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ABSTRACT: Venous duplex surveillance (VDS) is commonly used in trauma patients considered at risk for deep venous thrombosis. Economic evaluations have not addressed the quality of either the process of care or the outcomes achieved through the use of VDS. We sought to determine the value (quality/cost) of VDS in trauma patients stratified by risk for venous thromboembolism.
We reviewed records of all trauma patients from July 2006 to December 2010 who received weekly VDS examinations of the lower extremities. Prophylaxis and risk stratification were performed according to the American College of Chest Physicians recommendations. Patients were stratified by level of venous thromboembolism risk according to the results of a systematic review of the literature. The "value" of VDS was expressed as the number of clinically relevant findings divided by the cost (defined as the percent full-time equivalent of a certified vascular technologist performing VDS).
A total of 2,169 patients met inclusion criteria and were stratified by deep venous thrombosis risk (218 moderate, 1,173 high, 778 highest). The quality of the process (the percent of sites adequately visualized per VDS) was not clinically different among risk groups. The quality of the outcome (number of clinically relevant findings) was significantly greater, and the work time required per finding was significantly lower in the highest-risk group (p < 0.001). The value of VDS was significantly greater in the highest-risk group compared with high or moderate-risk groups (1,104 vs. 337 vs. 76 findings per percent full-time equivalent, respectively; p < 0.001).
VDS has significantly greater value in the highest-risk group and is warranted in this group. It is of less value in the moderate risk trauma patient. Calculating the value of specific health care interventions can guide the allocation of limited resources.
Prognostic study, level II; value-based evaluation, level III.
The journal of trauma and acute care surgery. 02/2013; 74(2):575-80.
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ABSTRACT: Reliance on chest-abdomen-pelvis computed tomography (CAP) in the initial evaluation of blunt trauma is a major source of patient radiation exposure. Our trauma surgeon group (TSG) modified its practice to limit the use of CAP. We evaluated the effect of this practice change on patient radiation exposure and diagnostic accuracy.
We compared data on blunt injury trauma activations evaluated by the five-member TSG for two 6-month intervals, before (T1) and after (T2) instituting the practice change. Patient demographic and injury data, complications, torso imaging and radiation dosage were collected. Following analysis of T1, the surgeon with the lowest CAP use was identified and found to have no errors or delays in diagnosis. The TSG agreed to adopt that surgeon's focus on findings of the physical examination and Focused Assessment Sonography for Trauma to reduce CAP use in the initial evaluation. T2 was analyzed to assess the effect of implementation of this guideline.
There were 897 patients in T1 and 948 in T2. In the two intervals, patients did not differ by age, sex, mortality, or probability of survival. CAP use decreased by 38.5% with a significant drop in mean patient radiation exposure (p < 0.001). There were no missed injuries or delays in diagnosis in either interval.
The use of CAP and its associated radiation burden in the initial evaluation of blunt trauma can be reduced without diagnostic errors by comparing use and identifying best practice. This process has implications for optimal trauma care.
Diagnostic study, level IV; case management study, level IV.
The journal of trauma and acute care surgery. 01/2013; 74(1):92-9.
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ABSTRACT: Withdrawal or limitation of care (WLC) in trauma patients has not been well studied. We reviewed 10 years of deaths at our adult Level I trauma center to identify the patients undergoing WLC and to describe the process of trauma surgeon-managed WLC.
This is a retrospective review of WLC. Each patient was assigned to one of three modes of WLC: care withdrawn, limited or no resuscitation, or organ harvest. Frequency, timing, and circumstances of WLC, including family involvement, ethics committee consultation, palliative care, and hospice, were reviewed.
From 2000 through 2009, 375 patients died with WLC (54% of all deaths; 93% at ≥ 24 hours). For age ≥ 65 years, 80% were WLC. Overall, 15% had advance directive documents. Traumatic brain or high cervical spine injury was the cause of death in 63%. Factors associated with WLC included age, comorbidities, injury mechanism and severity, and nontrauma activation status. At time of death, 316 (84%) WLC were under trauma surgeon management. In this group, mode of WLC was care withdrawn in 74%, organ harvest in 20%, and limited or no resuscitation in 6%. Rationale for WLC in non-organ harvest patients was poor neurologic prognosis in 86% and futility in 76%. When family was identified, end-of-life discussions with physicians occurred in 100%. Conflicts over WLC occurred in 6.6% and were not associated with any demographic group. Ethics committee was involved in 2.8%. For care-withdrawn patients, median time to death from first WLC order was 6.6 hours. Palliative care and hospice consults (6% and 9%) increased yearly.
