Steven A. Santanello

Occurrence of nosocomial pneumonia in mechanically ventilated trauma patients: a comparison of sucralfate and ranitidine.

To determine if there is a difference in nosocomial pneumonia frequency rate in mechanically ventilated trauma patients treated with sucralfate vs. ranitidine for stress ulcer prophylaxis. Design:Prospective, randomized trial. Setting:A 640-bed urban teaching hospital and trauma center. Patients:Ninety-two mechanically ventilated trauma patients. Interventions:Thirty-nine patients received sucralfate and 44 patients received intravenous ranitidine for stress ulcer prophylaxis; nine patients were excluded from the study for protocol breaks. Measurements and Main Results:The study population was severely injured and critically ill. The Trauma Score averaged 11.3, the Injury Severity Score averaged 27.7, and the Acute Physiology and Chronic Health Evaluation (APACHE) score averaged 18.1. There were no significant differences in demographics, mechanisms of injury, Trauma Score, Injury Severity Score, APACHE score, length of hospital stay, length of surgical intensive care unit stay, or duration of endotracheal intubation between the sucralfate and ranitidine groups. Eleven (13.2%) patients developed nosocomial pneumonia: six (15.4%) of 39 patients in the sucralfate group and five (11.4%) of 44 patients in the ranitidine group; these numbers were not significantly different (x2 = 0.0226, p = .8805). There were no episodes of significant upper gastrointestinal bleeding. Six patients died during hospitalization, all secondary to severe head injury and none with pneumonia. Conclusions:There was no statistically significant difference in pneumonia rate in mechanically ventilated trauma patients receiving stress ulcer prophylaxis with sucralfate vs. ranitidine. (Crit Care Med 1993; 21:1856–1862)

Colorectal trauma : primary repair or anastomosis with intracolonic bypass vs. ostomy

This prospective, randomized, controlled study was undertaken to compare primary repair or anastomosis with intracolonic bypassvs.ostomy in severe colon and intraperitoneal rectal injury. Patients were randomized at surgery following confirmation of injury. Data collected included demographics, mechanism and location of injury, trauma score (TS), injury severity score (ISS), penetrating abdominal trauma index (PATI), complications, length of hospital stay, and hospital charges. Twenty-two patients were studied: 11 with intracolonic bypass and 11 controls. The experimental and control groups were statistically similar in demographics and mechanism of injury, severity of injury (TS=13.8vs.12.8; ISS=27.5vs.24.2; PATI=40.5vs.35.0), and complication rate. Length of stay (12.2 daysvs.20.7 days) and charges

Percutaneous Endoscopic vs Surgical Gastrostomy

27,885vs.

Clinical Clearance of Spinal Immobilization in the Air Medical Environment: A Feasibility Study

53,599) tended to be greater in controls, and the comparison did not include subsequent colostomy closure. This study supports intracolonic bypass as a safe alternative to ostomy in severe colon and intraperitoneal rectal trauma.

Speaking the same language: underestimating financial impact when using diagnosis-related group versus ICD-9-based definitions for trauma inclusion criteria

The percutaneous endoscopic gastrostomy (PEG) has replaced the surgical gastrostomy (GT) on our service. We reviewed our data in an effort to determine relative efficacy and cost effectiveness of the two techniques. Thirty-five patients with PEGs were matched for age and diagnosis with 35 patients with GTs done by the same surgical service. PEGs were done in the endoscopy suite; GTs were done in the operating room: both under local anesthesia. Patients in PEG and GT groups were comparable in sex, diagnosis, and age. The PEG took less time to insert (15.3 vs 25.4 min, p less than 0.001). Major postoperative morbidity was similar with 10 systemic complications for each group and 11 deaths for the PEG vs 12 deaths for the GT group (at 90 days). Minor morbidity was higher for the PEG group with nine complications vs 1. Estimated cost for PEG was half the cost of GT. Hospital stay for the two groups was similar (36 vs 45 days, p greater than 0.1), but postop stay for the PEG group tended to be shorter (17 vs 24 days, p less than 0.08). The PEG is faster and cheaper to insert than the GT, however major morbidity and mortality are the same.

Ultrasound evaluation of blunt abdominal trauma: program implementation, initial experience, and learning curve.

BACKGROUND Various decision algorithms have been developed for use in the prehospital setting to analyze those trauma patients who do not require spinal immobilization. The feasibility of applying these algorithms in the air medical transport environment has not been studied. METHODS All adult patients (>/=age 16) transported to three Level I trauma centers were eligible for the study. Medical crews completed a data collection sheet during transport which was later used to analyze whether the transported patient would be eligible for spinal clearance based on the absence of all of the following clinical findings: (1) abnormal level of consciousness; (2) evidence of intoxication; (3) distracting painful injury; (4) spinal tenderness or pain; or (5) abnormal neurologic examination. The outcomes were (1) the proportion of transported patients potentially eligible for spinal clearance and (2) the ability of the algorithm to predict spinal injury. RESULTS Three hundred twenty-nine patients were enrolled in the study. Forty-nine (15%) had spinal injuries with 12 (24%) considered unstable. Only 40 patients met criteria for deferring spinal immobilization; 4 of these patients had spinal fractures. The algorithm had a sensitivity of 90% and a specificity of 16%. CONCLUSION Clearance of spinal immobilization using prehospital clinical algorithms during air medical transport did not appear to be useful. These criteria were not found to be sensitive, specific, or predictive of spinal injury in this population of blunt trauma patients. Prehospital spinal immobilization clearance algorithms using existing criteria should not be adopted for patients transported by helicopter.

Correlation of metabolic acidosis with outcome following injury and its value as a scoring tool.

BACKGROUND Hospital accounting methods use diagnosis-related group (DRG) data to identify patients and derive financial analyses and reports. The National Trauma Data Bank and trauma programs identify patients with trauma by International Classification of Diseases, Ninth Edition (ICD-9)-based definitions for inclusion criteria. These differing methods of identifying patients result in economic reports that vary significantly and fail to accurately identify the financial impact of trauma services. METHODS Routine financial data were collected for patients admitted to our Trauma Service from July 1, 2005 to June 30, 2006 using two methods of identifying the cases; by trauma DRGs and by trauma registry database inclusion criteria. The resulting data were compared and stratified to define the financial impact on hospital charges, reimbursement, costs, contribution to margin, downstream revenue, and estimated profit or loss. The results also defined the impact on supporting services, market share and total revenue from trauma admissions, return visits, discharged trauma alerts, and consultations. RESULTS A total of 3,070 patients were identified by the trauma registry as meeting ICD-9 inclusion criteria. Trauma-associated DRGs accounted for 871 of the 3,070 admissions. The DRG-driven data set demonstrated an estimated profit of

Laparoscopic vs. Open Wedge Biopsy of the Liver

800,000 dollars; the ICD-9 data set revealed an estimated 4.8 million dollar profit, increased our market share, and showed substantial revenue generated for other hospital service lines. CONCLUSIONS Trauma DRGs fail to account for most trauma admissions. Financial data derived from DRG definitions significantly underestimate the trauma service lines financial contribution to hospital economics. Accurately identifying patients with trauma based on trauma database inclusion criteria better defines the business of trauma.