Postinjury employment as a surrogate for functional outcomes: a quality indicator for trauma systems.

Return to work may be easily monitored as a surrogate of long-term functional outcome for benchmarking and performance improvement of trauma systems. We hypothesized that employment rates among survivors of traumatic brain injury (TBI) decrease following injury and remain depressed for an extended period of time. Data were obtained from a statewide surveillance system of 3522 TBI patients (aged >15 years) who were discharged alive from acute care hospitals and followed yearly using telephone interviews (1996-1999). The study population consisted of patients with severe TBI (head abbreviated injury score 3, 4, or 5) and complete follow-up for 3 years postinjury (n = 572). Patients were mostly young males (43 ± 19 years, 65% male) with blunt TBI (92%). The preinjury employment rate was 67%, which declined to 52% (P < 0.001) in the first year and slowly rose in subsequent years but never reached the preinjury level (54% in year 2, P < 0.001; 57% in year 3, P = 0.001). Increasing severity of TBI was associated with a lower employment rate. Patients who remained employed worked the same number of hours as they did before the injury (47.8 ± 10.5 hours). Female employment rates rose similar to rates for males. However, women who were employed full-time before TBI were more likely to work part-time after TBI than men (50% vs 24%, P < 0.001). In conclusion, survivors of severe injury do not attain preinjury employment levels for several years. Once validated in other studies, postinjury employment may be used as an indicator to monitor functional outcomes in trauma registries.

Dissecting delays in trauma care using corporate lean six sigma methodology.

OBJECTIVE: The Institute of Medicine has identified trauma center overcrowding as a crisis. We applied corporate Lean Six Sigma methodology to reduce overcrowding by quantifying patient dwell times in trauma resuscitation units (TRU) and to identify opportunities for reducing them. METHODS: TRU dwell time of all patients treated at a Level I trauma center were measured prospectively during a 3-month period (n = 1,184). Delays were defined as TRU dwell time >6 hours. Using personnel trained in corporate Lean Six Sigma methodology, we created a detailed process map of patient flow through our TRU and measured time spent at each step prospectively during a 24/7 week-long time study (n = 43). Patients with TRU dwell time below the median (3 hours) were compared with those with longer dwell times to identify opportunities for improvement. RESULTS: TRU delays occurred in 183 of 1,184 trauma patients (15%), and peaked on days with >15 patients or with presence of five simultaneous patients. However, 135 delays (74%) occurred on days when

The Parkland formula under fire: is the criticism justified?

Controversy has continued regarding the practicality and accuracy of the Parkland burn formula since its introduction over 35 years ago. The best guide for adequacy of resuscitation is urine output (UOP) per hour. A retrospective study of patients resuscitated with the Parkland formula was conducted to determine the accuracy (calculated vs. actual volume) based on UOP. A review of burn resuscitation from a single institution over 15 years was conducted. The Parkland formula was defined as fluid resuscitation of 3.7 to 4.3 ml/kg/% total body surface area (TBSA) burn in the first 24 hours. Adequate resuscitation was defined as UOP of 0.5 to 1.0 ml/kg/hr. Over-resuscitation was defined as UOP > 1.0 ml/kg/hr. Patients were stratified according to UOP. Burns more than 19% TBSA were included. Electrical burns, trauma, and children (<15 years) were excluded. Four hundred and eighty-three patients were reviewed. Forty-three percent (n = 210) received adequate resuscitation. Forty-eight percent (n = 233) received over-resuscitation. The mean fluid in the adequately and over-resuscitated groups was 5.8 and 6.1 ml/kg/%, respectively (P = .188). Mean TBSA and full thickness burns in the adequately and over-resuscitated groups were 38 and 43%, and 19 and 24%, respectively (P < .05). Inhalation injury was present in 12 and 18% (P = .1). Only 14% of adequately resuscitated and 12% of over-resuscitated patients met Parkland formula criteria. The mean Ivy index in the adequately and over-resuscitated groups was 216 and 259 ml/kg (P < .05). There was no significant difference in complication rates (80 vs. 82%) or mortality (14 vs. 17%). The actual burn resuscitation infrequently met the standard set forth by the Parkland formula. Patients commonly received fluid volumes higher than predicted by the Parkland formula. Emphasis should be placed not on calculated formula volumes, as these should represent the initial resuscitation volume only, but instead on parameters used to guide resuscitation. The Parkland formula only represents a resuscitation "starting" point. The UOP is the important parameter.

Teaching trauma care in India: an educational pilot study from Bangalore.

BACKGROUND: Trauma has become a major cause of death and disability in developing countries. In India, most trauma patients receive initial care at general practitioner-staffed hospitals. We hypothesize that general practitioners (GPs) could improve their knowledge of trauma care after attending an educational course. METHODS: A 2-day trauma course was conducted at a teaching hospital (170 bed) in Bangalore, India. Referral GPs, local surgeons and residents in training attended. A pre-course test was given to assess baseline trauma knowledge. The core didactic sessions included: resuscitation/recognition of shock states, airway prioritization, and evaluation/initial management of head, cardiothoracic, abdominal, pelvic/genitourinary, and thermal injuries. A post-course test was used to assess trauma knowledge obtained from the course. Paired t tests were performed on the test scores and demographic data were stratified by specialty and training status. RESULTS: Of the 44 participants, 32 (72%) met study inclusion criteria: MBBS degree and course completion. The study population was 62.5% male with 47% surgeons and 53% GPs. Residents were 71.8% of the entire group. Overall, the pre- and post- course scores improved from 70.7% +/-11.2 to 87.5% +/-8.9, P = 0.000 (95%CI 12.1, 21.2). There was an increase of mean scores: 21.4% (SD +/-13.7) for GPs and 11.3% (SD +/-8.5) for surgeons (P = 0.02). CONCLUSION: Although GPs had significantly lower pre-course scores than surgeons, at the end of the course, GPs performed as well as surgeons. These findings suggest allocation of limited educational resources for trauma care in India may be best used by GPs.

Systemic hypotension is a late marker of shock after trauma: a validation study of Advanced Trauma Life Support principles in a large national sample.

BACKGROUND: Systolic blood pressure is used extensively to triage trauma patients as stable or unstable, contrary to Advanced Trauma Life Support recommendations. We hypothesized that systemic hypotension is a late marker of shock. METHODS: The National Trauma Data Bank was queried (n = 115,830). Base deficit was used as a measure of circulatory shock. Systolic blood pressure was correlated with the presence and the severity of base-deficit derangement. RESULTS: Systolic blood pressure correlated poorly with base deficit (r = .28). There was wide variation in systolic blood pressure within each base-deficit group. The mean and median systolic blood pressure did not decrease to less than 90 mm Hg until the base deficit was worse than -20, with mortality reaching 65%. CONCLUSIONS: We validated the Advanced Trauma Life Support principle that systemic hypotension is a late marker of shock. A normal blood pressure should not deter aggressive evaluation and resuscitation of trauma patients.