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Cardenas TC, Trust MD, Davis KA, Joseph BA, Jurkovich GJ, Brown CV. Effects of gender on work-life balance satisfaction among trauma surgeons: A survey study. Am J Surg 2024; 227:44-47. [PMID: 37718169 DOI: 10.1016/j.amjsurg.2023.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/31/2023] [Accepted: 09/07/2023] [Indexed: 09/19/2023]
Abstract
BACKGROUND Physician burnout rates are rising. Because dissatisfaction with work-life balance (WLB) is associated with burnout, improving this balance is a key solution. This cross-sectional survey study aims to evaluate factors associated with WLB in trauma surgeons, stratified by gender. METHODS This is a secondary analysis, studying gender, of a AAST survey evaluating predictors of WLB in trauma surgeons. Survey topics include demographics, clinical practice, family, lifestyle, and emotional support. Subgroups were analyzed independently; primary outcome was WLB satisfaction. RESULTS 292 AAST members completed the survey. Responses were stratified by gender (29% females, 71% males). Independent predictors of WLB satisfaction are: Females: more awake hours at home, having a job well-suited for them, better about meeting deadlines. Males: comfortable declining new tasks, fair compensation, healthy diet, workplace emotional support. CONCLUSION Factors associated with WLB satisfaction in trauma surgeons are different based on gender. This information may help trauma surgeons mitigate burnout.
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Affiliation(s)
- Tatiana Cp Cardenas
- Department of Surgery and Perioperative Care, Dell Medical School University of Texas at Austin, Austin, TX, USA.
| | - Marc D Trust
- Department of Surgery and Perioperative Care, Dell Medical School University of Texas at Austin, Austin, TX, USA.
| | - Kimberly A Davis
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA.
| | - Bellal A Joseph
- Department of Surgery, University of Arizona, Tucson, AZ, USA.
| | - Gregory J Jurkovich
- Department of Surgery, University of California Davis Health, Sacramento, CA, USA.
| | - Carlos Vr Brown
- Department of Surgery and Perioperative Care, Dell Medical School University of Texas at Austin, Austin, TX, USA.
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Albert RK, Jurkovich GJ, Connett J, Helgeson ES, Keniston A, Voelker H, Lindberg S, Proper JL, Bochicchio G, Stein DM, Cain C, Tesoriero R, Brown CVR, Davis J, Napolitano L, Carver T, Cipolle M, Cardenas L, Minei J, Nirula R, Doucet J, Miller PR, Johnson J, Inaba K, Kao L. Sigh Ventilation in Patients With Trauma: The SiVent Randomized Clinical Trial. JAMA 2023; 330:1982-1990. [PMID: 37877609 PMCID: PMC10600720 DOI: 10.1001/jama.2023.21739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 10/15/2023] [Indexed: 10/26/2023]
Abstract
Importance Among patients receiving mechanical ventilation, tidal volumes with each breath are often constant or similar. This may lead to ventilator-induced lung injury by altering or depleting surfactant. The role of sigh breaths in reducing ventilator-induced lung injury among trauma patients at risk of poor outcomes is unknown. Objective To determine whether adding sigh breaths improves clinical outcomes. Design, Setting, and Participants A pragmatic, randomized trial of sigh breaths plus usual care conducted from 2016 to 2022 with 28-day follow-up in 15 academic trauma centers in the US. Inclusion criteria were age older than 18 years, mechanical ventilation because of trauma for less than 24 hours, 1 or more of 5 risk factors for developing acute respiratory distress syndrome, expected duration of ventilation longer than 24 hours, and predicted survival longer than 48 hours. Interventions Sigh volumes producing plateau pressures of 35 cm H2O (or 40 cm H2O for inpatients with body mass indexes >35) delivered once every 6 minutes. Usual care was defined as the patient's physician(s) treating the patient as they wished. Main Outcomes and Measures The primary outcome was ventilator-free days. Prespecified secondary outcomes included all-cause 28-day mortality. Results Of 5753 patients screened, 524 were enrolled (mean [SD] age, 43.9 [19.2] years; 394 [75.2%] were male). The median ventilator-free days was 18.4 (IQR, 7.0-25.2) in patients randomized to sighs and 16.1 (IQR, 1.1-24.4) in those receiving usual care alone (P = .08). The unadjusted mean difference in ventilator-free days between groups was 1.9 days (95% CI, 0.1 to 3.6) and the prespecified adjusted mean difference was 1.4 days (95% CI, -0.2 to 3.0). For the prespecified secondary outcome, patients randomized to sighs had 28-day mortality of 11.6% (30/259) vs 17.6% (46/261) in those receiving usual care (P = .05). No differences were observed in nonfatal adverse events comparing patients with sighs (80/259 [30.9%]) vs those without (80/261 [30.7%]). Conclusions and Relevance In a pragmatic, randomized trial among trauma patients receiving mechanical ventilation with risk factors for developing acute respiratory distress syndrome, the addition of sigh breaths did not significantly increase ventilator-free days. Prespecified secondary outcome data suggest that sighs are well-tolerated and may improve clinical outcomes. Trial Registration ClinicalTrials.gov Identifier: NCT02582957.
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Affiliation(s)
| | | | - John Connett
- Division of Biostatistics, University of Minnesota, Minneapolis
| | | | | | - Helen Voelker
- Division of Biostatistics, University of Minnesota, Minneapolis
| | - Sarah Lindberg
- Division of Biostatistics, University of Minnesota, Minneapolis
| | | | - Grant Bochicchio
- Department of Surgery, Washington University, St Louis, St Louis, Missouri
| | | | - Christian Cain
- Department of Surgery, University of Maryland, Baltimore
| | - Ron Tesoriero
- Department of Surgery, University of Maryland, Baltimore
| | | | - James Davis
- Department of Surgery, University of California San Francisco, Fresno
| | | | - Thomas Carver
- Department of Surgery, Medical College of Wisconsin, Milwaukee
| | - Mark Cipolle
- Department of Surgery, Lehigh Valley Health Network, Bethlehem, Pennsylvania
| | - Luis Cardenas
- Department of Surgery, Christiana Care Health System, Wilmington, Delaware
| | - Joseph Minei
- Department of Surgery, University of Texas Southwestern, Dallas
| | | | - Jay Doucet
- Department of Surgery, University of California San Diego
| | - Preston R. Miller
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Jeffrey Johnson
- Department of Surgery, Henry Ford Hospital, Detroit, Michigan
| | - Kenji Inaba
- Department of Surgery, University of Southern California Los Angeles County
| | - Lillian Kao
- Department of Surgery, University of Texas, Houston
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Lupton JR, Davis-O'Reilly C, Jungbauer RM, Newgard CD, Fallat ME, Brown JB, Mann NC, Jurkovich GJ, Bulger E, Gestring ML, Lerner EB, Chou R, Totten AM. Under-Triage and Over-Triage Using the Field Triage Guidelines for Injured Patients: A Systematic Review. PREHOSP EMERG CARE 2023; 27:38-45. [PMID: 35191799 DOI: 10.1080/10903127.2022.2043963] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVES The Field Triage Guidelines (FTG) are used across North America to identify seriously injured patients for transport to appropriate level trauma centers, with a goal of under-triaging no more than 5% and over-triaging between 25% and 35%. Our objective was to systematically review the literature on under-triage and over-triage rates of the FTG. METHODS We conducted a systematic review of the FTG performance. Ovid Medline, EMBASE, and the Cochrane databases were searched for studies published between January 2011 and February 2021. Two investigators dual-reviewed eligibility of abstracts and full-text. We included studies evaluating under- or over-triage of patients using the FTG in the prehospital setting. We excluded studies not reporting an outcome of under- or over-triage, studies evaluating other triage tools, or studies of triage not in the prehospital setting. Two investigators independently assessed the risk of bias for each included article. The primary accuracy measures to assess the FTG were under-triage, defined as seriously injured patients transported to non-trauma hospitals (1-sensitivity), and over-triage, defined as non-injured patients transported to trauma hospitals (1-specificity). Due to heterogeneity, results were synthesized qualitatively. RESULTS We screened 2,418 abstracts, reviewed 315 full-text publications, and identified 17 studies that evaluated the accuracy of the FTG. Among eight studies evaluating the entire FTG (steps 1-4), under-triage rates ranged from 1.6% to 72.0% and were higher for older (≥55 or ≥65 years) adults (20.1-72.0%) and pediatric (<15 years) patients (15.9-34.8%) compared to all ages (1.6-33.8%). Over-triage rates ranged from 9.9% to 87.4% and were higher for all ages (12.2-87.4%) compared to older (≥55 or ≥65 years) adults (9.9-48.2%) and pediatric (<15 years) patients (28.0-33.6%). Under-triage was lower in studies strictly applying the FTG retrospectively (1.6-34.8%) compared to as-practiced (10.5-72.0%), while over-triage was higher retrospectively (64.2-87.4%) compared to as-practiced (9.9-48.2%). CONCLUSIONS Evidence suggests that under-triage, while improved if the FTG is strictly applied, remains above targets, with higher rates of under-triage in both children and older adults.
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Affiliation(s)
- Joshua R Lupton
- Department of Emergency Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Cynthia Davis-O'Reilly
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR, USA
| | - Rebecca M Jungbauer
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR, USA
| | - Craig D Newgard
- Department of Emergency Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Mary E Fallat
- Department of Surgery, University of Louisville School of Medicine, Louisville, KY, USA
| | - Joshua B Brown
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - N Clay Mann
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | | | - Eileen Bulger
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - Mark L Gestring
- Department of Surgery, University of Rochester, Rochester, NY, USA
| | - E Brooke Lerner
- Department of Emergency Medicine, University at Buffalo, Buffalo, NY, USA
| | - Roger Chou
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR, USA
| | - Annette M Totten
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR, USA
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Lupton JR, Davis‐O'Reilly C, Jungbauer RM, Newgard CD, Fallat ME, Brown JB, Mann NC, Jurkovich GJ, Bulger E, Gestring ML, Lerner EB, Chou R, Totten AM. Mechanism of injury and special considerations as predictive of serious injury: A systematic review. Acad Emerg Med 2022; 29:1106-1117. [PMID: 35319149 PMCID: PMC9545392 DOI: 10.1111/acem.14489] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 03/17/2022] [Accepted: 03/19/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVES The Centers for Disease Control and Prevention's field triage guidelines (FTG) are routinely used by emergency medical services personnel for triaging injured patients. The most recent (2011) FTG contains physiologic, anatomic, mechanism, and special consideration steps. Our objective was to systematically review the criteria in the mechanism and special consideration steps that might be predictive of serious injury or need for a trauma center. METHODS We conducted a systematic review of the predictive utility of mechanism and special consideration criteria for predicting serious injury. A research librarian searched in Ovid Medline, EMBASE, and the Cochrane databases for studies published between January 2011 and February 2021. Eligible studies were identified using a priori inclusion and exclusion criteria. Studies were excluded if they lacked an outcome for serious injury, such as measures of resource use, injury severity scores, mortality, or composite measures using a combination of outcomes. Given the heterogeneity in populations, measures, and outcomes, results were synthesized qualitatively focusing on positive likelihood ratios (LR+) whenever these could be calculated from presented data or adjusted odds ratios (aOR). RESULTS We reviewed 2418 abstracts and 315 full-text publications and identified 42 relevant studies. The factors most predictive of serious injury across multiple studies were death in the same vehicle (LR+ 2.2-7.4), ejection (aOR 3.2-266.2), extrication (LR+ 1.1-6.6), lack of seat belt use (aOR 4.4-11.3), high speeds (aOR 2.0-2.9), concerning crash variables identified by vehicle telemetry systems (LR+ 4.7-22.2), falls from height (LR+ 2.4-5.9), and axial load or diving (aOR 2.5-17.6). Minor or inconsistent predictors of serious injury were vehicle intrusion (LR+ 0.8-7.2), cardiopulmonary or neurologic comorbidities (LR+ 0.8-3.1), older age (LR+ 0.6-6.8), or anticoagulant use (LR+ 1.1-1.8). CONCLUSIONS Select mechanism and special consideration criteria contribute positively to appropriate field triage of potentially injured patients.
