discharge, and rate of improvement of pulmonary status as gauged by chest radiograph, arterial/alveolar PO2 ratio, patient temperature, WBC count, suctioning frequency, sputum volume, and days on ventilator. The KTT group (n = 23) and conventional bed care group (n = 26) were well matched for age, sex, severity of injury, and pulmonary status. There was no significant difference in mortality, CNS morbidity, LOS in ICU or hospital, or rate of pulmonary improvement between the groups. The efficacy of the KTT in reducing pulmonary complications in head-injured patients remains unclear.