WLC occurred in over 50% of all trauma deaths and exceeded 90% at ≥ 24 hours. Hospice and palliative care were increasingly important adjuncts to WLC. Guidelines for WLC should be developed to ensure quality end-of-life care for trauma patients in whom further care is futile.
III, therapeutic study.
The journal of trauma and acute care surgery. 05/2012; 72(5):1186-93.
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ABSTRACT: Trauma centers are more frequently evaluating patients who are receiving anticoagulant or prescription antiplatelet (ACAP) therapy at the time of injury. Because there are reports of delayed intracranial hemorrhage (ICH) after blunt trauma in this patient group, we evaluated patients receiving ACAP with a head computed tomography (CT) on admission (CT1) followed by a routine repeat head CT (CT2) in 6 hours. We hypothesized that among patients with no traumatic findings on CT1 and a normal or unchanged interval neurologic examination, the incidence of clinically significant delayed ICH would be zero.
We retrospectively reviewed adult blunt trauma patients admitted to our Level I trauma center from January 2006 to August 2009 who were receiving preinjury ACAP therapy. We reviewed medications, mechanism of injury, head CT results, and outcomes. Demographic data, injury severity scores, international normalized ratio, and neurologic examinations were recorded. We determined the incidence of delayed ICH on CT2 for patients with a negative CT1.
Five hundred patients qualified for the protocol. Of these, 424 patients (85%) had a negative CT1. Among these patients, mean age was 75 years; 210 (50%) were male. Fall from standing was the most common mechanism of injury found in 357 patients (84%). Warfarin alone was taken in 68%, clopidogrel alone in 24%, and other agents in 2%. Six percent of patients were taking two agents. Mean international normalized ratio for patients on warfarin was 2.5. Among patients with a negative CT1, CT2 was obtained in 362 patients (85%) and was negative in 358 patients (99%). Four patients (1%) with a negative CT1 had a positive (n = 3) or equivocal (n = 1) CT2. All the changes on CT2 were minor and had either resolved or stabilized on third head CT. Of the four patients with positive or equivocal CT2, none had a change in neurologic examination; however, two had symptoms that could be attributed to head injury. Three were discharged home and one died of cardiac disease unrelated to head trauma.
The incidence of delayed ICH in our study was 1%. However, none of the delayed findings were clinically significant. Among patients on ACAP therapy with a negative CT1 and a normal or unchanged neurologic examination, a routine CT2 is unnecessary. We recommend a period of observation to recognize those patients with symptoms that could be due to delayed ICH.
The Journal of trauma 12/2011; 71(6):1600-4. · 2.48 Impact Factor
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ABSTRACT: Little is known about the impact of postinjury depression after major trauma in adolescents. A prospective epidemiologic study was conducted to examine depression in injured adolescents. Specific objectives of this report are to identify risk factors for depression onset and the impact of depression on quality of life (QoL) outcomes.
Four hundred one trauma patients were enrolled in this study (age, 12-19 years; injury severity score [ISS] ≥4). Depression diagnosis was based on the Children's Depression Inventory. QoL outcomes were measured using the Quality of Well-being Scale at 3-, 6-, 12-, 18-, and 24-month follow-up.
Depression at discharge was diagnosed in 41% of 399 adolescent trauma survivors with complete Children's Depression Inventory data. Multivariate logistic regression identified ISS, >3 body regions injured, low socioeconomic status, family members injured at the scene, and suicidal ideology or attempted suicide before injury as strong and independent predictors of depression risk. ISS and three or more body regions injured predicted depression risk. Patients with severe injury (ISS ≥17) were twice more likely to have depressive symptoms than patients with moderate injury (ISS <17; odds ratio [OR] = 2.0; p < 0.01). Patients with three or more body regions injured were more likely to have depressive symptoms than patients with less than three body regions injured (OR = 2.1; p < 0.01). Adolescents from low socioeconomic status families were more likely to be depressed (OR = 2.2; p < 0.05). Adolescent patients who witnessed family injured at the trauma event were also more likely to be depressed (OR = 2.4; p < 0.01). Patients who experienced suicidal ideology or attempted suicide preinjury were more likely to be depressed than adolescent patients who did not (OR = 2.87; p < 0.05). Quality of well-being scores were significantly and markedly lesser for patients with depression across the 24-month follow-up (3-18 months follow-up, p < 0.0001; 24 months: with depression = 0.738 vs. without depression = 0.784, p < 0.0001). Patients with depression were also significantly more likely to develop acute stress disorder and long-term posttraumatic stress disorder (OR = 1.8, p < 0.001).