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Affiliation(s)
- Joshua R. Lupton
- Department of Emergency MedicineOregon Health & Science UniversityPortlandOregonUSA
| | - Cynthia Davis‐O'Reilly
- Pacific Northwest Evidence‐based Practice Center, Department of Medical Informatics and Clinical EpidemiologyOregon Health & Science UniversityPortlandOregonUSA
| | - Rebecca M. Jungbauer
- Pacific Northwest Evidence‐based Practice Center, Department of Medical Informatics and Clinical EpidemiologyOregon Health & Science UniversityPortlandOregonUSA
| | - Craig D. Newgard
- Department of Emergency MedicineOregon Health & Science UniversityPortlandOregonUSA
| | - Mary E. Fallat
- Department of SurgeryUniversity of Louisville School of MedicineLouisvilleKentuckyUSA
| | - Joshua B. Brown
- Department of SurgeryUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - N. Clay Mann
- Department of PediatricsUniversity of UtahSalt Lake CityUtahUSA
| | | | - Eileen Bulger
- Department of SurgeryUniversity of WashingtonSeattleWashingtonUSA
| | - Mark L. Gestring
- Department of SurgeryUniversity of RochesterRochesterNew YorkUSA
| | - E. Brooke Lerner
- Department of Emergency MedicineUniversity at BuffaloBuffaloNew YorkUSA
| | - Roger Chou
- Pacific Northwest Evidence‐based Practice Center, Department of Medical Informatics and Clinical EpidemiologyOregon Health & Science UniversityPortlandOregonUSA
| | - Annette M. Totten
- Pacific Northwest Evidence‐based Practice Center, Department of Medical Informatics and Clinical EpidemiologyOregon Health & Science UniversityPortlandOregonUSA
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Newgard CD, Fischer PE, Gestring M, Michaels HN, Jurkovich GJ, Lerner EB, Fallat ME, Delbridge TR, Brown JB, Bulger EM. National guideline for the field triage of injured patients: Recommendations of the National Expert Panel on Field Triage, 2021. J Trauma Acute Care Surg 2022; 93:e49-e60. [PMID: 35475939 PMCID: PMC9323557 DOI: 10.1097/ta.0000000000003627] [Citation(s) in RCA: 50] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 03/09/2022] [Accepted: 03/15/2022] [Indexed: 11/26/2022]
Abstract
This work details the process of developing the updated field triage guideline, the supporting evidence, and the final version of the 2021 National Guideline for the Field Triage of Injured Patients.
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Affiliation(s)
- Craig D. Newgard
- From the Department of Emergency Medicine (C.D.N., J.R.L.), Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland, Oregon; Department of Surgery (P.E.F.), University of Tennessee Health Science Center, Memphis, Tennessee; Department of Surgery (M.G.), University of Rochester, Rochester, New York; Committee on Trauma (H.N.M., M.N., M.D., J.D.), American College of Surgeons, Chicago, Illinois; Department of Surgery (G.J.J.), UC Davis Health, Sacramento, California; Department of Emergency Medicine (E.B.L.), University at Buffalo, Buffalo, New York; Department of Surgery (M.E.F.), University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky; Maryland Institute for Emergency Medical Services Systems (T.R.D.), Baltimore, Maryland; Division of Trauma and General Surgery, Department of Surgery (J.B.B.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington
| | - Peter E. Fischer
- From the Department of Emergency Medicine (C.D.N., J.R.L.), Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland, Oregon; Department of Surgery (P.E.F.), University of Tennessee Health Science Center, Memphis, Tennessee; Department of Surgery (M.G.), University of Rochester, Rochester, New York; Committee on Trauma (H.N.M., M.N., M.D., J.D.), American College of Surgeons, Chicago, Illinois; Department of Surgery (G.J.J.), UC Davis Health, Sacramento, California; Department of Emergency Medicine (E.B.L.), University at Buffalo, Buffalo, New York; Department of Surgery (M.E.F.), University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky; Maryland Institute for Emergency Medical Services Systems (T.R.D.), Baltimore, Maryland; Division of Trauma and General Surgery, Department of Surgery (J.B.B.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington
| | - Mark Gestring
- From the Department of Emergency Medicine (C.D.N., J.R.L.), Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland, Oregon; Department of Surgery (P.E.F.), University of Tennessee Health Science Center, Memphis, Tennessee; Department of Surgery (M.G.), University of Rochester, Rochester, New York; Committee on Trauma (H.N.M., M.N., M.D., J.D.), American College of Surgeons, Chicago, Illinois; Department of Surgery (G.J.J.), UC Davis Health, Sacramento, California; Department of Emergency Medicine (E.B.L.), University at Buffalo, Buffalo, New York; Department of Surgery (M.E.F.), University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky; Maryland Institute for Emergency Medical Services Systems (T.R.D.), Baltimore, Maryland; Division of Trauma and General Surgery, Department of Surgery (J.B.B.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington
| | - Holly N. Michaels
- From the Department of Emergency Medicine (C.D.N., J.R.L.), Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland, Oregon; Department of Surgery (P.E.F.), University of Tennessee Health Science Center, Memphis, Tennessee; Department of Surgery (M.G.), University of Rochester, Rochester, New York; Committee on Trauma (H.N.M., M.N., M.D., J.D.), American College of Surgeons, Chicago, Illinois; Department of Surgery (G.J.J.), UC Davis Health, Sacramento, California; Department of Emergency Medicine (E.B.L.), University at Buffalo, Buffalo, New York; Department of Surgery (M.E.F.), University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky; Maryland Institute for Emergency Medical Services Systems (T.R.D.), Baltimore, Maryland; Division of Trauma and General Surgery, Department of Surgery (J.B.B.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington
| | - Gregory J. Jurkovich
- From the Department of Emergency Medicine (C.D.N., J.R.L.), Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland, Oregon; Department of Surgery (P.E.F.), University of Tennessee Health Science Center, Memphis, Tennessee; Department of Surgery (M.G.), University of Rochester, Rochester, New York; Committee on Trauma (H.N.M., M.N., M.D., J.D.), American College of Surgeons, Chicago, Illinois; Department of Surgery (G.J.J.), UC Davis Health, Sacramento, California; Department of Emergency Medicine (E.B.L.), University at Buffalo, Buffalo, New York; Department of Surgery (M.E.F.), University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky; Maryland Institute for Emergency Medical Services Systems (T.R.D.), Baltimore, Maryland; Division of Trauma and General Surgery, Department of Surgery (J.B.B.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington
| | - E. Brooke Lerner
- From the Department of Emergency Medicine (C.D.N., J.R.L.), Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland, Oregon; Department of Surgery (P.E.F.), University of Tennessee Health Science Center, Memphis, Tennessee; Department of Surgery (M.G.), University of Rochester, Rochester, New York; Committee on Trauma (H.N.M., M.N., M.D., J.D.), American College of Surgeons, Chicago, Illinois; Department of Surgery (G.J.J.), UC Davis Health, Sacramento, California; Department of Emergency Medicine (E.B.L.), University at Buffalo, Buffalo, New York; Department of Surgery (M.E.F.), University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky; Maryland Institute for Emergency Medical Services Systems (T.R.D.), Baltimore, Maryland; Division of Trauma and General Surgery, Department of Surgery (J.B.B.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington
| | - Mary E. Fallat
- From the Department of Emergency Medicine (C.D.N., J.R.L.), Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland, Oregon; Department of Surgery (P.E.F.), University of Tennessee Health Science Center, Memphis, Tennessee; Department of Surgery (M.G.), University of Rochester, Rochester, New York; Committee on Trauma (H.N.M., M.N., M.D., J.D.), American College of Surgeons, Chicago, Illinois; Department of Surgery (G.J.J.), UC Davis Health, Sacramento, California; Department of Emergency Medicine (E.B.L.), University at Buffalo, Buffalo, New York; Department of Surgery (M.E.F.), University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky; Maryland Institute for Emergency Medical Services Systems (T.R.D.), Baltimore, Maryland; Division of Trauma and General Surgery, Department of Surgery (J.B.B.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington
| | - Theodore R. Delbridge
- From the Department of Emergency Medicine (C.D.N., J.R.L.), Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland, Oregon; Department of Surgery (P.E.F.), University of Tennessee Health Science Center, Memphis, Tennessee; Department of Surgery (M.G.), University of Rochester, Rochester, New York; Committee on Trauma (H.N.M., M.N., M.D., J.D.), American College of Surgeons, Chicago, Illinois; Department of Surgery (G.J.J.), UC Davis Health, Sacramento, California; Department of Emergency Medicine (E.B.L.), University at Buffalo, Buffalo, New York; Department of Surgery (M.E.F.), University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky; Maryland Institute for Emergency Medical Services Systems (T.R.D.), Baltimore, Maryland; Division of Trauma and General Surgery, Department of Surgery (J.B.B.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington
| | - Joshua B. Brown
- From the Department of Emergency Medicine (C.D.N., J.R.L.), Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland, Oregon; Department of Surgery (P.E.F.), University of Tennessee Health Science Center, Memphis, Tennessee; Department of Surgery (M.G.), University of Rochester, Rochester, New York; Committee on Trauma (H.N.M., M.N., M.D., J.D.), American College of Surgeons, Chicago, Illinois; Department of Surgery (G.J.J.), UC Davis Health, Sacramento, California; Department of Emergency Medicine (E.B.L.), University at Buffalo, Buffalo, New York; Department of Surgery (M.E.F.), University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky; Maryland Institute for Emergency Medical Services Systems (T.R.D.), Baltimore, Maryland; Division of Trauma and General Surgery, Department of Surgery (J.B.B.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington
| | - Eileen M. Bulger
- From the Department of Emergency Medicine (C.D.N., J.R.L.), Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland, Oregon; Department of Surgery (P.E.F.), University of Tennessee Health Science Center, Memphis, Tennessee; Department of Surgery (M.G.), University of Rochester, Rochester, New York; Committee on Trauma (H.N.M., M.N., M.D., J.D.), American College of Surgeons, Chicago, Illinois; Department of Surgery (G.J.J.), UC Davis Health, Sacramento, California; Department of Emergency Medicine (E.B.L.), University at Buffalo, Buffalo, New York; Department of Surgery (M.E.F.), University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky; Maryland Institute for Emergency Medical Services Systems (T.R.D.), Baltimore, Maryland; Division of Trauma and General Surgery, Department of Surgery (J.B.B.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington
| | - the Writing Group for the 2021 National Expert Panel on Field Triage
- From the Department of Emergency Medicine (C.D.N., J.R.L.), Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland, Oregon; Department of Surgery (P.E.F.), University of Tennessee Health Science Center, Memphis, Tennessee; Department of Surgery (M.G.), University of Rochester, Rochester, New York; Committee on Trauma (H.N.M., M.N., M.D., J.D.), American College of Surgeons, Chicago, Illinois; Department of Surgery (G.J.J.), UC Davis Health, Sacramento, California; Department of Emergency Medicine (E.B.L.), University at Buffalo, Buffalo, New York; Department of Surgery (M.E.F.), University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky; Maryland Institute for Emergency Medical Services Systems (T.R.D.), Baltimore, Maryland; Division of Trauma and General Surgery, Department of Surgery (J.B.B.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington
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McFadden NR, Gosdin MM, Jurkovich GJ, Utter GH. Patient and clinician perceptions of the trauma and acute care surgery hospitalization discharge transition of care: a qualitative study. Trauma Surg Acute Care Open 2022; 7:e000800. [PMID: 35128068 PMCID: PMC8772453 DOI: 10.1136/tsaco-2021-000800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 10/08/2021] [Indexed: 11/17/2022] Open
Abstract
Objectives Trauma and acute care surgery (TACS) patients face complex barriers associated with hospitalization discharge that hinder successful recovery. We sought to better understand the challenges in the discharge transition of care, which might suggest interventions that would optimize it. Methods We conducted a qualitative study of patient and clinician perceptions about the hospital discharge process at an urban level 1 trauma center. We performed semi-structured interviews that we recorded, transcribed, coded both deductively and inductively, and analyzed thematically. We enrolled patients and clinicians until we achieved data saturation. Results We interviewed 10 patients and 10 clinicians. Most patients (70%) were male, and the mean age was 57±16 years. Clinicians included attending surgeons, residents, nurse practitioners, nurses, and case managers. Three themes emerged. (1) Communication (patient-clinician and clinician-clinician): clinicians understood that the discharge process malfunctions when communication with patients is not clear. Many patients discussed confusion about their discharge plan. Clinicians lamented that poorly written discharge summaries are an inadequate means of communication between inpatient and outpatient clinicians. (2) Discharge teaching and written instructions: patients appreciated discharge teaching but found written discharge instructions to be overwhelming and unhelpful. Clinicians preferred spending more time teaching patients and understood that written instructions contain too much jargon. (3) Outpatient care coordination: patients and clinicians identified difficulties with coordinating ongoing outpatient care. Both identified the patient’s primary care physician and insurance coverage as important determinants of the outpatient experience. Conclusion TACS patients face numerous challenges at hospitalization discharge. Clinicians struggle to effectively help their patients with this stressful transition. Future interventions should focus on improving communication with patients, active communication with a patient’s primary care physician, repurposing, and standardizing the discharge summary to serve primarily as a means of care coordination, and assisting the patient with navigating the transition. Level of evidence III—descriptive, exploratory study.
