Prospective evaluation of low health literacy and its impact on outcomes in trauma patients.

BACKGROUND: Health literacy is an emerging focus of interest in public health and is evolving as an important component of national health policy. Low health literacy (LHL) is associated with poor outcomes. We aimed to identify factors associated with LHL and its relationship with health outcomes in trauma patients. METHODS: We prospectively enrolled all adult trauma patients (age, > 18 years) in our analysis. Patients were surveyed at discharge and followed up at 4 weeks postdischarge. At discharge, patient's health literacy was assessed using the Short-Assessment of Health Literacy score. Low health literacy was defined as Short-Assessment of Health Literacy score less than 14. Patients were surveyed regarding their understanding of their injuries, treatment received, discharge instructions, and interaction with the physician. Four weeks postdischarge, all patients were inquired about clinic follow-up details and recovery. RESULTS: We enrolled 140 patients, of which 70% were white. Mean age was 45 ± 20 years, and median Injury Severity Score was 10 (6-12). Overall, 24% (34) patients had LHL. There was no difference in the Injury Severity Score between LHL and health literate (HL) patients (p = 0.41). The LHL patients were more likely to be Hispanic-white (78% vs. 41%, p = 0.02), had lower socioeconomic status (91% vs. 51%, p = 0.01), uninsured (45% vs. 18%, p = 0.01), and were less likely to have graduated (0% vs. 49%, p = 0.01) compared with the HL patients. At discharge, both groups were satisfied with the time spent by a physician to explain the condition, however, the LHL patients were less likely to recall their injuries (p = 0.03) or how they were treated (p = 0.01). Patients with LHL had lower follow-up rates (p = 0.01) with no difference in the readmission rate (p = 0.71) compared with HL. CONCLUSION: Every 1 in 4 trauma patients have LHL. Low health literacy is associated with poor understanding of injuries and treatment provided to them, leading to a decrease in compliance with discharge instructions and longer time to recovery. Identifying LHL in high-risk patients and developing appropriate intervention before discharge may help improve outcomes. LEVEL OF EVIDENCE: Prognostic study, level I.

Assessing the Efficacy of Prothrombin Complex Concentrate in Multiply Injured Patients With High-Energy Pelvic and Extremity Fractures.

OBJECTIVES: Prothrombin complex concentrate (PCC) is being increasingly used for reversing induced coagulopathy of trauma. However, the use of PCC for reversing coagulopathy in multiply injured patients with pelvic and/or lower extremity fractures remains unclear. The aim of our study was to assess the efficacy of PCC for reversing coagulopathy in this group of patients. DESIGN: Two-year retrospective analysis. SETTING: Our level I trauma center. PATIENTS/PARTICIPANTS: All coagulopathic [International normalized ratio (INR) ≥1.5] trauma patients. Patients with femur, tibia, or pelvic fracture were included. Patients were divided into 2 groups: PCC (single dose) and fresh frozen plasma (FFP). Patients in the 2 groups were matched using propensity score matching. MAIN OUTCOME MEASUREMENTS: Time to correction of INR, time to intervention, development of thromboembolic complications, mortality, and cost of therapy. RESULTS: A total of 81 patients (PCC: 27, FFP: 54) were included. Patients who received PCC had faster correction of INR and shorter time to surgical intervention in comparison to patients who received FFP. PCC therapy was also associated with lower overall blood product requirement (P = 0.02) and lower transfusion costs (P = 0.0001). CONCLUSIONS: In a matched cohort of multiply injured patients with pelvic and/or lower extremity fractures, administration of a single dose of PCC significantly reduced the time to correction of INR and time to intervention compared with patients who received FFP therapy. This may allow orthopaedic surgeons to more safely proceed with early, definitive fixation strategies. LEVEL OF EVIDENCE: Therapeutic level III. See Instructions for Authors for a complete description of levels of evidence.

Stress among surgical attending physicians and trainees: A quantitative assessment during trauma activation and emergency surgeries.

