Real-time infection prediction with wearable physiological monitoring and AI to aid military workforce readiness during COVID-19.

Infectious threats, like the COVID-19 pandemic, hinder maintenance of a productive and healthy workforce. If subtle physiological changes precede overt illness, then proactive isolation and testing can reduce labor force impacts. This study hypothesized that an early infection warning service based on wearable physiological monitoring and predictive models created with machine learning could be developed and deployed. We developed a prototype tool, first deployed June 23, 2020, that delivered continuously updated scores of infection risk for SARS-CoV-2 through April 8, 2021. Data were acquired from 9381 United States Department of Defense (US DoD) personnel wearing Garmin and Oura devices, totaling 599,174 user-days of service and 201 million hours of data. There were 491 COVID-19 positive cases. A predictive algorithm identified infection before diagnostic testing with an AUC of 0.82. Barriers to implementation included adequate data capture (at least 48% data was needed) and delays in data transmission. We observe increased risk scores as early as 6 days prior to diagnostic testing (2.3 days average). This study showed feasibility of a real-time risk prediction score to minimize workforce impacts of infection.

Radiographic Reread Protocols to Identify Clinically Relevant Errors in Initial Trauma Evaluations.

INTRODUCTION: Diagnostic radiology interpretive errors in trauma patients can lead to missed diagnoses, compromising patient care. Due to this, our level II trauma center implemented a reread protocol of all radiographic imaging within 24 hours on our highest trauma activation level (Code T). We sought to determine the efficacy of this reread protocol in identifying missed diagnoses in Code T patients. We hypothesized that a few, but clinically relevant errors, would be identified upon reread. METHODS: All radiographic study findings (initial read and reread) performed for Code T admissions from July 2015 to May 2016 were queried. The reviewed radiological imaging was given one of four designations: agree with interpretation, minor (non-life threatening) nonclinically relevant error(s)-addendum/correction required or clinically relevant error(s) (major [life threatening] and minor)-addendum/correction required, and trauma surgeon notified. The results were compiled, and the number of each type of error was calculated. RESULTS: Of the 752 radiological imaging studies reviewed on the 121 Code T patients during this period, 3 (0.40%) contained minor clinically relevant errors, 11 (1.46%) contained errors that were not clinically relevant, and 738 (98.1%) agreed with the original interpretation. The three clinically relevant errors included a right mandibular fracture found on X-ray and a temporal bone fracture that crossed the clivus and bilateral rib fractures found on computerized tomography. DISCUSSION: Clinically relevant errors, although minimal, were discovered during rereads for Code T patients. Although the clinical errors were significant, none affected patient outcomes. We propose that the implementation of reread protocols should be based upon institution-specific practices.

Elderly trauma associated with high-risk recreational activity: A population-based study, United States, 2010 through 2016.

BACKGROUND: Understanding trends in prevalence and etiology is critical to public health strategies for prevention and management of injury related to high-risk recreation in elderly Americans. METHODS: The National Emergency Department Sample from 2010 through 2016 was queried for patients with a principal diagnosis of trauma (ICD-9 codes 800.0-959.9) and who were 55 years and older. High-risk recreation was determined from e-codes a priori. Primary outcome measures were mortality and total hospital charges. RESULTS: Of the 29,491,352 patient cohort, 458,599 (1.56%) engaged in high-risk activity, including those age 85 and older. High-risk cases were younger (median age 61 vs 70) and majority male (71.87% vs 39.24%). The most frequent activities were pedal cycling (45.81%), motorcycling (29.08%), and off-road vehicles (9.13%). Brain injuries (8.82% vs 3.88%), rib/sternal fractures (13.35% vs 3.53%), and cardiopulmonary injury (5.25% vs 0.57%) were more common among high-risk cases. Mortality (0.75% vs 0.40%) and total median hospital charges ($3,360 vs $2,312) were also higher for high-risk admissions, where the odds of mortality increased exponentially per year of age (odds ratio, 1.06; 99.5% CI, 1.05-1.08). High-risk recreation was associated with more than $1 billion in total hospital charges and more than 100 deaths among elderly Americans per year. CONCLUSION: Morbidity, mortality, and resource utilization due to high-risk recreation extend into the ninth decade of life. The patterns of injury described here offer opportunities for targeted injury prevention education to minimize risk among this growing segment of the United States population.

