Outcomes in patients with spontaneous bacterial peritonitis utilizing first-line or alternative agents for secondary prophylaxis.

PURPOSE: The American Association for the Study of Liver Diseases guidelines recommend ciprofloxacin as a first-line option for spontaneous bacterial peritonitis (SBP) prophylaxis, citing literature that is over 30 years old. There is insufficient data and guidance for prophylaxis in cases of fluoroquinolone treatment failure or intolerance. This study aimed to evaluate outcomes in patients whose antimicrobial prophylaxis was switched from first-line therapies to an alternative agent versus those who were not switched following recurrent SBP. METHODS: This study was an institutional review board-approved retrospective chart review of patients admitted to University of Kentucky HealthCare from 2014 through 2020. Patients included were 18 years of age or older with a diagnosis of recurrent SBP. The primary outcome examined was SBP recurrence rate following initial prophylaxis failure. Additional analyses targeted secondary outcomes, including 6-month mortality, development of SBP complications, development of an adverse drug reaction, and development of multidrug-resistant pathogens. RESULTS: Fifty-three patients were identified with recurrent SBP and divided into 2 cohorts: 25 patients were switched from their original prophylactic agent while 28 patients continued on the same agent after SBP recurrence. Patients in the switch group had lower rates of recurrence (52% vs 100%). Additionally, these patients had lower 6-month mortality rates (24% vs 57.1%; P = 0.015). Thirteen patients in the no-switch group and 3 patients in the switch group required intensive care on a subsequent admission (46.4% vs 12%; P = 0.008). There were no significant differences between the groups in rates of other SBP complications. CONCLUSION: Patients switched from their original prophylactic agent had lower rates of SBP recurrence with significantly lower 6-month mortality rates.

Evaluation of Burnout and Work-Life in Surgical Trauma Acute Care Units.

INTRODUCTION: Stressors unique to trauma patients may potentiate burnout in the trauma care team. Among health care workers, nurses historically demonstrate high rates of burnout and are often the first caregivers in which patients interact. There is limited research, however, investigating burnout in trauma nurses. This study aims to evaluate levels of burnout and perceptions of work-life in nurses and ancillary staff at a Level 1 trauma center. METHODS: An anonymous, cross-sectional, online survey was administered utilizing the Maslach Burnout Toolkit to investigate levels of burnout and work-life. Supplemental questions developed by investigators were included to gather additional details about the work environment. RESULTS: A total of 126 trauma staff completed the survey yielding a response rate of 73%. Trauma staff exhibited low degrees of emotional exhaustion (M = 2.53, SD = 1.29) and depersonalization (M = 1.83, SD = 1.33). Staff with 4 to less than 9 years of tenure at the study institution experienced these emotions at the highest level. Overall, staff cited documentation requirements and patient-to-staff ratios as prominent concerns with their work-life. There were significant negative associations between manageable workload with emotional exhaustion (r = -0.68) and depersonalization (r = -0.56). CONCLUSIONS: Overall, low degrees of emotional exhaustion and depersonalization were exhibited, but significant increases were noted in staff with increasing tenure. These findings suggest that cited aspects of work-life may impact the development of emotional exhaustion and depersonalization over time. Pilot interventions are underway to identify an acuity-adjusted staffing process and a user-friendly electronic documentation platform to improve the institution's work environment.

Rate of Nonsurgical Admissions at a Level 1 Trauma Center: Impact of a Trauma Nurse Practitioner Model.

The American College of Surgeons (ACS) mandates all trauma centers conduct individual case reviews of nonsurgical admissions when rates of allocation to this service exceed 10% of all inpatient traumas. Nonsurgical admission rates at the study institution, which is a Level I trauma center, historically exceeded this ACS criterion. In an effort to decrease nonsurgical admissions, the study institution recruited trauma nurse practitioners (TNPs) who began managing low acuity patients with oversight from trauma attending physicians. This study examines the impact of TNPs on the rate of nonsurgical admissions. A retrospective cohort study was conducted with 1,400 patients between January 2017 and October 2018. Two cohorts examined in this study included trauma patients whose care was managed by the TNPs versus those admitted under the care of hospitalists. The rate of admission to nonsurgical services (NSS) was 19.6% in 2017 and 13.9% in 2018, which yielded a significant decrease from previous years' percentages (p < .001). The average hospital length of stay was 1.17 days shorter in the TNP group, which translated into a savings of approximately $876,330 in hospital charges for the study period. Additional significant findings noted in favor of the TNP cohort were for discharge orders placed prior to noon, discharge location, and reduced time to the operating room. This TNP model proved to be successful in significantly reducing admissions to NSS and substantiated the quality of patient care provided by TNPs. Hospitals struggling to meet the ACS criterion for NSS admissions may consider implementing a similar TNP model.

