Sandy Widder

Prospective evaluation of computed tomographic scanning for the spinal clearance of obtunded trauma patients: Preliminary results

BACKGROUND Screening methods for detecting cervical spine injury in obtunded ventilated patients continue to evolve. This study compared the use of plain radiography to computed tomographic (CT) scanning of cervical spines in the obtunded blunt trauma patient. The accuracy of plain radiography and CT scanning in detecting clinically significant cervical spine injury in the obtunded blunt trauma patient was evaluated. METHODS We conducted a prospective cohort study with a 3-year convenience sample. The study population consisted of a high-risk subpopulation of severely injured patients, intubated or with a Glasgow Coma Scale score < 9 at presentation. Patients were assessed with a three-view cervical spine series and a CT scan of their cervical spines from the skull base to T1. Independent-blinded review of plain radiographs and CT scans was performed by two radiologists. Sensitivity, specificity, and accuracy of plain films were compared with CT scanning. Sensitivity of CT scanning was compared with discharge diagnosis of cervical spine or cord injury. RESULTS One hundred two patients were eligible and underwent three-view plain radiography and CT scanning. Sensitivity, specificity, and accuracy of plain films compared with CT scanning were 39%, 98%, and 88%, respectively. CT scanning was 100% sensitive in detecting cervical spine injury. CONCLUSION CT scanning in conjunction with plain films enhances the number of cervical spine injuries seen radiographically. Application of a protocol of plain radiographs and CT scanning may be used to clear cervical spines in the obtunded trauma patient. Ongoing evaluation of this protocol is required.

ATLS adherence in the transfer of rural trauma patients to a level I facility

BACKGROUND Injury sustained in rural areas has been shown to carry higher mortality rates than trauma in urban settings. This disparity is partially attributed to increased distance from definitive care and underscores the importance of proper primary trauma management prior to transfer to a trauma facility. The purpose of this study was to assess Advanced Trauma Life Support (ATLS) guideline adherence in the management of adult trauma patients transferred from rural hospitals to a level I facility. METHODS We performed a retrospective analysis of all adult major trauma patients transferred ≥50km from an outlying hospital to a level I trauma centre from 2007 through 2009. Transfer practices were evaluated using ATLS guidelines. RESULTS 646 patients were analyzed. Mean age was 40.5years and 94% sustained blunt injuries with a median Injury Severity Score (ISS) of 22. Median transport distance was 253km. Among all patients, there were notable deficiencies (<80% adherence) in 8 of 11 ATLS recommended interventions, including patient rewarming (8% adherence), chest tube insertion (53%), adequate IV access (53%), and motor/sensory exam (72%). Patients with higher ISS scores, and those transferred by air were more likely to receive ATLS recommended interventions. CONCLUSIONS Key aspects of ATLS resuscitation guidelines are frequently missed during transfer of trauma patients from the periphery to level I trauma centres. Comprehensive quality improvement initiatives, including targeted education, telemedicine and trauma team training programmes could improve quality of care.

Compliance to advanced trauma life support protocols in adult trauma patients in the acute setting

IntroductionAdvanced Trauma Life Support (ATLS) protocols provide a common approach for trauma resuscitations. This was a quality review assessing compliance with ATLS protocols at a Level I trauma center; specifically whether the presence or absence of a trauma team leader (TTL) influenced adherence.MethodsThis retrospective study was conducted on adult major trauma patients with acute injuries over a one-year period in a Level I Canadian trauma center. Data were collected from the Alberta Trauma Registry, and adherence to ATLS protocols was determined by chart review.ResultsThe study identified 508 patients with a mean Injury Severity Score of 24.5 (SD 10.7), mean age 39.7 (SD 17.6), 73.8% were male and 91.9% were involved in blunt trauma. The overall compliance rate was 81.8% for primary survey and 75% for secondary survey. The TTL group compared to non-TTL group was more likely to complete the primary survey (90.9% vs. 81.8%, p = 0.003), and the secondary survey (100% vs. 75%, p = 0.004). The TTL group was more likely than the non-TTL group to complete the following tasks: insertion of two large bore IVs (68.2% vs. 57.7%, p = 0.014), digital rectal exam (64.6% vs. 54.7%, p = 0.023), and head to toe exam (77% vs. 67.1%, p = 0.013). Mean times from emergency department arrival to diagnostic imaging were also significantly shorter in the TTL group compared to the non-TTL group, including times to pelvis xray (mean 68min vs. 107min, p = 0.007), CT chest (mean 133min vs. 172min, p = 0.005), and CT abdomen and pelvis (mean 136min vs. 173min, p = 0.013). Readmission rates were not significantly different between the TTL and non-TTL groups (3.5% vs. 4.5%, p = 0.642).ConclusionsWhile many studies have demonstrated the effectiveness of trauma systems on outcomes, few have explored the direct influence of the TTL on ATLS compliance. This study demonstrated that TTL involvement during resuscitations was associated with improved adherence to ATLS protocols, and increased efficiency (compared to non TTL involvement) to diagnostic imaging. Findings from this study will guide future quality improvement and education for early trauma management.

