Emergencies do not shut down during a pandemic: COVID pandemic impact on Acute Care Surgery volume and mortality at a level I trauma center

BACKGROUND

The aim of this study was to evaluate the impact of the COVID-19 pandemic on volume and outcomes of Acute Care Surgery patients, and we hypothesized that inpatient mortality would increase due to COVID+ and resource constraints.

METHODS

An American College of Surgeons verified Level I Trauma Center's trauma and operative emergency general surgery (EGS) registries were queried for all patients from Jan. 2019 to Dec. 2020. April 1st, 2020, was the demarcation date for pre- and during COVID pandemic. Primary outcome was inpatient mortality.

RESULTS

There were 14,460 trauma and 3091 EGS patients, and month-over-month volumes of both remained similar (p > 0.05). Blunt trauma decreased by 7.4% and penetrating increased by 31%, with a concomitant 25% increase in initial operative management (p < 0.001). Despite this, trauma (3.7%) and EGS (2.9-3.0%) mortality rates remained stable which was confirmed on multivariate analysis; p > 0.05. COVID + mortality was 8.8% and 3.7% in trauma and EGS patients, respectively.

CONCLUSION

Acute Care Surgeons provided high quality care to trauma and EGS patients during the pandemic without allowing excess mortality despite many hardships and resource constraints.

Emergency General Surgery Regionalization: Retrospective Cohort Study of Emergency General Surgery Patients at a Tertiary Care Center

BACKGROUND

Emergency general surgery (EGS) patients presenting at tertiary care hospitals may bypass local hospitals with adequate resources. However, many tertiary care hospitals frequently operate at capacity. We hypothesized that understanding patient geographic origin could identify opportunities for enhanced system triage and optimization and be an important first step for EGS regionalization and care coordination that could potentially lead to improved utilization of resources.

METHODS

We analyzed patient zip code and categorized EGS patients who were cared for at our tertiary care hospital as potentially divertible if the southern region hospital was geographically closer to their home, regional hospital admission (RHA) patients, or local admission (LA) patients if the tertiary care facility was closer. Baseline characteristics and outcomes were compared for RHA and LA patients.

RESULTS

Of 14 714 EGS patients presenting to the tertiary care hospital, 30.2% were categorized as RHA patients. Overall, 1526 (10.4%) patients required an operation including 527 (34.5%) patients who were potentially divertible. Appendectomy and cholecystectomy comprised 66% of the operations for potentially divertible patients. Length of stay was not significantly different (P = .06) for RHA patients, but they did have lower measured short-term and long-term mortality when compared to their LA counterparts (P < .05).

CONCLUSIONS

EGS diagnoses and patient geocode analysis can identify opportunities to optimize regional operating room and bed utilization. Understanding where EGS patients are cared for and factors that influenced care facility will be critical for next steps in developing EGS regionalization within our system.

The Obesity Paradox in Emergency General Surgery Patients

Operative management of emergency general surgery (EGS) diagnoses involves a range of procedures which can carry high morbidity and mortality. Little is known about the impact of obesity on patient outcomes. The aim of this study was to examine the association between body mass index (BMI) >30 kg/m² and mortality for EGS patients. We hypothesized that obese patients would have increased mortality rates.

A regional integrated health system EGS registry derived from The American Association for the Surgery of Trauma EGS ICD-9 codes was analyzed from January 2013 to October 2015. Patients were stratified into BMI categories based on WHO classifications. The primary outcome was 30-day mortality. Longer-term mortality with linkage to the Social Security Death Index was also examined. Univariate and multivariable analyses were performed.

A total of 60 604 encounters were identified and 7183 (11.9%) underwent operative intervention. Patient characteristics include 53% women, mean age 58.2 ± 18.7 years, 64.2% >BMI 30 kg/m², 30.2% with chronic obstructive pulmonary disease, 19% with congestive heart failure, and 31.1% with diabetes. The most common procedure was laparoscopic cholecystectomy (36.4%). Overall, 90-day mortality was 10.9%. In multivariable analysis, all classes of obesity were protective against mortality compared to normal BMI. Underweight patients had increased risk of inpatient (OR = 1.9, CI = 1.7-2.3), 30-day (OR = 1.9, CI = 1.7-2.1), 90-day (OR = 1.8, CI 1.6-2.0), 1-year (OR = 1.8, CI = 1.7-2.0), and 3-year mortality (OR = 1.7, CI = 1.6-1.9).