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Affiliation(s)
- Nikia R McFadden
- Department of Surgery, Division of Trauma, Acute Care Surgery, and Surgical Critical Care, University of California Davis, Davis, California, USA
| | - Melissa M Gosdin
- Center for Healthcare Policy and Research, University of California Davis, Davis, California, USA
| | - Gregory J Jurkovich
- Department of Surgery, Division of Trauma, Acute Care Surgery, and Surgical Critical Care, University of California Davis, Davis, California, USA
- Department of Surgery Outcomes Research Group, University of California Davis, Davis, California, USA
| | - Garth H Utter
- Department of Surgery, Division of Trauma, Acute Care Surgery, and Surgical Critical Care, University of California Davis, Davis, California, USA
- Center for Healthcare Policy and Research, University of California Davis, Davis, California, USA
- Department of Surgery Outcomes Research Group, University of California Davis, Davis, California, USA
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Biffl WL, Ball CG, Moore EE, Lees J, Todd SR, Wydo S, Privette A, Weaver JL, Koenig SM, Meagher A, Dultz L, Udekwu PO, Harrell K, Chen AK, Callcut R, Kornblith L, Jurkovich GJ, Castelo M, Schaffer KB. Don't mess with the pancreas! A multicenter analysis of the management of low-grade pancreatic injuries. J Trauma Acute Care Surg 2021; 91:820-828. [PMID: 34039927 DOI: 10.1097/ta.0000000000003293] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Current guidelines recommend nonoperative management (NOM) of low-grade (American Association for the Surgery of Trauma-Organ Injury Scale Grade I-II) pancreatic injuries (LGPIs), and drainage rather than resection for those undergoing operative management, but they are based on low-quality evidence. The purpose of this study was to review the contemporary management and outcomes of LGPIs and identify risk factors for morbidity. METHODS Multicenter retrospective review of diagnosis, management, and outcomes of adult pancreatic injuries from 2010 to 2018. The primary outcome was pancreas-related complications (PRCs). Predictors of PRCs were analyzed using multivariate logistic regression. RESULTS Twenty-nine centers submitted data on 728 patients with LGPI (76% men; mean age, 38 years; 37% penetrating; 51% Grade I; median Injury Severity Score, 24). Among 24-hour survivors, definitive management was NOM in 31%, surgical drainage alone in 54%, resection in 10%, and pancreatic debridement or suturing in 5%. The incidence of PRCs was 21% overall and was 42% after resection, 26% after drainage, and 4% after NOM. On multivariate analysis, independent risk factors for PRC were other intra-abdominal injury (odds ratio [OR], 2.30; 95% confidence interval [95% CI], 1.16-15.28), low volume (OR, 2.88; 1.65, 5.06), and penetrating injury (OR, 3.42; 95% CI, 1.80-6.58). Resection was very close to significance (OR, 2.06; 95% CI, 0.97-4.34) (p = 0.0584). CONCLUSION The incidence of PRCs is significant after LGPIs. Patients who undergo pancreatic resection have PRC rates equivalent to patients resected for high-grade pancreatic injuries. Those who underwent surgical drainage had slightly lower PRC rate, but only 4% of those who underwent NOM had PRCs. In patients with LGPIs, resection should be avoided. The NOM strategy should be used whenever possible and studied prospectively, particularly in penetrating trauma. LEVEL OF EVIDENCE Therapeutic Study, level IV.
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Affiliation(s)
- Walter L Biffl
- From the Scripps Memorial Hospital (W.L.B., M.C., K.B.S.), La Jolla, La Jolla, CA; University of Calgary, Calgary (C.G.B.), Alberta, Canada; Ernest E. Moore Shock Trauma Center at Denver Health (E.E.M.), Denver, CO; University of Oklahoma (J.L.), Oklahoma City, OK; Grady Memorial Hospital (S.R.T.), Atlanta, GA; Cooper University Hospital (SW), Camden, NJ; Medical University of South Carolina (A.P.), Charleston, SC; University of California-San Diego (J.L.W.), San Diego, CA; Virginia Tech Carilion School of Medicine (S.M.K.), Carilion Clinic, Roanoke VA; Indiana University School of Medicine- Methodist (A.M.), Indianapolis, IN; Parkland- UT Southwestern Medical Center (L.D.), Dallas, TX; WakeMed Health (P.O.U.), Raleigh, NC; University of Tennessee College of Medicine (K.H.), Chattanooga, TN; UCSF Fresno (A.K.C.), Fresno, CA; and San Francisco General Hospital (R.C., L.K.), San Francisco, CA; University of California-Davis (G.J.J.), Sacramento, CA
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Anderson JE, Jurkovich GJ, Galante JM, Farmer DL. A Survey of the Surgical Morbidity and Mortality Conference in the United States and Canada: A Dying Tradition or the Key to Modern Quality Improvement? J Surg Educ 2021; 78:927-933. [PMID: 33139215 DOI: 10.1016/j.jsurg.2020.10.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 09/16/2020] [Accepted: 10/10/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE We seek to identify the current role and practices of the surgery morbidity and mortality (M&M) conference in academic surgery departments in the United States and Canada. DESIGN, SETTING, AND PARTICIPANTS All members of the Society of Surgical Chairs, a program of the American College of Surgeons, were e-mailed an IRB-approved 28-question electronic survey in fall 2017. Up to 3 reminders were sent. RESULTS Responses from 129/186 (69%) departments of surgery were received. Nearly all departments (96%) continue to have a departmental M&M conference. The M&M conference is typically weekly (93%), between 7 and 9 AM (80%), on weekdays during which there are no scheduled elective operations (84%). Attendance is mandatory for residents (98%), but required for faculty in only 49% of departments. Fewer than half of all departments (44%) have written guidelines as to which complications should be reported to M&M. Most conferences are prepared case presentations (89%), but may include unprepared discussions (17%), case-based educational presentations (30%), or a combination (28%). The most common classification category was by root case of the error (60%) and preventability (58%). Most departments keep electronic and/or physical M&M reports, while 21% maintain a relational database and 25% do not retain records. While almost all (96%) departments reported participating in at least one national quality improvement program, these are not often linked to the M&M process. CONCLUSIONS M&M is predominantly seen as an educational conference based on a few select cases. Departmental quality is monitored with hospital-driven or national quality improvement efforts. Integration of hospital-based quality metric programs with surgery M&M conference is uncommon and represents an opportunity for hospital-department collaboration.
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Affiliation(s)
- Jamie E Anderson
- Department of Surgery, University of California, Davis Medical Center, Sacramento, California
| | - Gregory J Jurkovich
- Department of Surgery, University of California, Davis Medical Center, Sacramento, California.
| | - Joseph M Galante
- Department of Surgery, University of California, Davis Medical Center, Sacramento, California
| | - Diana L Farmer
- Department of Surgery, University of California, Davis Medical Center, Sacramento, California
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Biffl WL, Zhao FZ, Morse B, McNutt M, Lees J, Byerly S, Weaver J, Callcut R, Ball CG, Nahmias J, West M, Jurkovich GJ, Todd SR, Bala M, Spalding C, Kornblith L, Castelo M, Schaffer KB, Moore EE. A multicenter trial of current trends in the diagnosis and management of high-grade pancreatic injuries. J Trauma Acute Care Surg 2021; 90:776-786. [PMID: 33797499 DOI: 10.1097/ta.0000000000003080] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Outcomes following pancreatic trauma have not improved significantly over the past two decades. A 2013 Western Trauma Association algorithm highlighted emerging data that might improve the diagnosis and management of high-grade pancreatic injuries (HGPIs; grades III-V). We hypothesized that the use of magnetic resonance cholangiopancreatography, pancreatic duct stenting, operative drainage versus resection, and nonoperative management of HGPIs increased over time. METHODS Multicenter retrospective review of diagnosis, management, and outcomes of adult pancreatic injuries from 2010 to 2018 was performed. Data were analyzed by grade and time period (PRE, 2010-2013; POST, 2014-2018) using various statistical tests where appropriate. RESULTS Thirty-two centers reported data on 515 HGPI patients. A total of 270 (53%) had penetrating trauma, and 58% went directly to the operating room without imaging. Eighty-nine (17%) died within 24 hours. Management and outcomes of 426 24-hour survivors were evaluated. Agreement between computed tomography and operating room grading was 38%. Magnetic resonance cholangiopancreatography use doubled in grade IV/V injuries over time but was still low.Overall HGPI treatment and outcomes did not change over time. Resection was performed in 78% of grade III injuries and remained stable over time, while resection of grade IV/V injuries trended downward (56% to 39%, p = 0.11). Pancreas-related complications (PRCs) occurred more frequently in grade IV/V injuries managed with drainage versus resection (61% vs. 32%, p = 0.0051), but there was no difference in PRCs for grade III injuries between resection and drainage.Pancreatectomy closure had no impact on PRCs. Pancreatic duct stenting increased over time in grade IV/V injuries, with 76% used to treat PRCs. CONCLUSION Intraoperative and computed tomography grading are different in the majority of HGPI cases. Resection is still used for most patients with grade III injuries; however, drainage may be a noninferior alternative. Drainage trended upward for grade IV/V injuries, but the higher rate of PRCs calls for caution in this practice. LEVEL OF EVIDENCE Retrospective diagnostic/therapeutic study, level III.
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Affiliation(s)
- Walter L Biffl
- From the Scripps Memorial Hospital La Jolla (WLB, FZZ, MC, KBS), La Jolla, CA; Maine Medical Center (BM), Portland, ME; Memorial Hermann Hospital (MM), Houston, TX; University of Oklahoma (JL), Oklahoma City, OK; Ryder Trauma Center (SB), Miami, FL; University of California-San Diego (JW), San Diego, CA; San Francisco General Hospital (RC, LK), San Francisco, CA; University of Calgary (CCGB), Calgary, Alberta, Canada; University of California-Irvine (JN), Irvine, CA; North Memorial Health Hospital (MW), Robbinsdale, MN; University of California-Davis (GJJ), Sacramento, CA; Grady Memorial Hospital (SRT), Atlanta, GA; Hadassah- Hebrew University Medical Center (MB), Jerusalem, Israel; Grant Medical Center (CS), Columbus, OH; Ernest E. Moore Shock Trauma Center at Denver Health (EEM), Denver, CO
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O'Toole RV, Stein DM, Frey KP, O'Hara NN, Scharfstein DO, Slobogean GP, Taylor TJ, Haac BE, Carlini AR, Manson TT, Sudini K, Mullins CD, Wegener ST, Firoozabadi R, Haut ER, Bosse MJ, Seymour RB, Holden MB, Gitajn IL, Goldhaber SZ, Eastman AL, Jurkovich GJ, Vallier HA, Gary JL, Kleweno CP, Cuschieri J, Marvel D, Castillo RC. PREVENTion of CLots in Orthopaedic Trauma (PREVENT CLOT): a randomised pragmatic trial protocol comparing aspirin versus low-molecular-weight heparin for blood clot prevention in orthopaedic trauma patients. BMJ Open 2021; 11:e041845. [PMID: 33762229 PMCID: PMC7993181 DOI: 10.1136/bmjopen-2020-041845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 01/27/2021] [Accepted: 02/25/2021] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Patients who sustain orthopaedic trauma are at an increased risk of venous thromboembolism (VTE), including fatal pulmonary embolism (PE). Current guidelines recommend low-molecular-weight heparin (LMWH) for VTE prophylaxis in orthopaedic trauma patients. However, emerging literature in total joint arthroplasty patients suggests the potential clinical benefits of VTE prophylaxis with aspirin. The primary aim of this trial is to compare aspirin with LMWH as a thromboprophylaxis in fracture patients. METHODS AND ANALYSIS PREVENT CLOT is a multicentre, randomised, pragmatic trial that aims to enrol 12 200 adult patients admitted to 1 of 21 participating centres with an operative extremity fracture, or any pelvis or acetabular fracture. The primary outcome is all-cause mortality. We will evaluate non-inferiority by testing whether the intention-to-treat difference in the probability of dying within 90 days of randomisation between aspirin and LMWH is less than our non-inferiority margin of 0.75%. Secondary efficacy outcomes include cause-specific mortality, non-fatal PE and deep vein thrombosis. Safety outcomes include bleeding complications, wound complications and deep surgical site infections. ETHICS AND DISSEMINATION The PREVENT CLOT trial has been approved by the ethics board at the coordinating centre (Johns Hopkins Bloomberg School of Public Health) and all participating sites. Recruitment began in April 2017 and will continue through 2021. As both study medications are currently in clinical use for VTE prophylaxis for orthopaedic trauma patients, the findings of this trial can be easily adopted into clinical practice. The results of this large, patient-centred pragmatic trial will help guide treatment choices to prevent VTE in fracture patients. TRIAL REGISTRATION NUMBER NCT02984384.
