Outcomes of patients enrolled in a prospective and randomized trial on basis of gestalt assessment or ABC score

BACKGROUND

The Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial rapidly enrolled patients based on an Assessment of Blood Consumption (ABC) ≥ 2 score, or physician gestalt (PG) when ABC score was <2. The objective of this study was to describe what patients were enrolled by the two methods and whether patient outcomes differed based on these enrollments. We hypothesized that there would be no differences in outcomes based on whether patients were enrolled via ABC score or PG.

METHODS

Patients were enrolled with an ABC ≥ 2 or by PG when ABC was <2 by the attending trauma surgeon. We compared 1-hour, 3-hour, 6-hour, 12-hour, 18-hour, and 24-hour mortality, 30-day mortality, time to hemostasis, emergent surgical or interventional radiology procedure and the proportion of patients who required either >10 units of blood in 24 hours or >3 units in 1 hour.

RESULTS

Of 680 patients, 438 (64%) were enrolled on the basis of an ABC score ≥2 and 242 (36% by PG when the ABC score was <2). Patients enrolled by PG were older (median, 44; interquartile range [IQR], 28-59; p < 0.001), more likely to be White (70.3% vs. 60.3%, p = 0.014), and more likely to have been injured by blunt mechanisms (77.3% vs. 37.2%, p < 0.001). They were also less hypotensive and less tachycardic than patients enrolled by ABC score (both p < 0.001). The groups had similar Injury Severity Scores in the ABC ≥ 2 and PG groups (26 and 27, respectively) and were equally represented (49.1% and 50.8%, respectively) in the 1:1:1 treatment arm. There were no significant differences between the ABC score and PG groups for mortality at any point. Time to hemostasis (108 for patients enrolled on basis of Gestalt, vs. 100 minutes for patients enrolled on basis of ABC score), and the proportion of patients requiring a massive transfusion (>10 units/24 hours) (44.2% vs. 47.3%), or meeting the critical administration threshold (>3 unit/1 hour) (84.7% vs. 89.5%) were similar ( p = 0.071).

CONCLUSION

Early identification of trauma patients likely to require a massive transfusion is important for clinical care, resource use, and selection of patients for clinical trials. Patients enrolled in the PROPPR trial based on PG when the ABC score was <2 represented 36% of the patients and had identical outcomes to those enrolled on the basis of an ABC score of ≥2.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Preferential whole blood transfusion during the early resuscitation period is associated with decreased mortality and transfusion requirements in traumatically injured patients

Introduction

Whole blood (WB) transfusion represents a promising resuscitation strategy for trauma patients. However, a paucity of data surrounding the optimal incorporation of WB into resuscitation strategies persists. We hypothesized that traumatically injured patients who received a greater proportion of WB compared with blood product components during their resuscitative efforts would have improved early mortality outcomes and decreased transfusion requirements compared with those who received a greater proportion of blood product components.

Methods

Retrospective review from our Level 1 trauma center of trauma patients during their initial resuscitation (2019-2022) was performed. WB to packed red blood cell ratios (WB:RBC) were assigned to patients based on their respective blood product resuscitation at 1, 2, 3, and 24 hours from presentation. Multivariable regression models were constructed to assess the relationship of WB:RBC to 4 and 24-hour mortality, and 24-hour transfusion requirements.

Results

390 patients were evaluated (79% male, median age of 33 years old, 48% penetrating injury rate, and a median Injury Severity Score of 27). Overall mortality at 4 hours was 9%, while 24-hour mortality was 12%. A significantly decreased 4-hour mortality was demonstrated in patients who displayed a WB:RBC≥1 at 1 hour (5.9% vs. 12.3%; OR 0.17, p=0.015), 2 hours (5.5% vs. 13%; OR 0.16, p=0.019), and 3 hours (5.5% vs. 13%, OR 0.18, p<0.01), while a decreased 24-hour mortality was displayed in those with a WB:RBC≥1 at 24 hours (7.9% vs. 14.6%, OR 0.21, p=0.01). Overall 24-hour transfusion requirements were significantly decreased within the WB:RBC≥1 cohort (12.1 units vs. 24.4 units, p<0.01).

Conclusion

Preferential WB transfusion compared with a balanced transfusion strategy during the early resuscitative period was associated with a lower 4 and 24-hour mortality, as well as decreased 24-hour transfusion requirements, in trauma patients. Future prospective studies are warranted to determine the optimal use of WB in trauma.

Level of evidence

Level III/therapeutic.

Feasibility of using an automated call service to collect quality of life and functional outcome data in trauma patients

Objectives

Following up trauma patients after discharge, to evaluate their subsequent quality of life and functional outcomes, is notoriously difficult, time consuming, and expensive. Automated systems are a conceptually attractive solution. We prospectively assessed the feasibility of using a series of automated phone calls administered by Emmi Patient Engagement to survey trauma patients after discharge.