When stratified by BMI, underweight EGS patients have the highest odds of death. Paradoxically, obesity appears protective against death, even when controlling for potentially confounding factors. Increased rates of nonoperative management in the obese population may impact these findings.

Endovascular Graft Repair for Blunt Traumatic Disruption of the Thoracic Aorta: Experience at a Nonuniversity Hospital

Blunt thoracic aortic injury (BAI) represents the second leading cause of death from blunt trauma. Admission rates for BAI are extremely low because instant fatality occurs in nearly 75 per cent of patients. Management strategies have transitioned from the more invasive immediate thoracotomy to delayed endograft repair with strict hemodynamic management. In this study, we assess outcomes and complications of open versus endograft repair for BAI at a nonuniversity hospital. Retrospective chart review was conducted on 49 patients admitted to a Level I trauma center who incurred BAI from 2004 to 2011. Collected data points included demographics, mortality, complication rates, and intensive care unit and hospital length of stay (LOS). Twenty-one patients underwent open thoracotomy (OPEN), whereas 28 patients were managed with thoracic endovascular aortic repair (TEVAR). The overall 30-day mortality rate was significantly lower comparing TEVAR to OPEN (7.1 vs 50%, P = 0.028); seven deaths occurred in the OPEN group versus two with TEVAR. Overall complications, including mortality, acute respiratory distress syndrome, renal failure, pneumonia, pulmonary embolism, and cardiac arrest, were fewer after TEVAR (32.1 vs 81.0%, P < 0.001) despite similar injury severity. Survivor hospital LOS (26.0 ± 15.3 vs 27.7 ± 18.7 days, P = 0.79), intensive care unit LOS (13.5 ± 10.9 vs 12.7 ± 8.8 days, P = 0.94), and ventilator days (11.4 ± 13.4 vs 16.4 ± 14.5 days, P = 0.25) were similar. Early nonoperative management with TEVAR for BAIs is a feasible and effective management strategy. Improved patient outcomes over traditional open thoracotomy in the presence of similar injury severity can be seen after TEVAR in the nonuniversity hospital setting.

Cirrhosis and Trauma: A Deadly Duo

It has been previously reported that trauma patients with cirrhosis undergoing emergency abdominal operations exhibit a fourfold increase in mortality independent of their Child's classification. We undertook this review to assess the impact of cirrhosis on trauma patients. We reviewed the records of patients from 1993 to 2003 with documented hepatic cirrhosis and compared them to a 2:1 control population without hepatic cirrhosis and matched for age, sex, Injury Severity Score (ISS), and Glasgow Coma Score (GCS). Demographic, severity of injury, and outcome data were recorded. Student's t test and χ2 were used for statistical analysis and a P < 0.05 was significant. Sixty-one patients had documented cirrhosis and were compared to 156 matched controls. Comparing the two groups demonstrates there was no difference in age, ISS, or GCS. Intensive care stay, hospital length of stay, blood requirements in the first 24 hours postinjury, and mortality (33% vs 1%) was significantly greater in the trauma patients with cirrhosis. Fifty-five per cent of deaths in the cirrhosis group was due to sepsis, and, as the Child's class increases, so does the mortality (Child's A, 15%; B, 37%; and C, 63%). In 64 per cent of cirrhotics without an emergent abdominal operation, mortality was 21 per cent. In the 36 per cent of cirrhotics who had emergent abdominal operation, mortality was 55 per cent. Hepatic cirrhosis in trauma patients, regardless of severity of injury or the need for an abdominal intervention, is a poor prognostic indicator. The necessity of an abdominal operative intervention further amplifies this effect. Trauma and cirrhosis is, in fact, a deadly duo.

