Mark E. Hamill

Contact isolation is a risk factor for venous thromboembolism in trauma patients.

BACKGROUND Contact isolation (CI) is a series of precautions used to prevent the transmission of medically significant infectious pathogens in the health care setting. Our institution’s implementation of CI includes limiting patient movement to the assigned room. Our objective was to define the association between CI and venous thromboembolism (VTE) at our Level I trauma center. METHODS Our institution’s prospective trauma database was retrospectively queried for all patients admitted to the trauma service between January 1, 2011, and December 31, 2012. Data including demographics, Injury Severity Score (ISS), preexisting medical conditions, injury type, and VTE development were collected. CI status data were obtained from our institution’s infection control database. &khgr;2 was used to examine the unadjusted relationship between CI status and VTE. As the groups were not equivalent, logistic regression was then used to examine the relationship between CI and VTE while adjusting for relevant covariates including sex, age, ISS, and comorbidities. RESULTS Of the 4,423 trauma patients admitted during the study period, 4,318 (97.6%) had complete records and were included in subsequent analyses. A total of 249 (5.8%) of the patients were on CI. VTE occurred in 44 patients (17.7%) on CI versus 141 patients (3.5%) who were not isolated (p < 0.0001; odds ratio, 6.0; 95% confidence interval, 4.1–8.6). With the use of lasso [least absolute shrinkage and selection operator] regression to adjust for patient risk factors, this relationship remained highly significant (p < 0.0001; odds ratio, 2.61; 95% confidence interval, 1.7–4.0). CONCLUSION CI, ISS, hospital length of stay, and cardiac comorbidity were associated with VTE. After adjustment for other risk factors, CI remained most strongly associated with VTE. Although any medical intervention may come with unintended consequences, the risks and benefits of CI in this population need to be reevaluated. Further study is planned to identify opportunities to mitigate this increased VTE risk. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III; therapeutic study, level IV.

Higher surgical critical care staffing levels are associated with improved National Surgical Quality Improvement Program quality measures.

BACKGROUND The changing face of American health care demands careful scrutiny of resource allocation. The impact of the surgical intensivist model on general surgical quality measures has not been studied. Our objective was to investigate the relationship between surgical critical care staffing and indicators of general surgical quality measured by the National Surgical Quality Improvement Program (NSQIP). METHODS We retrospectively examined the number of attending surgical intensivists at our tertiary care center biannually from January 2008 through June 2012. Risk-adjusted indicators of general surgical quality were captured and reported semiannually by NSQIP. Mortality, overall morbidity, patients on ventilator for more than 48 hours, unplanned intubations, and venous thromboembolism were included. Student’s t test was used to compare the staffing levels and associated NSQIP odds ratios of a 3-year control period of full commitment with a 2-year period following significant provider attrition. RESULTS The number of full-time surgical intensivists ranged from 2 to 8, with a period of rapid decline in late 2010 to early 2011 followed by slow recovery. There was a mean of 6.6 surgical intensivists during the 3 years before the decline and a mean of 4 in the 2 years after the decline and recovery (p < 0.005). This period of decline was associated with a significant increase in the odds ratio of ventilation for more than 48 hours (before, 0.936; after, 1.87; p = 0.0086) and of venous thromboembolism (before, 0.844; after 1.43; p = 0.0268). A trend in increased unplanned intubations was also observed. Overall morbidity and mortality were not affected. Notably, quality indicators seemed to rapidly approach baseline levels as new surgical intensivists were recruited. CONCLUSION Institutional commitment to recruitment and retention of a surgical critical care team leads to improved NSQIP general surgery quality measures. LEVEL OF EVIDENCE Care management study, level IV.

Insurance status, mortality, and hospital use among pediatric trauma patients over three decades

BACKGROUND We investigated the association between lack of insurance and mortality, resource use, and medical comorbidities among pediatric trauma patients. METHODS Our trauma database was queried for patients <18 years old from 1989 through 2013. Data collected included demographics, injury severity score (ISS), and insurance status. Dependent variables included major medical comorbidities, hospital and ICU lengths of stay (LOS), and mortality. Logistic regression and tests of equivalence were used to analyze the data. RESULTS A total of 3120 patients were included. The mortality among patients with insurance was 3.6% compared to 8.4% among those without insurance (p=0.0001, OR =2.42, 95% CI=1.53-3.82). This relationship remained statistically significant with adjustment via multivariable logistic regression (p=0.0001, OR =2.83, 95% CI: 1.64-4.74). Hospital and ICU LOS were significantly greater among insured patients in severely and moderately injured samples, respectively. There was no correlation between insurance and medical comorbidities. The uninsured mortality rate was 12.9% from 1989 to 1997 compared to 3.9% in 2006-2013. CONCLUSION Lack of insurance was associated with mortality but not preexisting comorbidity. This relationship persisted over time despite an overall decline in mortality. Additionally, lack of insurance was associated with decreased hospital stay and ICU utilization. LEVEL OF EVIDENCE Treatment Study, Level III.

