Clinical Outcomes of Intermediate-Length Cephalomedullary Nails for Intertrochanteric Femur Fracture Repair in Older Adults.

INTRODUCTION: Hip fracture is a major cause of morbidity and mortality in older adults. Intertrochanteric hip fractures often are treated surgically using cephalomedullary nails (CMN), in either a short or long length. Their outcomes are documented in the literature; however, outcomes of the intermediate-length CMN have not been well described. METHODS: A retrospective review was conducted of older adults with intertrochanteric hip fractures that were treated with cephalomedullary nail fixation using an intermediate-length (235 mm Synthes Trochanteric Fixation® nail or 240 mm Stryker Gamma 3®) nail. Outcome data were collected during the inpatient stay and 16 months post-operatively. RESULTS: Seventy-seven patients met inclusion criteria and were reviewed during inpatient stay; however, only 42 had documented post-operative outcomes. Of those, two patients died post-discharge and were not included in the 16-month follow-up. Comparison of results to published literature suggested that intermediate-length nails are comparable to short-length nails with regard to time in the operating room and estimated blood loss. The rate of blood transfusion was lower and length of hospital stay was shorter than in comparable studies of both short- and long-length nails. There were no post-operative peri-prosthetic fractures in the 16-month follow-up. This rate was lower than published rates for short and long nails. The hardware failure rate (3/42, 7.1%) of intermediate-length nails was higher than comparison studies of both short- and long-length nails. CONCLUSION: Patient outcomes for intermediate-length nails were similar to outcomes of shorter length nails. Utilization of the intermediate-length nail appears to be an effective treatment option for repair of intertrochanteric femur fractures. However, direct comparison is difficult since peri-prosthetic fracture rate may increase over time and nail length and hardware failure are not defined consistently in the literature. Further study is needed with a larger sample size followed over a longer period of time to confirm our findings.

PA student assessment of body mass index in children using visual cues.

OBJECTIVE: Pediatric weight or body mass index often is underestimated by providers when relying solely upon visual cues. This study sought to determine physician assistant (PA) students' and recent graduates' ability to accurately assess BMI for age in patients ages 3 to 5 years using visual cues. METHODS: PA students and recent graduates visually assessed pictures of three children ages 3 to 5 years-one obese, one overweight, and one with healthy weight-for BMI categorization via online survey. Responses were scored for accuracy. RESULTS: Ninety-eight PA students and recent graduates completed the assessment. Accuracy for BMI categorization was low, especially in the obese and overweight children for visual assessment alone. Accuracy improved slightly when height and weight data were provided. CONCLUSIONS: PA student and recent graduate visual assessment for categorization of BMI is unreliable, similar to studies with other providers. PAs should be aware of discrepancy and not rely on visual assessment to determine weight-related interventions.

A Survey of Safety Recommendations for All-Terrain Vehicle Dealers and Track Owners in Kansas.

INTRODUCTION: All-terrain vehicles (ATVs) are associated with injury, mortality, and healthcare costs. ATV related injuries are less severe when consistent safety practices are followed, however, ATV safety regulations are varied among states. This study sought to survey Kansas ATV dealers and track owners to determine safety promotion practices. METHODS: A cross-sectional telephone survey was conducted of Kansas ATV dealers and tracks. Survey questions included promotion and sale of safety equipment, provision of ATV safety information, and respondent characteristics. RESULTS: Of those contacted, 32% of dealers and 31% of tracks responded to the survey. Most ATV dealers sell safety gear (70% - 100%) and all recommend safety gear to buyers and riders. All ATV tracks reported requiring helmets (100%) but were varied regarding other forms of safety gear. The majority of ATV dealers (77%) recommended safety courses, but only 31% of dealers and 40% of tracks offered courses. Eighty percent of ATV tracks and 52% of dealers felt they had a professional responsibility to educate riders/owners on safety. CONCLUSION: Safety promotion by ATV dealers in Kansas consistently was recommended, but often limited to the sales of safety gear (helmets and gloves) or the provision of manufacturer provided safety materials. Further, ATV dealers reported rarely offering skills tests or safety courses to buyers. In Kansas, safety promotion at the point of sale or track level could be improved to increase public awareness of ATV safety practices.

Physician assistant program education on spirituality and religion in patient encounters.

