Screening for Risk of Fall-Related Inpatient Trauma in a US Acute Care Setting.

Introduction Falls during hospitalization are a leading cause of preventable trauma-related injuries. Factors associated with fall risk include an unfamiliar environment, changes in health status, and efficacy based on the home environment. Assessing fall efficacy with an individualized prevention plan can decrease falls. The primary aim of this study was to estimate the effect of implementing a fall efficacy screening and intervention on reducing patient falls. Methods The study utilized a quasi-experimental, cross-sectional design with a convenience sample of patients admitted to an in-patient adult medical unit within a community hospital over a twelve-month period. Sampling times included pre-implementation, immediately post-implementation, and a second post-implementation phase. The intervention consisted of an admission fall efficacy screening tool and an individualized educational initiative. Statistical analysis included descriptive statistics of central tendency and dispersion, along with inferential statistics using independent sample t-tests, chi-square tests, correlations, and binary logistic regression. Results Among the study participants (n=2,074), the total sample had an average age of 67.7 (+/- 17.4) years and had mean scores of 13.3 (6.9) on the Short Falls Efficacy Scale-International and 51.8 (20.3) on the Morse Fall Scale. Fifty-two percent of the study population were female; 16.2% of the patients were diagnosed with cerebrovascular accident (CVA) or CVA-like symptoms. Fall rates decreased with a rate of change of -4.15% after efficacy screening and intervention. Males demonstrated higher efficacy in avoiding falls compared to females (t(828) = 3.369, p <0.001). Patients with a CVA diagnosis demonstrated higher efficacy scores compared to non-CVA patients (t(2071) = -3.348, p <0.001). FES risk groups (OR of 5.632, 95% CI (2.171-7.892)) and age over 65 (OR 1.21, 95% CI (1.006-1.442)) were significant predictors of a fall when patients with a primary CVA diagnosis were omitted from the sample (p= 0.022 and 0.046 respectively). Conclusion The findings suggest that efficacy screening may be associated with decreased falls for acute care non-CVA inpatient populations over 65 years of age. Further research into the predictive utility of fall efficacy screening in acute care CVA and non-CVA hospitalized patient populations aged 65 years and above is recommended.

Use of Andexanet Alfa for Factor Xa Inhibitor Reversal in US Verified Trauma Centers: A National Survey.

Direct oral factor Xa inhibitors are replacing vitamin K-dependent antagonists as anticoagulation treatment in many clinical scenarios. Trauma centers are noting an increase in patients presenting on these medications. The 2018 Food and Drug Administration approval of andexanet alfa provides an alternative anticoagulation reversal. Barriers may limit utilization of new medications including a lack of grade 1A evidence supporting the use of prothrombin complex concentrate (PCC) versus andexanet alfa and cost. To evaluate barriers of andexanet alfa utilization by trauma surgeons, a 15-question survey was conducted. There was a 9% completion rate (n = 89). The results revealed 23.5% would choose andexanet alfa as first-line treatment in children, and 25.8% as first-line treatment in adults. The majority of respondents, 64.7% and 67.4%, would use PCC preferentially in children and adults, respectively. Respondents indicated that cost burden was an overriding factor (76.3%); 42.4% cited lack of high-level efficacy data of andexanet alfa for reversal of factor Xa inhibitors. Additional double-blinded multi-institutional randomized controlled trials comparing 4F-PCC and andexanet alfa for factor Xa inhibitor reversal are needed to support efficacy especially with the increased cost associated.

Resource Deployment in Response to Trauma Patients.