Progressive Mobility Protocol Reduces Venous Thromboembolism Rate in Trauma Intensive Care Patients: A Quality Improvement Project

The intensive care unit (ICU) trauma population is at high risk for complications associated with immobility. The purpose of this project was to compare ICU trauma patient outcomes before and after implementation of a structured progressive mobility (PM) protocol. Outcomes included hospital and ICU stays, ventilator days, falls, respiratory failure, pneumonia, or venous thromboembolism (VTE). In the preintervention cohort, physical therapy (PT) consults were placed 53% of the time. This rose to more than 90% during the postintervention period. PT consults seen within 24 hr rose from a baseline 23% pre- to 74%–94% in the 2 highest compliance postintervention months. On average, 40% of patients were daily determined to be too unstable for mobility per protocol guidelines—most often owing to elevated intracranial pressure. During PM sessions, there were no adverse events (i.e., extubation, hypoxia, fall). There were no significant differences in clinical outcomes between the 2 cohorts regarding hospital and ICU stays, average ventilator days, mortality, falls, respiratory failure, or pneumonia overall or within ventilated patients specifically. There was, however, a difference in the incidence of VTE between the preintervention cohort (21%) and postintervention cohort (7.5%) (p = .0004). A PM protocol for ICU trauma patients is safe and may reduce patient deconditioning and VTE complications in this high-risk population. Multidisciplinary commitment, daily protocol reinforcement, and active engagement of patients/families are the cornerstones to success in this ICU PM program.

Monitoring modalities and assessment of fluid status: A practice management guideline from the Eastern Association for the Surgery of Trauma

BACKGROUND Fluid administration in critically ill surgical patients must be closely monitored to avoid complications. Resuscitation guided by invasive methods are not consistently associated with improved outcomes. As such, there has been increased use of focused ultrasound and Arterial Pulse Waveform Analysis (APWA) to monitor and aid resuscitation. An assessment of these methods using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework is presented. METHODS A subsection of the Surgical Critical Care Task Force of the Practice Management Guideline Committee of EAST conducted two systematic reviews to address the use of focused ultrasound and APWA in surgical patients being evaluated for shock. Six population, intervention, comparator, and outcome (PICO) questions were generated. Critical outcomes were prediction of fluid responsiveness, reductions in organ failures or complications and mortality. Forest plots were generated for summary data and GRADE methodology was used to assess for quality of the evidence. Reviews are registered in PROSPERO, the International Prospective Register of Systematic Reviews (42015032402 and 42015032530). RESULTS Twelve focused ultrasound studies and 20 APWA investigations met inclusion criteria. The appropriateness of focused ultrasound or APWA-based protocols to predict fluid responsiveness varied widely by study groups. Results were mixed in the one focused ultrasound study and 9 APWA studies addressing reductions in organ failures or complications. There was no mortality advantage of either modality versus standard care. Quality of the evidence was considered very low to low across all PICO questions. CONCLUSION Focused ultrasound and APWA compare favorably to standard methods of evaluation but only in specific clinical settings. Therefore, conditional recommendations are made for the use of these modalities in surgical patients being evaluated for shock. LEVEL OF EVIDENCE Systematic Review, level II.

