Improving the time to diagnosis after an abnormal screening mammogram.

INTRODUCTION: Five community-specific interventions to reduce the time to diagnosis after an abnormal breast screen have been evaluated. METHODS: Subjects with abnormal screening mammograms in 1998 were assessed through five community pilot projects (N = 1137) and a control random sample assessed elsewhere in BC (N = 1053). The number, types, dates and physician costs of breast-related interventions after an abnormal screen were compared between pilots and control. RESULTS: The median time to diagnosis for women without a biopsy was reduced from 23 days to 7 days (p = 0.001) in the pilot with facilitated referral to diagnosis. The median time to diagnosis for women with a biopsy was reduced from 57 days to 22-43 days in the pilots. Median physician costs per subject were lower (p = 0.02) in pilots that more frequently used core biopsy to obtain a diagnosis. CONCLUSIONS: Process changes can improve the time to diagnosis after an abnormal breast screen, with similar or lower physician costs per subject. Facilitating the referral process had the greatest impact.

Canadian attitudes toward use of primary repair in management of colon trauma. A survey of 317 members of the Canadian Association of General Surgeons.

PURPOSE: The majority of recent American articles on management of colon trauma promote liberal use of primary repair. The extent to which Canadian surgeons have embraced such recommendations is unknown. METHOD: To determine the current attitude of Canadian surgeons toward the use of primary repair, we surveyed the members of The Canadian Association of General Surgeons regarding their management of three fictitious cases of penetrating and blunt colon trauma. RESULTS: Three hundred seventeen members of the Canadian Association of General Surgeons responded. Ninety-two percent managed a fictitious case of early, uncontaminated stab wounds by primary repair. Delay in treatment or fecal contamination was associated with a significantly reduced number of respondents choosing primary repair (P < 0.001). Surgeons were less likely to choose primary repair for management of a case of blunt colon injury (35 percent; P <0.001), and only 25 percent considered primary repair an option for a case of low velocity bullet wounds; 2 percent chose it for high velocity bullet wounds. Overall, the most common response to colon trauma scenarios was colostomy. However, 96 percent of respondents selected primary repair as the treatment of choice for at least one clinical situation depicted in the questionnaire. The likelihood of choosing primary repair was independent of surgeons' experiences or the level of the surgeons' trauma center. CONCLUSIONS: Although there are still settings in which many Canadian surgeons consider colostomy the appropriate treatment for colon injuries, primary repair has definitely established a foothold in all levels of Canadian general surgery practice.

The utility of a multicenter regional trauma registry.

We report on the experience of five trauma receiving hospitals (four general hospitals and one spinal cord unit) in establishing a multicenter trauma registry (TR) for the purpose of data sharing. To ensure data comparability, all coders were oriented to standard data definitions and injury severity scaling. Coders and their physician sponsors met regularly to review data. Data presented for the four general hospitals from January through September 1992 address comparison of mortality rates, resource implications of isolated hip fractures, and the utility of knowing regional neurosurgical (NS) trauma volumes. Because of a statistically significant higher mortality rate at hospital 2, 7.2% versus 4.7% overall, mortality data were further characterized by patient age, mean ISS, and frequency of severe head injury. This still failed to explain the mortality difference. Hip fractures utilized 11,120 (26.3%) of the total 42,341 TR hospital days. Interhospital differences in median length of stay in this population suggest that greater resource efficiencies can be realized. Earlier questions about the value of including isolated hip fractures in the data set have been answered by understanding the resource implications of this population. Problems of NS coverage arising from a regional shortage of neurosurgeons can now be addressed with a better appreciation of the intraregional differences in NS volumes. Use of congruent data sets, combined with a collaborative approach, has stimulated the application of multicenter TR data to quality improvement, and utilization and regional planning issues.

Cardiopulmonary bypass for resuscitation of patients with accidental hypothermia and cardiac arrest.

Hypothermic patients have been successfully rewarmed by a number of methods. However, when cardiac arrest occurs, as it frequently does at core temperatures of less than 27 degrees C, prolonged cardiopulmonary resuscitation (CPR) is required, because defibrillation can rarely be achieved until the patient has been rewarmed to 30 degrees to 34 degrees C. Five cases of accidental hypothermia with cardiac arrest treated with cardiopulmonary bypass are discussed. The first patient died as a result of inadequate low-flow cardiopulmonary bypass by the femorofemoral route. The second patient had prolonged CPR by closed-chest cardiac massage and warm peritoneal lavage followed by transthoracic cardiopulmonary bypass. This patient regained consciousness but was found to be paraplegic and died from bowel infarction related to peritoneal rewarming without adequate perfusion. In the last three patients, high-flow cardiopulmonary bypass was rapidly achieved using a no. 28 French chest tube for femoral venous cannulation, and they recovered completely. In cases of accidental hypothermia with cardiac arrest, rapid institution of full cardiopulmonary bypass provides excellent circulatory support and rapid rewarming. This avoids the complications of prolonged inadequate circulation that occur when closed-chest cardiac massage and external rewarming are used.