Postinjury depression is a major and an important complication in seriously injured adolescents. Adolescent trauma survivors have high rates of predischarge depression. Depression severely impacts QoL outcomes and is associated with injury severity, injury event-related factors, social factors, acute stress disorder, and posttraumatic stress disorder. Early recognition and treatment of DEPR in seriously injured adolescents will improve acute trauma care and long-term QoL outcomes.
The Journal of trauma 04/2011; 70(4):923-30. · 2.48 Impact Factor
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ABSTRACT: Purpose: We evaluated the utility and acceptability of an informational magnet to prevent college student suicide by raising awareness of warning signs and counseling services.
Methods: A total of 708 (97%) of 729 entering freshmen at a public university completed a survey of suicidal behavior, help-seeking, and willingness to use a magnet inscribed with suicide warning signs and 2 prevention services to call for support.
Results: Twenty-two percent reported they or someone they knew seriously considered or attempted suicide in the last 6 months; 59% were likely to visibly display the magnet; and 63% would call the listed services if someone they knew was depressed or had suicidal thoughts. When provided scenarios of a friend with a given suicide warning sign, students expressed a clear hierarchy of alarm.
Conclusions: A majority of students were willing to use a magnet displaying suicide warning signs and prevention services, and to apply this information to assist a suicidal peer.
Journal of trauma nursing: the official journal of the Society of Trauma Nurses 03/2011; 18(2):89–96.
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ABSTRACT: Optimal care of trauma patients requires cost-effective organization and commitment of trauma center resources. We examined the impact of creating a dedicated trauma care unit (TCU) and adding advanced practice nurses on the quality and cost of care at an adult Level I trauma center.
Patient demographic and injury data, length of stay, complications, outcomes, and total direct cost of care were evaluated for four 1-year intervals in the recent history of our trauma center: Year A, a trauma team of in-house trauma surgeons and resident physicians; Year B, the addition of nurse practitioners to the trauma team 5 days/week; Year C, the creation of a dedicated TCU for all non intensive care unit trauma patients; and Year D, the addition of a permanent clinical nurse specialist and an increase in nurse practitioner coverage to 7 days/week. For each year, value was determined by calculating the median cost of a survivor and the median cost of a survivor with no complications. Significance was attributed to p<0.05.
Patient volume increased from 1,927 in year A to 2,546 by year D. Over the period of study, there was an increase in blunt trauma (87.1-89.9%; p<0.05), median Injury Severity Score (5-6; p<0.05), and patients aged ≥65 years (11.4-19.8%; p<0.05). However, risk-adjusted mortality was unchanged. There was a decrease in patients with a complication (20.8-14.9%; p < 0.05), median intensive care unit length of stay (39.5-23.4 hours; p < 0.05), and median cost of care ($4,306-$3,698; p<0.05). Value increased: both the median costs of a survivor and of a survivor with no complications decreased from $4,259 to $3,658 (p<0.05) and from $3,898 to $3,317 (p<0.05), respectively. The median cost of a survivor with severe injury (Injury Severity Score ≥15) decreased from $17,651 to $12,285 (p<0.05).
The addition of a dedicated TCU and advanced practice nurses improved the quality and reduced the cost of care, resulting in increased value at an adult Level I trauma center.
The Journal of trauma 03/2011; 70(3):560-8. · 2.48 Impact Factor
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ABSTRACT: This study compared damage control measures (DCM), including operative techniques (DCO) and resuscitative measures (DCR), with standard treatment (ST) for ruptured abdominal aortic aneurysm (rAAA).
Historical cohort study methodology was used to evaluate outcomes for rAAA repairs related to DCM or ST over a 74-month period at a level I trauma center.