1556: TRACHEOSTOMY AND GASTROSTOMY IN GERIATRIC TRAUMA ASSOCIATED WITH HIGH POST-DISCHARGE MORTALITY

www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives: A link has been established between psychiatric illness and burn injury, however there are few studies which evaluate this link at a national level. This study aims to explore psychiatric morbidity in the Scottish burns population. Methods: This retrospective population-based cohort study included 903 adult patients admitted to Scottish Burns Units from 2012–2015. Burn injury data was prospectively collected by the Managed Clinical Network Care of Burns in Scotland (COBIS). COBIS data was joined to Scottish Morbidity Record 04 (SMR04); the national Mental Health Inpatient and Day Case database. SMR04 provided information on psychiatric admissions to hospital from 2007–2015. Psychiatric conditions were recorded as World Health Organisation (WHO) International Classification of Disease (ICD) Codes. Data analysis was conducted using the statistical package R and descriptive statistics were performed. Results: For the 903 patients included in the study mean age was 45 years, mean total body surface area (TBSA) burned was 5.5% and mean length of hospital stay was 8.6 days. Ninety-three burns patients were on the SMR04 database meaning they had a psychiatric admission to hospital around the time of the burn injury. There were 402 distinct admissions. Mean TBSA of this subgroup was > 2% higher than that of the full cohort. Despite being only 34.1% of all burns patients, females made up 60.8% of psychiatric admissions. The mean psychiatric admission length of stay was 10 days. The most common psychiatric condition, recorded for 91 admissions, was “mental and behavioural disorders due to use of alcohol” followed by “emotionally unstable personality disorder” for 56 admissions. Thirty-nine admissions had “schizophrenia” and 28 had “depressive episode”. All other conditions had < 10 admissions each. Conclusions: There is currently no standard format for delivering psychological support to burns patients in Scotland. By establishing a link between burn injury and psychopathology, it is recommended that psychological support be formally included in the long-term package of care offered to these patients.

Parathyroid hormone as a marker for hypoperfusion in trauma: a prospective observational study.

BACKGROUND Hyperparathyroidism is common in critical illness. Intact parathyroid hormone has a half-life of 3 minutes to 5 minutes due to rapid clearance by the liver, kidneys, and bone. In hemorrhagic shock, decreased clearance may occur, thus making parathyroid hormone a potential early marker for hypoperfusion. We hypothesized that early hyperparathyroidism predicts mortality and transfusion in trauma patients. METHODS A prospective observational study was performed at a Level I trauma center in consecutive adult patients receiving the highest level of trauma team activation. Parathyroid hormone and lactic acid were added to the standard laboratory panel drawn in the trauma bay on arrival, before the administration of any blood products. The primary outcomes assessed were transfusion in 24 hours and mortality. RESULTS Forty-six patients were included. Median age was 47 years, 82.6% were men, 15.2% suffered penetrating trauma, and 21.7% died. Patients who were transfused in the first 24 hours (n = 17) had higher parathyroid hormone (182.0 pg/mL vs. 73.5 pg/mL, p < 0.001) and lactic acid (4.6 pg/mL vs. 2.3 pg/mL, p = 0.001). Patients who did not survive to discharge (n = 10) also had higher parathyroid hormone (180.3 pg/mL vs. 79.3 pg/mL, p < 0.001) and lactic acid (5.5 mmol/L vs. 2.5 mmol/L, p = 0.001). For predicting transfusion in the first 24 hours, parathyroid hormone has an area under the receiver operating characteristic curve of 0.876 compared with 0.793 for lactic acid and 0.734 for systolic blood pressure. Parathyroid hormone has an area under the receiver operating characteristic curve of 0.875 for predicting mortality compared with 0.835 for lactic acid and 0.732 for systolic blood pressure. CONCLUSION Hyperparathyroidism on hospital arrival in trauma patients predicts mortality and transfusion in the first 24 hours. Further research should investigate the value of parathyroid hormone as an endpoint for resuscitation. LEVEL OF EVIDENCE Prognostic, level II.

Double Jeopardy: Use of Contact Isolation in Trauma Patients is Significantly Associated with the Development of Ileus

Background: Trauma patients are at risk for malnutrition due to metabolic needs associated with injuries and surgery. Ileus may result in improper withholding of vital enteral nutrition. Contact isolation precautions (CI) are a set of restrictions intended to prevent spread of certain organisms. Our goal was to study a possible association between CI and development of ileus among trauma patients. Methods: Our Level I trauma centers institutional trauma database was queried for all patients evaluated between January 1, 2011 and December 31, 2012. Data collected included demographics, comorbidities, and development of ileus. A separate infection control database was used to determine patients on CI. Unadjusted relationships were determined by chi-square. Logistic regression was then used to adjust for patient and injury characteristics. Results: A total of 4,423 trauma patients were evaluated during the study period; of these, 4,317 (97.6%) patients had complete records and were analyzed. CI was in place for 251 (5.8%) patients; 4,066 (94.2%) were not isolated. In the CI group, 14 (5.6%) had ileus vs. 74 (1.8%) in the non-CI group (p<0.0001; OR 3.19; 95% CI 1.77-5.73). Next, logistic regression was used to adjust for potential confounders. Gender, ISS, and CI were all statistically significant (p<0.05) in their association with ileus. Conclusion: The use of CI in trauma patients is significantly associated with the development of ileus. A growing body of evidence suggests that CI among this population, which is already at greater risk of malnutrition and caloric deficit, should be re-evaluated.