Selective computed tomographic angiography in traumatic subarachnoid hemorrhage: a pilot study.

BACKGROUND: Computed tomographic angiography (CTA) tends to be overused in patients with traumatic subarachnoid hemorrhage (tSAH) to rule out intracranial aneurysmal disease. We hypothesized that there are two exclusive subsets of patients with tSAH that maybe at increased risk for aneurysm and thus should undergo CTA, those "found down" with an unknown mechanism of injury and those with "central subarachnoid hemorrhage" (CSH, in the subarachnoid cisterns and Sylvian fissures). This pilot study was performed to provide more information on the validity of our hypothesis. METHODS: A retrospective analysis was performed on trauma patients with tSAH who underwent CTA of the brain. Patients presented to a level I trauma center from January 2008-December 2012. Our principal outcome was the diagnosis of an intracranial aneurysm. Student t-test, chi-squared test, Mann-Whitney U test, and binary logistic regression were used for statistical analysis, with significance set at alpha = 0.05. RESULTS: Of 617 total patients with tSAH, 186 patients underwent CTA. Majority of patients were male (64%), with median age of 56 y. Median Glasgow coma scale on presentation was 15, and the median injury severity score was 16. Thirteen patients (6.99%) had an aneurysm on the follow-up CTA. Of those, 8 of 13 (61.5%) were felt to have presented with a ruptured aneurysm. Among those, 5 of 8 (62.5%) sustained a fall and 3 of 8 (37.5%) resulted from a motor vehicle crash. Among the 14 patients (7.5%) "found down", none had an aneurysm. All eight patients with a ruptured aneurysm (100%) had CSH, whereas none of the five patients with unruptured aneurysm had CSH. On multivariate analysis, suprasellar cistern hemorrhage was the most predictive noncontrast computed tomographic finding with regard to aneurysm presence (odds ratio, 4.78; 95% confidence interval, 1.33-17.1). Patients with an aneurysmal disease had a significantly higher mean arterial pressure on presentation (median, 115 mm Hg) than those without an aneurysm (median, 96 mm Hg, P < 0.05). Of the eight ruptured aneurysms, six underwent neurosurgical clipping or coiling, one underwent a ventriculostomy, and one underwent a craniotomy for evacuation of hemorrhage. CONCLUSIONS: These preliminary data support a more selective approach to screening CTAs in patients with tSAH. CTA should be used in those patients with CSH regardless of mechanism of injury. A more restrictive approach should be used in patients with only peripheral subarachnoid hemorrhage.

Comorbidity-Polypharmacy Score as Predictor of Outcomes in Older Trauma Patients: A Retrospective Validation Study.

INTRODUCTION: Traditional injury severity assessment is insufficient in estimating the morbidity and mortality risk for older (≥45 years) trauma patients. Commonly used tools involve complex calculations or tables, do not consider all comorbidities, and often rely on data that are not available early in the trauma patient's hospitalization. The comorbidity-polypharmacy score (CPS), a sum of all pre-injury medications and comorbidities, was found in previous studies to independently predict morbidity and mortality in this older patient population. However, these studies are limited by relatively small sample sizes. Consequently, we sought to validate previous research findings in a large, administrative dataset. METHODS: A retrospective study of patients ages≥45 years was performed using an administrative trauma database from St. Luke's University Hospital's Level I Trauma Center. The study period was from 1 January 2008 to 31 December 2013. Abstracted data included patient demographics, injury mechanism and severity [injury characteristics and severity score (ISS)], Glasgow coma scale (GCS), hospital and intensive care unit lengths of stay (HLOS and ILOS, respectively), morbidity, post-discharge destination, and in-hospital mortality. Univariate analyses were conducted with mortality, all-cause morbidity, and discharge destination as primary end-points. Variables reaching statistical significance (p≤0.20) were included in a multivariate logistic regression model. Data are presented as adjusted odds ratios (AORs), with p<0.05 denoting statistical significance. RESULTS: A total of 5863 patient records were analyzed. Average patient age was 68.5±15.3 years (52% male, 89% blunt mechanism, mean GCS 14.3). Mean HLOS and ILOS increased significantly with increasing CPS (p<0.01). Independent predictors of mortality included age (AOR 1.05, p<0.01), CPS (per-unit AOR 1.08, p<0.02), GCS (AOR 1.43 per-unit decrease, p<0.01), and ISS (per-unit 1.08, p<0.01). Independent predictors of all-cause morbidity included age (AOR 1.02, p<0.01), GCS (AOR per-unit decrease 1.08, p<0.01), ISS (per-unit AOR 1.09, p<0.01), and CPS (per-unit AOR 1.04, p<0.01). CPS did not independently predict need for discharge to a facility. CONCLUSIONS: This study confirms that CPS is an independent predictor of all-cause morbidity and mortality in older trauma patients. However, CPS was not independently associated with need for discharge to a facility. Prospective multicenter studies are needed to evaluate the use of CPS as a predictive and interventional tool, with special focus on correlations between specific pre-existing conditions, pharmacologic interactions, and morbidity/mortality patterns.