Quality of life and long-term outcomes of octo- and nonagenarians following acute care surgery: a cross sectional study

BackgroundWhile advanced age is often associated with poorer surgical outcomes, long-term age-related health status following acute care surgery is unknown. The objective of our study was to assess post-operative cognitive impairment, functional status, and quality of life in elderly patients who underwent emergency surgery.MethodsWe identified 159 octo- and nonagenarians who underwent emergency surgery between 2008 and 2010 at a single tertiary hospital. Patients were grouped into three cohorts: 1, 2, and 3 years post-operative. We conducted a survey in 2011, with octo- and nonagenarians regarding the impact of emergency surgical procedures. Consenting participants responded to four survey questionnaires: (1) Abbreviated Mental Test Score-4, (2) Barthel Index, (3) Vulnerable Elders Survey, and (4) EuroQol-5 Dimensional Scale.ResultsOf the 159 octo- and nonagenarians, 88 (55.3%) patients were alive at the time of survey conduction, and 55 (62.5%) of the surviving patients consented to participate. At 1, 2, and 3 years post-surgery, mortality rates were 38.5%, 44.7%, and 50.0%, respectively. More patients had cognitive impairments at 3 years (33.3%) than at 1 (9.5%) and 2 years (9.1%) post-operatively. No statistical difference in the ability to carry out activities of daily living or functional decline with increasing time post-operatively. However, patients perceived a significant health decline with the greater time that passed following surgery.ConclusionsOur study showed that half of the patients over the age of 80 are surviving up to 3 years post-operatively. While post-operative functional status appears to be stable across the 3 cohorts of patients, perceived health status declines over time. Understanding the long-term post-operative impact on cognitive impairment, functional status, and quality of life in elderly patients who undergo acute care surgery allows health care professionals to predict their patients’ likely post-operative needs.

Acute general surgery in Canada: a survey of current handover practices

BACKGROUND Todays acute care surgery (ACS) service model requires multiple handovers to incoming attending surgeons and residents. Our objectives were to investigate current handover practices in Canadian hospitals that have an ACS service and assess the quality of handover practices in place. METHODS We administered an electronic survey among ACS residents in 6 Canadian general surgery programs. RESULTS Resident handover of patient care occurs frequently and often not under ideal circumstances. Most residents spend less than 5 minutes preparing handovers. Clinical uncertainty owing to inadequate handover is most likely to occur during overnight and weekend coverage. Almost one-third of surveyed residents rate the overall quality of the handovers they received as poor. CONCLUSION Handover skills must be taught in a systematic fashion. Improved resident communication will likely decrease loss of patient information and therefore improve ACS patient safety.

CCCS-SSAI WikiRecs Clinical Practice Guideline: vasopressor blood pressure targets in critically ill adults with hypotension

Recommendation: We suggest against the use of a higher blood pressure (BP) target (MAP 75-85) when compared with a lower BP target (MAP 60-70) in adult critically ill patients with hypotension and requiring vasopressors. (Conditional recommendation) This is a recommendation developed by the Canadian Critical Care Society and the Scandinavian Society of Anaesthesiology and Intensive Care Medicine (CCCS-SSAI) according to standards for trustworthy guidelines in collaboration with the MAGIC WikiRecs project. The WikiRecs project is an ongoing collaborative effort by a network of expert clinicians andmethodologists whose aim is to produce trustworthy evidence summaries and clinical practice recommendations within 90 days of identifying potentially practice-changing evidence. See www. magicapp.org/public/guideline/OLwWKL for more details about methods and processes, full evidence summary (GRADE SoF-table), and practical information presented in multilayered formats—available on all digital devices. The electronic supplemental material also contains similar information expanding on the WikiRecs methods and processes. This is a recommendation developed by the Canadian Critical Care Society and the Scandinavian Society of Anaesthesiology and Intensive Care Medicine according to standards for trustworthy guidelines in collaboration with the MAGIC WikiRecs project. An abridged version of the guideline is published in Intensive Care Medicine (10.1007/s00134-016-4539-5).