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Affiliation(s)
- Robert V O'Toole
- Department of Orthopaedics, University of Maryland Baltimore, Baltimore, Maryland, USA
| | - Deborah M Stein
- Department of Surgery, University of California in San Francisco, San Francisco, California, USA
| | - Katherine P Frey
- METRC Coordinating Center, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Nathan N O'Hara
- Department of Orthopaedics, University of Maryland Baltimore, Baltimore, Maryland, USA
| | - Daniel O Scharfstein
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah, USA
| | - Gerard P Slobogean
- Department of Orthopaedics, University of Maryland Baltimore, Baltimore, Maryland, USA
| | - Tara J Taylor
- METRC Coordinating Center, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Bryce E Haac
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Anthony R Carlini
- METRC Coordinating Center, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Theodore T Manson
- Department of Orthopaedics, University of Maryland Baltimore, Baltimore, Maryland, USA
| | - Kuladeep Sudini
- METRC Coordinating Center, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - C Daniel Mullins
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Stephen T Wegener
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Reza Firoozabadi
- Department of Orthopaedic Surgery and Sports Medicine, University of Washington - Harborview Medical Center, Seattle, Washington, USA
| | - Elliott R Haut
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Michael J Bosse
- Department of Orthopaedic Surgery, Atrium Health, Charlotte, North Carolina, USA
| | - Rachel B Seymour
- Department of Orthopaedic Surgery, Atrium Health, Charlotte, North Carolina, USA
| | - Martha B Holden
- Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Ida Leah Gitajn
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Samuel Z Goldhaber
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Alexander L Eastman
- Department of Surgery, University of Texas Southwestern Medical School, Dallas, Texas, USA
| | - Gregory J Jurkovich
- Department of Surgery, University of California Davis, Davis, California, USA
| | - Heather A Vallier
- Department of Orthopaedics, MetroHealth System, Cleveland, Ohio, USA
| | - Joshua L Gary
- Department of Orthopedic Surgery, University of Texas McGovern Medical School, Houston, Texas, USA
| | - Conor P Kleweno
- Department of Orthopaedic Surgery and Sports Medicine, University of Washington - Harborview Medical Center, Seattle, Washington, USA
| | - Joseph Cuschieri
- Department of Surgery, University of Washington - Harborview Medical Center, Seattle, Washington, USA
| | - Debra Marvel
- PREVENT CLOT Stakeholder Committee, Baltimore, Maryland, USA
| | - Renan C Castillo
- METRC Coordinating Center, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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Abstract
BACKGROUND Trauma is the leading cause of death in children, and most deaths occur within 24 hours of injury. A better understanding of the causes of death in the immediate period of hospital care is needed. METHODS Trauma admissions younger than 18 years from 2009 to 2019 at a Level I pediatric trauma center were reviewed for deaths (n = 7,145). Patients were stratified into ages 0-6, 7-12, and 13-17 years old. The primary outcome was cause of death, with early death defined as less than 24 hours after trauma center arrival. RESULTS There were 134 (2%) deaths with a median age of 7 years. The median time from arrival to death was 14.4 hours (interquartile range, 0.5-87.8 hours). Half (54%) occurred within 24 hours. However, most patients who survived initial resuscitation in the emergency department died longer than 24 hours after arrival (69%). Traumatic brain injury was the most common cause of death (66%), followed by anoxia (9.7%) and hemorrhage (8%). Deaths from hemorrhage were most often in patients sustaining gunshot wounds (73% vs. 11% of all other deaths, p < 0.0001), more likely to occur early (100% vs. 50% of all other deaths, p = 0.0009), and all died within 6 hours of arrival. Death from hemorrhage was more common in adolescents (21.4% of children aged 13-17 vs. 6.3% of children aged 0-6, and 0% of children aged 7-12 p = 0.03). The highest case fatality rates were seen in hangings (38.5%) and gunshot wounds (9.6%). CONCLUSION Half of pediatric trauma deaths occurred within 24 hours. Death from hemorrhage was rare, but all occurred within 6 hours of arrival. This is a critical time for interventions for bleeding control to prevent death from hemorrhage in children. Analysis of these deaths can focus efforts on the urgent need for development of new hemorrhage control adjuncts in children. LEVEL OF EVIDENCE Epidemiological study, level IV.
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Affiliation(s)
- Christina M. Theodorou
- University of California Davis Medical Center, 2335 Stockton Blvd Room 5107, Sacramento, CA, 95817, USA
| | - Laura A. Galganski
- University of California Davis Medical Center, 2335 Stockton Blvd Room 5107, Sacramento, CA, 95817, USA
| | - Gregory J. Jurkovich
- University of California Davis Medical Center, 2335 Stockton Blvd Room 5107, Sacramento, CA, 95817, USA
| | - Diana L. Farmer
- University of California Davis Medical Center, 2335 Stockton Blvd Room 5107, Sacramento, CA, 95817, USA
| | - Shinjiro Hirose
- University of California Davis Medical Center, 2335 Stockton Blvd Room 5107, Sacramento, CA, 95817, USA
| | - Jacob T. Stephenson
- University of California Davis Medical Center, 2335 Stockton Blvd Room 5107, Sacramento, CA, 95817, USA. Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD 20814
| | - A. Francois Trappey
- University of Texas Health Science Center at Houston, 6431 Fannin St Suite 5.258, Houston, TX, 77030, USA
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Affiliation(s)
- Gregory J Jurkovich
- Department of Surgery, University of California Davis Medical Center, Sacramento, CA.
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Inaba K, Jurkovich GJ. Police Transport for Penetrating Trauma-Lessons From Patients in Philadelphia. JAMA Netw Open 2021; 4:e2035122. [PMID: 33492370 DOI: 10.1001/jamanetworkopen.2020.35122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Kenji Inaba
- Department of Surgery, University of Southern California, LAC+USC Medical Center, Los Angeles
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Abstract
INTRODUCTION A balance between work and life outside of work can be difficult for practicing physicians to achieve, especially for trauma surgeons. Work-life balance (WLB) has been associated with burnout and career changes. The specific aim of this study was to investigate factors associated with WLB for trauma surgeons. We hypothesized that trauma surgeons are dissatisfied with their WLB, and there are modifiable factors that can be adjusted to improve and maintain WLB. METHODS Survey study of AAST members including detailed questions regarding demographics, clinical practice, family, lifestyle, and emotional support. Primary outcome was WLB, while the secondary outcome was surgeon burnout. RESULTS A total of 1,383 American Association for the Surgery of Trauma members received an email with the survey, and 291 (21%) completed the survey. There was a total of 125 members (43%) satisfied with their WLB, and 166 (57%) were not. Factors independently associated with satisfying WLB included hobbies (2.3 [1.1-4.7], p = 0.03), healthy diet (2.6 [1.2-4.4], p = 0.02), exercise (2.6 [1.3-5.1], p = 0.006), vacation weeks off (1.3 [1.0-1.6], p = 0.02), and fair compensation (2.6 [1.3-5.3], p = 0.008). Conversely, factors independently associated with a poor WLB included being midcareer (0.3 [0.2-0.7], p = 0.002), more work hours (0.4 [0.2-0.7], p = 0.006), fewer awake hours at home (0.2 [0.1-0.6], p = 0.002), and feeling that there is a better job (0.4 [0.2-0.9], p = 0.02]. Risk factors for burnout were the same as those for poor WLB. CONCLUSION Only 43% of trauma surgeons surveyed were satisfied with their WLB, and 61% reported burnout. Modifiable factors independently associated with a satisfying WLB were related to lifestyle and fair compensation. Factors independently associated with poor WLB and suffering burnout were being midcareer, increased hours at work, decreased awake hours at home, and feeling that there was a better job for yourself. Many factors associated with trauma surgeon WLB are modifiable. Trauma surgeons, as well as trauma leaders, should focus on these modifiable factors to optimize WLB and minimize burnout. LEVEL OF EVIDENCE Care management, Level III.
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Affiliation(s)
- Carlos V R Brown
- From the Department of Surgery, Division of Acute Care Surgery, Dell Medical School (C.V.R.B.), University of Texas at Austin, Austin, Texas; University of Arizona College of Medicine (B.A.J.), Tucson, Arizona; Yale School of Medicine (K.D.), New Haven, Connecticut; and University of California Davis (G.J.J.), Sacramento, California
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Abstract
IMPORTANCE The optimal level of care for older patients with rib fractures as an isolated injury is unknown. OBJECTIVES To characterize interhospital variability in intensive care unit (ICU) vs non-ICU admission of older patients with isolated rib fractures and to evaluate whether greater hospital-level use of ICU admission is associated with improved outcomes. DESIGN, SETTING, AND PARTICIPANTS This cohort study included trauma patients aged 65 years and older with isolated rib fractures who were admitted to US trauma centers participating in the National Trauma Data Bank between January 1, 2015, and December 31, 2016. Patients were excluded if they had other significant injuries, were intubated or had assisted respirations in the emergency department (ED), or had a Glasgow Coma Scale (GCS) score of less than 9 in the ED. Hospitals with fewer than 10 eligible patients were excluded. Data analysis was conducted from May 2019 through September 2020. EXPOSURES Admission to the ICU. MAIN OUTCOMES AND MEASURES Composite of unplanned intubation, pneumonia, or death during hospitalization. RESULTS Among 23 951 patients (11 066 [46.2%] women; mean [SD] age, 77.0 [7.2] years) at 573 hospitals, the median (interquartile range) proportion of ICU use was 16.7% (7.4%-32.0%), but this varied from a low of 0% to a high of 91.9%. The composite outcome occurred in 787 patients (3.3%), with unplanned intubation in 317 (1.3%), pneumonia in 180 (0.8%), and death in 451 (1.9%). Accounting for the hierarchical nature of the data and adjusting for propensity scores reflecting factors associated with ICU admission, receiving care at a hospital with the greatest ICU use (quartile 4), compared with a hospital with the lowest ICU use, was associated with decreased likelihood of the composite outcome (adjusted odds ratio, 0.71; 95% CI, 0.55-0.92). CONCLUSIONS AND RELEVANCE In this study, admission location of older patients with isolated rib fractures was variable across hospitals, but hospitalization at a center with greater ICU use was associated with improved outcomes. It may be warranted for hospitals with low ICU use to admit more such patients to an ICU.
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Affiliation(s)
| | - Miriam Nuño
- Department of Surgery, University of California, Davis
- Department of Public Health Sciences, University of California, Davis
- Department of Surgery Outcomes Research Group, University of California, Davis
| | - Gregory J. Jurkovich
- Department of Surgery, University of California, Davis
- Department of Surgery Outcomes Research Group, University of California, Davis
| | - Garth H. Utter
- Department of Surgery Outcomes Research Group, University of California, Davis
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of California, Davis
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Price MA, A Kozar R, Bulger EM, Jurkovich GJ. Building the future for national trauma research. Trauma Surg Acute Care Open 2020; 5:e000421. [PMID: 32154380 PMCID: PMC7046959 DOI: 10.1136/tsaco-2019-000421] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 12/05/2019] [Indexed: 11/04/2022] Open
Abstract
This paper describes the current funding, infrastructure growth and future state of trauma research. It also introduces a group of review articles generated from The Future of Trauma Research: Innovations in Research Methodology conference hosted by the American College of Surgeons Committee on Trauma in July 2019.
