Melvin E. Stone

Factors associated with trauma clinic follow-up compliance after discharge: experience at an urban Level I trauma center.

BACKGROUND Disparities in access to postdischarge services for trauma patients exist, and clinic follow-up remains an important avenue to ensure initial and continued access to postdischarge services. In addition, follow-up is vital to rigorous long-term trauma outcomes research. However, there is a relative paucity of literature specifically addressing clinic follow-up. The purposes of this study were to elucidate factors associated with clinic follow-up compliance and noncompliance after discharge from an urban Level I trauma center and to confirm the prevailing notion that follow-up in trauma clinic is poor. METHODS Our trauma registry was queried for all trauma service discharges of patients 18 years and older for a 2-year period. Patients with incomplete information were excluded. Demographic data such as race/ethnicity and insurance status were collected on all patients. Primary outcome was defined as trauma clinic follow-up within 4 weeks after discharge. Patients compliant with follow-up were compared with noncompliant patients. RESULTS After exclusion criteria were applied, there were 1,818 discharges included in the analysis, with 564 (31%) complying with follow-up (p < 0.001). Factors significantly associated with follow-up noncompliance included patients older than 35 years, white race, Medicaid/Medicare payers, blunt mechanism, extended hospital length of stay, and discharge to rehabilitation facilities. No insurance, penetrating mechanism, short hospital stay, discharge to home, and weekend discharge were all significantly associated with follow-up compliance. Discharge on weekends and to home were independent predictors of compliance, whereas, Medicaid/Medicare insurance status and operative intervention were independent predictors of noncompliance. CONCLUSION This study indentifies factors associated with trauma clinic follow-up compliance and confirms the notion that trauma clinic follow-up compliance at an urban Level I trauma center is alarmingly low. These findings may serve as targets to improve follow-up, thereby improving trauma outcomes research and long-term outcomes. Consequently, clinic follow-up compliance warrants further study and consideration as an essential trauma registry datum. LEVEL OF EVIDENCE Prognostic study, level III.

Daily Multidisciplinary Rounds To Implement the Ventilator Bundle Decreases Ventilator-Associated Pneumonia in Trauma Patients: But Does It Affect Outcome?

BACKGROUND The incidence of ventilator-associated pneumonia (VAP) in trauma patients can be decreased with use of the ventilator bundle (VAPB). Our VAP rate remained high despite the adoption of the VAPB. To better implement the VAPB, a multidisciplinary team composed of the surgical intensive care unit (SICU) nursing staff, physician, and respiratory therapist reviewed briefly a checklist of VAPB goals for each patient before morning attending rounds. We hypothesized that such daily goal rounds (GR) focused on the VAPB would decrease the VAP rate. METHODS A pre-GR ten-month period (November 2006 to August 2007) was compared with the ten-month period (September 2007 to June 2008) with daily GRs. The occurrence of VAPs was tallied prospectively in all intubated trauma patients using the National Nosocomial Infection Surveillance criteria. Patient characteristics and outcome data were obtained from our trauma registry and medical records. Patient characteristics were similar in the 85 pre-GR patients and the 89 GR patients. RESULTS The number of VAPs decreased 67% in the GR patients (15 pre-GR vs. 5 GR; p=0.02); however, the all-cause mortality rate remained similar (16.5% vs. 21.3%; p=0.41). When patients were divided into those with and without VAP, there was a significant increase in mean ventilator, SICU, and hospital days in patients with VAP (p=0.01 for all). There were only two deaths among trauma patients with VAP. CONCLUSION Daily multidisciplinary GRs focused on the VAPB can decrease the incidence of VAP significantly in trauma patients. Ventilator-associated pneumonia correlated with extended mean ventilator, SICU, and hospital days. Interestingly, despite a significant decrease in VAP, a decrease in the mortality rate was not observed. Given the small number of deaths in the VAP cohort, this study has insufficient statistical power to elucidate the true impact of GR intervention or VAP on the mortality rate in trauma patients.

Diagnosis and treatment of a perforated duodenal diverticulum

Perforation is an exceptionally rare complication of duodenal diverticula and often presents with nonspecific symptoms and signs. We present a case of a perforated duodenal diverticulum diagnosed on computed tomography and successfully repaired with a diverticulectomy.

Elderly hip fracture patients admitted to the trauma service: does it impact patient outcome?

BACKGROUND Hip fractures are primarily a disease of the elderly. Advanced age and associated comorbidities in this patient population can lead to adverse outcomes. We routinely admit our hip fracture patients to the Trauma Service (TS). The goal of this study is to see if this policy has had a positive impact on patient outcome. METHODS The Jacobi Medical Center Trauma and Operating Room registries were used to identify all patients aged 65 and over who presented with a hip fracture during the 5-year period from January 1, 2000 to December 31, 2004. Patient charts were used for data retrieval. Outcome variables were length of hospital stay (LOS), time from admission to surgery, in-hospital complication, and in-hospital mortality rates. RESULTS Complete data were available in 255 patients out of a total of 274 admitted in the study period. The mean age was 81.0 years. The median Injury Severity Score was 10 (range, 9-34). Two hundred forty (94.1%) patients were admitted to the TS. The mean time from admission to surgery was 1.9 days and the mean LOS was 10.5 days. In-hospital complication rate and mortality were 35.8% and 2.1%, respectively. CONCLUSION Our policy of admitting elderly hip fracture patients to the TS has resulted in a mortality and LOS among the lowest reported in the literature. This data suggest that there is a clear benefit to admitting elderly hip fractures to the TS.