Initial phase of Pu-238 production in Idaho National Laboratory.

The initial phase of Plutonium-238 (Pu-238) production for radioisotope thermal generation is described here in detail. Two dosimeters with/without cadmium sleeve containing Neptunium-237 (Np-237) and other neutron sensors were inserted into the low power Advanced Test Reactor Critical (ATRC) for Pu-238 production testing. The gamma-ray energy measurements from Np-238, the short-lived intermediate product, confirmed that sizable amount of Pu-238 can be produced in the full power Advanced Test Reactor (ATR). The Pu-238 production determined from the irradiation experiment was in accord with the modelling predictions. Detailed studies of the Au/Cu sensors for thermal and epithermal flux analysis and their consistency for sensors in different locations, bare and in Cd-sleeve, provided confidence in the Pu-238 production data.

Predictors of Trauma High Resource Consumers in a Mature Trauma System.

BACKGROUND: Extended hospital length of stay (LOS) is widely associated with significant healthcare costs. Since LOS is a known surrogate for cost, we sought to evaluate outliers. We hypothesized that particular characteristics are likely predictive of trauma high resource consumers (THRC) and can be used to more effectively manage care of this population. METHODS: The Pennsylvania Trauma Outcome Study database was retrospectively queried from 2003-2017 for all adult (age ≥15) trauma patients admitted to accredited trauma centers in Pennsylvania. THRC were defined as patients with hospital LOS two standard deviations above the population mean or ≥22 days (p<0.05). Patient demographics, comorbid conditions and clinical variables were compared between THRC and non-THRC to identify potential predictor variables. A multilevel mixed-effects logistic regression model controlling for age, gender, injury severity, admission Glasgow coma score, systolic blood pressure, and injury year assessed the adjusted impact of clinical factors in predicting THRC status. The National Trauma Data Bank (NTDB) was retrospectively queried from 2014-2016 for all adult (age ≥15) trauma patients admitted to state-accredited trauma centers and likewise were assessed for factors associated with THRC. RESULTS: A total of 465,601 patients met inclusion criteria [THRC: 16,818 (3.6%); non-THRC 448,783 (96.4%)]. Compared to non-THRC counterparts, THRC patients were significantly more severely injured (median ISS: 9 vs. 22, p<0.001). In adjusted analysis, gunshot wound (GSW) to the abdomen, undergoing major surgery and reintubation along with injury to the spine, upper or lower extremities were significantly associated with THRC. From the NTDB, 2 323 945 patients met inclusion criteria. In adjusted analysis, GSW to the abdomen was significantly associated with THRC. Penetrating injury overall was associated with decreased risk of being a THRC in the NTDB dataset. Those who had either GSW to abdomen, surgery, or reintubation required significantly longer LOS (p<0.001). CONCLUSIONS: Reintubation, major surgery, gunshot wound to abdomen, along with injury to the spine, upper or lower extremities are all strongly predictive of THRC. Understanding the profile of the THRC will allow clinicians and case management to proactively put processes in place to streamline care and potentially reduce costs and LOS.

An analysis of overtriage and undertriage by advanced life support transport in a mature trauma system.

BACKGROUND: While issues regarding triage of severely injured trauma patients are well publicized, little information exists concerning the difference between triage rates for patients transported by advanced life support (ALS) and basic life support (BLS). We sought to analyze statewide trends in undertriage (UT) and overtriage (OT) to address this question, hypothesizing that there would be a difference between the UT and OT rates for ALS compared with BLS over a 13-year period. METHODS: All patients submitted to Pennsylvania Trauma Outcomes Study database from 2003 to 2015 were analyzed. Undertriage was defined as not calling a trauma alert for patients with an Injury Severity Score (ISS) of 16 or greater. Overtriage was defined as calling a trauma alert for patients with an ISS of 9 or less. A logistic regression was used to assess mortality between triage groups in ALS and BLS. A multinomial logistic regression assessed the adjusted impact of ALS versus BLS transport on UT and OT versus normal triage while controlling for age, sex, Glasgow Coma Scale, systolic blood pressure (SBP), pulse, Shock Index and injury year. RESULTS: A total of 462,830 patients met inclusion criteria, of which 115,825 had an ISS of 16 or greater and 257,855 had an ISS of 9 or less. Both ALS and BLS had significantly increased mortality when patients were undertriaged compared with the reference group. Multivariate analysis in the form of a multinomial logistic regression revealed that patients transported by ALS had a decreased adjusted rate of undertriage (relative risk ratio, 0.92; 95% confidence interval, 0.87-0.97; p = 0.003) and an increased adjusted rate of OT (relative risk ratio, 1.59; 95% confidence interval, 1.54-1.64; p < 0.001) compared with patients transported by BLS. CONCLUSION: Compared with their BLS counterparts, while UT is significantly lower, OT is substantially higher in ALS-further increasing the high levels of resource (over)utilization in trauma patients. Undertriage in both ALS and BLS are associated with increased mortality rates. Additional education, especially in the BLS provider, on identifying the major trauma victim may be warranted based on the results of this study. LEVEL OF EVIDENCE: Epidemiological, Level III.