Methods

Recruitment into the study was incorporated into the patient discharge process by nursing staff. For this pilot, we included trauma patients discharging home and who were able to answer phone calls. A script was created to evaluate the Extended Glasgow Outcome Scale and the EuroQol EQ-5D to assess functional status and quality of life, respectively. Call attempts were made at 6 weeks, 3 months, 6 months, and 1 year after discharge.

Results

A total of 110 patients initially agreed to participate. 368 attempted patient encounters (calls or attempted calls) took place, with 104 (28.3%) patients answering a least one question in the study. 21 unique patients (19.1% of those enrolled) completed 27 surveys.

Conclusions

Automated, scripted phone calls to survey patients after discharge are not a feasible way of collecting functional and quality of life data.

Level of evidence

Level II/prospective.

Developing the Ready Military Medical Force: military-specific training in Graduate Medical Education

Introduction

Graduate Medical Education plays a critical role in training the next generation of military physicians, ensuring they are ready to uphold the dual professional requirements inherent to being both a military officer and a military physician. This involves executing the operational duties as a commissioned leader while also providing exceptional medical care in austere environments and in harm's way. The purpose of this study is to review prior efforts at developing and implementing military unique curricula (MUC) in residency training programs.

Methods

We performed a literature search in PubMed (MEDLINE), Embase, Web of Science, and the Defense Technical Information Center through August 8, 2023, including terms "graduate medical education" and "military." We included articles if they specifically addressed military curricula in residency with terms including "residency and operational" or "readiness training", "military program", or "military curriculum".

Results

We identified 1455 articles based on title and abstract initially and fully reviewed 111. We determined that 64 articles met our inclusion criteria by describing the history or context of MUC, surveys supporting MUC, or military programs or curricula incorporated into residency training or military-specific residency programs.

Conclusion

We found that although there have been multiple attempts at establishing MUC across training programs, it is difficult to create a uniform curriculum that can be implemented to train residents to a single standard across services and specialties.

The 16-Year Evolution of a Military-Civilian Partnership: The University of Alabama at Birmingham Experience

BACKGROUND

At the University of X at X (UXX), a multi-tiered military-civilian partnership (MCP) has evolved since 2006. We aimed to outline this model to facilitate potential replication nationally.

METHODS

We performed a comprehensive review of the partnership between UXX, the United States Air Force Special Operations Command (AFSOC), and the Department of Defense (DoD) reviewing key documents and conducting interviews with providers. As a purely descriptive study, this project did not involve any patient data acquisition or analysis and therefore was exempt from Institutional Review Board (IRB) approval per institutional policy.

RESULTS

At the time of this review, six core programs existed targeting training, clinical proficiency, and research. Training: 1) The Special Operations Center for Medical Integration and Development (SOCMID) trains up to 144 combat medics yearly. 2) UXX trains one integrated military Surgery resident yearly with two additional civilian-sponsored military residents in Emergency Medicine. 3) UXX's Surgical Critical Care Fellowship had one National Guard member with two incoming Active-Duty, one Reservist and one prior service member in August 2022. Clinical Proficiency: 4) UXX hosts four permanently assigned AFSOC Special Operations Surgical Teams composed of General Surgeons, Anesthesiologists, Certified Registered Nurse Anesthetists, Surgical Technologists, Emergency Physicians, Critical Care Registered Nurses, and Respiratory Therapists totaling twenty-four permanently assigned Active-Duty Healthcare Professionals. 5) Additionally, two fellowship-trained Air Force Trauma Critical Care Surgeons, one Active-Duty and one Reservist, are permanently assigned to UXX. These clinicians participate fully and independently in the routine care of patients alongside their civilian counterparts. Research: 6) UXX's Division of Trauma and Acute Care Surgery is currently conducting nine DoD-funded research projects totaling $6,482,790, and four research projects with military relevance funded by other agencies totaling $15,357,191.

CONCLUSIONS

The collaboration between UXX and various elements within the DoD illustrates a comprehensive approach to MCP. Replicating appropriate components of this model nationally may aid in the development of a truly integrated trauma system best prepared for the challenges of the future.

LEVEL OF EVIDENCE

IV, Economic and Value-based Evaluations.

A case study demonstrating tolerance of the gut to large volumes of enteral fluids as a complement to IV fluid resuscitation in burn shock

Appropriate intravenous fluid resuscitation has improved early post burn outcomes. However, clinical and pre-clinical evidence suggests that enteral or oral resuscitation may complement intravenous fluid administration. While this strategy is often discussed in the context of resource-limited settings, its implementation could reduce overall IV fluid requirements and simplify management during routine care. Conversely, concerns about this strategy have been raised over impaired gut perfusion and function leading to adverse effects. We present a case of an 82-year-old man with a total burn size of 14% who was encouraged to ingest the oral rehydration solution Drip Drop® starting 7 hours post-burn. In the ensuing 17 hours he consumed over 5 L of oral rehydration solution, which was nearly 1 L more than the total amount of IV fluids he received. There were no adverse gastrointestinal side effects. This demonstrates tolerance of a significant volume of voluntary oral fluids in combination with IV resuscitation. Clinical trials are warranted.