PURPOSE: To describe educational practices of physician assistant (PA) programs regarding spirituality and religion discussions during patient encounters. Patients want their health care provider to be aware of their spiritual and religious beliefs. This topic is addressed in physician and nursing education but may not be included in PA programs. METHODS: Data regarding curriculum were collected via electronic survey emailed to 143 PA programs across the United States. RESULTS: Thirty-eight programs responded for a response rate of 27%. Most (68.4%) program respondents reported students' desire to be trained to discuss spirituality and religion, yet 36.8% do not offer this training. Just over half (69.2%) would consider adding curriculum to teach students to discuss spirituality, but the majority (92.3%) would not add curriculum to discuss religion during patient encounters. CONCLUSION: PA programs offer training to discuss spirituality in patient encounters but not to discuss religiosity. Programs may want to consider adding some curriculum to increase PAs awareness of spirituality and religion needs of patients.

Evaluation of process variations in noncompliance in the implementation of evidence-based sepsis care.

INTRODUCTION: Sepsis is recognized as an often-lethal disease. Recommended guidelines are complex and time sensitive. Response teams (RTs) have demonstrated success in implementation of quality initiatives. The purpose of this study was to evaluate variations in noncompliance with recommended sepsis guidelines overall and between a sepsis-focused RT and standard care. METHODS: This retrospective chart review categorized septic patients based on treatment by a sepsis response team (SRT) versus standard care (non-SRT). Guideline compliance was based upon the Surviving Sepsis evaluation and treatment guidelines. RESULTS: Patient records for 123 identified septic patients post first-year implementation were evaluated. Overall, compliance rates were low and there were variations in compliance between the treatment providers. The SRT was more compliant than the non-SRT. SRT noncompliance was more often due to failure to achieve therapeutic goals within the recommended time. Mortality benefit was not statistically significant between groups; however mortality was higher in the non-SRT group. CONCLUSION: Noncompliance is more complex than simple failure to initiate, especially in time-dependent therapies. The development and education of an RT demonstrates improvement in application of sepsis-focused therapies over standard care.

Kansas physician assistants' attitudes and beliefs regarding spirituality and religiosity in patient care.

Research indicates patients want to discuss spirituality/religious (S/R) beliefs with their healthcare provider. This was a cross-sectional study of Kansas physician assistants (PA) regarding S/R in patient care. Surveys included questions about personal S/R beliefs and attitudes about S/R in patient care. Self-reported religious respondents agreed (92%) they should be aware of patient S/R; 82% agreed they should address it. Agreement with incorporating S/R increased significantly based on patient acuity. This research indicates Kansas PAs' personal S/R beliefs influence their attitudes toward awareness and addressing patient S/R.

Trauma patient satisfaction with physician assistants: testing a structural equation model.

OBJECTIVE: Physician assistants (PAs) are increasingly utilized in the health care workforce and should be aware of how their interpersonal and technical skills are perceived by patients. The purpose of this study was to test associations among Perceived Interpersonal Care, Perceived Technical Care, and Global Satisfaction. METHODS: This cross-sectional telephone survey of recently discharged trauma patients tested a structural equation model which hypothesized that interpersonal satisfaction ratings predicted technical care and global satisfaction ratings. RESULTS: A total of 251 completed surveys were analyzed. Results indicated a relationship among interpersonal care, technical care, and global satisfaction. Satisfaction with interpersonal care predicted satisfaction with technical care. CONCLUSION: In this study of how satisfied recently discharged trauma patients are with care by physician assistants, perceptions of technical care were associated with perceptions of interpersonal care, or how the patient was treated as a person. Since physician assistants have direct patient contact, this association demonstrates the strength of the PA-patient relationship as an asset to the health care organization.

Near-infrared spectroscopy measurement of sacral tissue oxygen saturation in healthy volunteers immobilized on rigid spine boards.