Background Variance in the deployment of the trauma team to the emergency department (ED) can result in patient treatment delays and excess burden on ED personnel. Characteristics of trauma patients, including mechanism of injury, injury type, and age, have been associated with differences in trauma resource deployment. Therefore, this retrospective, single-site study aimed to examine the deployment patterns of trauma resources, the characteristics of the trauma patients associated with levels of trauma resource deployment, and the deployment impact on ED workforce utilization and non-trauma ED patients. Methodology This was an investigator-initiated, single-institution, retrospective cohort study of all patients designated as a trauma response and admitted to a community hospital's ED from July 01, 2019, through July 01, 2022. Results Resource deployment for trauma patients varied by mechanism of injury (p < 0.001), injury type (p < 0.001), and patient age groups (p < 0.001). Specifically, there was a lower average trauma activation for geriatric trauma patients with a fall as a mechanism of injury compared to all younger patient groups with any mechanism of injury (F(5) = 234.49, p < 0.001). In the subsample, there was an average of 3.35 ED registered nurses (RNs) allocated to each trauma patient. Additionally, the ED RNs were temporarily reallocated from an average of 4.09 non-trauma patients to respond to trauma patients, despite over a third of the trauma patients in the subsample being the trauma patients being discharged home from the ED. Conclusions Trauma activation responses need to be standardized with a specific plan for geriatric fall patients to ensure efficient use of trauma and ED personnel resources.

The Impact of Screening for Perioperative ICU Admission in Geriatric Hip Fracture Patients: A Retrospective Analysis.

BACKGROUND: Hip fracture patients are a subset of trauma patients with high peri-operative mortality. To mitigate the mortality risk, the use of predictive scoring systems (e.g., RSI or Nomograms) for risk stratification and monitoring of high-risk patients in the intensive care unit (ICU) has been proposed. Screening patients for ICU admission with relatively low-cost tools may achieve high-quality, low-cost care. The aim of this study was to assess the effectiveness and feasibility of screening postoperative hip fracture patients for ICU admission. METHODS: This is a retrospective single-site study comparing two groups of patients, before and after implementation of a hip fracture postoperative screening intervention in a level 1 trauma center in the United States. All hip fracture patients > 55 years of age admitted to the hospital between January 2021 and May 2023 were included. Trauma team members assessed and screened patients postoperatively in the post-anesthesia care unit (PACU), ordering standardized tests, including laboratory tests, a chest x-ray, and electrocardiogram (EKG). Assessment of the effect of the intervention included a comparison of a number of major adverse events (MAEs), mortality, planned and unplanned ICU admissions, ICU length of stay (LOS), and hospital LOS between pre- and post-intervention groups. Propensity score (PS) estimates were used to compare outcomes between the matched participants in the sample. A predictive model for ICU admission for the overall sample was estimated, and discriminative ability was assessed with an area under the curve (AUC) receiver operator characteristics (ROC) analysis. Lastly, feasibility was assessed by compliance with screening intervention and charges per patient related to the intervention. RESULTS: The sample consisted of 290 patients in the pre-intervention and 180 patients in the post-intervention groups, respectively, with a mean age of 81.4 ± (9.9) years. There was a significant increase (p<0.01) in planned ICU admissions (OR=2.387, 95% CI (1.430, 3.983)) after screening protocol implementation. There was no significant difference between the pre-intervention group and post-intervention group in the number of MAEs (p=0.392), mortality (p=0.591), ICU LOS (p=0.617), and hospital LOS (p=0.151). When the PS-matched sample (n=424) was analyzed, there was a significant decrease (p=0.45) in unplanned ICU admissions (OR=6.40, 95% CI (0.81, 50.95)) after protocol implementation. Anticoagulants, emergency department (ED) respiratory rate (RR), injury severity score (ISS), number of comorbidities, substance use disorder (SAD), peripheral artery disease (PAD), and chronic obstructive pulmonary disease (COPD) were significant predictors of ICU admission (p=0.002, 0.022, 0.030, 0.034, 0.039, 0.039, and 0.042), respectively, and, demonstrated the discriminative ability between high and low risk for ICU admission (AUC=0.597, 0.587, 0.581, 0.578, 0.513, and 0.587, respectively). The screening intervention was achievable with 99% compliance (Kappa estimate 0.94) among trauma team members with an average charge of $282 per patient. CONCLUSION: The addition of a postoperative screening intervention for hip fracture patients > 55 years of age is achievable and decreases unplanned ICU admissions in matched samples. Presenting clinical indicators and comorbidities are associated with ICU admission and provide sufficient discriminatory ability as criteria for ICU admission.