An analysis of outcomes and predictors of intensive care unit bouncebacks in a mature trauma system.

BACKGROUND: With the recent birth of the Pennsylvania TQIP Collaborative, statewide data identified unplanned admissions to the intensive care unit (ICU) as an overarching issue plaguing the state trauma community. To better understand the impact of this unique population, we sought to determine the effect of unplanned ICU admission/readmission on mortality to identify potential predictors of this population. We hypothesized that ICU bounceback (ICUBB) patients would experience increased mortality compared with non-ICUBB controls and would likely be associated with specific patterns of complications. METHODS: The Pennsylvania Trauma Outcome Study database was retrospectively queried from 2012 to 2015 for all ICU admissions. Unadjusted mortality rates were compared between ICUBB and non-ICUBB counterparts. Multilevel mixed-effects logistic regression models assessed the adjusted impact of ICUBB on mortality and the adjusted predictive impact of 8 complications on ICUBB. RESULTS: A total of 58,013 ICU admissions were identified from 2012 to 2015. From these, 53,715 survived their ICU index admission. The ICUBB rate was determined to be 3.82% (2,054/53,715). Compared with the non-ICUBB population, ICUBB patients had a significantly higher mortality rate (12% vs. 8%; p < 0.001). In adjusted analysis, ICUBB was associated with a 70% increased odds ratio for mortality (adjusted odds ratio, 1.70; 95% confidence interval, 1.44-2.00; p < 0.001). Adjusted analysis of predictive variables revealed unplanned intubation, sepsis, and pulmonary embolism as the strongest predictors of ICUBB. CONCLUSION: Intensive care unit bouncebacks are associated with worse outcomes and are disproportionately burdened by respiratory complications. These findings emphasize the importance of the TQIP Collaborative in identifying statewide issues in need of performance improvement within mature trauma systems. LEVEL OF EVIDENCE: Epidemiological study, level III.

A comparison of adolescent penetrating trauma patients managed at pediatric versus adult trauma centers in a mature trauma system.

BACKGROUND: While there is little debate that pediatric trauma centers (PTC) are uniquely equipped to manage pediatric trauma patients, the extent to which adolescents benefit from treatment there remains controversial. We sought to elucidate differences in management approach and outcome between PTC and adult trauma centers (ATC) for the adolescent penetrating trauma population. We hypothesized that improved mortality would be observed at ATC for this subset of patients. METHODS: Adolescent patients (age, 15-18 years), presenting to Pennsylvania-accredited trauma centers between 2003 and 2017 with penetrating injury, were queried from the Pennsylvania Trauma Outcome Study database. Dead on arrival, transfer patients, and those admitted to a Level III or Level IV trauma center were excluded from analysis. Patient length of stay, number of complications, surgical intervention, and mortality were compared between ATC and PTC. Multilevel mixed effects logistic regression models with trauma center as the clustering variable were used to assess the impact of center type (ATC/PTC) on management approach and mortality adjusted for appropriate covariates. RESULTS: A total of 2,630 adolescent patients met inclusion criteria (PTC: n = 428 [16.3%]; ATC: n = 2,202 [83.7%]). Pediatric trauma centers had a lower adjusted odds of mortality (adjusted odds ratio [AOR], 0.35; 95% confidence interval [CI], 0.17-0.74; p = 0.006) and a lower adjusted odds of surgery (AOR, 0.67; 95% CI, 0.0.48-0.93; p = 0.016) than their ATC counterparts. There were no differences in complication rates (AOR, 0.94; 95% CI, 0.57-1.55; p = 0.793) or length of stay longer than 4 days (AOR, 0.95; 95% CI, 0.61-1.48; p = 0.812) between the PTCs and ATCs. There were also differences in penetrating injury type between PTC and ATC. CONCLUSION: The adolescent penetrating trauma patient population treated at PTC had less surgery performed with improved mortality compared with ATC. LEVEL OF EVIDENCE: Therapeutic, Level IV.