Maximizing the Calm before the Storm: Tiered Surgical Response Plan for Novel Coronavirus (COVID-19)

The novel coronavirus (COVID-19) was first diagnosed in Wuhan, China in December 2019 and has now spread throughout the world, being verified by the World Health Organization as a pandemic on March 11. This had led to the calling of a national emergency on March 13 in the US. Many hospitals, healthcare networks, and specifically, departments of surgery, are asking the same questions about how to cope and plan for surge capacity, personnel attrition, novel infrastructure utilization, and resource exhaustion. Herein, we present a tiered plan for surgical department planning based on incident command levels. This includes acute care surgeon deployment (given their critical care training and vertically integrated position in the hospital), recommended infrastructure and transfer utilization, triage principles, and faculty, resident, and advanced care practitioner deployment.

PATHway to success: Implementation of a multiprofessional acute trauma health care team decreased length of stay and cost in patients with neurological injury requiring tracheostomy

BACKGROUND

The aim of this study was to determine whether the implementation of a dedicated multiprofessional acute trauma health care (mPATH) team would decrease length of stay without adversely impacting outcomes of patients with severe traumatic brain and spinal cord injuries. The mPATH team was comprised of a physical, occupational, speech, and respiratory therapist, nurse navigator, social worker, advanced care provider, and physician who performed rounds on the subset of trauma patients with these injuries from the intensive care unit to discharge.

METHODS

Following the formation and implementation of the mPATH team at our Level I trauma center, a retrospective cohort study was performed comparing patients in the year immediately prior to the introduction of the mPATH team (n = 60) to those in the first full year following implementation (n = 70). Demographics were collected for both groups. Inclusion criteria were Glasgow Coma Scale score less than 8 on postinjury Day 2, all paraplegic and quadriplegic patients, and patients older than 55 years with central cord syndrome who underwent tracheostomy. The primary endpoint was length of stay; secondary endpoints were time to tracheostomy, days to evaluation by occupational, physical, and speech therapy, 30-day readmission, and 30-day mortality.

RESULTS

The median time to evaluation by occupational, physical, and speech therapy was universally decreased. Injury Severity Score was 27 in both cohorts. Time to tracheostomy and length of stay were both decreased. Thirty-day readmission and mortality rates remained unchanged. A cost savings of US $11,238 per index hospitalization was observed.

CONCLUSION

In the year following the initiation of the mPATH team, we observed earlier time to occupational, physical, and speech therapist evaluation, decreased length of stay, and cost savings in severe traumatic brain and spinal cord injury patients requiring tracheostomy compared with our historical control. These benefits were observed without adversely impacting 30-day readmission or mortality.

LEVEL OF EVIDENCE

Therapeutic/care management, Level III.

Filled to the brim: The characteristics of over-triage at a level I trauma center

BACKGROUND

Interfacility transfers are necessary and valuable for the trauma system, but despite regional guidelines, many patients are inappropriately transferred. We evaluated over-triage at our Level I center and identified risk factors for over-triage.

METHODS

Retrospective analysis at our Level I urban trauma center assessed patients transferred from regional facilities during 2017. Over-triage was defined as patients discharged <48 h without procedures. Exclusion criteria were leaving against medical advice or no outside records.

RESULTS

Overall, 2352 patients met criteria. Nine hundred thirty (39.5%) with complete hospital records were discharged in <48 h; 498 (53.5%) received no procedural intervention and 909 (97.7%) were ultimately discharged home.

CONCLUSION

Many patients are inappropriately transferred to tertiary care centers without a definitive need for advanced services. Studies are needed to improve triage criteria without increasing under-triage.

Not a Routine Case, Why Expect the Routine Outcome? Quantifying the Infectious Burden of Emergency General Surgery Using the NSQIP

