Simulation Using TeamSTEPPS to Promote Interprofessional Education and Collaborative Practice.

Effective interprofessional collaborative practice is critical to maximizing patient safety and providing quality patient care; incorporating these strategies into the curriculum is an important step toward implementation. This study assessed whether TeamSTEPPS training using simulation could improve student knowledge of TeamSTEPPS principles, self-efficacy toward interprofessional collaborative practice, and team performance. Students (N = 201) demonstrated significant improvement in all of the targeted measurements.

Developing a Foundation for Interprofessional Education Within Nursing and Medical Curricula.

Effective teamwork is essential to foster patient safety and promote quality patient care. Students may have limited to no exposure to interprofessional education (IPE) or collaborative practice, therefore making it challenging to learn how to work in teams. This article describes how a nursing and a medical school collaborated to systematically integrate IPE simulations into the curricula so that every graduate from the respective schools received TeamSTEPPS® education and participated in a standardized IPE simulation experience.

Novel markers predict death and organ failure following hemorrhagic shock.

BACKGROUND: ADAMTS 13, sP-Selectin and HSP27 have been investigated as potential prognostic markers in patients with hemorrhagic shock. METHODS: This study was part of a double-blind, randomized, parallel-group, controlled trial and included seventeen trauma patients presented to ED with severe hemorrhagic. The sera for testing were collected from these patients at the time of admission. Investigators and laboratory personnel performing testing were blinded to the patients' identity and clinical course. RESULTS: The prognostic value of ADAMTS13, sP-Selectin, and HSP27 was compared to prognostic value of systolic blood pressure (SBP), base deficit estimation (BD), heart rate (HR), shock index (SI) and tissue oxygen saturation (StO2) by constructing the receiver operation characteristics (ROC). The area under the curve (AUC) of the ROC for HSP27 (0.92) was greater than for SBP (0.45), BD (0.89), HR (0.61), SI (0.45) and StO2 (0.46). AUC for sP-Selectin (0.86) and for ADAMTS13 antigen (0.74) were comparable with BD one, but greater than for the rest of currently used tests. CONCLUSION: Serum concentrations of ADAMTS13, HSP27 and sP-Selectin measured during the admission, appear to be comparable to or better than SBP, BD, SI, HR and StO2 in predicting MODS and death after hemorrhage from trauma. These potential new markers deserve further investigation.

Impact of the age of transfused red blood cells in the trauma population: a feasibility study.

UNLABELLED: Following injury, transfusion of red blood cells (RBCs) of increased storage duration has been associated with an increased morbidity and mortality. Prospective trials focusing on the impact of the storage age of RBCs in severely bleeding trauma patients have failed to accrue patients. This has been attributed to an inability to maintain a large inventory of fresh RBCs, and the difficulties in obtaining consent in severely bleeding trauma patients. To address these issues, we performed a prospective, observational pilot study to evaluate the feasibility of conducting a trial focusing on RBC age in patients following injury. METHODS: Patients with bleeding due to trauma were transfused RBCs ≤10 day old if they were ABO blood Type O (Group O) or were transfused the oldest RBCs in inventory if they were Type A, B or AB (Group A/B/AB). Clinicians were unaware of the specific age of the RBCs. RESULTS: 63 patients were analyzed (Group O, n=19; Group A/B/AB, n=44). Half of all patients had severe injuries ISS (median 22). The median admission base deficit was -5 mEq/L, and median total 24h use of RBC and FFP was 1.2 L. The age of RBCs transfused to Group O was significantly lower than for Group A/B/AB [median (IQR) A/B/AB=18.4 (11.4-25.4) days, and Group O=6 (4.2-7.8) days; p<0.001]. CONCLUSIONS: It appears feasible to conduct a RBC age trial in trauma patients using ABO blood type to construct comparative groups. Adequate RBC age separation between cohorts and reduced RBC age in the "young" group of patients who received units ≤10 days old was achieved.

Characterizing vasopressin and other vasoactive mediators released during resuscitation of trauma patients.

BACKGROUND: We sought to perform the first characterization of vasopressin and other vasoactive mediators released during resuscitation of hypotensive trauma patients. METHODS: This institutional review board-approved study was conducted under waiver of consent. Adults with clinical evidence of acute traumatic injury and systolic blood pressure less than or equal to 90 mm Hg within 1 hour of arrival were evaluated at our Level I trauma center. Two hundred three patients were screened with 50 enrolled from February 2010 to February 2011. Demographic information was also collected. Blood samples were obtained at 0, 30, 60, 90, 120, and 240 minutes after arrival, and assays were performed for vasopressin, angiotensin II, epinephrine, and cortisol. We assessed the significance of variation in these vasoactive mediators with injury and transfusion of more than 600 mL, with adjustment for time using repeated-measures linear models in log units. RESULTS: We found that vasopressin (p = 0.005) and epinephrine (p = 0.01) increased significantly with injury, while angiotensin (p = 0.60) and cortisol (p = 0.46) did not and that vasopressin (p < 0.001) and epinephrine (p = 0.004) increased significantly in patients requiring transfusion of more than 600 mL but angiotensin II (p = 0.11) and cortisol (p = 0.90) did not. Relatively low levels of vasopressin (<30 pg/mL) were observed at least once during the first 2 hours in 88% of trauma patients, and abnormally low epinephrine levels (<100 pg/mL) were observed at least once during the first 2 hours in 18% of trauma patients. CONCLUSION: This is the first clinical trial to serially evaluate vasopressin and other vasoactive mediators following trauma during the resuscitation phase. Vasopressin, in particular, and epinephrine seem to be the key mediators produced in the human response to severe injury. A deficiency of vasopressin may contribute to intractable shock after trauma. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III.