BACKGROUND: The adverse effects of stress on the wellness of trauma team members are well established; however, the level of stress has never been quantitatively assessed. The aim of our study was to assess the level of stress using subjective data and objective heart rate variability (HRV) among attending surgeons (ASs), junior residents (JRs) (PGY2/PGY3), and senior residents (SRs) (PGY5/PGY6) during trauma activation and emergency surgery. METHODS: We preformed a prospective study enrolling participants over eight 24-hour calls in our Level I trauma center. Stress was assessed based on decrease in HRV, which was recorded using body worn sensors. Stress was defined as HRV of less than 85% of baseline HRV. We collected subjective data on stress for each participant during calls. Three groups (ASs, JRs, SRs) were compared for duration of different stress levels through trauma activation and emergency surgery. RESULTS: A total of 22 participants (ASs: n = 8, JRs: n = 7, SRs: n = 7) were evaluated over 192 hours, which included 33 trauma activations and 50 emergency surgeries. Stress level increased during trauma activations and operations regardless of level of training. The ASs had significantly lower stress when compared with SRs and JRs during trauma activation (21.9 ± 10.7 vs. 51.9 ± 17.2 vs. 64.5 ± 11.6; p < 0.001) and emergency surgery (30.8 ± 7.0 vs. 53.33 ± 6.9 vs. 56.1 ± 3.8; p < 0.001). The level of stress was similar between JRs and SRs during trauma activation (p = 0.37) and emergency surgery (p = 0.19). There was no correlation between objectively measured stress level and subjectively measured stress using State-Trait Anxiety Inventory (R = 0.16; p = 0.01) among surgeons or residents. CONCLUSIONS: Surgeon wellness is a significant concern, and this study provides empirical evidence that trauma and acute care surgeons encounter mental strain and fail to recognize it. Stress management and burnout are very important in this high-intensity field, and this research may provide some insight in finding those practitioners who are at risk. LEVEL OF EVIDENCE: Epidemiologic study, level II.

Evidence-based Comprehensive Approach to Forearm Arterial Laceration.

INTRODUCTION: Penetrating injury to the forearm may cause an isolated radial or ulnar artery injury, or a complex injury involving other structures including veins, tendons and nerves. The management of forearm laceration with arterial injury involves both operative and nonoperative strategies. An evolution in management has emerged especially at urban trauma centers, where the multidisciplinary resource of trauma and hand subspecialties may invoke controversy pertaining to the optimal management of such injuries. The objective of this review was to provide an evidence-based, systematic, operative and nonoperative approach to the management of isolated and complex forearm lacerations. A comprehensive search of MedLine, Cochrane Library, Embase and the National Guideline Clearinghouse did not yield evidence-based management guidelines for forearm arterial laceration injury. No professional or societal consensus guidelines or best practice guidelines exist to our knowledge. DISCUSSION: The optimal methods for achieving hemostasis are by a combination approach utilizing direct digital pressure, temporary tourniquet pressure, compressive dressings followed by wound closure. While surgical hemostasis may provide an expedited route for control of hemorrhage, this aggressive approach is often not needed (with a few exceptions) to achieve hemostasis for most forearm lacerations. Conservative methods mentioned above will attain the same result. Further, routine emergent or urgent operative exploration of forearm laceration injuries are not warranted and not cost-beneficial. It has been widely accepted with ample evidence in the literature that neither injury to forearm artery, nerve or tendon requires immediate surgical repair. Attention should be directed instead to control of bleeding, and perform a complete physical examination of the hand to document the presence or absence of other associated injuries. Critical ischemia will require expeditious surgical restoration of arterial perfusion. In a well-perfused hand, however, the presence of one intact artery is adequate to sustain viability without long-term functional disability, provided the palmar arch circulation is intact. Early consultation with a hand specialist should be pursued, and follow-up arrangement made for delayed primary repair in cases of complex injury. CONCLUSION: Management in accordance with well-established clinical principles will maximize treatment efficacy and functional outcome while minimizing the cost of medical care.