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Affiliation(s)
- Michelle A Price
- National Trauma Insitute, San Antonio, Texas, USA.,Department of Surgery, UT Health - San Antonio, San Antonio, TX, United States
| | | | - Eileen M Bulger
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Gregory J Jurkovich
- Department of Surgery, University of California Davis School of Medicine, Sacramento, California, USA
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Bowman JA, Jurkovich GJ, Nishijima DK, Utter GH. Older Adults With Isolated Rib Fractures Do Not Require Routine Intensive Care Unit Admission. J Surg Res 2019; 245:492-499. [PMID: 31446191 DOI: 10.1016/j.jss.2019.07.098] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 06/25/2019] [Accepted: 07/24/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Older adults with isolated rib fractures are often admitted to an intensive care unit (ICU) because of presumedly increased morbidity and mortality. However, evidence-based guidelines are limited. We sought to identify characteristics of these patients that predict the need for ICU care. MATERIALS AND METHODS We analyzed patients ≥50 y old at our center during 2013-2017 whose only indication for ICU admission, if any, was isolated rib fractures. The primary outcome was any critical care intervention (e.g., intubation) or adverse event (e.g., hypoxemia) (CCIE) based on accepted critical care guidelines. We used stepwise logistic regression to identify characteristics that predict CCIEs. RESULTS Among 401 patients, 251 (63%) were admitted to an ICU. Eighty-three patients (33%) admitted to an ICU and 7 (5%) admitted to the ward experienced a CCIE. The most common CCIEs were hypotension (10%), frequent respiratory therapy (9%), and oxygen desaturation (8%). Predictors of CCIEs included incentive spirometry <1 L (OR 4.72, 95% CI 2.14-10.45); use of a walker (OR 2.86, 95% CI 1.29-6.34); increased chest Abbreviated Injury Scale score (AIS 3 OR 5.83, 95% CI 2.34-14.50); age ≥72 y (OR 2.68, 95% CI 1.48-4.86); and active smoking (OR 2.11, 95% CI 1.06-4.20). CONCLUSIONS Routine ICU admission is not necessary for most older adults with isolated rib fractures. The predictors we identified warrant prospective evaluation for development of a clinical decision rule to preclude unnecessary ICU admissions.
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Affiliation(s)
- Jessica A Bowman
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of California, Davis
| | - Gregory J Jurkovich
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of California, Davis; Department of Surgery Outcomes Research Group, University of California, Davis
| | | | - Garth H Utter
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of California, Davis; Department of Surgery Outcomes Research Group, University of California, Davis.
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Lombardo S, Millar D, Jurkovich GJ, Coimbra R, Nirula R. Factor VIIa administration in traumatic brain injury: an AAST-MITC propensity score analysis. Trauma Surg Acute Care Open 2018; 3:e000134. [PMID: 29766126 PMCID: PMC5887758 DOI: 10.1136/tsaco-2017-000134] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Revised: 01/09/2018] [Accepted: 01/10/2018] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Recombinant factor VIIa (rFVIIa) has been used off-label as an adjunct in the reversal of warfarin therapy and management of hemorrhage after trauma. Only a handful of these reports are rigorous studies, from which results regarding safety and effectiveness have been mixed. There remains no clear consensus as to the role of rFVIIa in traumatic brain injury (TBI). METHODS Eleven level 1 trauma centers provided clinical data and head CT scans of patients with a Glasgow Coma Scale (GCS) score of ≤13 and radiographic evidence of TBI. A propensity score (PS) to receive rFVIIa in those surviving ≥2 days was calculated for each patient based on patient demographics, comorbidities, physiology, Injury Severity Score, admission GCS score, and treatment center. Patients receiving rFVIIa within 24 hours of admission were matched to patients who did not receive rFVIIa for outcomes assessment. Subgroup analysis evaluated patients with primary head injury with PS matching. RESULTS There were 4284 patient observations; 129 received rFVIIa. Groups were comparable after matching. No differences in mortality or morbidity were found. Improvement in GCS score from admission to discharge was less among those receiving rFVIIa (5.5 vs. 2.4; P value 0.001); however, there was no difference in average GCS score at discharge. No significant differences in outcomes were identified in patients with isolated TBI receiving rFVIIa. DISCUSSION rFVIIa in early management of TBI is not associated with a decreased risk of mortality or morbidity, and may negatively impact recovery and functional status at discharge in the severely injured patient with polytrauma. LEVEL OF EVIDENCE Level III. STUDY TYPE Therapeutic/care management.
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Affiliation(s)
- Sarah Lombardo
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - D Millar
- Division of Trauma, Critical Care and Acute Care Surgery, Department of General Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Gregory J Jurkovich
- Division of Trauma, Acute Care Surgery and Surgical Critical Care, Department of Surgery, University of California Davis School of Medicine, Sacramento, California, USA
| | - Raul Coimbra
- Division of Trauma, Surgical Critical Care and Burns, Department of Surgery, University of San Diego, San Diego, California, USA
| | - Ram Nirula
- Acute Care Surgery Section, Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
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Raper SE, Hoffman RL, Jurkovich GJ, Kelz RR. Overcoming adversity-a critical step toward career satisfaction and leadership in academic surgery. J Surg Res 2018; 224:ix-xviii. [PMID: 29472003 DOI: 10.1016/j.jss.2018.01.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 01/22/2018] [Accepted: 01/23/2018] [Indexed: 11/30/2022]
Abstract
The experiences of life are what shape us. This article relays stories of adversity and resiliency as experienced and told by members of our own surgical community at the Academic Surgical Congress in Las Vegas, NV in February 2017. We aim to express in words the lessons of each experience so that others can learn about life and leadership.
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Affiliation(s)
- Steven E Raper
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rebecca L Hoffman
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
| | | | - Rachel R Kelz
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Jurkovich GJ, Davis KA, Becher RD, Burlew CC, de Moya M, Dente CJ, Galante JM, Goodwin II JS, Joseph B, Pandit V. In brief. Curr Probl Surg 2017. [DOI: 10.1067/j.cpsurg.2017.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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21
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Jurkovich GJ, Davis KA, Burlew CC, Dente CJ, Galante JM, Goodwin JS, Joseph B, de Moya M, Becher RD, Pandit V. Acute care surgery: An evolving paradigm. Curr Probl Surg 2017; 54:364-395. [PMID: 28756821 DOI: 10.1067/j.cpsurg.2017.05.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
| | - Kimberly A Davis
- Department of Surgery, Yale School of Medicine, New Haven, CT; Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Clay Cothren Burlew
- Department of Surgery, Denver Health Medical Center, University of Colorado, Denver, CO
| | - Christopher J Dente
- Department of Surgery, Emory University at Grady Memorial Hospital, Atlanta, GA
| | | | | | - Bellal Joseph
- Department of Surgery, University of Arizona, Tucson, AZ
| | - Marc de Moya
- Chief of the Division of Trauma, Critical Care, and Acute Care Surgery, Medical College of Wisconsin, Milwaukee
| | - Robert D Becher
- Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Viraj Pandit
- Department of Surgery, The University of Arizona, Tucson, AZ
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22
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Kelly CM, Van Eaton EG, Russo JE, Kelly VC, Jurkovich GJ, Darnell DA, Whiteside LK, Wang J, Parker LE, Payne TH, Mooney SD, Bush N, Zatzick DF. Technology Use, Preferences, and Capacity in Injured Patients at Risk for Posttraumatic Stress Disorder. Psychiatry 2017; 80:279-285. [PMID: 29087256 PMCID: PMC7428173 DOI: 10.1080/00332747.2016.1271162] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/30/2022]
Abstract
OBJECTIVE This investigation comprehensively assessed the technology use, preferences, and capacity of diverse injured trauma survivors with posttraumatic stress disorder (PTSD) symptoms. METHOD A total of 121 patients participating in a randomized clinical trial (RCT) of stepped collaborative care targeting PTSD symptoms were administered baseline one-, three-, and six-month interviews that assessed technology use. Longitudinal data about the instability of patient cell phone ownership and phone numbers were collected from follow-up interviews. PTSD symptoms were also assessed over the course of the six months after injury. Regression analyses explored the associations between cell phone instability and PTSD symptoms. RESULTS At baseline, 71.9% (n = 87) of patients reported current cell phone ownership, and over half (58.2%, n = 46) of these patients possessed basic cell phones. Only 19.0% (n = 23) of patients had no change in cell phone number or physical phone over the course of the six months postinjury. In regression models that adjusted for relevant clinical and demographic characteristics, cell phone instability was associated with higher six-month postinjury PTSD symptom levels (p < 0.001). CONCLUSIONS Diverse injured patients at risk for the development of PTSD have unique technology use patterns, including high rates of cell phone instability. These observations should be strongly considered when developing technology-supported interventions for injured patients with PTSD.
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Affiliation(s)
- Cory M. Kelly
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine
| | | | - Joan E. Russo
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine
| | | | | | - Doyanne A. Darnell
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine
| | - Lauren K. Whiteside
- Department of Emergency Medicine, University of Washington School of Medicine
| | - Jin Wang
- Harborview Injury Prevention and Research Center, University of Washington School of Medicine
| | - Lea E. Parker
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine
| | - Thomas H. Payne
- Division of Internal Medicine, University of Washington School of Medicine
| | - Sean D. Mooney
- Academic Medical Center Information Systems, University of Washington School of Medicine
| | - Nigel Bush
- U.S. Department of Defense, National Center for Telehealth and Technology
| | - Douglas F. Zatzick
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine
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Jenkins DH, Cioffi WG, Cocanour CS, Davis KA, Fabian TC, Jurkovich GJ, Rozycki GS, Scalea TM, Stassen NA, Stewart RM. Position statement of the Coalition for National Trauma Research on the National Academies of Sciences, Engineering and Medicine report, A National Trauma Care System. J Trauma Acute Care Surg 2016; 81:816-818. [DOI: 10.1097/ta.0000000000001218] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Davidson AJ, Russo RM, DuBose JJ, Roberts J, Jurkovich GJ, Galante JM. Potential benefit of early operative utilization of low profile, partial resuscitative endovascular balloon occlusion of the aorta (P-REBOA) in major traumatic hemorrhage. Trauma Surg Acute Care Open 2016; 1:e000028. [PMID: 29766066 PMCID: PMC5891715 DOI: 10.1136/tsaco-2016-000028] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Accepted: 08/07/2016] [Indexed: 11/04/2022] Open
Affiliation(s)
- Anders J Davidson
- Division of Trauma, Acute Care Surgery, and Surgical Critical Care, UC Davis Medical Center, Sacramento, California, USA.,Department of General Surgery, David Grant USAF Medical Center, Travis Air Force Base, California, USA
| | - Rachel M Russo
- Division of Trauma, Acute Care Surgery, and Surgical Critical Care, UC Davis Medical Center, Sacramento, California, USA.,Department of General Surgery, David Grant USAF Medical Center, Travis Air Force Base, California, USA
| | - Joseph J DuBose
- Division of Trauma, Acute Care Surgery, and Surgical Critical Care, UC Davis Medical Center, Sacramento, California, USA.,Department of General Surgery, David Grant USAF Medical Center, Travis Air Force Base, California, USA.,Department of Vascular and Endovascular Surgery, David Grant USAF Medical Center, Travis Air Force Base, California, USA
| | - Jon Roberts
- Division of Trauma, Acute Care Surgery, and Surgical Critical Care, UC Davis Medical Center, Sacramento, California, USA
| | - Gregory J Jurkovich
- Division of Trauma, Acute Care Surgery, and Surgical Critical Care, UC Davis Medical Center, Sacramento, California, USA
| | - Joseph M Galante
- Division of Trauma, Acute Care Surgery, and Surgical Critical Care, UC Davis Medical Center, Sacramento, California, USA
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Napolitano LM, Biester TW, Jurkovich GJ, Buyske J, Malangoni MA, Lewis FR. General surgery resident rotations in surgical critical care, trauma, and burns: what is optimal for residency training? Am J Surg 2016; 212:629-637. [PMID: 27634425 DOI: 10.1016/j.amjsurg.2016.07.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Revised: 07/25/2016] [Accepted: 07/29/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND There are no specific Accreditation Council for Graduate Medical Education General Surgery Residency Program Requirements for rotations in surgical critical care (SCC), trauma, and burn. We sought to determine the experience of general surgery residents in SCC, trauma, and burn rotations. METHODS Data analysis of surgical rotations of American Board of Surgery general surgery resident applicants (n = 7,299) for the last 8 years (2006 to 2013, inclusive) was performed through electronic applications to the American Board of Surgery Qualifying Examination. Duration (months) spent in SCC, trauma, and burn rotations, and postgraduate year (PGY) level were examined. RESULTS The total months in SCC, trauma and burn rotations was mean 10.2 and median 10.0 (SD 3.9 months), representing approximately 16.7% (10 of 60 months) of a general surgery resident's training. However, there was great variability (range 0 to 29 months). SCC rotation duration was mean 3.1 and median 3.0 months (SD 2, min to max: 0 to 15), trauma rotation duration was mean 6.3 and median 6.0 months (SD 3.5, min to max: 0 to 24), and burn rotation duration was mean 0.8 and median 1.0 months (SD 1.0, min to max: 0 to 6). Of the total mean 10.2 months duration, the longest exposure was 2 months as PGY-1, 3.4 months as PGY-2, 1.9 months as PGY-3, 2.2 months as PGY-4 and 1.1 months as PGY-5. PGY-5 residents spent a mean of 1 month in SCC, trauma, and burn rotations. PGY-4/5 residents spent the majority of this total time in trauma rotations, whereas junior residents (PGY-1 to 3) in SCC and trauma rotations. CONCLUSIONS There is significant variability in total duration of SCC, trauma, and burn rotations and PGY level in US general surgery residency programs, which may result in significant variability in the fund of knowledge and clinical experience of the trainee completing general surgery residency training. As acute care surgery programs have begun to integrate emergency general surgery with SCC, trauma, and burn rotations, it is an ideal time to determine the optimal curriculum and duration of these important rotations for general surgery residency training.