Utility of the Military Acute Concussion Evaluation as a screening tool for mild traumatic brain injury in a civilian trauma population.

BACKGROUND Mild traumatic brain injury (mTBI) constitutes 75% of more than 1.5 million traumatic brain injuries annually. There exists no consensus on point-of-care screening for mTBI. The Military Acute Concussion Evaluation (MACE) is a quick and easy test used by the US Army to screen for mTBI; however, its utility in civilian trauma is unclear. It has two parts: a history section and the Standardized Assessment of Concussion (SAC) score (0–30) previously validated in sports injury. As a performance improvement project, our institution sought to evaluate the MACE as a concussion screening tool that could be used by housestaff in a general civilian trauma population. METHODS From June 2013 to May 2014, patients 18 years to 65 years old with suspected concussion were given the MACE within 72 hours of admission to our urban Level I trauma center. Patients with a positive head computed tomography were excluded. Demographic data and MACE scores were recorded in prospect. Concussion was defined as loss of consciousness and/or posttraumatic amnesia; concussed patients were compared with those nonconcussed. Sensitivity and specificity for each respective MACE score were used to plot a receiver operating characteristic (ROC) curve. An ROC curve area of 0.8 was set as the benchmark for a good screening test to distinguish concussion from nonconcussion. RESULTS There were 84 concussions and 30 nonconcussed patients. Both groups were similar; however, the concussion group had a lower mean MACE score than the nonconcussed patients. Data analysis demonstrated the sensitivity and specificity of a range of MACE scores used to generate an ROC curve area of only 0.65. CONCLUSION The MACE showed a lower mean score for individuals with concussion, defined by loss of consciousness and/or posttraumatic amnesia. However, the ROC curve area of 0.65 highly suggests that MACE alone would be a poor screening test for mTBI in a general civilian trauma population. LEVEL OF EVIDENCE Diagnostic study, level II.

Bronchobiliary fistula after penetrating thoracoabdominal trauma: case report and literature review.

We report a case of bronchobiliary fistula after penetrating thoracoabdominal trauma. Bronchobiliary fistula is a communication between the bronchial and biliary systems. It is most typically a rare complication of hydatid cyst rupture1 or hepatobiliary surgery2 but has also been reported in association with blunt trauma.3 To our knowledge, this is the second report of bronchobiliary fistula secondary to penetrating trauma.4 Multiple management strategies have been described though the optimal course has not been well defined because of the rarity of the problem. Management options described include both conservative and operative approaches to management, utilizing any or all of the endoscopic retrograde cholangiopancreatography (ERCP), resection of involved lung, repair of the diaphragm, and drainage of the chest and abdomen.3–5 However, the patient with head injuries may be too unstable to undergo definitive surgical therapy initially. In this case report, we describe a novel-staged method of diagnosis and management of a bronchobiliary fistula caused by penetrating thoracoabdominal trauma.

Penetrating neck trauma in children: an uncommon entity described using the National Trauma Data Bank

BACKGROUND Penetrating neck trauma is uncommon in children; consequently, data describing epidemiology, injury pattern, and management are sparse. The aim of this study was to use the National Trauma Data Bank (NTDB) to describe pediatric penetrating neck trauma (PPNT). METHODS The NTDB was queried for children (defined as <15 years old) with PPNT between years 2008 and 2012. Descriptive analysis was used to describe age groups (0–5, 6–10, and 11–14 years) and injury type categorized as aerodigestive, vascular, cervical spine, and nerve. RESULTS A total of 1,238 patients with penetrating neck trauma were identified among 434,788 children in the NTDB (0.28%). Mean age was 7.9 years, and 70.6% of patients were male. The most common mechanisms of injury were stabbing (44%) and gunshot/firearm (24%). Most patients were treated at a pediatric trauma center (65.8%). Computed tomographic scan was the most frequent (42.2%) diagnostic study performed, followed by laryngoscopy (27.0%) and esophagoscopy (27.4%). Almost a quarter of patients (23.7%) went directly to the operating room from the emergency department (ED). Aerodigestive injuries were most common and occurred more frequently in the youngest age group (p < 0.001). Operative procedures for aerodigestive type injuries were most common (82.7%). There were 69 deaths, yielding a mortality rate of 5.6%. When adjusting for age, admission to a pediatric trauma center, and injury type, only vascular injury (odds ratio, 3.92; 95% confidence interval, 2.19–7.24; p < 0.0001) and ED hypotension (odds ratio, 27.12; 95% confidence interval, 15.11–48.67; p < 0.0001) were found to be independently associated with death. CONCLUSION PPNT is extremely rare—0.28% reported NTDB incidence. Age seems to influence injury type but does not affect mortality. Computed tomographic scan is the dominant diagnostic study used for selective management. Vascular injury type and hypotension on presentation to the ED were independently associated with mortality. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III.