Population-Based Analysis of Firearm Injuries among Young Children in the United States, 2010-2015.

Firearm violence in the United States knows no age limit. This study compares the survival of children younger than five years to children and adolescents of age 5-19 years who presented to an ED for gunshot wounds (GSWs) in the United States to test the hypothesis of higher GSW mortality in very young children. A study of GSW patients aged 19 years and younger who survived to reach medical care was performed using the Nationwide ED Sample for 2010-2015. Hospital survival and incidence of fatal and nonfatal GSWs in the United States were the study outcomes. A multilevel logistic regression model estimated the strength of association among predictors of hospital mortality. The incidence of ED presentation for GSW is as high as 19 per 100,000 population per year. Children younger than five years were 2.7 times as likely to die compared with older children (15.3% vs 5.6%). Children younger than one year had the highest hospital mortality, 33.1 per cent. The mortality from GSW is highest among the youngest children compared with older children. This information may help policy makers and the public better understand the impact of gun violence on the youngest and most vulnerable Americans.

A preliminary analysis of Level IV trauma centers within an organized trauma system.

BACKGROUND: The effect of Level IV trauma center (TC) accreditation within an existing trauma network remains understudied. This study compared preaccreditation to postaccreditation data from Level IV TCs within a mature trauma system in Pennsylvania to determine whether TC designation affected time to and/or rate of transfer to definitive care. Level IV TCs were hypothesized to have a decreased time to transfer following accreditation and improved mortality. METHODS: The Pennsylvania Trauma Systems Foundation collects predesignation and postdesignation data from hospitals pursuing accreditation. Data from Pennsylvania Trauma Systems Foundation between 2012 and 2017 were analyzed. Variables of interest included patient demographics, injury severity, mortality, and incidence of surgical interventions precredentialingto postcredentialing. A multilevel mixed-effects logistic regression model assessed the adjusted impact of Level IV TC accreditation on transfer rate. ArcGIS Desktop was used for geospatial mapping of lives and geographic area covered by the addition of Level IV TCs in Pennsylvania. RESULTS: Five hospitals underwent Level IV credentialing from 2012 to 2017, providing data on 5,076 cases (pre, 2,395 [47.2%]; post, 2,681 [52.8%]). No significant difference in age, admission Glasgow Coma Scale score, or shock index was observed preaccreditation to postaccreditation. A difference in transfer rate was observed after credentialing in unadjusted (62.7% vs. 63.3%; p < 0.014) and adjusted analyses (adjusted odds ratios, 1.13, p = 0.389). There was a trend toward reduced odds of mortality postcredentialing (adjusted odds ratios, 0.59, p = 0.261). Major surgical intervention decreased (Pre, 0.42%; Post, 0.04%; p = 0.004). CONCLUSION: Level IV TC accreditation has beneficial effects on increased transfer rates and may improve mortality. It is important to continue to observe the impact of Level IV TCs on patient outcomes within a mature trauma system. LEVEL OF EVIDENCE: Prognostic and epidemiological, level III.

A core genome approach that enables prospective and dynamic monitoring of infectious outbreaks.

Whole-genome sequencing is increasingly adopted in clinical settings to identify pathogen transmissions, though largely as a retrospective tool. Prospective monitoring, in which samples are continuously added and compared to previous samples, can generate more actionable information. To enable prospective pathogen comparison, genomic relatedness metrics based on single-nucleotide differences must be consistent across time, efficient to compute and reliable for a large variety of samples. The choice of genomic regions to compare, i.e., the core genome, is critical to obtain a good metric. We propose a novel core genome method that selects conserved sequences in the reference genome by comparing its k-mer content to that of publicly available genome assemblies. The conserved-sequence genome is sample set-independent, which enables prospective pathogen monitoring. Based on clinical data sets of 3436 S. aureus, 1362 K. pneumoniae and 348 E. faecium samples, ROC curves demonstrate that the conserved-sequence genome disambiguates same-patient samples better than a core genome consisting of conserved genes. The conserved-sequence genome confirms outbreak samples with high sensitivity: in a set of 2335 S. aureus samples, it correctly identifies 44 out of 44 known outbreak samples, whereas the conserved-gene method confirms 38 known outbreak samples.