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Affiliation(s)
| | | | | | - Jo Buyske
- American Board of Surgery, Philadelphia, PA, USA
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26
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Nathens AB, Neff MJ, Jurkovich GJ. Randomized, Prospective Trial of Antioxidant Supplementation in Critically Ill Surgical Patients. Nutr Clin Pract 2016. [DOI: 10.1177/0115426503018003264] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Davis KA, Jurkovich GJ. Fellowship training in Acute Care Surgery: from inception to current state. Trauma Surg Acute Care Open 2016; 1:e000004. [PMID: 29766052 PMCID: PMC5891699 DOI: 10.1136/tsaco-2016-000004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 05/05/2016] [Accepted: 05/09/2016] [Indexed: 11/05/2022] Open
Abstract
Recognizing the need for urgent and emergent surgical care across America, the American Association for the Surgery of Trauma developed and implemented, and oversees, the Acute Care Surgery Fellowship Training Program. Now in its 10th year, the fellowship has become an established post-General Surgery Fellowship Training Program, with 20 approved programs and 82 fellows trained. Consistent with the desire to have this non-Accreditation Council for Graduate Medical Education (ACGME) fellowship one with the highest standards, several educational improvements have occurred since its origin. The following is an account of the background and evolution of what has become a significant educational contribution to surgery.
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Affiliation(s)
- Kimberly A Davis
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
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28
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Staples JA, Wang J, Zaros MC, Jurkovich GJ, Rivara FP. The application of IMPACT prognostic models to elderly adults with traumatic brain injury: A population-based observational cohort study. Brain Inj 2016; 30:899-907. [DOI: 10.3109/02699052.2016.1146964] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- John A. Staples
- Department of Medicine, University of British Columbia, Vancouver, Canada
- Department of Medicine, University of Washington, Seattle, WA, USA
- Harborview Injury Prevention and Research Center, Seattle, WA, USA
| | - Jin Wang
- Harborview Injury Prevention and Research Center, Seattle, WA, USA
| | - Mark C. Zaros
- Department of Medicine, University of Washington, Seattle, WA, USA
| | | | - Frederick P. Rivara
- Harborview Injury Prevention and Research Center, Seattle, WA, USA
- Department of Pediatrics, University of Washington, Seattle, WA, USA
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Pieracci FM, Johnson JL, Stovall RT, Jurkovich GJ. Completely thoracoscopic, intra-pleural reduction and fixation of severe rib fractures. Trauma Case Rep 2015; 1:39-43. [PMID: 30101174 PMCID: PMC6082437 DOI: 10.1016/j.tcr.2015.10.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2015] [Indexed: 11/16/2022] Open
Affiliation(s)
- Fredric M Pieracci
- Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO, USA
| | - Jeffrey L Johnson
- Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO, USA
| | - Robert T Stovall
- Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO, USA
| | - Gregory J Jurkovich
- Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO, USA
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Pieracci FM, Rodil M, Haenel J, Stovall RT, Johnson JL, Burlew CC, Jurkovich GJ, Moore EE. Screening for Ventilator-Associated Pneumonia in the Surgical Intensive Care Unit: A Single-Institution Analysis of 1,013 Lower Respiratory Tract Cultures. Surg Infect (Larchmt) 2015. [PMID: 26207397 DOI: 10.1089/sur.2014.086] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Refinement of criteria for both screening and initiation of empiric therapy in ventilator-associated pneumonia (VAP) will minimize antibiotic overuse. We hypothesized that variables within the commonly used Clinical Pulmonary Infection Score (CPIS) have unfavorable test performance characteristics. METHODS Consecutive bronchoalveolar lavage (BAL) cultures obtained from surgical intensive care unit patients were abstracted (2009-2012). Ventilator-associated pneumonia was defined as ≥10(5) cfu/mL. The CPIS both without (CPISclinical) and with (CPISclinical+GS) the result of gram stain (GS) was calculated. Test performance characteristics for the sample, as well as several subgroups, were compared. RESULTS One thousand thirteen lower respiratory tract cultures from 492 patients were analyzed; 438 (43.2%) of cultures were classified as VAP, and 310 of 492 patients (62.4%) had ≥1 episode of VAP. Both CPISclinical and CPISclinical+GS had poor discrimination for VAP (Receiver-operating characteristic area under the curve=0.55 and 0.66, respectively). Sensitivity of CPISclinical using a threshold of >6 was 21%; the lowest threshold for CPISclinical for which the sensitivity was at least 85% was 3. The highest sensitivity among the individual CPIS components was new CXR infiltrate (91.1%). Among the subset of cultures sent during the early VAP window (days intubated 2-5), organisms on GS had a sensitivity of 93.3%. The CPISclinical, CPISclinical+GS, organisms, and neutrophils on GS parameters all became less accurate in both the late VAP window and when screening for recurrent VAP. Every case of VAP had at least one of the following: 1) fever; 2) new CXR infiltrate, or 3) organisms on GS. CONCLUSION In this series of BALs, traditional screening tools for VAP missed the majority of microbiological confirmed cases. Screening based on either new CXR infiltrate or fever yielded an acceptably high sensitivity. The only scenario identified in which empiric antibiotics could be withheld safely was the absence of organisms on GS in the early VAP window.
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Affiliation(s)
- Fredric M Pieracci
- Denver Health Medical Center/University of Colorado Health Sciences Center , Department of Surgery, Denver, Colorado
| | - Maria Rodil
- Denver Health Medical Center/University of Colorado Health Sciences Center , Department of Surgery, Denver, Colorado
| | - James Haenel
- Denver Health Medical Center/University of Colorado Health Sciences Center , Department of Surgery, Denver, Colorado
| | - Robert T Stovall
- Denver Health Medical Center/University of Colorado Health Sciences Center , Department of Surgery, Denver, Colorado
| | - Jeffrey L Johnson
- Denver Health Medical Center/University of Colorado Health Sciences Center , Department of Surgery, Denver, Colorado
| | - Clay C Burlew
- Denver Health Medical Center/University of Colorado Health Sciences Center , Department of Surgery, Denver, Colorado
| | - Gregory J Jurkovich
- Denver Health Medical Center/University of Colorado Health Sciences Center , Department of Surgery, Denver, Colorado
| | - Ernest E Moore
- Denver Health Medical Center/University of Colorado Health Sciences Center , Department of Surgery, Denver, Colorado
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Davis KA, Dente CJ, Burlew CC, Jurkovich GJ, Reilly PM, Toschlog EA, Cioffi WG. Refining the operative curriculum of the acute care surgery fellowship. J Trauma Acute Care Surg 2015; 78:192-6. [PMID: 25539221 DOI: 10.1097/ta.0000000000000477] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Kimberly A Davis
- From the Departments of Surgery, Yale School of Medicine (K.A.D.), New Haven, Connecticut; Emory School of Medicine (C.J.D.), Atlanta, Georgia; Denver Health Medical Center (C.C.B., G.J.J.), Denver, Colorado; University of Pennsylvania School of Medicine (P.M.R.), Philadelphia, Pennsylvania; East Carolina University School of Medicine (E.A.T.), Greenville, North Carolina; Alpert Medical School of Brown University (W.G.C.), Providence, Rhode Island
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Morshed S, Knops S, Jurkovich GJ, Wang J, MacKenzie E, Rivara FP. The impact of trauma-center care on mortality and function following pelvic ring and acetabular injuries. J Bone Joint Surg Am 2015; 97:265-72. [PMID: 25695975 PMCID: PMC6948797 DOI: 10.2106/jbjs.n.00008] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Lower mortality and improved physical function following major polytrauma have been associated with treatment at level-I trauma centers compared with that at hospitals without a trauma center (nontrauma centers). This study investigated the impact of trauma-center care on outcomes after pelvic and acetabular injuries. METHODS Mortality and quality-of-life-related scores were compared among patients treated in eighteen level-I trauma centers and fifty-one nontrauma centers in fourteen U.S. states. Complete data were obtained on 829 adult trauma patients (eighteen to eighty-four years old) who had at least one pelvic ring or acetabular injury (Orthopaedic Trauma Association [OTA] classification of 61 or 62). We used inverse probability of treatment weighting to adjust for observable confounding. RESULTS After adjusting for case mix, we found that, for patients with more severe acetabular injuries (OTA 62-B or 62-C), in-hospital mortality was significantly lower at trauma centers compared with nontrauma centers (relative risk [RR], 0.10; 95% confidence interval [CI], 0.02 to 0.47), as was death within ninety days (RR, 0.10; 95% CI, 0.02 to 0.47) and within one year (RR, 0.21; 95% CI, 0.06 to 0.76). Patients with combined pelvic ring and acetabular injuries treated at a trauma center had lower mortality at ninety days (RR, 0.34; 95% CI, 0.14 to 0.82) and at one year (RR, 0.30; 95% CI, 0.14 to 0.68). Care at trauma centers was also associated with mortality risk reduction for those with unstable pelvic ring injuries (OTA 61-B or 61-C) at one year (RR, 0.71; 95% CI, 0.24 to 0.91). Seventy-eight percent of included subjects discharged alive were available for interview at twelve months. For those with more severe acetabular injuries, average absolute differences in the Short Form-36 (SF-36) physical function component and the Musculoskeletal Function Assessment at one year were 11.4 (95% CI, 5.3 to 17.4) and 13.2 (1.7 to 24.7), respectively, indicating statistically and clinically significant improved outcomes following treatment at a trauma center for those patients. CONCLUSIONS Mortality was reduced for patients with unstable pelvic and severe acetabular injuries when care was provided in a trauma center compared with a nontrauma center. Moreover, those with severe acetabular fractures experienced improved physical function at one year. Patients with these injuries represent a well-defined subset of trauma patients for whom our findings suggest preferential triage or transfer to a level-I trauma center.
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Affiliation(s)
- Saam Morshed
- Orthopaedic Trauma Institute, Departments of Orthopaedic Surgery and of Epidemiology and Biostatistics, University of California, San Francisco and San Francisco General Hospital, 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA 94110. E-mail address for S. Morshed:
| | - Simon Knops
- Orthopaedic Trauma Institute, Departments of Orthopaedic Surgery and of Epidemiology and Biostatistics, University of California, San Francisco and San Francisco General Hospital, 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA 94110. E-mail address for S. Morshed:
| | - Gregory J. Jurkovich
- Denver Health Medical Center, 777 Bannock Street, Mail Code 0206, Denver, CO 80204
| | - Jin Wang
- University of Washington, Harborview Medical Center, 325 9th Avenue, Box 359660, Seattle, WA 98140
| | - Ellen MacKenzie
- John Hopkins Bloomberg School of Public Health, 624 North Broadway, Room 462, Baltimore, MD 21205
| | - Frederick P. Rivara
- University of Washington, Harborview Medical Center, 325 9th Avenue, Box 359660, Seattle, WA 98140
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Burlew CC, Biffl WL, Moore EE, Pieracci FM, Beauchamp KM, Stovall R, Wagenaar AE, Jurkovich GJ. Endovascular stenting is rarely necessary for the management of blunt cerebrovascular injuries. J Am Coll Surg 2014; 218:1012-7. [PMID: 24661857 DOI: 10.1016/j.jamcollsurg.2014.01.042] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Revised: 01/21/2014] [Accepted: 01/22/2014] [Indexed: 11/15/2022]
Abstract
BACKGROUND The role of stenting for blunt cerebrovascular injuries (BCVI) continues to be debated, with a trend toward more endovascular stenting. With the recent intracranial stenting trial halted in favor of medical therapy, however, management of BCVI warrants reassessment. The study purpose was to determine if antithrombotic therapy, rather than stenting, was effective in post-injury patients with high-grade vascular dissections and pseudoaneurysms. STUDY DESIGN In 1996, we began screening for BCVI. After the 2005 report on the risks of carotid stenting for BCVI, a virtual moratorium was placed on stenting at our institution; our primary therapy for BCVI has been antithrombotics. Patients with grade II (luminal narrowing >25%) and grade III (pseudoaneurysms) injuries were included in the analysis. RESULTS Grade II or III BCVIs were diagnosed in 195 patients. Before 2005, 25% (21 of 86) of patients underwent stent placement, with 2 patients suffering stroke. Of patients treated with antithrombotics, 1 had a stroke. After 2005, only 2% (2 of 109) of patients with high-grade injuries had stents placed. After 2005, no patient treated with antithrombotics suffered a stroke and there was no rupture of a pseudoaneurysm. CONCLUSIONS Antithrombotic treatment for BCVI is effective for stroke prevention. Routine stenting entails increased costs and potential risk for stroke, and does not appear to provide additional benefit. Intravascular stents should be reserved for the rare patient with symptomatology or a markedly enlarging pseudoaneurysm.
