Resource commitment to improve outcomes and increase value at a level I trauma center.

BACKGROUND: Optimal care of trauma patients requires cost-effective organization and commitment of trauma center resources. We examined the impact of creating a dedicated trauma care unit (TCU) and adding advanced practice nurses on the quality and cost of care at an adult Level I trauma center. METHODS: Patient demographic and injury data, length of stay, complications, outcomes, and total direct cost of care were evaluated for four 1-year intervals in the recent history of our trauma center: Year A, a trauma team of in-house trauma surgeons and resident physicians; Year B, the addition of nurse practitioners to the trauma team 5 days/week; Year C, the creation of a dedicated TCU for all non intensive care unit trauma patients; and Year D, the addition of a permanent clinical nurse specialist and an increase in nurse practitioner coverage to 7 days/week. For each year, value was determined by calculating the median cost of a survivor and the median cost of a survivor with no complications. Significance was attributed to p<0.05. RESULTS: Patient volume increased from 1,927 in year A to 2,546 by year D. Over the period of study, there was an increase in blunt trauma (87.1-89.9%; p<0.05), median Injury Severity Score (5-6; p<0.05), and patients aged ≥65 years (11.4-19.8%; p<0.05). However, risk-adjusted mortality was unchanged. There was a decrease in patients with a complication (20.8-14.9%; p < 0.05), median intensive care unit length of stay (39.5-23.4 hours; p < 0.05), and median cost of care ($4,306-$3,698; p<0.05). Value increased: both the median costs of a survivor and of a survivor with no complications decreased from $4,259 to $3,658 (p<0.05) and from $3,898 to $3,317 (p<0.05), respectively. The median cost of a survivor with severe injury (Injury Severity Score ≥15) decreased from $17,651 to $12,285 (p<0.05). CONCLUSION: The addition of a dedicated TCU and advanced practice nurses improved the quality and reduced the cost of care, resulting in increased value at an adult Level I trauma center.

Implementing screening, brief intervention, and referral for alcohol and drug use: the trauma service perspective.

BACKGROUND: Most trauma surgeons are unfamiliar with screening, brief intervention, and referral (SBIR) programs for substance use disorders, and few trauma centers provide them. This report describes how an urban private-teaching hospital adapted a protocol from an existing emergency department-based program to include patients treated by the trauma service. METHODS: We recorded the rates of SBIR completion and reasons for failure during each phase of the implementation, interviewed trauma service staff and health educators to assess attitudes toward the program, and evaluated patient satisfaction surveys. RESULTS: By adding SBIR staff to the trauma outpatient clinic and to trauma morning rounds, the capture rate increased from 12 to 71%. Most screened patients (59%) were found at risk for problems or probably dependent on alcohol or drugs. Trauma service staff and health educators reported high satisfaction with the program. Patients reported higher satisfaction with SBIR. CONCLUSION: SBIR services can be effectively integrated into all components of a busy, urban trauma service by adding specially trained health educators to the trauma service staff. This collaboration provides effective SBIR services to both trauma and emergency service patients without interfering with patient flow or medical procedures. The relatively high percentage of patients at risk for alcohol or drug problems supports the inclusion of routine alcohol and drug screening for all eligible trauma patients.

Hypovolemic shock: an overview.

Resuscitation of major trauma victims suffering from shock remains a challenge for trauma systems and trauma centers. Rapid identification, and ensuring correct, aggressive treatment, are necessary for patient survival. This article discusses shock encountered in trauma victims: hypovolemic, cardiogenic, obstructive, and distributive shock. Emphasis is placed on hypovolemic shock and its sequelae. The critical care nurse plays an important role as part of the team involved in the resuscitation and ongoing care of these patients. Understanding the underlying pathophysiology, recognizing signs and symptoms, and being prepared to effectively respond will further enable the nurse to contribute to positive patient outcomes.

Orthopedic trauma: critical care nursing issues.

Orthopedic trauma is frequently encountered by critical care nurses as trauma team members providing care to the severely injured. Through actual case examples, the role of the critical care nurse and orthopedic trauma management is reviewed. Focus is on unstable pelvic fractures, extremity fractures, compartment syndrome, rhabdomyolysis, mangled extremities, gunshot-wound fractures, and damage-control orthopedics.