Integration of genomic and clinical data augments surveillance of healthcare-acquired infections.

BACKGROUND: Determining infectious cross-transmission events in healthcare settings involves manual surveillance of case clusters by infection control personnel, followed by strain typing of clinical/environmental isolates suspected in said clusters. Recent advances in genomic sequencing and cloud computing now allow for the rapid molecular typing of infecting isolates. OBJECTIVE: To facilitate rapid recognition of transmission clusters, we aimed to assess infection control surveillance using whole-genome sequencing (WGS) of microbial pathogens to identify cross-transmission events for epidemiologic review. METHODS: Clinical isolates of Staphylococcus aureus, Enterococcus faecium, Pseudomonas aeruginosa, and Klebsiella pneumoniae were obtained prospectively at an academic medical center, from September 1, 2016, to September 30, 2017. Isolate genomes were sequenced, followed by single-nucleotide variant analysis; a cloud-computing platform was used for whole-genome sequence analysis and cluster identification. RESULTS: Most strains of the 4 studied pathogens were unrelated, and 34 potential transmission clusters were present. The characteristics of the potential clusters were complex and likely not identifiable by traditional surveillance alone. Notably, only 1 cluster had been suspected by routine manual surveillance. CONCLUSIONS: Our work supports the assertion that integration of genomic and clinical epidemiologic data can augment infection control surveillance for both the identification of cross-transmission events and the inclusion of missed and exclusion of misidentified outbreaks (ie, false alarms). The integration of clinical data is essential to prioritize suspect clusters for investigation, and for existing infections, a timely review of both the clinical and WGS results can hold promise to reduce HAIs. A richer understanding of cross-transmission events within healthcare settings will require the expansion of current surveillance approaches.

The magic number: Are improved outcomes observed at trauma centers with undertriage rates below 5%?

BACKGROUND: The American College of Surgeons Committee on Trauma (ACSCOT) advises trauma centers maintain <5% undertriage rate (UTR), but provides limited rationale for this figure. We sought to determine whether patients managed at Level I/II trauma centers with a UTR less than 5% had improved outcomes compared with centers with greater than 5% UTR. We hypothesized that similar overall adjusted outcomes would be observed at trauma centers in Pennsylvania regardless of their compliance with ACSCOT undertriage recommendation. METHODS: The Pennsylvania Trauma Outcome Study database was retrospectively queried for all trauma patients managed at accredited adult Level I/II trauma centers (n = 27) from 2003 to 2015. Patients with missing data on Injury Severity Score and/or Trauma Activation Status were excluded from the analysis. Institutional UTR were calculated for all trauma centers based on ACSCOT criteria (Injury Severity Score >15; no trauma activation) and were categorized into less than 5% or greater than 5% subgroups. A multilevel mixed-effects logistic regression model assessed the adjusted impact of management at centers with less than 5% undertriage. Statistical significance was set at p less than 0.05. RESULTS: A total of 404,315 patients from 27 trauma centers met inclusion criteria. Institutional UTRs ranged from 0% to 20.5%, with 15 centers exhibiting UTR less than 5% and 12 centers with UTR greater than 5%. No clinically meaningful difference in unadjusted mortality rate was observed between subgroups (<5% UTR: 5.19%; >5% UTR: 5.20%; p < 0.001). In adjusted analysis, no difference in mortality was found for patients managed at centers with less than 5% UTR compared to those with greater than 5% UTR (adjusted odds ratio, 1.06; 95% confidence interval, 0.85-1.33; p = 0.608). CONCLUSION: Achieving ACSCOT less than 5% undertriage standards appears to have limited impact on institutional mortality. Further research should seek to identify new triage criteria that can be uniformly applied to all trauma centers. LEVEL OF EVIDENCE: Epidemiological study, level III.

Undertriage in trauma: Does an organized trauma network capture the major trauma victim? A statewide analysis.