Emergent surgeries have different causes and physiologic patient responses than the same elective surgery, many of which are due to infectious etiologies. Therefore, we hypothesized that emergency cases have a higher risk of postoperative SSI than their elective counterparts. The ACS NSQIP database was queried from 2005 to 2016 for all cholecystectomies, ventral hernia repairs, and partial colectomies to examine common emergency and elective general surgery operations. Thirty-day outcomes were compared by emergent status. Any SSI was the primary outcome. There were 863,164 surgeries: 416,497 cholecystectomies, 220,815 ventral hernia repairs, and 225,852 partial colectomies. SSIs developed in 38,865 (4.5%) patients. SSIs increased with emergencies (5.3% vs 3.6% for any SSI). Postoperative sepsis (5.8% vs 1.5%), septic shock (4.7% vs 0.6%), length of stay (8.1 vs 2.9 days), and mortality (3.6% vs 0.4%) were increased in emergent surgery; P < 0.001 for all. When controlling for age, gender, BMI, diabetes, smoking, wound classification, comorbidities, functional status, and procedure on multivariate analysis, emergency surgery (odds ratio 1.15, 95% confidence interval 1.11–1.19) was independently associated with the development of SSI. Patients undergoing emergency general surgery experience increased rates of SSI. Patients and their families should be appropriately counseled regarding these elevated risks when consenting for emergency surgery.

Not a Routine Case, Why Expect the Routine Outcome? Quantifying the Infectious Burden of Emergency General Surgery Using the NSQIP

Emergent surgeries have different causes and physiologic patient responses than the same elective surgery, many of which are due to infectious etiologies. Therefore, we hypothesized that emergency cases have a higher risk of postoperative SSI than their elective counterparts. The ACS NSQIP database was queried from 2005 to 2016 for all cholecystectomies, ventral hernia repairs, and partial colectomies to examine common emergency and elective general surgery operations. Thirty-day outcomes were compared by emergent status. Any SSI was the primary outcome. There were 863,164 surgeries: 416,497 cholecystectomies, 220,815 ventral hernia repairs, and 225,852 partial colectomies. SSIs developed in 38,865 (4.5%) patients. SSIs increased with emergencies (5.3% vs 3.6% for any SSI). Postoperative sepsis (5.8% vs 1.5%), septic shock (4.7% vs 0.6%), length of stay (8.1 vs 2.9 days), and mortality (3.6% vs 0.4%) were increased in emergent surgery; P < 0.001 for all. When controlling for age, gender, BMI, diabetes, smoking, wound classification, comorbidities, functional status, and procedure on multivariate analysis, emergency surgery (odds ratio 1.15, 95% confidence interval 1.11-1.19) was independently associated with the development of SSI. Patients undergoing emergency general surgery experience increased rates of SSI. Patients and their families should be appropriately counseled regarding these elevated risks when consenting for emergency surgery.

“Death Knell” for Prophylactic Vena Cava Filters? A 20-Year Experience with a Venous Thromboembolism Guideline

The role of prophylactic vena cava filters (pVCFs) in trauma patients remains controversial. After 20 years of data collection and experience, we reviewed our venous thromboembolism guideline for the efficacy of pVCFs in preventing pulmonary embolism (PE). A retrospective cohort study was performed using our Level I trauma center registry from January 1997 thru December 2016. This population was then divided by the presence of pVCFs. Univariate analysis was performed comparing the incidence of PEs, deep vein thrombosis, and mortality between those with and without a pVCF. There were 35,658 patients identified, of whom 2 per cent (n = 847) received pVCFs. The PE rate was 0.4 per cent in both groups. The deep vein thrombosis rate for pVCFs was 3.9 per cent compared with 0.6 per cent in the no-VCF group ( P < 0.0001). Given that there was no difference in the rates of PEs between the cohorts, the subset of patients with a PE were analyzed by their risk factors. Only ventilator days > 3 were associated with a higher risk in the no-pVCF group (0.2 vs 1.5%, P = 0.033). pVCFs did not confer benefit reducing PE rate. In addition, despite their intended purpose, pVCFs cannot eliminate PEs in high-risk trauma patients, suggesting a lack of utility for prophylaxis in this population.