INTRODUCTION: Immobilization of patients utilizing rigid spine boards (RSBs) is standard practice in the management of trauma patients. Pressure ulcers have been associated with prolonged immobilization, and the possibility exists that formation may begin when the patient is initially immobilized on the RSB. The effects may not be fully recognized because of limited research on the direct tissue effects of prolonged immobilization. Near-infrared spectroscopy is an emerging tool to measure peripheral tissue oxygen saturation (StO(2)). The purpose of this research was to study the effects of prolonged spinal immobilization on an RSB on sacral tissue oxygenation of healthy volunteers. METHODS: This experimental study measured StO(2) in healthy volunteers at baseline and again after 30 minutes of immobilization on an RSB at two sites: the sacral area (intervention) and 8-10 cm above the buttocks (control). Tissue oxygenation was measured with the InSpectra Tissue Oxygenation Monitor (Hutchinson Technology, Hutchinson, MN) by placing the probe at the measurement site and waiting for 15 seconds for equilibration prior to recording StO(2). Data were analyzed utilizing mixed-model and within-subjects analysis of variance (ANOVA), chi-square, and t-tests. RESULTS: Seventy-three participants were included in the analysis. A slight majority of participants were female (55%), the average age was 38 years, the average height was 170 cm, and the average weight was 82 kg. There was a significant increase in the StO(2) percentage at the sacral (intervention) area following immobilization, p < 0.001, point biserial correlation (r(pb)) = 0.48. Significant changes in oxygenation were not noted at the control site. CONCLUSION: An increase in sacral tissue oxygenation following immobilization was a finding consistent with other research. This is likely a result of initial, rapid tissue reperfusion at the time of pressure release. Rapid reperfusion indicates that a period of previous hypoperfusion has occurred. This research indicates that there are detrimental effects of spine board immobilization in healthy volunteers, which suggests that pressure ulcer formation may begin prior to hospital admission with immobilization on an RSB.

Acceptance of physician assistants and nurse practitioners in trauma centers.

OBJECTIVE: Census data published by professional organizations indicate an upward trend in the number of physician assistants (PAs) working in many specialty fields, including the subspecialty of trauma surgery. As the role of hospital-based PAs and nurse practitioners (NPs) continues to evolve, greater understanding of these roles will help identify future employment trends for these professions. The purpose of this study is to determine the prevalence of PAs and NPs in US trauma centers, to document their roles, and to identify their potential future utilization by trauma centers. METHODS: A survey was mailed to 464 directors of major trauma centers in the United States. The survey was designed to evaluate trauma centers' utilization of PAs/NPs. Respondents were asked to identify specific daily tasks of PAs/NPs and to indicate potential for their future utilization. RESULTS: Two hundred forty-six (246) of 464 surveys were returned, for a response rate of 53%. Approximately one-third of reporting major trauma centers reported utilizing PAs/NPs. More American College of Surgeons (ACS)-verified trauma facilities utilized PAs/NPs than did nonverified facilities; and Level I trauma centers used significantly more PAs/NPs than did Level II trauma centers. Nineteen percent (19%) of respondents who did not currently utilize PAs/NPs indicated that they intended to do so in the future. The majority of facilities utilized PAs/NPs to assist with trauma resuscitation and in performing traditional tasks, including obtaining and dictating histories and physical findings, participating in rounds on the general medical floor, and dictating discharge summaries. Fewer than half of reporting facilities indicated that PAs/NPs performed more invasive procedures, such as inserting arterial lines, central lines, chest tubes, and intracranial pressure monitors. CONCLUSIONS: PAs and NPs are increasingly utilized as clinicians in the surgical subspecialty of trauma. In most trauma centers, PAs/NPs are utilized to complete the traditional duties of a surgical PA/NP, with fewer performing invasive procedures. Finally, 19% of responding trauma centers who do not currently utilize PAs/NPs state that they intend to in the future, indicating the potential for continued job growth for PAs/NPs in trauma care. This evaluation of the utilization of PAs/NPs in direct care to trauma patients indicates acceptance of PAs/NPs in trauma staffing models.

Midlevel providers in a Level I trauma service: experience at Wesley Medical Center.

BACKGROUND: Changes in the health care system have led to reduced availability of surgical residents to function as house officers in teaching hospitals. The purpose of this cross-sectional study was to assess the level of satisfaction of patients, physicians and nurses, and ancillary providers with the care provided by the midlevel providers (MLPs) who are utilized as house officers in a Level I trauma service. This type of care model is unusual because the trauma service no longer utilizes surgical residents to provide trauma coverage. METHODS: Trauma patients admitted to the hospital during a 3-month period in 2004 were surveyed, as were physicians and hospital employees who work most closely with MLPs. RESULTS: Patients are very satisfied (84%-86%) with the care they received from the MLPs (n = 109). There were no significant differences in satisfaction with MLPs when looking at the patient's age, gender, length of stay, or whether the patient was in the intensive care unit. Analysis of physician and hospital employee satisfaction is also strongly positive overall. Of the respondents, 84% (n = 281) agreed that MLPs have made a positive impact on the care of the trauma patient, 86% agreed that MLPs are available to address patient and staff concerns, and 80% think that MLPs have made trauma care more efficient. CONCLUSION: Trauma patients and healthcare team members of the trauma service at Wesley Medical Center, an accredited Level I trauma center, are generally satisfied with care provided by MLPs.