Of 28 repairs, 13 (46.4%) were DCM. Compared to ST patients, DCM patients had a lower mean preoperative BP (64.6 vs. 83.2 mm Hg, P = .03) and greater intraoperative blood loss (4.6 vs. 2.1 liters, P = .033). Patients who had both DCR and DCO (DCO & DCR) received more plasma (6.8 vs 2.6 units, P = .039) and less crystalloid (2.8 vs 10.5 liters, P = .005) than those receiving DCO only. A modest decrease in mortality was seen in the DCO & DCR group compared to DCO only. No DCO-related graft infections were observed.
DCR use may prove beneficial in the management of rAAA.
Vascular and Endovascular Surgery 11/2010; 44(8):638-44. · 0.99 Impact Factor
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Gabrielle M Paci,
Michael J Sise, C Beth Sise,
Daniel I Sack,
Steven R Shackford,
Sohaib A Kureshi,
Turner M Osler,
Randall S Yale,
Steven T Riccoboni,
Kimberly A Peck,
Eamon B O'Reilly
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ABSTRACT: Patients with severe traumatic brain injury (TBI) require aggressive management to prevent secondary brain injury. "Preemptive" craniectomy (CE)--craniectomy performed as a primary procedure in conjunction with craniotomy--has been used as prophylaxis for secondary injury, but the indications and outcomes of craniectomy used for this purpose are not well defined.
To evaluate the role of CE in the management of TBI, we retrospectively reviewed 62 consecutive patients who underwent CE in a 78-month period at our level I trauma center. A cohort of patients who underwent craniotomy only (CO) during this period was compared with the CE group for TBI patterns, indications for operation, and outcomes. Multivariable logistic regression and matched propensity score analysis were used to test the association between CE and survival. The rate of CE was determined by individual neurosurgeons.
Of 197 patients with brain injuries who underwent craniotomy, 62 (31.5%) had CE and 135 (68.5%) had CO. Mean age for CE versus CO was 41 years versus 51 years (p < 0.01). Mean admission Glasgow Coma Score was lower in CE versus CO (7.6 vs. 11.8, p < 0.001); Injury Severity Score was higher (30.2 vs. 26.3, p < 0.01). The indication for operation for CE compared with CO was subdural hematoma in 41 (66.1%) versus 87 (64.4%, p = 0.82), epidural hematoma in 2 (3.2%) versus 26 (19.3%, p < 0.01), and cerebral contusion or hematoma in 15 (24.2%) versus 8 (5.9%, p < 0.001). Postoperative intracranial pressure was monitored in 48 (77.4%) CE and 44 (32.6%) CO patients (p < 0.001). Intracranial pressure <20 was maintained in 26 (54.2%) after CE and in 31 (70.5%) after CO (p = 0.12). In the CE group, 26 (42%) died compared with 31 (26%, p < 0.01) in the CO group. When adjusted for severity of injury, however, there was no significant difference in mortality between the two groups (p = 0.134). The CE rate obtained by a neurosurgeon varied from 8.6% to 75.0% (p < 0.001).
CE was used in patients with more severe injuries, and particularly in those with more severe head injuries. When adjusted for injury severity, CE was not associated with worsened survival, and therefore may reasonably be included in the armamentarium of neurotrauma care. Use of CE by our neurosurgeons, however, varied significantly. These findings underscore the need for practice guidelines based on randomized trials to fully evaluate the role of CE in the management of TBI.
The Journal of trauma 09/2009; 67(3):531-6. · 2.48 Impact Factor
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ABSTRACT: Underage drinking carries a high risk of injury. An important approach for reducing underage drinking is limiting youth access to alcohol. Underage drinkers obtain alcohol from multiple sources and patterns of access may vary by region. We examined patterns of access to alcohol and alcohol use among youth in a local court-ordered diversion program for first-time adolescent alcohol offenders as a basis for designing and evaluating community prevention efforts.
Youth in the program completed a survey of demographic data, type of offense, source, setting, and quantity of alcohol consumed at time of offense, and 1-year alcohol-related high-risk behaviors. Significance was attributed to p < or = 0.05.