BACKGROUND: Proper triage of critically injured trauma patients to accredited trauma centers (TCs) is essential for survival and patient outcomes. We sought to determine the percentage of patients meeting trauma criteria who received care at non-TCs (NTCs) within the statewide trauma system that exists in the state of Pennsylvania. We hypothesized that a substantial proportion of the trauma population would be undertriaged to NTCs with undertriage rates (UTR) decreasing with increasing severity of injury. METHODS: All adult (age ≥15) hospital admissions meeting trauma criteria (ICD-9, 800-959; Injury Severity Score [ISS], > 9 or > 15) from 2003 to 2015 were extracted from the Pennsylvania Health Care Cost Containment Council (PHC4) database, and compared with the corresponding trauma population within the Pennsylvania Trauma Systems Foundation (PTSF) registry. PHC4 contains all hospital admissions within PA while PTSF collects data on all trauma cases managed at designated TCs (Level I-IV). The percentage of patients meeting trauma criteria who are undertriaged to NTCs was determined and Network Analyst Location-Allocation function in ArcGIS Desktop was used to generate geospatial representations of undertriage based on ISSs throughout the state. RESULTS: For ISS > 9, 173,022 cases were identified from 2003 to 2015 in PTSF, while 255,263 cases meeting trauma criteria were found in the PHC4 database over the same timeframe suggesting UTR of 32.2%. For ISS > 15, UTR was determined to be 33.6%. Visual geospatial analysis suggests regions with limited access to TCs comprise the highest proportion of undertriaged trauma patients. CONCLUSION: Despite the existence of a statewide trauma framework for over 30 years, approximately, a third of severely injured trauma patients are managed at hospitals outside of the trauma system in PA. Intelligent trauma system design should include an objective process like geospatial mapping rather than the current system which is driven by competitive models of financial and health care system imperatives. LEVEL OF EVIDENCE: Epidemiological study, level III; Therapeutic, level IV.

Development of a trauma system and optimal placement of trauma centers using geospatial mapping.

BACKGROUND: The care of patients at individual trauma centers (TCs) has been carefully optimized, but not the placement of TCs within the trauma systems. We sought to objectively determine the optimal placement of trauma centers in Pennsylvania using geospatial mapping. METHODS: We used the Pennsylvania Trauma Systems Foundation (PTSF) and Pennsylvania Health Care Cost Containment Council (PHC4) registries for adult (age ≥15) trauma between 2003 and 2015 (n = 377,540 and n = 255,263). TCs and zip codes outside of PA were included to account for edge effects with trauma cases aggregated to the Zip Code Tabulation Area centroid of residence. Model assumptions included no previous TCs (clean slate); travel time intervals of 45, 60, 90, and 120 minutes; TC capacity based on trauma cases per bed size; and candidate hospitals ≥200 beds. We used Network Analyst Location-Allocation function in ArcGIS Desktop to generate models optimally placing 1 to 27 TCs (27 current PA TCs) and assessed model outcomes. RESULTS: At a travel time of 60 minutes and 27 sites, optimally placed models for PTSF and PHC4 covered 95.6% and 96.8% of trauma cases in comparison with the existing network reaching 92.3% or 90.6% of trauma cases based on PTSF or PHC4 inclusion. When controlled for existing coverage, the optimal numbers of TCs for PTSF and PHC4 were determined to be 22 and 16, respectively. CONCLUSIONS: The clean slate model clearly demonstrates that the optimal trauma system for the state of Pennsylvania differs significantly from the existing system. Geospatial mapping should be considered as a tool for informed decision-making when organizing a statewide trauma system. LEVEL OF EVIDENCE: Epidemiological study/Care management, level III.

Preliminary results of a novel hay-hole fall prevention initiative.