"Death Knell" for Prophylactic Vena Cava Filters? A 20-Year Experience with a Venous Thromboembolism Guideline

The role of prophylactic vena cava filters (pVCFs) in trauma patients remains controversial. After 20 years of data collection and experience, we reviewed our venous thromboembolism guideline for the efficacy of pVCFs in preventing pulmonary embolism (PE). A retrospective cohort study was performed using our Level I trauma center registry from January 1997 thru December 2016. This population was then divided by the presence of pVCFs. Univariate analysis was performed comparing the incidence of PEs, deep vein thrombosis, and mortality between those with and without a pVCF. There were 35,658 patients identified, of whom 2 per cent (n = 847) received pVCFs. The PE rate was 0.4 per cent in both groups. The deep vein thrombosis rate for pVCFs was 3.9 per cent compared with 0.6 per cent in the no-VCF group (P < 0.0001). Given that there was no difference in the rates of PEs between the cohorts, the subset of patients with a PE were analyzed by their risk factors. Only ventilator days > 3 were associated with a higher risk in the no-pVCF group (0.2 vs 1.5%, P = 0.033). pVCFs did not confer benefit reducing PE rate. In addition, despite their intended purpose, pVCFs cannot eliminate PEs in high-risk trauma patients, suggesting a lack of utility for prophylaxis in this population.

Mitigating clinical waste in the trauma intensive care unit: Limited clinical utility of cardiac troponin testing for trauma patients with atrial fibrillation

BACKGROUND

The clinical significance of obtaining cardiac troponin (cTn) levels among trauma patients with new onset arrhythmias is unknown. We aimed to assess whether cTn levels actually influence clinical decision making or represent an inappropriate use of resources.

METHODS

Trauma patients admitted from 2013 to 2014 diagnosed with atrial fibrillation (AF) were retrospectively reviewed using the institutional trauma database. Demographics, cTn levels, and myocardial infarction (MI) diagnosis data were recorded. Standard univariate tests were used to compare data between patients with and without cTn.

RESULTS

There were 258 patients included of which 126 patients had cTn levels obtained (48.8%, TEST group). The remaining 132 patients (51.2%) were untested (noTEST group). Among TEST patients, use of echocardiography nearly doubled and cardiology consultations increased (all p < 0.05). No TEST patients suffered MI or PE.

CONCLUSIONS

Obtaining cTn values in trauma patients with new-onset AF resulted in increased resource utilization without clinical utility.

Defining Dogma: Quantifying Crystalloid Hemodilution in a Prospective Randomized Control Trial with Blood Donation as a Model for Hemorrhage

BACKGROUND

The concept of hemodilution after blood loss and crystalloid infusion is a surgical maxim that remains unproven in humans. We sought to quantify the effect of hemodilution after crystalloid administration in voluntary blood donors as a model for acute hemorrhage.

STUDY DESIGN

A prospective, randomized control trial was conducted in conjunction with community blood drives. Donors were randomized to receive no IV fluid (noIVF), 2 liters of normal saline (NS), or 2 liters lactated Ringer's (LR) after blood donation. Blood samples were taken before donation of 500 mL of blood, immediately after donation, and after IV fluid administration. Hemoglobin (Hgb) was measured at each time point. Hemoglobin measurements between time points were compared between groups using standard statistical tests and the Bonferroni correction for multiple comparisons. Statistical significance was set at p ≤ 0.0167.

RESULTS

Of 165 patients consented, 157 patients completed the study. Average pre-donation Hgb was 14.3 g/dL. There was no difference in the mean Hgb levels after blood donation between the 3 groups (p > 0.05). Compared with the control group, there was a significant drop in Hgb in the crystalloid infused groups from the post-donation level to post-resuscitation (13.2 vs 12.1 vs 12.2 g/dL, p < 0.0001). A formula was created to predict hemoglobin levels from a given estimated blood loss (EBL) and volume replacement (VR): Hemodilution Hgb = (mean pre-donation Hgb - hemorrhage Hgb drop - equilibration hemoglobin drop - resuscitation Hgb drop) = Mean pre-donation Hgb - [(EBL/TBV)*l] - [(EBL/TBV)*h] - [(VR/TBV)*r], l = 5.111g/dL = blood loss coefficient, h = 6.722 g/dL = equilibration coefficient, r = 2.617g/dL = resuscitation coefficient.

CONCLUSIONS

This study proves the concept of hemodilution and derived a mathematical relationship between blood loss and resuscitation. These data may help to estimate response of hemoglobin levels to blood loss and fluid resuscitation in clinical practice.