Completed surveys were obtained from 1,158 (84.8%) of 1,366 eligible participants during the 23-month study period. There were 71% males and 29% females with a mean age of 17.2 years (range, 12-24 years). Respondents were Caucasian (64.5%), Hispanic/Latino (19.9%), Asian (3.5%), African American (2.5%), and others (9.6%). Offenses included minor in possession (55.8%), driving under the influence (21.2%), and drunk in public (20.4%). Consumption at time of offense was one or less drinks in 36.3%, two to five drinks in 31.7%, and 32.0% reported six or more drinks. Social sources of alcohol (got it from someone else) were reported by 72.9% and commercial sources (bought it or took it from a store) were reported in 11.9%. The two most common places of consumption were someone else's home (30.7%) and the beach (14.6%). Multiple 1-year high-risk behaviors were reported and 41.0% drove after drinking or rode with someone else who had been drinking. Binge drinking (5 or more drinks for males; 4 or more drinks for females) was reported by 43.1% of males and 36.7% of females. All high-risk behaviors were more common in binge drinkers (p < 0.001). Drinking and driving or riding with a drinking driver was reported in 54.2% of those who binged. Females who binged reported a higher rate than males in 8 of 10 high-risk behaviors.
This study revealed the predominance of social sources of alcohol among young first-time alcohol offenders. Drinking and driving or riding with a drinking driver was reported at an alarmingly high rate. Other alcohol-related high-risk behaviors were also common. Efforts to prevent alcohol-related trauma should target social access to alcohol, the resulting high-risk behaviors, and include a special focus on young females.
The Journal of trauma 09/2009; 67(3):498-502. · 2.48 Impact Factor
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ABSTRACT: The Eastern Association for the Surgery of Trauma Practice Management Guidelines identify indications (EI) for early intubation. However, EI have not been clinically validated. Many intubations are performed for other discretionary indications (DI). We evaluated early intubation to assess the incidence and outcomes of those performed for both EI and DI.
One thousand consecutive intubations performed in the first 2 hours after arrival at our Level I trauma center were reviewed. Indications, outcomes, and trauma surgeon (TS) intubation rates were evaluated.
During a 56-month period, 1,000 (9.9%) of 10,137 trauma patients were intubated within 2 hours of arrival. DI were present in 444 (44.4%) and EI in 556 (55.6%). DI were combativeness or altered mental status in 375 (84.5%), airway or respiratory problems in 21 (4.7%), and preoperative management in 48 (10.8%). Injury Severity Score was 14.6 in DI patients and 22.7 in EI patients (p < 0.001). Predicted versus observed survival was 96.6% versus 95.9% in DI patients and 75.2% versus 75.0% in EI patients (p < 0.001). Head Abbreviated Injury Scale score of >or=3 occurred in 32.7% with DI and 52.0% with EI (p < 0.001). Seven (0.7%) surgical airways were performed; two for DI (0.2%). Eleven (1.1%) patients aspirated during intubation and five (0.5%) suffered oral trauma. There were no other significant complications of intubation for either DI or EI and complication rates were similar in the two groups. Delayed intubation (early intubation after leaving the trauma bay) was required in 67 (6.7%) patients and 59 (88.1%) were for combativeness, neurologic deterioration, or respiratory distress or airway problems. Intubation rates varied among TS from 7.6% to 15.3% (p < 0.001) and rates for DI ranged from 3.3% to 7.4% (p < 0.001). There was a statistically insignificant trend among TS with higher intubation rates to perform fewer delayed intubations.
Early intubation for EI as well as DI was safe and effective. One third of the DI patients had significant head injury. Surgical airways were rarely needed and delayed intubations were uncommon. The intubation rates for EI and DI varied significantly among TSs. The Eastern Association for the Surgery of Trauma Guidelines may not identify all patients who would benefit from early intubation after injury.
The Journal of trauma 02/2009; 66(1):32-9; discussion 39-40. · 2.48 Impact Factor
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ABSTRACT: Patients who undergo emergency craniotomy for head injury require vigilant postoperative (postop) care to obtain the best possible outcome. Although repeat head computed tomography (CT) scans are a key component of the management of these patients, there is no consensus on the optimal timing of the initial postop CT.
We conducted a retrospective registry-based review of the care of 199 consecutive trauma patients who underwent craniotomy for head injury at a Level I trauma center to evaluate the role of postop CT in their management.