Multicenter validation of the Quality of Trauma Care Patient-Reported Experience Measure (QTAC-PREM).

BACKGROUND Incorporating patient and family perspectives into injury care quality assessment is a necessary part of comprehensive quality improvement. However, tools to measure patient and family perspectives of injury care are lacking. Therefore, our objective was to assess the psychometric properties of the Quality of Trauma Care Patient-Reported Experience Measure (QTAC-PREM), the first measure developed to assess patient experiences with overall injury care. METHODS We conducted a prospective multicenter cohort study of adult injury patients recruited from three trauma centers. Patients or surrogates completed an acute care survey measure in the hospital and a post–acute care survey measure after hospital discharge. RESULTS Four hundred participants (78%) completed the acute care measure, and 207 (59%) completed the post–acute care measure. We identified three subscales on the acute measure and two subscales on the post–acute measure. All subscales and items had evidence of construct validity. Four subscales had good internal consistency, and three were independent predictors of participants’ overall ratings of injury care quality. The majority of items demonstrated suitable test-retest reliability. Comparison of QTAC-PREM scores with those of an existing patient experience tool, the Hospital version of the Consumer Assessment of Healthcare Providers and Systems (HCAHPS), demonstrated evidence of appropriate divergent and convergent validity. CONCLUSION This study demonstrates that the QTAC-PREM is feasible to implement at trauma centers and provides evidence of validity and reliability. The tool may be useful to incorporate patient perspectives into trauma care quality measurement and improvement.

CCCS-SSAI WikiRecs Clinical Practice Guideline: vasopressors in early traumatic shock

This is a recommendation developed by the Canadian Critical Care Society and the Scandinavian Society of Anaesthesiology and Intensive Care Medicine (CCCSSSAI) according to standards for trustworthy guidelines in collaboration with the MAGIC WikiRecs project. The WikiRecs project is an ongoing collaborative effort by a network of expert clinicians and methodologists whose aim is to produce trustworthy evidence summaries and clinical practice recommendations within 90 days of identifying potentially practice-changing evidence. See www. magicapp.org/public/guideline/OLwWKL for more details about methods and processes, full evidence summary (GRADE SoF-table), and practical information presented in multilayered formats—available on all digital devices. The electronic supplemental material also contains similar information expanding on the WikiRecs methods and processes.

CCCS-SSAI WikiRecs clinical practice guideline: vasopressor blood pressure targets in critically ill adults with hypotension and vasopressor use in early traumatic shock

These recommendations were developed by the Canadian Critical Care Society and the Scandinavian Society of Anaesthesiology and Intensive Care Medicine according to standards for trustworthy guidelines in collaboration with the MAGIC WikiRecs project. The WikiRecs project is an ongoing collaborative effort from a network of expert clinicians and methodologists aiming to rapidly produce trustworthy evidence summaries and clinical practice recommendations within 90 days of identification of potentially practice-changing evidence. See www.magicapp.org/public/guideline/OLwWKL for more details about methods and processes, full evidence summary (GRADE SoF-table), and practical information presented in multilayered formats, available on all devices.

Short form version of the Quality of Trauma Care Patient-Reported Experience Measure (SF QTAC-PREM)

ObjectiveTo enable the valid and reliable measurement of patient experiences we previously published a multicenter multi-center validation of the Quality of Trauma Care Patient-Reported Experience Measure (QTAC-PREM). The purpose of this study was to derive a simplified, short form version of the QTAC-PREM to further enhance the feasibility of measuring patient experiences in injury care. To identify candidate items for the short form we reviewed the results of the original multi-center long form validation cohort study, which included 400 injury care patients and their family members recruited from three trauma centers. We only included the best performing items on the revised short form.ResultsThe acute care component of the measure was shortened by 30% and the post-acute care component was shortened by 42%. We identified two subscales on the acute measure (information and communication; clinical and ancillary care) and one subscale on the post-acute measure (post-discharge information and communication). The measurement properties of the short form measure were similar to that of the validated long form. This short form assessment of patient injury care experiences offers a useful, practical, and easy tool for trauma centers to implement for service evaluation, quality improvement, and injury care research.