Effect of Systemic Triphenylphosphonium on Organ Function and Oxidative Stress

Conditions of systemic stress can lead to increased reactive oxygen species production, mitochondrial dysfunction, systemic inflammation, and multiorgan dysfunction. Triphenylphosphonium (TPP1) is a lipophilic cation used to target therapeutics to mitochondria. We sought to determine the effects of TPP1 on mitochondrial integrity. Male rats were anesthetized and TPP1 (5 mg/kg) or vehicle (saline) was administered intravenously 30-minutes after anesthesia initiation and intraperitoneally (20 mg/kg) 60-minutes later. Rats were exsanguinated 2-hours postinjection. Cardiac, pulmonary, hepatic, splenic, and renal tissues were analyzed for inflammation, lipid peroxidation, endogenous antioxidant activity, cytokine expression, and mitochondrial function. In vitro modeling was performed using freshly isolated hepatocytes subjected to 8-hours hypoxia/30-minutes reoxygenation in the absence or presence of TPP1. TPP1 increased lipid peroxidation in the liver, lung, and kidney as well as antioxidant activity in the liver, kidney, and spleen. Conversely, antioxidant activity decreased in the lung with TPP1. In addition, TPP1 altered hepatic inflammatory mediators. In vitro, TPP1 attenuated oxygen consumption and, when combined with hypoxic injury, depolarized mitochondrial membranes in hepatocytes. TPP1 induces systemic responses associated with oxidative stress and worsening pathologies in animals. Caution should be exercised when employing TPP1 for therapeutics.

Effect of Systemic Triphenylphosphonium on Organ Function and Oxidative Stress

Conditions of systemic stress can lead to increased reactive oxygen species production, mitochondrial dysfunction, systemic inflammation, and multiorgan dysfunction. Triphenylphosphonium (TPP+) is a lipophilic cation used to target therapeutics to mitochondria. We sought to determine the effects of TPP+ on mitochondrial integrity. Male rats were anesthetized and TPP+ (5 mg/kg) or vehicle (saline) was administered intravenously 30-minutes after anesthesia initiation and intraperitoneally (20 mg/kg) 60-minutes later. Rats were exsanguinated 2-hours postinjection. Cardiac, pulmonary, hepatic, splenic, and renal tissues were analyzed for inflammation, lipid peroxidation, endogenous antioxidant activity, cytokine expression, and mitochondrial function. In vitro modeling was performed using freshly isolated hepatocytes subjected to 8-hours hypoxia/30-minutes reoxygenation in the absence or presence of TPP+. TPP+ increased lipid peroxidation in the liver, lung, and kidney as well as antioxidant activity in the liver, kidney, and spleen. Conversely, antioxidant activity decreased in the lung with TPP+. In addition, TPP+ altered hepatic inflammatory mediators. In vitro, TPP+ attenuated oxygen consumption and, when combined with hypoxic injury, depolarized mitochondrial membranes in hepatocytes. TPP+ induces systemic responses associated with oxidative stress and worsening pathologies in animals. Caution should be exercised when employing TPP+ for therapeutics.

Returning from the acidotic abyss: Mortality in trauma patients with a pH < 7.0

INTRODUCTION

We hypothesized that a pH of <7.0 on presentation would correlate with almost universal mortality in trauma patients.

METHODS

A retrospective cohort study was performed on a Level I trauma center registry from 2013 to 2014. Hospital mortality was the primary outcome, which was compared by pH cohort (<7.0 or ≥7.0) using standard univariate statistics and multivariate logistic regression.

RESULTS

There were 593 patients included in the analysis: 66 in <7.0, 527 in ≥7.0. Mortality was 3× higher in the <7.0 pH cohort (62.1 vs. 20.3%; p < 0.0001), however there was no threshold for a pH below which there was 100% mortality. After controlling for these confounding variables, initial pH was found to be an independent predictor of inpatient mortality: pH < 7.0 (OR 6.33, 3.29-12.19; p < 0.0001).

CONCLUSION

This data indicates that while patients with severe acidosis are at increased risk for mortality, a pH < 7.0 is still recoverable in select cases.