One hundred and ninety-nine patients underwent 218 craniotomies for head injury during the 78-month study period. Mean age was 48 years and 73.9% were men. Overall survival was 71.4%. The primary indication for operation included subdural hematoma (SDH) in 136 (62.4%), epidural hematoma (EDH) in 32 (14.7%), intraparenchymal hemorrhage or contusion in 21 (9.6%), depressed skull fracture in 17 (7.8%), and other indications in 12 (5.5%). Postop CTs were obtained after 197 (90.4%) of the operations at a mean of 19.2 hours and revealed a variety of unexpected findings with clinical implications. The only variable statistically associated with unexpected findings was SDH as an indication for operation (p < 0.01). Fourteen (7.0%) patients required a second craniotomy in the 2 days after their initial operation. In six (3.0%) patients, postop CTs were obtained between 4.2 hours and 21.1 hours after initial craniotomy and an earlier postop CT would most likely have prevented a significant delay in operation. Findings in these six patients included recurrent SDH or EDH in two, new SDH or EDH in two, and intraparenchymal hemorrhage in two. Neither neurologic examination nor postop intracranial pressure monitoring reliably predicted the presence of new or recurrent hemorrhage or other significant findings.
Early, if not immediate, postop CT after emergency craniotomy for head trauma appears to be warranted. We found a significant incidence of unexpected findings on postop CT and encountered avoidable delays in treatment of new or recurrent findings.
The Journal of trauma 03/2008; 64(2):326-33; discussion 333-4. · 2.48 Impact Factor
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ABSTRACT: Methamphetamine (METH) use is associated with high-risk behavior and serious injury. The aim of this study was to assess the impact of METH use in trauma patients on a Level I trauma center to guide prevention efforts.
A retrospective registry-based review of 4,932 consecutive trauma patients who underwent toxicology screening at our center during a 3-year period (2003-2005). This sample represented 76% of all trauma patients seen during this interval.
From the first half of 2003 to the second half of 2005, overall use of METH increased 70% (p < 0.001), surpassing marijuana as the most common illicit drug used by the trauma population. Other illicit drug use did not significantly change during this interval. METH-positive patients were more likely to have a violent mechanism of injury (47.3% vs. 26.3%, p < 0.001), with 33% more assaults (p < 0.01), 96% more gunshot wounds (p < 0.001), and 158% more stab wounds (p < 0.001). They were more likely to have attempted suicide (4.8% vs. 2.6%, p < 0.01), to have had an altercation with law enforcement (1.8% vs. 0.3%, p < 0.001), or been the victim of domestic violence (4.4% vs. 2.1%, p < 0.001). METH users had a higher mean Injury Severity Score (11.2 vs. 10.0, p < 0.01), were 62% more likely to receive mechanical ventilation (p < 0.001), and 53% more likely to undergo an operation (p < 0.001). They were more prone to leave against medical advice (4.9% vs. 2.1%, p < 0.001) and 113% more likely to die from their injuries (6.4% vs. 3.0%, p < 0.001). The average cost of care per METH user was 9% higher than that for nonusers, and METH users were more likely to be unfunded than nonusers (47.6% vs. 23.1%, p < 0.001). The annual uncompensated cost of care of METH users increased 70% during the study period to $1,477,108 in 2005.
METH use in trauma patients increased significantly and was associated with adverse outcomes and a significant financial burden on our trauma center. Evidence-based prevention efforts must be a priority for trauma centers to help stop the scourge of METH.
The Journal of trauma 10/2007; 63(3):531-7. · 2.48 Impact Factor
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ABSTRACT: The evaluation of patients with head, neck, and torso trauma frequently includes high-definition spiral computed tomography (SCT) scanning, which can reveal non-injury-related lesions. These incidental findings vary in their importance, from trivial lesions to findings that may have a greater impact on the health of the trauma patient than the injuries that led to the SCT. We evaluated the incidence and clinical importance of incidental findings found on SCT, and the effectiveness of a trauma practice guideline calling for appropriate management and follow-up.
The trauma registry was accessed to identify patients evaluated at an urban Level I trauma center from January to November, 2002. Trauma registry data, inpatient chart records, and the digital record of the filmless radiology archives were reviewed. Demographic data, including age, sex, type and mechanism of injury, and outcome, were recorded. All CT studies were reviewed for incidental findings. Mucus retention cysts, sinusitis (except mastoiditis), degenerative joint disease, evidence of previous operation, and age-related cerebral atrophy were excluded. Incidental findings were divided into three categories based on clinical importance. Category 1 required attention before discharge. Category 2 required follow-up with primary doctor within 1 or 2 weeks, and Category 3 required no specific follow-up. Categories 1 and 2 were considered clinically significant findings.
