Impact of Fluid Balance on Intensive Care Unit Length of Stay in Critically Ill Trauma Patients.

BACKGROUND: There is significant data in the medical and surgical literature supporting the correlations between positive volume balance and negative outcomes such as AKI, prolonged mechanical ventilation, intensive care unit and hospital length of stay and increased mortality. METHODS: This single-center, retrospective chart review included adult patients identified from a Trauma Registry database. The primary outcome was the total ICU LOS. Secondary outcomes include hospital LOS, ventilator-free days, incidence of compartment syndrome, acute respiratory distress syndrome (ARDS), renal replacement therapy (RRT), and days of vasopressor therapy. RESULTS: In general, baseline characteristics were similar between groups with the exception of mechanism of injury, FAST exam, and disposition from the ED. The ICU LOS was shortest in the negative fluid balance and longest in the positive fluid balance group (4 days vs 6 days, P = .001). Hospital LOS was also shorter in the negative balance group than that of the positive balance group (7 days vs 12 days, P < .001). More patients in the positive balance group experienced acute respiratory distress syndrome compared to the negative balance group (6.3% vs 0%, P = .004). There was no significant difference in the incidence of renal replacement therapy, days of vasopressor therapy, or ventilator-free days. DISCUSSION: A negative fluid balance at seventy-two hours was associated with a shorter ICU and hospital LOS in critically ill trauma patients. Our observed correlation between positive volume balance and total ICU days merits further exploration with prospective, comparative studies of lower volume resuscitation to key physiologic endpoints compared with routine standard of care.

Comparative Analysis of State Trauma Triage Criteria vs. Paramedic Discretion.

OBJECTIVE: The Florida Adult Trauma Triage Criteria (FATTC) define specific parameters concerning injury mechanism and physiologic data that prompt paramedics to initiate a trauma alert and necessitate transport to a trauma center. In the state of Florida, paramedics are also given discretion to bring patients to the trauma center who do not meet those criteria. Our aim was to compare the injury characteristics and outcomes of adult patients who were evaluated in our trauma center after activation due to FATTC criteria vs. paramedic discretion (PD) and to identify predictors of PD. METHODS: This retrospective study included all patients 18 years and older evaluated in our trauma center from January 1, 2007, to December 31, 2014. Descriptive statistics were computed for all variables. Bivariate and multivariate analyses were performed to compare demographic, injury severity, and outcome differences between groups. RESULTS: A total of 13,963 patients met FATTC during the study period, and 1,811 were brought in by PD. PD patients had lower injury severity and crude mortality. Regression modeling of demographic and injury variables found that only the combination of older age and higher heart rate predicted PD when both were lower than FATTC alone. CONCLUSIONS: While PD patients were less seriously injured and had lower mortality, they experienced similar lengths of stay and resource utilization after presentation. Paramedics may be able to identify patients at risk for poor outcomes who would otherwise not be captured by FATTC.

ICD-10: cracking the code.

Healthcare organizations should address physician clinical documentation improvement now, before the Oct. 1, 2014, implementation deadline for ICD-10, if they are to mitigate risk related to ICD-10 and optimize operational processes. Improving documentation now will have an immediate effect on revenue and will minimize the potential for losses related to denied claims after ICD-10 goes into effect. Training of physicians should not be just a "once-and-done" process. Organizations should plan now for training to continue even after the implementation deadline.