Assessing the academic and professional needs of trauma nurse practitioners and physician assistants.

Because of multiple changes in the health care environment, the use of services of physician assistants (PAs) and nurse practitioners (NPs) in trauma and critical care has expanded. Appropriate training and ongoing professional development for these providers are essential to optimize clinical outcomes. This study offers a baseline assessment of the academic and professional needs of the contemporary trauma PAs/NPs in the United States. A 14-question electronic survey, using SurveyMonkey, was distributed to PAs/NPs at trauma centers identified through the American College of Surgeons Web site and other online resources. Demographic questions included trauma center level, provider type, level of education, and professional affiliations. Likert scale questions were incorporated to assess level of mentorship, comfort level with training, and individual perceived needs for academic and professional development. There were 120 survey respondents: 60 NPs and 60 PAs. Sixty-two respondents (52%) worked at level I trauma centers and 95 (79%) were hospital-employed. Nearly half (49%) reported working in trauma centers for 3 years or less. One hundred nineteen respondents (99%) acknowledged the importance of trauma-specific education; 98 (82%) were required by their institution to obtain such training. Thirty-five respondents (32%) reported receiving $1000 per year or less as a continuing medical education benefit. Insufficient mentorship, professional development, and academic development were identified by 22 (18%), 16 (13%), and 30 (25%) respondents, respectively. Opportunities to network with trauma PAs/NPs outside their home institution were identified as insufficient by 79 (66%). While PAs/NPs in trauma centers recognize the importance of continued contemporary trauma care and evidence-based practices, attending trauma-related education is not universally required by their employers. Financial restrictions may pose an additional impediment to academic development. Therefore, resource-efficient opportunities should be a prime consideration for advanced practitioners education, especially since half of the reported workforce has 3 years or less experience. The Eastern Association of Trauma and other organizations can provide an ideal venue for mentorship, academic development, and networking that is vital to PA/NP professional development and, ultimately, quality patient care.

Long-term survival after major trauma in geriatric trauma patients: the glass is half full.

BACKGROUND: The objective is to examine the long-term survival status of geriatric trauma patients (GTPs) after major trauma. METHODS: A 10-year retrospective review at a Level I trauma center was performed. GTP were defined as age ≥ 65 years, with Injury Severity Score ≥ 30. Primary endpoints: survival at hospital discharge and long-term survival and discharge status. Two groups were defined: Abbreviated Injury Score (AIS) head >3 (G1, n = 116) and AIS head ≤ 3 (G2, n = 29). For GTP surviving hospitalization, two subgroups were defined: AIS head >3 (SG1, n = 77) and AIS head ≤ 3 (SG2, n = 20). Comparisons were analyzed for exploratory purposes only by independent t-tests or Mann-Whitney rank sums tests as appropriate. Long-term survival was plotted by a Kaplan-Meier curve. RESULTS: A total of 145 GTP met inclusion criteria. In-hospital mortality was 33%. Nonsurvivors had lower Glasgow Coma Scale score (6 vs. 14, p < 0.001), higher Injury Severity Score (38 vs. 34, p < 0.003), and lower Revised Trauma Score (5.97 vs. 7.84, p < 0.002). Hospital mortality for G1 was 34% (39 of 116) and for G2 was 31% (9 of 29). In group 1 (n = 116), 39 patients (34%) died while 77 (66%) survived a median of 29 months (interquartile range [IQR] = 6-62). In group 2 (n = 29), 9 patients (31%) died while 20 (69%) survived a median of 46.50 months (IQR = 26.75-79). For the 77 patients who were alive at discharge (subgroup 1, AIS >3), 25 (32%) died while 52 (68%) survived a median of 33 months (IQR = 10.50-72.75). For the 20 patients with AIS ≤ 3 (subgroup 2), 7 of 20 (35%) died while 13 (65%) survived a median of 49 months (IQR = 30.50-93.50). A total of 28 patients (19%) survived more than 5 years from the time of discharge. For these 65 GTPs who are currently alive at the time of follow-up, living status could be determined for 49 (75%) and 33 of 49 (67%) were living at home. CONCLUSIONS: This study documents appreciable long-term survival for GTP with major injury including severe head injury. A substantial proportion of these patients was able to return home. LEVEL OF EVIDENCE: III, prognostic/epidemiological study.