Update on trauma care in Canada. 6. Update on trauma registries and trauma scoring.

Developments in microcomputer technology and user friendly software have resulted in rapidly expanding interest in trauma registries and injury scoring. The trauma registry, particularly when it is population based, is an empowering tool for epidemiologic research, planning of trauma systems, development of prevention programs, outcome evaluation and research. Injury coding performed in conjunction with trauma registry can also provide the basis for institutional quality assurance. The Major Trauma Outcome Study has played a major role in this, through the development of normative standards, permitting inter-institutional comparisons. These issues as well as some of the present Canadian and American initiatives in the trauma registry field are reviewed in this paper. Advances in injury scaling are addressed as are some of the limitations in existing coding methodologies.

Interinstitutional transfers to a trauma center.

To determine patient demographics, referral patterns, and problems with trauma transfer, records of 412 patients received over a 1-year period at the Vancouver General Hospital, a Level I Trauma Center, were reviewed. The average Injury Severity Score (ISS) was 15 (range: 1 to 75), with 142 patients (34%) having an ISS of 16 or greater. One hundred ninety-six (47%) of the transfers were accomplished by fixed-wing aircraft, 15 (4%) by helicopter, and 201 (49%) by land. Seventy-two percent were transported within 24 hours of injury. The injury mechanisms were as follows: 193 (47%) vehicular, 108 (26%) falls, 50 (12%) penetrating, 43 (10%) thermal, and 18 (5%) assaults/crush. Transfer was prompted by musculo-skeletal injuries in 157 (38%), neurosurgical problems in 71 (17%), multiple injuries in 64 (16%), burns in 45 (11%), hand injuries in 27 (7%), facial injuries in 26 (6%), and other problems in 22 (5%). Transfer management problems included airway in 4 patients, respiratory care in 8, and hemodynamic instability in 10. Only two of these patients had an ISS less than 16. Although most transfers were appropriate, some could have been avoided by more careful physician screening. For example, of six patients referred for digit replantation, only one was a suitable candidate. Lack of adequate regional care resulted in 10 long-distance air transports for isolated hip fractures. It is concluded that the majority of transfers were indicated and were safely carried out. However, there is a need for better patient screening, regionalized service, and improved communication regarding appropriate stabilization prior to transfer, particularly for patients with serious injuries.

A profile of urban adult pedestrian trauma.

The interaction between the pedestrians, drivers, and vehicles involved in pedestrian trauma often receives less attention than motor vehicle occupant accidents. To better define these factors, records of 161 pedestrians admitted to two urban university hospitals were reviewed. There were 87 females and 74 males. Females were older, with a median age of 62 years, compared to 43 years for males. Alcohol was a factor in 39 (52%) males and ten (12%) females. The mean Injury Severity Score (ISS) was 14.6, with injuries most commonly to the extremities in 135 (84%), external surfaces in 103 (64%), and the head and neck in 71 (44%). There were 18 deaths (11.2%) with a mean ISS of 40.3. Of the 143 survivors, 18 (12.5%) with a mean age of 68.4 years required placement in long-term care facilities. Elderly survivors also had longer hospital stays, consuming 51% of all hospital days. Driver information from the governmental universal automobile insurance agency was available for 134 accidents. Drivers failed to yield the right of way in 31 instances (23%). Fifteen (11%) were driving without due care and five (4%) at an unsafe speed. Nine (7%) had documented alcohol involvement. Forty drivers (30%) incurred a total of 50 traffic charges. Previous driving records were available for 109. Forty-six (42%) had been involved in two or more previous accidents and 40 (37%) had five or more previous citations for moving violations. Pedestrian action at road intersections was recorded in 75 accidents.(ABSTRACT TRUNCATED AT 250 WORDS)

Impact of advanced trauma life support training on early trauma management.

To assess the impact of ATLS education on early trauma management, charts of patients with an ISS of 14 or greater were reviewed for a 1 year period before and after ATLS training of emergency room trauma care providers. There were 50 patients in the before ATLS group, with a mean age of 41.6 years and an ISS of 29.8, and 71 patients in the after ATLS group, with a mean age of 40.6 years and an ISS of 30.6. Of those parameters evaluated as measures of early assessment, only rectal examination was found to be performed significantly more frequently after ATLS training. The mortality rates of 26 percent before ATLS and 20 percent after ATLS were not significantly different. In evaluating assessment and management parameters in the patients who died, no airway management errors were found in the after ATLS group; however, there were more missed injuries in this group. We have concluded that ATLS instruction failed to produce a quantifiable improvement in patient assessment or outcome. Further studies directed at assessing the retention rate for ATLS education and determining the impact on clinical performance are needed.