Complete data were available for 991 patients (677 men, 314 women). Eight hundred and forty-eight (85.6%) patients received at least one CT scan. A total of 289 incidental findings were discovered. Thirty-one patients (3.1%) had 36 Category 1 findings. There were 108 Category 2 and 145 Category 3 findings. When comparing those patients with at least one incidental finding, the incidence of incidental findings was higher in women than in men (34.1% versus 27.6%; p < 0.05). Older patients also had a higher incidence of all categories of findings (over 40 versus 40 and younger: 46.1% versus 19.9%; p < 0.001). SCT yielded 90 (62.5%) of the clinically significant incidental findings in the abdomen/pelvis, 29 (20.1%) in the chest, and 25 (17.4%) in the head and neck. The charts of only 15 (48.4%) of the patients with Category 1 findings adequately documented the management of the incidental finding.
SCT for the evaluation of trauma patients reveals a significant number of incidental findings. These lesions are common in the abdomen and pelvis and show an increased incidence in women and among older patients. Although many require early follow-up and specialty physician referral, there was insufficient documentation of the management of these injuries. Incidental findings in the injured remain a significant challenge for trauma centers. An organized approach is required for successful follow-up and management.
The Journal of trauma 01/2007; 62(1):157-61. · 2.48 Impact Factor
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ABSTRACT: Most trauma surgeons are unfamiliar with screening, brief intervention, and referral (SBIR) programs for substance use disorders, and few trauma centers provide them. This report describes how an urban private-teaching hospital adapted a protocol from an existing emergency department-based program to include patients treated by the trauma service.
We recorded the rates of SBIR completion and reasons for failure during each phase of the implementation, interviewed trauma service staff and health educators to assess attitudes toward the program, and evaluated patient satisfaction surveys.
By adding SBIR staff to the trauma outpatient clinic and to trauma morning rounds, the capture rate increased from 12 to 71%. Most screened patients (59%) were found at risk for problems or probably dependent on alcohol or drugs. Trauma service staff and health educators reported high satisfaction with the program. Patients reported higher satisfaction with SBIR.
SBIR services can be effectively integrated into all components of a busy, urban trauma service by adding specially trained health educators to the trauma service staff. This collaboration provides effective SBIR services to both trauma and emergency service patients without interfering with patient flow or medical procedures. The relatively high percentage of patients at risk for alcohol or drug problems supports the inclusion of routine alcohol and drug screening for all eligible trauma patients.
The Journal of trauma 10/2005; 59(3 Suppl):S112-8; discussion S124-33. · 2.48 Impact Factor
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ABSTRACT: Surgeons face difficult communication challenges with patients and their families. There is a need for improved education in communication skills, especially in giving bad news. Understanding surgeons' attitudes is the first step in designing effective education programs.
To determine surgeons' self-assessment of competence, rating of importance, and perceived need for training in communication skills relevant to patient care.
Anonymous self-report mail survey of demographic information and attitudes toward 12 patient care-related communication skills.
San Diego County, California, a geographically distinct area of close to 3 million inhabitants receiving health care from over 6000 physicians.
A total of 351 (43.4%) respondents from the 833 surgical specialists in the San Diego County Medical Society list of member and nonmember physicians.
Measurement of surgeons' attitudes toward self-perceived competence, importance, need for training in the communication skills, and the influence of age, duration of practice, and surgical-specialty on attitudes.
Most respondents rated their competence high except in 3 skills relating to a patient's death. They found all skills important and indicated a need for training in them. Younger surgeons rated their competence and the importance significantly lower in the 3 skills relating to a patient's death (p < 0.05). Critical care surgical specialists rated their competence and the importance higher in skills relating to breaking bad news and a patient's death than did the non-critical care group (p < 0.05). Older surgeons and critical care specialists also indicated a higher level of support for training in these skills.
These results suggest that surgical specialists rate themselves as competent in effective communication, believe in its importance, and agree with the need for training. An organized approach to training in interaction skills, especially in giving bad news, is warranted.
Current Surgery 63(3):213-8.