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Affiliation(s)
- Clay Cothren Burlew
- Department of Surgery, Denver Health Medical Center and the University of Colorado School of Medicine, Denver, CO.
| | - Walter L Biffl
- Department of Surgery, Denver Health Medical Center and the University of Colorado School of Medicine, Denver, CO
| | - Ernest E Moore
- Department of Surgery, Denver Health Medical Center and the University of Colorado School of Medicine, Denver, CO
| | - Fredric M Pieracci
- Department of Surgery, Denver Health Medical Center and the University of Colorado School of Medicine, Denver, CO
| | - Kathryn M Beauchamp
- Department of Surgery, Denver Health Medical Center and the University of Colorado School of Medicine, Denver, CO
| | - Robert Stovall
- Department of Surgery, Denver Health Medical Center and the University of Colorado School of Medicine, Denver, CO
| | - Amy E Wagenaar
- Department of Surgery, Denver Health Medical Center and the University of Colorado School of Medicine, Denver, CO
| | - Gregory J Jurkovich
- Department of Surgery, Denver Health Medical Center and the University of Colorado School of Medicine, Denver, CO
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Shafi S, Barnes SA, Millar D, Sobrino J, Kudyakov R, Berryman C, Rayan N, Dubiel R, Coimbra R, Magnotti LJ, Vercruysse G, Scherer LA, Jurkovich GJ, Nirula R. Suboptimal compliance with evidence-based guidelines in patients with traumatic brain injuries. J Neurosurg 2014; 120:773-7. [PMID: 24438538 DOI: 10.3171/2013.12.jns132151] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Evidence-based management (EBM) guidelines for severe traumatic brain injuries (TBIs) were promulgated decades ago. However, the extent of their adoption into bedside clinical practices is not known. The purpose of this study was to measure compliance with EBM guidelines for management of severe TBI and its impact on patient outcome. METHODS This was a retrospective study of blunt TBI (11 Level I trauma centers, study period 2008-2009, n = 2056 patients). Inclusion criteria were an admission Glasgow Coma Scale score ≤ 8 and a CT scan showing TBI, excluding patients with nonsurvivable injuries-that is, head Abbreviated Injury Scale score of 6. The authors measured compliance with 6 nonoperative EBM processes (endotracheal intubation, resuscitation, correction of coagulopathy, intracranial pressure monitoring, maintaining cerebral perfusion pressure ≥ 50 cm H2O, and discharge to rehabilitation). Compliance rates were calculated for each center using multivariate regression to adjust for patient demographics, physiology, injury severity, and TBI severity. RESULTS The overall compliance rate was 73%, and there was wide variation among centers. Only 3 centers achieved a compliance rate exceeding 80%. Risk-adjusted compliance was worse than average at 2 centers, better than average at 1, and the remainder were average. Multivariate analysis showed that increased adoption of EBM was associated with a reduced mortality rate (OR 0.88; 95% CI 0.81-0.96, p < 0.005). CONCLUSIONS Despite widespread dissemination of EBM guidelines, patients with severe TBI continue to receive inconsistent care. Barriers to adoption of EBM need to be identified and mitigated to improve patient outcomes.
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Affiliation(s)
- Shahid Shafi
- Institute for Health Care Research and Improvement and
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Weir S, Salkever DS, Rivara FP, Jurkovich GJ, Nathens AB, Mackenzie EJ. One-year treatment costs of trauma care in the USA. Expert Rev Pharmacoecon Outcomes Res 2014; 10:187-97. [DOI: 10.1586/erp.10.8] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Jurkovich GJ. The Surgery Morbidity and Mortality Conference. Patient Saf Surg 2014. [DOI: 10.1007/978-1-4471-4369-7_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Chapman BC, Moore EE, Barnett C, Stovall RT, Biffl WL, Burlew CC, Bensard DD, Jurkovich GJ, Pieracci FM. Hypercoagulability following blunt solid abdominal organ injury: when to initiate anticoagulation. Am J Surg 2013; 206:917-22; discussion 922-3. [PMID: 24112665 DOI: 10.1016/j.amjsurg.2013.07.024] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2013] [Revised: 07/27/2013] [Accepted: 07/31/2013] [Indexed: 11/17/2022]
Abstract
BACKGROUND The optimal time to initiate venous thromboembolism pharmacoprophylaxis after blunt abdominal solid organ injury is unknown. METHODS Postinjury coagulation status was characterized using thromboelastography (TEG) in trauma patients with blunt abdominal solid organ injuries; TEG was divided into 12-hour intervals up to 72 hours. RESULTS Forty-two of 304 patients (13.8%) identified underwent multiple postinjury thromboelastographic studies. Age (P = .45), gender (P = .45), and solid organ injury grade (P = .71) were similar between TEG and non-TEG patients. TEG patients had higher Injury Severity Scores compared with non-TEG patients (33.2 vs 18.3, respectively, P < .01). Among the TEG patients, the shear elastic modulus strength and maximum amplitude values began in the normal range within the first 12-hour interval after injury, increased linearly, and crossed into the hypercoagulable range at 48 hours (15.1 ± 1.9 Kd/cs and 57.6 ± 1.6 mm, respectively; P < .01, analysis of variance). CONCLUSIONS Patients sustaining blunt abdominal solid organ injuries transition to a hypercoagulable state approximately 48 hours after injury. In the absence of contraindications, pharmacoprophylaxis should be considered before this time for effective venous thromboembolism prevention.
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Affiliation(s)
- Brandon C Chapman
- Department of Surgery, Denver Health Medical Center, University of Colorado Health Sciences Center, 777 Bannock Street MC0206, Denver, CO 80206, USA
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Stovall RT, Haenal JB, Jenkins TC, Jurkovich GJ, Pieracci FM, Biffl WL, Barnett CC, Johnson JL, Bensard DD, Moore EE, Cothren Burlew C. A negative urinalysis rules out catheter-associated urinary tract infection in trauma patients in the intensive care unit. J Am Coll Surg 2013; 217:162-6. [PMID: 23639202 DOI: 10.1016/j.jamcollsurg.2013.02.030] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Revised: 02/22/2013] [Accepted: 02/25/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND Urinary tract infection (UTI) in trauma patients is associated with increased mortality. Whether the urinalysis (UA) is an adequate test for a urinary source of fever in the ICU trauma patient has not been demonstrated. We hypothesized that the UA is a valuable screen for UTI in the febrile, critically ill trauma patient. STUDY DESIGN All trauma ICU patients in our surgical ICU who had a fever (temperature >38.0°C), urinary catheter, UA, and a urine culture between January 1, 2011 and December 13, 2011 were reviewed. A positive UA was defined as positive leukocyte esterase, positive nitrite, WBC > 10/high power field, or presence of bacteria. A positive urine culture was defined as growth of ≥10(5) colony forming units (cfu) of an organism irrespective of the UA result or ≥10(3) cfu in the setting of a positive UA. A UTI was defined as positive urine culture without an alternative cause of the fever. RESULTS There were 232 UAs from 112 patients that met criteria. The majority (75%) of patients were men; the mean age was 40 (±16) years. Of the 232 UAs, 90 (38.7%) were positive. There were 14 UTIs. The sensitivity, specificity, positive predictive value, and negative predictive value of the UA for UTI were 100%, 65.1%, 15.5%, and 100%, respectively. CONCLUSIONS A negative UA reliably excludes a catheter-associated UTI in the febrile, trauma ICU patient with a 100% negative predictive value, and it can rapidly direct the clinician toward more likely sources of fever and reduce unnecessary urine cultures.
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Affiliation(s)
- Robert T Stovall
- Department of Surgery, Denver Health Medical Center and the University of Colorado School of Medicine, Denver, CO 80206, USA.
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Lerner EB, Roberts J, Guse CE, Shah MN, Swor R, Cushman JT, Blatt A, Jurkovich GJ, Brasel K. Does EMS perceived anatomic injury predict trauma center need? PREHOSP EMERG CARE 2013; 17:312-6. [PMID: 23627418 DOI: 10.3109/10903127.2013.785620] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Our objective was to determine the predictive value of the anatomic step of the 2011 Field Triage Decision Scheme for identifying trauma center need. METHODS Emergency medical services (EMS) providers caring for injured adults transported to regional trauma centers in three midsized communities were interviewed over two years. Patients were included, regardless of injury severity, if they were at least 18 years old and were transported by EMS with a mechanism of injury that was an assault, motor vehicle or motorcycle crash, fall, or pedestrian or bicyclist struck. The interview was conducted upon emergency department (ED) arrival and collected physiologic condition and anatomic injury data. Patients who met the physiologic criteria were excluded. Trauma center need was defined as nonorthopedic surgery within 24 hours, intensive care unit admission, or death prior to hospital discharge. Data were analyzed by calculating descriptive statistics, including positive likelihood ratios (+LRs) with 95% confidence intervals (CIs). RESULTS A total of 11,892 interviews were conducted. One was excluded because of missing outcome data and 1,274 were excluded because they met the physiologic step. EMS providers identified 1,167 cases that met the anatomic criteria, of which 307 (26%) needed the resources of a trauma center (38% sensitivity, 91% specificity, +LR 4.4; CI: 3.9-4.9). Criteria with a +LR ≥5 were flail chest (9.0; CI: 4.1-19.4), paralysis (6.8; CI: 4.2-11.2), two or more long-bone fractures (6.3; CI: 4.5-8.9), and amputation (6.1; CI: 1.5-24.4). Criteria with a +LR >2 and <5 were penetrating injury (4.8; CI: 4.2-5.6) and skull fracture (4.8; CI: 3.0-7.7). Only pelvic fracture (1.9; CI: 1.3-2.9) had a +LR less than 2. CONCLUSIONS The anatomic step of the Field Triage Guidelines as determined by EMS providers is a reasonable tool for determining trauma center need. Use of EMS perceived pelvic fracture as an indicator for trauma center need should be reevaluated. Key words: wounds and injury; triage; emergency medical services; emergency medical technicians.
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Zatzick DF, Donovan DM, Dunn C, Jurkovich GJ, Wang J, Russo J, Rivara FP, Zatzick CD, Love JR, McFadden CR, Gentilello LM. Disseminating Organizational Screening and Brief Intervention Services (DO-SBIS) for alcohol at trauma centers study design. Gen Hosp Psychiatry 2013; 35:174-80. [PMID: 23273831 PMCID: PMC3594343 DOI: 10.1016/j.genhosppsych.2012.11.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Revised: 11/19/2012] [Accepted: 11/20/2012] [Indexed: 11/19/2022]
Abstract
OBJECTIVE In 2005, the American College of Surgeons passed a mandate requiring that Level I trauma centers have a mechanism to identify patients who are problem drinkers and have the capacity to provide an intervention for patients who screen positive. The aim of the Disseminating Organizational Screening and Brief Intervention Services (DO-SBIS) cluster randomized trial is to test a multilevel intervention targeting the implementation of high-quality alcohol screening and brief intervention (SBI) services at trauma centers. METHOD Twenty sites selected from all United States Level I trauma centers were randomized to participate in the trial. Intervention site providers receive a combination of workshop training in evidence-based motivational interviewing (MI) interventions and organizational development activities prior to conducting trauma-center-based alcohol SBI with blood-alcohol-positive injured patients. Control sites implement care as usual. Provider MI skills, patient alcohol consumption, and organizational acceptance of SBI implementation outcomes are assessed. RESULTS The investigation has successfully recruited provider, patient and trauma center staff samples into the study, and outcomes are being followed longitudinally. CONCLUSION When completed, the DO-SBIS trial will inform future American College of Surgeons' policy targeting the sustained integration of high-quality alcohol SBI at trauma centers nationwide.