Impact of low-dose vasopressin on trauma outcome: prospective randomized study.

BACKGROUND: We previously found that regardless of the animal injury model used resuscitation strategies that minimize fluid administration requirements lead to better outcomes. We hypothesized that a resuscitation regimen that limited the total volume of fluid administered would reduce morbidity and mortality rates in critically ill trauma patients. METHODS: We performed a double-blind randomized trial to assess the safety and efficacy of adding vasopressin to resuscitative fluid. Subjects were hypotensive adults who had sustained acute traumatic injury. Subjects were given fluid alone (control group) or fluid plus vasopressin (experimental group), first as a bolus (4 IU) and then as an intravenous infusion of 200 ml/h (vasopressin 2.4 IU/h) for 5 h. RESULTS: We randomly assigned 78 patients to the experimental group (n=38) or the control group (n=40). The groups were similar in age, sex, preexisting medical illnesses, and mechanism and severity of injury. Serum vasopressin concentrations were higher in the experimental group than in the control group at admission, after infusion of vasopressin (p=0.01), and 12 h later. The experimental group required a significantly lower total volume of resuscitation fluid over 5 days than did the control group (p=0.04). The mortality rate at 5 days was 13% in the experimental group and 25% in the control group (p=0.19). The rates of adverse events, organ dysfunction, and 30-day mortality were similar. CONCLUSIONS: This is the first trial to investigate the impact of vasopressin administration in trauma patients. Infusion of low-dose vasopressin maintained elevated serum vasopressin levels and decreased fluid requirements after injury.

Less is more: improved outcomes in surgical patients with conservative fluid administration and central venous catheter monitoring.

BACKGROUND: The ARDS Clinical Trials Network Fluid and Catheter Treatment Trial (FACTT) addressed fluid management and central monitoring of patients with acute respiratory distress syndrome/acute lung injury (ARDS/ALI). Because surgical patients may have been fundamentally different from the overall FACTT cohort, we set out to separately analyze the surgery patients in the trial. STUDY DESIGN: We performed a posthoc, surgical subgroup analysis of 1,000 patients enrolled in the FACTT. Patients were randomized using a 2x2 factorial design comparing a conservative (CON) versus a liberal (LIB) strategy of fluid management and the use of a pulmonary artery catheter (PAC) or a central venous catheter (CVC). The primary end point was death at 60 days. Secondary end points included the number of ventilator-free days, ICU-free days, and dialysis-free days until hospital discharge up to day 90. We defined surgical patients as those admitted to a surgical ICU, burn ICU, or cardiac surgical ICU; trauma patients; or those with an APACHE III surgical admission type. RESULTS: There were 244 surgical patients. Risk of death within 60 days of randomization did not vary with catheter or fluid management, and a corresponding lack of effect was evident with regard to dialysis-free days. Ventilator-free days were increased in the fluid-conservative group (LIB, 13+/-1 days; CON, 15+/-1 days; p=0.04) at 28 days. CVC patients had more ventilator-free days at 28 and 90 days (28 days: CVC, 16+/-1 days; PAC, 13+/-1 days; p=0.03; 90 days: CVC, 64+/-3 days; PAC, 57+/-4 days; p=0.03). CVC patients had more ICU-free days at 90 days (90 days: CVC, 63+/-3 days; PAC, 55+/-3 days; p=0.04). CONCLUSIONS: The risk of death did not vary with fluid management or catheter. A conservative fluid-administration strategy and central venous catheter monitoring resulted in more ventilator-free and ICU-free days in surgical patients with acute lung injury, and conservative fluid administration did not result in more renal failure.

Surgical critical care and private practice surgeons: a different world out there!

BACKGROUND: Few graduating residents seek surgical critical care (SCC) fellowships; fewer than half of positions fill. We hypothesized substantial differences exist in practice patterns and attitudes between SCC surgeons in academic practice (ACs) and in private practice (PVTs). STUDY DESIGN: A survey instrument was sent to 1,544 board-certified SCC intensivists in North America. RESULTS: Of those invited, 489 responded (32% response rate). Respondents were mostly men (88%) and Caucasian (86%), with a mean age of 48 years; 60% were ACs, 28% were PVTs, and 12% reported "other;" 94% currently practiced SCC. PVTs (50%) were more likely than ACs (18%) to provide SCC for only their own patients, less likely (24% versus 74%) to function as an "ICU attending," and less likely to work with residents (36% versus 91%) and fellows (4% versus 60%; all p < 0.001). PVTs (48%) spent more time performing elective operations than ACs (27%; p < 0.001). They were more likely than ACs to relinquish management of SCC patients to medical consultants: infectious disease (34% versus 12%), cardiology (31% versus 12%), and pulmonary (23% versus 3%; all p < 0.001). Conflicts with medical specialists were a bigger problem for PVTs (43%) than for ACs (17%; p < 0.001). CONCLUSIONS: Private practice surgical intensivists are more likely than academic intensivists to provide critical care for only their own patients and to use consultants to avoid conflicts.