Risk factors associated with bladder and urethral injuries in female children with pelvic fractures: An analysis of the National Trauma Data Bank.

BACKGROUND Bladder and/or urethral injuries (BUIs) secondary to pelvic fractures are rare in children and are associated with a high morbidity. These injuries are much less likely to occur in females and are often missed in the emergency department. To help clinicians detect these injuries in female children, larger studies are needed to identify risk factors specific to this patient population. This study aimed to identify risk factors associated with BUI in female children with a pelvic fracture. METHODS We reviewed the National Trauma Data Bank for females younger than 16 years who sustained a pelvic fracture from 2010 to 2012. Patients with penetrating injuries were excluded. Variables including patient characteristics, mechanism of injury, and type of pelvic fracture were selected for bivariate analysis. Variables with an association of p < 0.05 were then tested using binary logistic regression. RESULTS Of the 149,091 females younger than 16 years in the National Trauma Data Bank, 2,639 patients (2%) with pelvic fractures were identified. The median patient age was 12 years (interquartile range [IQR], 7–14 years). BUI was identified in 81 patients (3%). Patients with BUI had a significantly higher median Injury Severity Score (ISS) (25 [IQR, 17–34] vs. 13 [IQR, 6–22], p < 0.001). Four variables were found to be independently associated with BUI in the logistic regression model: vaginal laceration (adjusted odds ratio [OR], 9.1; 95% confidence interval [CI], 4.4–18.7), disruption of the pelvic circle (adjusted OR, 3.0; 95% CI, 1.6–5.6), multiple pelvic fractures (adjusted OR, 2.3; 95% CI, 1.3–3.9), and sacral spine injury (adjusted OR, 1.6; 95% CI, 1.0–2.6). In total, 62 patients (77%; 95% CI, 67–86%) with BUI had at least one of these findings. CONCLUSION Female children who sustained a pelvic fracture and have a vaginal laceration, disruption of the pelvic circle, multiple pelvic fractures, or a sacral spine injury seem to be at highest risk for BUI. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III.

WOUNDED BUT NOT BROKEN: OUTCOMES OF CARDIAC CONTUSION IN PATIENTS WITH A PRE-EXISTING HEART FAILURE

Heart failure is known to be a common co-morbidity that worsens mortality outcomes in both medical and non-medical admissions. We sought to describe the effects of a direct impact to the heart - such as a cardiac contusion injury on the failing heart. We identified all patients with the ICD-9 codes

Re: Military Acute Concussion Evaluation screen in a civilian population.

was associated with poor sensitivity and specificity. A delay in administering the MACE was acknowledged as a limitation in the study by Stone et al., and it is not surprising that they did not find the MACE useful because they tested patients up to 72 hours after the injury and not immediately after the injury as it was intended to be used. Indeed, the studies referred to earlier showed that the cognitive portions of the MACE should be expected to normalize in most cases within 48 hours of the injury. In the study of Stone et al., evaluation with the MACE immediately after injury would not have been possible for the 25% of the cohort that was intoxicated on admission to the trauma center. In that subset, they intentionally waited 12 hours to 24 hours until those patients were ‘‘deemed sober enough to participate reliably.’’ Another important distinction between previous studies and the study of Stone et al. is the age group being examined. The cohorts in which the SAC was independently validated were high school and college athletes, and the studies validating the SAC portion of the MACE were in active duty service members with a mean age of 27 years. In contrast, the patients in the studyofStoneet al.were considerablyolder, with a mean age of 36 years and an age range of 18 years to 65 years. We conclude that the MACE remains an important screening tool for concussion in the military. Based on the clinical evidence supporting the use of the SAC and the MACE immediately after trauma for successfully identifying those who had a concussion, the US military mandated the MACE for deployed troops at risk for concussion during the conflicts inAfghanistan and Iraq. Following this mandate, a sharp increase in the identification of concussed service members occurred and was, in part at least, attributed to the widespread implementation of the MACE by corpsmen and combat medics. We further believe that the cognitive portion of the MACE has been properly validated for use immediately after the injury in high school and college athletes, and in the active duty military, to assess cognitive deficits in patients believed to be concussed. TheMACE has not been validated for use days after the injury or in thosewho are intoxicated. We encourage expansion of the use of the MACE to civilian prehospital and acute trauma centers and agree with the original premise of Stone et al. that this tool can play an important role in the performance improvement when used properly. The MACE can be effectively used to screen patients at risk for a concussion, but only if it is used within a few hours after the injury. Donald W. Marion, MD Defense and Veterans Brain Injury Center US Department of Defense Silver Spring, MD