Utilization of PAs and NPs at a level I trauma center: effects on outcomes.

OBJECTIVE: This study analyzes the impact of midlevel practitioners (MLPs) on patient care and resource utilization at a level I trauma center. METHODS: A retrospective review of trauma patients admitted during two periods was performed: PRE-MLP, during which limited MLP coverage was available; and POST-MLP, when MLP coverage was expanded. Demographics, injury severity scores (ISS), and preexisting medical conditions (PEC) were recorded. Trauma service activity was measured by daily admissions, inpatient census, and daily discharges. Outcome variables included hospital mortality, total length of stay (HLOS), ICU length of stay (ICU-LOS), and incidence of the three most prevalent complications: deep vein thrombosis (DVT), major arrhythmia (MA), urinary tract infection (UTI). RESULTS: PRE-MLP and POST-MLP groups were similar with respect to age, gender, and ISS. Mean daily admissions were 3.05 during the PRE-MLP period and 4.01 during the POST-MLP period (P = .0001). Reduced incidence of UTI was demonstrated in the POST-MLP period: 0.9% versus 2.6% (P = .0001). Incidence of DVT and MA were unchanged. HLOS decreased from 5.09 days to 4.84 days (P = .092). ICU-LOS was reduced from 4.08 days to 3.28 days (P = .019). CONCLUSION: Use of MLPs led to a significant reduction in ICU-LOS with no increased incidence of complications. MLPs offer a clinically effective and resource-efficient alternative to residents on a trauma service.

Emergency traumatologists as partners in trauma care: the future is now.

BACKGROUND: Decreasing manpower available to care for trauma patients both in and out of the ICU has led to a number of proposed solutions, including increasing involvement of emergency medicine-trained physicians in the care of these patients. We performed a descriptive comparative study in an effort to define the role of fellowship-trained emergency medicine physicians as full-time traumatologists. STUDY DESIGN: We performed a retrospective review of concurrent and prospectively collected data comparing process of care and outcomes for the resuscitative phase of trauma patients cared for by full-time fellowship-trained trauma surgeons (TS), a fellowship-trained emergency medicine physician (ET), and a first-year fellowship-trained trauma surgeon (TS1). RESULTS: Patient age, Revised Trauma Score, and Injury Severity Score were similar between groups. Process of care, defined by transfusion of uncrossmatched blood, prevalence of hypotension in patients receiving uncrossmatched blood, time spent in the emergency department, frequency of ICU admission, severity of injury for ICU admission, and time between emergency department and operating room for patients requiring surgery, was equivalent between groups. Outcomes evaluated by mortality and length of stay in the hospital and ICU did not differ between groups, and provider group was not predictive of mortality in stepwise logistic regression. CONCLUSIONS: These data suggest that emergency traumatologists can provide trauma care effectively within a defined scope of practice and may provide an effective solution to manpower issues confronting trauma centers.

Emergency Nurse Documentation Improvement Tool.

Nursing documentation for trauma resuscitation has improved significantly at our level I trauma center because of the introduction of our Emergency Nurse Documentation Improvement Tool (END-IT). The END-IT system was implemented as a performance improvement model and utilizes existing computer software. It provides quick computerized feedback to professional nurses when documentation of trauma cases needs further attention. The feedback is provided in written form and uses peer mentoring to improve accountability in documentation. The program has been successful and has decreased documentation omissions and mistakes by 21%.