The impact of burnout syndrome on practitioners working within rural healthcare systems.

INTRODUCTION: Burnout syndrome (BOS) affects up to 50% of healthcare practitioners. Limited data exist on BOS in paramedics/firstresponders, or others whose practice involves trauma. We sought to assess the impact of BOS in practitioners of rural healthcare systems involved in the provision of trauma care within West Virginia. METHODS: A 3-part survey was distributed at two regional trauma conferences in 2018. The survey consisted of 1) Demographic/occupational items, 2) The Mini Z Burnout Survey, and 3) elements measuring the impact, and supportive infrastructure to prevent and/or manage BOS. RESULTS: Response rate was 74.7% (127/170 attendees). Respondents included emergency medical services (EMS) (44.9%), nurses (37.8%), and physicians (9.4%). Overall, 31% reported BOS - physicians (45.5%), EMS (35.1%), and nurses (25.0%). Most agreed that BOS impacts the health of medical professionals (99.2%) and presents a barrier to patient care (97.6%). Those with BOS reported higher stress (p < 0.001), chaos at work (p < 0.001), and excessive documentation time at home (p < 0.001). Fewer respondents with BOS reported job satisfaction (p < 0.001), control over workload (p = 0.001), sufficient time for documentation (p ≤0.001), value alignment with institutional leadership (p = 0.001), and team efficiency (p = 0.004). Unique factors for BOS in EMS included: lack of control over workload (p = 0.032), poor value alignment with employer (p = 0.002), lack of efficient teamwork (p = 0.006), and excessive time documenting at home (p = 0.003). CONCLUSIONS: Burnout syndrome impacts rural healthcare practitioners, regardless of discipline. These data highlight a need to address the entire team and implement occupation-specific approaches for prevention and treatment. Further prospective study of these findings is warranted.

Nurse Practitioners' Role in Improving Service for Elderly Trauma Patients.

Preexisting conditions and decreased physiological reserve in the elderly frequently complicate the provision of health care in this population. A Level 1 trauma center expanded its nurse practitioner (NP) model to facilitate admission of low-acuity patients, including the elderly, to trauma services. This model enabled NPs to initiate admissions and coordinate day-to-day care for low-acuity patients under the supervision of a trauma attending. The complexity of elderly trauma care and the need to evaluate the efficacy of management provided by NPs led to the development of the current study. Accordingly, this study endeavored to compare outcomes in elderly patients whose care was coordinated by trauma NP (TNP) versus nontrauma NP (NTNP) services. Patients under the care of TNPs had a 1.22-day shorter duration of hospitalization compared with that of the NTNP cohort (4.38 ± 3.54 vs. 5.60 ± 3.98, p = .048). Decreased length of stay in the TNP cohort resulted in an average decrease in hospital charges of $13,000 per admission ($38,053 ± $29,640.76 vs. $51,317.79 ± $34,756.83, p = .016). A significantly higher percentage of patients admitted to the TNP service were discharged home (67.1% vs. 36.0%, p = .002), and a significantly lower percentage of patients were discharged to skilled nursing facilities (25.7% vs. 51.9%, p = .040). These clinical and economic outcomes have proven beneficial in substantiating the care provided by TNPs at the study institution. Future research will focus on examining the association of positive outcomes with specific care elements routinely performed by the TNPs in the current practice model.

Determination of Optimal Weight-Based Enoxaparin Dosing and Associated Clinical Factors for Achieving Therapeutic Anti-Xa Assays for Deep Venous Thrombosis Prophylaxis.