BACKGROUND: Hay-hole falls are a prevalent source of trauma among Anabaptists-particularly Anabaptist youth. We sought to decrease hay-hole falls in South Central Pennsylvania through the development and distribution of all-weather hay-hole covers to members of the at-risk Anabaptist community. METHODS: Following the creation of a rural trauma prevention syndicate, hay-hole cover prototypes co-designed and endorsed by the Pennsylvania Amish Safety Committee were developed and distributed throughout South Central Pennsylvania. Preintervention and postintervention surveys were distributed to recipients to gain an understanding of the hay-hole fall problem in this population, to provide insight into the acceptance of the cover within the community, and to determine the efficacy of the cover in preventing falls. RESULTS: A total of 231 hay-hole covers were distributed throughout eight rural trauma-prone counties in Pennsylvania. According to preintervention survey data, 52% of cover recipients reported at least one hay-hole fall on their property, with 46% reporting multiple falls (median fall rate, 1.00 [1.00-2.00] hay-hole falls per respondent). The median self-reported distance from hay-hole to ground floor was 10.0 (8.00-12.0) feet, and the median number of hay-holes present on-property was 3.00 (2.00-4.00) per respondent. Postintervention survey data found 98% compliance with hay-hole cover installation and no subsequent reported hay-hole falls. CONCLUSION: With the support of the Pennsylvania Amish Safety Committee, we developed a well-received hay-hole cover which could effectively reduce fall trauma across other rural communities in the United States. LEVEL OF EVIDENCE: Epidemiological study, Level III.

Improved outcomes in elderly trauma patients with the implementation of two innovative geriatric-specific protocols-Final report.

BACKGROUND: Elderly trauma care is challenging owing to the unique physiology and comorbidities prevalent in this population. To improve the care of these patients, two practice management guidelines (PMGs) were implemented: high-risk geriatric protocol (HRGP), which triages patients based on injury patterns and comorbid conditions for occult hypotension, and the anticoagulation and trauma (ACT) alert, which is designed to streamline the care of geriatric trauma patients on anticoagulants. We hypothesized that both HRGP and ACT would decrease mortality and complications in geriatric trauma patients. METHODS: Geriatric blunt trauma patients (aged ≥65) presenting to our Level II center from January 2000 to July 2016 were extracted from the trauma registry. Do-not-resuscitate patients were excluded. The study period was divided into three phases: Phase 1, no PMGs in place (2000 to January 2006); Phase 2, HRGP only (February 2006 to February 2012); and Phase 3, HRGP + ACT (March 2012 to July 2016). Multivariate logistic regression models assessed adjusted mortality and complications during these phases to quantify the impact of these protocols. Statistical significance was set at p < 0.05. RESULTS: A total of 8,471 geriatric trauma patients met inclusion criteria. Overall mortality rate was 5.6% (Phase 1, 7.2%; Phase 2, 6.1%; Phase 3, 4.0%). No significant change in mortality was observed during Phase 2 with the HRGP only (adjusted odds ratio (OR), 0.98; 95% confidence interval, 0.73-1.34; p = 0.957); however, a significantly reduced OR of mortality was found during Phase 3 with the combination of both the HRGP and ACT (adjusted OR, 0.67; 95% confidence interval, 0.47-0.94; p = 0.021). No significant changes in incidence of complications was observed over the study duration. CONCLUSIONS: Geriatric trauma patients are not simply older adults. Improved outcomes can be realized with specific PMGs tailored to the geriatric trauma patients' needs. LEVEL OF EVIDENCE: Epidemiologic study, level III.

A Preliminary Analysis of Compassion Fatigue in a Surgeon Population: Are Female Surgeons at Heightened Risk?

Compassion fatigue (CF), a state of physical/emotional distress caused by repeatedly caring for those experiencing traumatic episodes, is a prevalent issue for today's healthcare provider. We sought to characterize levels of CF within a surgeon population, particularly comparing trauma surgery with other surgical specialties. A survey containing the Professional Quality of Life Scale (ProQOL), a validated tool assessing compassion satisfaction (CS), CF, and burnout (BO) was distributed via electronic newsletter to members of the American College of Surgeons. Demographic data and Professional Quality of Life Scale scores for CS, BO, and CF were collected and compared within specialty and gender subgroups. A total of 178 surgeons completed surveys. Respondents were predominantly male, general surgeons, >55 years old. Trauma surgeons composed the second largest subgroup. Levels of CS were significantly lower in the trauma surgeon subgroup compared to other surgical specialties (trauma: 37.1 ± 5.28, other: 39.5 ± 6.30; P = 0.044). Female surgeons from all specialties exhibited significantly higher levels of BO (female: 26.7 ± 6.10, male: 24.6 ± 6.79; P = 0.035) and CF (female: 24.2 ± 6.29, male: 21.9 ± 6.11; P = 0.021) compared with male surgeons. Subanalyses comparing female trauma surgeons to female surgeons in other specialties found female trauma surgeons exhibited significantly lower levels of CS (trauma: 34.8 ± 4.63, other: 38.8 ± 5.99; P = 0.038) and higher levels of BO (trauma: 29.1 ± 3.14, other: 25.3 ± 6.41; P = 0.049). Trauma surgeons, particularly female trauma surgeons, may be at a heightened risk for developing a poorer overall professional quality of life compared with surgeons of other specialties. In addition, female surgeons may be at greater risk for developing CF compared with male counterparts.