Improvement of Treatment Outcomes after Implementation of a Massive Transfusion Protocol: A Level I Trauma Center Experience

We assessed the effectiveness of the implementation of an institutional massive transfusion protocol (MTP) for resuscitation with a 1:1:1 transfusion ratio of packed red blood cell (PRBC), fresh frozen plasma, and platelet units. In a Level I trauma center database, all trauma admissions (2004–2012) that received massive transfusions (≥10 units PRBCs in the first 24 hours) were reviewed retrospectively. Demographic data, transfusion ratios, and outcomes were compared before (PRE) and after (POST) MTP implementation in May 2008. Age, sex, and mechanism of injury were similar between 239 PRE and 208 POST trauma patients requiring massive transfusion. Transfusion ratios of fresh frozen plasma:PRBC and platelet:PRBC increased after MTP implementation. Among survivors, MTP implementation shortened hospital length of stay from 31 to 26 days (P = 0.04) and intensive care unit length of stay from 31 to 26 days (P = 0.02). Linear regression identified treatment after (versus before) implementation of MTP as an independent predictor of decreased ventilator days after adjusting for age, Glasgow Coma Scale, and chest Abbreviated Injury Score (P < 0.0001). Modest improvement in ratios likely does not account for all significant improvements in outcomes. Implementing a standardized protocol likely impacts automation, efficiency, and/or timeliness of product delivery.

Improvement of Treatment Outcomes after Implementation of a Massive Transfusion Protocol: A Level I Trauma Center Experience

We assessed the effectiveness of the implementation of an institutional massive transfusion protocol (MTP) for resuscitation with a 1:1:1 transfusion ratio of packed red blood cell (PRBC), fresh frozen plasma, and platelet units. In a Level I trauma center database, all trauma admissions (2004-2012) that received massive transfusions (≥10 units PRBCs in the first 24 hours) were reviewed retrospectively. Demographic data, transfusion ratios, and outcomes were compared before (PRE) and after (POST) MTP implementation in May 2008. Age, sex, and mechanism of injury were similar between 239 PRE and 208 POST trauma patients requiring massive transfusion. Transfusion ratios of fresh frozen plasma:PRBC and platelet:PRBC increased after MTP implementation. Among survivors, MTP implementation shortened hospital length of stay from 31 to 26 days (P = 0.04) and intensive care unit length of stay from 31 to 26 days (P = 0.02). Linear regression identified treatment after (versus before) implementation of MTP as an independent predictor of decreased ventilator days after adjusting for age, Glasgow Coma Scale, and chest Abbreviated Injury Score (P < 0.0001). Modest improvement in ratios likely does not account for all significant improvements in outcomes. Implementing a standardized protocol likely impacts automation, efficiency, and/or timeliness of product delivery.

Hospital-based violence intervention programs targeting adult populations: an Eastern Association for the Surgery of Trauma evidence-based review

Background

Violent injury and reinjury take a devastating toll on distressed communities. Many trauma centers have created hospital-based violent injury prevention programs (HVIP) to address psychosocial, educational, and mental health needs of injured patients that may contribute to reinjury.

Objectives

To evaluate the overall effectiveness of HVIPs for violent injury prevention. We performed an evidence-based review to answer the following population, intervention, comparator, outcomes (PICO) question: Are HVIPs attending to adult patients (age 18+) treated for intentional injury more effective than the usual care at preventing: intentional violent reinjury and/or death; arrest and/or incarceration; substance abuse and/or mental issues; job and/or school attainment?

Data sources

PubMed, Web of Science, Google Scholar, and the Cochrane Library were queried for salient articles by a professional librarian on two separate occasions, and related articles were identified from references.

Study eligibility criteria, participants, interventions

Eligible studies examined adult patients treated for intentional injury in a hospital-based violence prevention program compared to a control group.

Study appraisal and synthesis methods

We used the Grading of Recommendations Assessment, Development, and Evaluation methodology to assess the breadth and quality of the evidence.

Results

71 articles were identified. After discarding duplicates, reviews, and those articles that did not address our PICO questions, we ultimately reviewed 10 articles. We found insufficient evidence to recommend adult-focused HVIP interventions.

Limitations

There was a relative paucity of data, and available studies were limited by self-selection bias and small sample sizes.

Conclusions

We make no recommendation with respect to adult-focused HVIP interventions.