BACKGROUND: Previous studies have evaluated dose-to-weight ratios to define best practices for obtaining therapeutic anti-Xa assays for enoxaparin venous thromboembolism (VTE) prophylaxis. These studies have not examined relationships among dosing, patient characteristics, and therapeutic assays. This study examines factors associated with therapeutic assays and enoxaparin prophylaxis. STUDY DESIGN: This is a retrospective review of patients admitted to a Level 1 trauma center between March 2016 and June 2018. Prophylaxis was managed according to the trauma service's enoxaparin VTE prophylaxis protocol, which targets anti-Xa concentrations of 0.2 to 0.5 IU/mL. Assays were divided into sub-therapeutic, therapeutic, and super-therapeutic groups to determine factors associated with therapeutic concentrations. RESULTS: Overall, 623 patients (634 total anti-Xa assays) were identified during the study period. Patients with sub-therapeutic (n = 35) and therapeutic (n = 536) assays did not differ. Significant differences were identified between patients with therapeutic and super-therapeutic assays (n = 63). Receiver operating characteristic curve analysis was used to determine that the optimal cutoff for the dose-to-weight ratio was 0.4 mg/kg/dose (area under the curve 0.78; 95% CI 0.73 to 0.84; p < 0.001) differentiating therapeutic and super-therapeutic assays. Logistic regression revealed male sex, doses of 0.31 to 0.4 mg/kg, and creatinine clearance > 90 mL/min were independently associated with therapeutic assays. The combined effect of these 3 variables showed that therapeutic assays were 13.76 times more likely to occur (OR 13.76; 95% CI 3.43 to 56.96; p < 0.001). CONCLUSIONS: These data demonstrate that a dose of 0.4 mg/kg predicts a therapeutic anti-Xa level. When regimens of 0.31 to 0.4 mg/kg/dose are administered in males with a creatinine clearance >90 mL/min therapeutic results are 13.76 times more likely, suggesting that monitoring with anti-Xa assays might be unnecessary in this subgroup. Additional prospective study of these findings is warranted.

Improving Pharmacologic Prevention of VTE in Trauma: IMPACT-IT QI Project.

Enoxaparin regimens commonly used for prophylaxis fail to achieve optimal anti-factor Xa levels in up to 70 per cent of trauma patients. Accordingly, trauma services at the study institution endeavored to develop a standardized approach to optimize pharmacologic prevention with enoxaparin. An enoxaparin venous thromboembolism (VTE) prophylaxis protocol implemented in October 2015 provided weight-adjusted initial dosing parameters with subsequent dose titration to achieve targeted anti-factor Xa levels. Symptomatic VTE rate was evaluated 12 months pre- and post-implementation. Data were obtained from the trauma registry and charts were reviewed from electronic medical records. The rate of symptomatic VTE significantly declined post-implementation (2.0% vs 0.9%, P = 0.009). Enoxaparin use was comparable in these two phases validating that the decline in symptomatic VTEs was not due to an increase in enoxaparin use. Symptomatic VTE rate for patients who received enoxaparin in the post-implementation cohort decreased from 3.2 to 1.0 per cent (P = 0.023, 95% confidence interval = 0.124-0.856). There was also a significant decrease in the rate of symptomatic deep vein thrombosis (2.8% vs 0.9%, P = 0.040, 95% confidence interval = 0.117-0.950). This approach to VTE prophylaxis with enoxaparin resulted in a significant reduction in symptomatic VTE rates. Implementation of similar practices may be equally impactful in other institutions that use enoxaparin.

An Outcome Analysis of Nurse Practitioners in Acute Care Trauma Services.

The department of trauma at a Level 1 trauma center sought to improve outcomes by enhancing the continuity of care for patients admitted to trauma services. Departmental leadership explored opportunities to improve this aspect of patient care through expansion of existing trauma nurse practitioner (NP) services. The restructured trauma NP service model was implemented in September 2013. A retrospective study was conducted with patients who presented at the trauma center between September 2012 and August 2015. Patients with at least a 24-hr hospital length of stay (LOS) were separated into 3 comparator groups by 12-month increments: 12 months pre-, 12 months during, and 12 months postimplementation. Data revealed improvement in hospital LOS, intensive care unit LOS, time to place rehabilitation consultation, and placement of discharge orders before noon. A significant decline in the rate of complications including pneumonia and deep vein thrombosis (DVT) was also noted. Accordingly, expansion of the trauma NP model resulted in significant improvements in patient and process of care outcomes. This model for NP services may prove to be beneficial for acute care settings at other hospitals with high volume trauma services.

Substance exposure and helmet use in all-terrain vehicle accidents: Nine years of experience at a level 1 trauma center.