The Effect of Time to International Normalized Ratio Reversal on Intracranial Hemorrhage Evolution in Patients With Traumatic Brain Injury.

The incidence of geriatric traumatic brain injury (TBI) is increasing throughout the United States, with many of these patients taking anticoagulation (AC) medication. The purpose of this investigation was to determine the effect of time to international normalized ratio (INR) reversal on intracranial hemorrhage evolution in TBI patients taking prehospital AC medication. We hypothesized that rapid reversal of INR improves outcomes of head-injured patients taking AC medication. Admissions to a Level II trauma center between February 2011 and December 2013 were reviewed. Patients presenting with an initial INR of 2.0 or more, computed tomographic scan positive for intracranial hemorrhage, and INR reversal to less than 1.5 in hospital were included. Patients with nontraumatic intracranial hemorrhage were excluded. Reversal of INR was achieved using some combination of fresh frozen plasma, prothrombin complex concentrate, and vitamin K. A binary logistic regression model assessed the adjusted impact of rapid INR reversal on intracranial hemorrhage evolution. Significance was defined as p < .05. One hundred subjects were included. Four patients with nontraumatic intracranial hemorrhage were excluded, resulting in a final study population of 96 patients. The most common intracranial hemorrhage in the study population was subarachnoid hemorrhage (71.9%), followed by subdural hemorrhage (35.4%). Reversal of INR of less than 5 hr was not associated with intracranial hemorrhage evolution; however, reversal of less than 10 hr was found to be associated with a decreased odds ratio for intracranial hemorrhage evolution (p = .043). Rapid reversal of elevated INR levels (<10 hr) may decrease intracranial hemorrhage evolution in TBI patients taking prehospital AC medication.

Outcome differences in adolescent blunt severe polytrauma patients managed at pediatric versus adult trauma centers.

BACKGROUND: Previous research suggests adolescent trauma patients can be managed equally effectively at pediatric and adult trauma centers. We sought to determine whether this association would be upheld for adolescent severe polytrauma patients. We hypothesized that no difference in adjusted outcomes would be observed between pediatric trauma centers (PTCs) and adult trauma centers (ATCs) for this population. METHODS: All severely injured adolescent (aged 12-17 years) polytrauma patients were extracted from the Pennsylvania Trauma Outcomes Study database from 2003 to 2015. Polytrauma was defined as an Abbreviated Injury Scale (AIS) score ≥3 for two or more AIS-defined body regions. Dead on arrival, transfer, and penetrating trauma patients were excluded from analysis. ATC were defined as adult-only centers, whereas standalone pediatric hospitals and adult centers with pediatric affiliation were considered PTC. Multilevel mixed-effects logistic regression models assessed the adjusted impact of center type on mortality and total complications while controlling for age, shock index, Injury Severity Score, Glasgow Coma Scale motor score, trauma center level, case volume, and injury year. A generalized linear mixed model characterized functional status at discharge (FSD) while controlling for the same variables. RESULTS: A total of 1,606 patients met inclusion criteria (PTC: 868 [54.1%]; ATC: 738 [45.9%]), 139 (8.66%) of which died in-hospital. No significant difference in mortality (adjusted odds ratio [AOR]: 1.10, 95% CI 0.54-2.24; p = 0.794; area under the receiver operating characteristic: 0.89) was observed between designations in adjusted analysis; however, FSD (AOR: 0.38, 95% CI 0.15-0.97; p = 0.043) was found to be lower and total complication trends higher (AOR: 1.78, 95% CI 0.98-3.32; p = 0.058) at PTC for adolescent polytrauma patients. CONCLUSION: Contrary to existing literature on adolescent trauma patients, our results suggest patients aged 12-17 presenting with polytrauma may experience improved overall outcomes when managed at adult compared to pediatric trauma centers. LEVEL OF EVIDENCE: Epidemiologic study, level III.