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Affiliation(s)
- Douglas F Zatzick
- Department of Psychiatry and Behavioral Sciences, Harborview Injury Prevention and Research Center, University of Washington School of Medicine, Box 359911, Seattle, WA 98104, USA.
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Cooper Z, Rivara FP, Wang J, MacKenzie EJ, Jurkovich GJ. Racial disparities in intensity of care at the end-of-life: are trauma patients the same as the rest? J Health Care Poor Underserved 2012; 23:857-74. [PMID: 22643629 DOI: 10.1353/hpu.2012.0064] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Medicare data show Blacks and Hispanics use more health care resources in the last six months of life than Whites. We sought to determine if similar differences exist in trauma patients who died following moderate to severe injury. METHODS We analyzed data from a prospective cohort study of 18 Level 1 and 51 non-trauma centers in 12 states to examine racial/ethnic variation in intensity of care and hospital costs. RESULTS Blacks were more likely than Whites to receive critical care consultation RR=1.67 (95% CI, 1.22, 2.30), specialty assessments RR=1.44 (95% CI, 1.12, 1.86) and procedures RR=1.22 (95% CI, 1.00, 150). Hispanics were less likely than Whites to have withdrawal-of-care orders, RR=0.72 (95% CI, 0.53, 0.98). CONCLUSION Among patients who die after trauma, Blacks receive higher intensity of care and Hispanics were less likely to have withdrawal of care orders than others. This suggests racial disparities in patient preferences and provider treatment.
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Affiliation(s)
- Zara Cooper
- Department of Surgery and the Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA 02115, USA.
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Affiliation(s)
- Gregory J Jurkovich
- Department of Surgery, University of Colorado School of Medicine and Denver Health and Hospitals Authority, Denver, CO 80204, USA
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Gage AM, Traven N, Rivara FP, Jurkovich GJ, Arbabi S. Compliance with Centers for Disease Control and Prevention field triage guidelines in an established trauma system. J Am Coll Surg 2012; 215:148-54; discussion 154-6. [PMID: 22626915 DOI: 10.1016/j.jamcollsurg.2012.02.025] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Revised: 02/19/2012] [Accepted: 02/20/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND Regionalization of trauma care reduces mortality and has clear guidelines for transport to the highest level of trauma care. Whether prehospital providers follow the CDC triage algorithm remains to be determined. STUDY DESIGN We performed a 5-year retrospective cohort analysis of linked data from Washington State's Central Region Trauma Registry (CRTR) and King County Emergency Medical Services (KCEMS). Patients were analyzed based on transport to their designated hospital, as determined by geocode mapping, or directly to the level I center (no level II center is available in this region). RESULTS Of the 12,106 patients in the study, 5,976 (49.4%) were transported directly to a level I center from the scene. Of the remaining 6,130 patients initially transported to level III to V centers, 5,024 (41.5%) remained in the respective level III to V centers and 1,106 (9.1%) were transferred to the level I center. Patients transported directly to a level I center were more likely to be male, younger, have a penetrating injury, lower scene Glasgow Coma Scale (GCS), lower scene blood pressure, and be more severely injured. Level I direct scene transport was significantly less likely for older patients. Compared with patients ages 18 to 45, the adjusted odds ratio for direct transport to the level I center was 0.7 (95% CI 0.59 to 0.83) for patients aged 46 to 55 years; 0.47 (95% CI 0.39 to 0.57) for those 56 to 65 years; 0.28 (95% CI 0.23 to 0.34) for patients 66 to 80 years; and 0.11 (95% CI 0.09 to 0.14) for those older than 81 years. CONCLUSIONS Prehospital providers follow physiologic, anatomic, and mechanistic parameters in steps 1 to 3 of the CDC field triage guidelines. However, contrary to the special considerations guideline in step 4, older age was associated with transport to the lower level of trauma care in our region.
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Affiliation(s)
- Alexis M Gage
- Department of Surgery, Harborview Medical Center, University of Washington, Seattle, WA 98104, USA
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Jurkovich GJ. Selective non-operative management in 25 737 patients with penetrating abdominal injuries (Br J Surg 2011; 99(Suppl 1): 157-167). Br J Surg 2012; 99 Suppl 1:164-5. [PMID: 22441872 DOI: 10.1002/bjs.7736] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- G J Jurkovich
- Harborview Medical Center, University of Washington, 325 Ninth Avenue, Box 359796, Seattle, Washington 98104-9796, USA.
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Sasser SM, Hunt RC, Faul M, Sugerman D, Pearson WS, Dulski T, Wald MM, Jurkovich GJ, Newgard CD, Lerner EB. Guidelines for field triage of injured patients: recommendations of the National Expert Panel on Field Triage, 2011. MMWR Recomm Rep 2012; 61:1-20. [PMID: 22237112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023] Open
Abstract
In the United States, injury is the leading cause of death for persons aged 1-44 years. In 2008, approximately 30 million injuries were serious enough to require the injured person to visit a hospital emergency department (ED); 5.4 million (18%) of these injured patients were transported by Emergency Medical Services (EMS). On arrival at the scene of an injury, the EMS provider must determine the severity of injury, initiate management of the patient's injuries, and decide the most appropriate destination hospital for the individual patient. These destination decisions are made through a process known as "field triage," which involves an assessment not only of the physiology and anatomy of injury but also of the mechanism of the injury and special patient and system considerations. Since 1986, the American College of Surgeons Committee on Trauma (ACS-COT) has provided guidance for the field triage process through its "Field Triage Decision Scheme." This guidance was updated with each version of the decision scheme (published in 1986, 1990, 1993, and 1999). In 2005, CDC, with financial support from the National Highway Traffic Safety Administration, collaborated with ACS-COT to convene the initial meetings of the National Expert Panel on Field Triage (the Panel) to revise the decision scheme; the revised version was published in 2006 by ACS-COT (American College of Surgeons. Resources for the optimal care of the injured patient: 2006. Chicago, IL: American College of Surgeons; 2006). In 2009, CDC published a detailed description of the scientific rationale for revising the field triage criteria (CDC. Guidelines for field triage of injured patients: recommendations of the National Expert Panel on Field Triage. MMWR 2009;58[No. RR-1]). In 2011, CDC reconvened the Panel to review the 2006 Guidelines in the context of recently published literature, assess the experiences of states and local communities working to implement the Guidelines, and recommend any needed changes or modifications to the Guidelines. This report describes the dissemination and impact of the 2006 Guidelines; outlines the methodology used by the Panel for its 2011 review; explains the revisions and modifications to the physiologic, anatomic, mechanism-of-injury, and special considerations criteria; updates the schematic of the 2006 Guidelines; and provides the rationale used by the Panel for these changes. This report is intended to help prehospital-care providers in their daily duties recognize individual injured patients who are most likely to benefit from specialized trauma center resources and is not intended as a mass casualty or disaster triage tool. The Panel anticipates a review of these Guidelines approximately every 5 years.
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Affiliation(s)
- Scott M Sasser
- Division of Injury Response, National Center for Injury Prevention and Control, CDC, Atlanta, Georgia 30341-3717, USA
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Abstract
OBJECTIVE To determine the predictive value of the mechanism-of-injury step of the American College of Surgeons Field Triage Decision Scheme for determining trauma center need. METHODS Emergency medical services (EMS) providers caring for injured adult patients transported to the regional trauma center in three midsized communities over two years were interviewed upon emergency department (ED) arrival. Included was any injured patient, regardless of injury severity. The interview collected patient physiologic condition, apparent anatomic injury, and mechanism of injury. Using the 1999 Scheme, patients who met the physiologic or anatomic steps were excluded. Patients were considered to need a trauma center if they had nonorthopedic surgery within 24 hours, had intensive care unit admission, or died prior to hospital discharge. Data were analyzed by calculating positive likelihood ratios (+LRs) and 95% confidence intervals (CIs) for each mechanism-of-injury criterion. RESULTS A total of 11,892 provider interviews were conducted. Of those, one was excluded because outcome data were not available, and 2,408 were excluded because they met the other steps of the Field Triage Decision Scheme. Of the remaining 9,483 cases, 2,363 met one of the mechanism-of-injury criteria, 204 (9%) of whom needed the resources of a trauma center. Criteria with a +LR ≥ 5 were death of another occupant in the same vehicle (6.8; CI: 2.7-16.7), fall >20 feet (5.3; CI: 2.4-11.4), and motor vehicle crash (MVC) extrication time >20 minutes (5.1; CI: 3.2-8.1). Criteria with a +LR between >2 and <5 were intrusion >12 inches (4.2; CI: 2.9-5.9), ejection (3.2; CI: 1.3-8.2), and deformity >20 inches (2.5; CI: 1.9-3.2). The criteria with a +LR ≤ 2 were MVC speed >40 mph (2.0; CI: 1.7-2.4), pedestrian/bicyclist struck at a speed >5 mph (1.2; CI:1.1-1.4), bicyclist/pedestrian thrown or run over (1.2; CI: 0.9-1.6), motorcycle crash at a speed >20 mph (1.2; CI: 1.1-1.4), rider separated from motorcycle (1.0; CI: 0.9-1.2), and MVC rollover (1.0; CI: 0.7-1.5). CONCLUSION Death of another occupant, fall distance, and extrication time were good predictors of trauma center need when a patient did not meet the anatomic or physiologic conditions. Intrusion, ejection, and vehicle deformity were moderate predictors. Key words: wounds and injury; triage; emergency medical services; emergency medical technicians; predictors; mechanism of injury; trauma center.
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Affiliation(s)
- E Brooke Lerner
- Medical College of Wisconsin, Milwaukee, Wisconsin 53226, USA.
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Jurkovich GJ. Invited commentary. J Am Coll Surg 2011; 213:721. [PMID: 22107918 DOI: 10.1016/j.jamcollsurg.2011.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2011] [Accepted: 10/12/2011] [Indexed: 11/16/2022]
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Lerner EB, Cushman JT, Blatt A, Lawrence RD, Shah MN, Swor RA, Brasel K, Jurkovich GJ. EMS Provider assessment of vehicle damage compared with assessment by a professional crash reconstructionist. PREHOSP EMERG CARE 2011; 15:483-9. [PMID: 21815732 DOI: 10.3109/10903127.2011.598614] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To determine the accuracy of emergency medical services (EMS) provider assessments of motor vehicle damage when compared with measurements made by a professional crash reconstructionist. METHODS EMS providers caring for adult patients injured during a motor vehicle crash and transported to the regional trauma center in a midsized community were interviewed upon emergency department arrival. The interview collected provider estimates of crash mechanism of injury. For crashes that met a preset severity threshold, the vehicle's owner was asked to consent to having a crash reconstructionist assess the vehicle. The assessment included measuring intrusion and external automobile deformity. Vehicle damage was used to calculate change in velocity. Paired t-test, correlation, and kappa were used to compare EMS estimates and investigator-derived values. RESULTS Ninety-one vehicles were enrolled; of these, 58 were inspected and 33 were excluded because the vehicle was not accessible. Six vehicles had multiple patients. Therefore, a total of 68 EMS estimates were compared with the inspection findings. Patients were 46% male, 28% were admitted to hospital, and 1% died. The mean EMS-estimated deformity was 18 inches and the mean measured deformity was 14 inches. The mean EMS-estimated intrusion was 5 inches and the mean measured intrusion was 4 inches. The EMS providers and the reconstructionist had 68% agreement for determination of external automobile deformity (kappa 0.26) and 88% agreement for determination of intrusion (kappa 0.27) when the 1999 American College of Surgeons Field Triage Decision Scheme criteria were applied. The mean (± standard deviation) EMS-estimated speed prior to the crash was 48 ± 13 mph and the mean reconstructionist-estimated change in velocity was 18 ± 12 mph (correlation -0.45). The EMS providers determined that 19 vehicles had rolled over, whereas the investigator identified 18 (kappa 0.96). In 55 cases, EMS and the investigator agreed on seat belt use; for the remaining 13 cases, there was disagreement (five) or the investigator was unable to make a determination (eight) (kappa 0.40). CONCLUSIONS This study found that EMS providers are good at estimating rollover. Vehicle intrusion, deformity, and seat belt use appear to be more difficult for EMS to estimate, with only fair agreement with the crash reconstructionist. As expected, the EMS provider -estimated speed prior to the crash does not appear to be a reasonable proxy for change in velocity.
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Affiliation(s)
- E Brooke Lerner
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin 53226, USA.
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