INTRODUCTION: The surging popularity of all-terrain vehicles (ATV) in the United States has caused an "epidemic of injuries and mortality." The U.S. Consumer Product Safety Commission reported 99,600 injuries and 426 fatalities from ATV accidents in 2013. The aim of this study was to examine the relationship between helmet use and positive toxicology screenings on outcomes in ATV accident victims. METHODS: This is a retrospective study of patients admitted to a Level 1 Trauma Center in southwestern West Virginia following an ATV accident between 2005 and 2013. Data were obtained from the institution's Trauma Registry. RESULTS: A total of 1,857 patients were admitted during the study period with 39 (1.9%) reported deaths. Positive serum alcohol and/or urine drug screens were obtained in 66.4% of the patients tested (n=1,293). Those with positive screenings were 9.5% less likely to utilize a helmet (13.2% vs. 22.7%, p<0.001); and the lack of helmet use was associated with an increase in traumatic brain injury (57.1% vs. 41.7%, p<0.001). Positivity for substances or the lack of helmet use was significantly associated with higher morbidity. Lack of helmet use resulted in a 3.94-fold increase in the risk of discharge in a vegetative state or death. CONCLUSIONS: Drugs and alcohol use may predispose riders to be less likely to wear helmets and significantly increase the risk of a poor clinical outcome following an ATV accident. Rigorous efforts should be made to enhance safety measures through educational endeavors and amendment of current regulations to promote safe and responsible use of ATVs. PRACTICAL APPLICATIONS: Modification of regulatory requirements should be considered in order to mandate the wearing of helmets during ATV operation. In addition, expansion of safety programs should be considered in an effort to improve availability, affordability and awareness of safe ATV practices.

The effect of ethanol on lactate and base deficit as predictors of morbidity and mortality in trauma.

OBJECTIVE: The objective of this study was to assess the predictive value of lactate and base deficit in determining outcomes in trauma patients who are positive for ethanol. METHODS: Retrospective cohort study of patients admitted to a level 1 trauma center between 2005 and 2014. Adult patients who had a serum ethanol, lactate, base deficit, and negative urine drug screen obtained upon presentation were included. RESULTS: Data for 2482 patients were analyzed with 1127 having an elevated lactate and 1092 an elevated base deficit. In these subgroups, patients with a positive serum ethanol had significantly lower 72-hour mortality, overall mortality, and hospital length of stay compared with the negative ethanol group. Abnormal lactate (odds ratio [OR], 2.607; 95% confidence interval [CI], 1.629-4.173; P = .000) and base deficit (OR, 1.917; 95% CI, 1.183-3.105; P = .008) were determined to be the strongest predictors of mortality in the ethanol-negative patients. Injury Severity Score was found to be the lone predictor of mortality in patients positive for ethanol (OR, 1.104; 95% CI, 1.070-1.138; P = .000). Area under the curve and Youden index analyses supported a relationship between abnormal lactate, base deficit, and mortality in ethanol-positive patients when the serum lactate was greater than 4.45 mmol/L and base deficit was greater than -6.95 mmol/L. CONCLUSIONS: Previously established relationships between elevated lactate, base deficit, and outcome do not remain consistent in patients presenting with positive serum ethanol concentrations. Ethanol skews the relationship between lactate, base deficit, and mortality thus resetting the threshold in which lactate and base deficit are associated with increased mortality.

Readmission within 30 days of discharge after hip fracture care.

The Affordable Care Act currently requires hospitals to report 30-day readmission rates for certain medical conditions. It has been suggested that surveillance will expand to include hip and knee surgery-related readmissions in the future. To ensure quality of care and avoid penalties, readmissions related to hip fractures require further investigation. The goal of this study was to evaluate factors associated with 30-day hospital readmission after hip fracture at a level I trauma center. This retrospective cohort study included 1486 patients who were 65 years or older and had a surgical procedure performed to treat a femoral neck, intertrochanteric, and/or subtrochanteric hip fracture during an 8-year period. Analysis of these patients showed a 30-day readmission rate of 9.35% (n=139). Patients in the readmission group had a significantly higher rate of pre-existing diabetes and pulmonary disease and a longer initial hospital length of stay. Readmissions were primarily the result of medical complications, with only one-fourth occurring secondary to orthopedic surgical failure. Pre-existing pulmonary disease (odds ratio [OR], 1.885; 95% confidence interval [CI], 1.305-2.724), initial hospitalization of 8 days or longer (OR, 1.853; 95% CI, 1.223-2.807), and discharge to a skilled nursing facility (OR, 1.586; 95% CI, 1.043-2.413) were determined to be predictors of readmission. Accordingly, patient management should be consistently geared toward optimizing chronic disease states while concomitantly working to minimize the duration of initial hospitalization and decrease readmission rates