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Summary: Background: The inflammatory response in patients with traumatic brain injury (TBI) offers opportunities for stratification and intervention. Previous unselected approaches to immunomodulation in patients with TBI have not improved patient outcomes. Methods: Serum and plasma samples from two prospective, multi-centre observational studies of patients with TBI were used to discover (Collaborative European NeuroTrauma Effectiveness Research [CENTER-TBI], Europe) and validate (Transforming Research and Clinical Knowledge in Traumatic Brain Injury [TRACK-TBI] Pilot, USA) individual variations in the immune response using a multiplex panel of 30 inflammatory mediators. Mediators that were associated with unfavourable outcomes (Glasgow outcome score-extended [GOS-E] ≤ 4) were used for hierarchical clustering to identify patients with similar signatures. Findings: Two clusters were identified in both the discovery and validation cohorts, termed early-inflammatory and pauci-inflammatory. The early-inflammatory phenotype had higher concentrations of interleukin-6 (IL-6), IL-15, and monocyte chemoattractant protein 1 (MCP1). Patients with the early-inflammatory phenotype were older and more likely to have an unfavourable GOS-E at 6 months. There were no differences in the baseline injury severity scores between patients in each phenotype. A combined IL-15 and MCP1 signature identified patients with the early-inflammatory phenotype in both cohorts. Inflammatory processes mediated outcomes in older patients with moderate-severe TBI. Interpretation: Our findings offer a precision medicine approach for future clinical trials of immunomodulation in patients with TBI, by using inflammatory signatures to stratify patients. Funding: CENTER-TBI study was supported by the European Union 7th Framework Programme. TRACK-TBI is supported by the National Institute of Neurological Disorders and Stroke.

The use of UCH-L1 detection with point-of-care (POC) assay alone has not been characterized for clinical use. This study compares the accuracies of POC UCH-L1 and Neuron-Specific Enolase (NSE) Elecsys® levels for identifying TBI patients with structural abnormalities on neuroimaging.The Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) Phase 1 Cohort, enrolled 1375 TBI patients (GCS 3–15) presenting to one of 18 US Level I trauma centers within 24 h of injury who had an admission head CT; blood samples were collected, along with 122 orthopedic and 209 healthy controls. The TBI cohort consisted of 810 CT-negative (CT-) and 549 CT-positive (CT+) subjects. Of the CT- subjects who had MRIs, 121 were MRI-positive (MRI+) and 333 were MRI-negative (MRI-). UCH-L1 POC showed best diagnostic performance for CT + versus CT-, 0–8 h post-injury with an AUC of 0·779 [0·708–0.850] when compared to the 0–25 h interval, with an AUC of 0.684 [0.655–0.712]. NSE assay has an AUC of 0.695 [0.619–0.770] for the 0–8 h interval and 0.634 [0.603–0.665] for the 0–25 h interval. During the first 8 after injury, POC UCH-L1 outperforms NSE in identifying TBI patients with structural abnormalities on neuroimaging.

Abstract Background Medication errors account for the most common adverse events and a significant cause of mortality in the USA. The Joint Commission has required medication reconciliation since 2006. We aimed to survey the literature and determine the challenges and effectiveness of medication reconciliation in the trauma patient population. Materials and methods We conducted a systematic review of the literature to determine the effectiveness of medication reconciliation in trauma patients. English language articles were retrieved from PubMed/Medline, CINAHL, and Cochrane Review databases with search terms “trauma OR injury, AND medication reconciliation OR med rec OR med rek, AND effectiveness OR errors OR intervention OR improvements.” Results The search resulted in 82 articles. After screening for relevance and duplicates, the 43 remaining were further reviewed, and only four articles, which presented results on medication reconciliation in 3041 trauma patients, were included. Two were retrospective and two were prospective. Two showed only 4% accuracy at time of admission with 48% of medication reconciliations having at least one medication discrepancy. There were major differences across the studies prohibiting comparative statistical analysis. Conclusions Trauma medication reconciliation is important because of the potential for adverse outcomes given the emergent nature of the illness. The few articles published at this time on medication reconciliation in trauma suggest poor accuracy. Numerous strategies have been implemented in general medicine to improve its accuracy, but these have not yet been studied in trauma. This topic is an important but unrecognized area of research in this field.

Introduction: Healthcare systems often expose patients to significant, preventable harm causing an estimated 44,000 to 98,000 deaths or more annually. This has propelled patient safety to the forefront, with reporting systems allowing for the review of local events to determine their root causes. As residents engage in a substantial amount of patient care in academic emergency departments, it is critical to use these safety event reports for resident-focused interventions and educational initiatives. This study analyzes reports from the Virginia Commonwealth University Health System to understand how the reports are categorized and how it relates to opportunities for resident education. Methods: Identifying categories from the literature, three subject matter experts (attending physician, nursing director, registered nurse) categorized an initial 20 reports to resolve category gaps and then 100 reports to determine inter-rater reliability. Given sufficient agreement, the remaining 400 reports were coded individually for type of event and education among other categories. Results: After reviewing 513 events, we found that the most common event types were issues related to staff and resident training (25%) and communication (18%), with 31% requiring no education, 46% requiring directed educational feedback to an individual or group, 20% requiring education through monthly safety updates or meetings, 3% requiring urgent communication by email or in-person, and

Background: Residencies are grappling with ways to identify methods to internally monitor and improve their learning environments. Building on prior work, the objective of this study was to determine emergency medicine (EM) internal evaluations of perceived organizational support and psychological safety and compare to the results from the Accreditation Council for Graduate Medical Education (ACGME) Resident Survey for the purpose of program improvement and to explore factors affecting residents' perception of their learning environment., Methods: In 2017, the Virginia Commonwealth University School of Medicine Office of Graduate Medical Education and Office of Quality and Safety conducted an in-person, anonymous safety survey of the residents across 19 residency programs on the Short Survey of Perceived Organizational Support (SPOS) and Psychological Safety Scale (PSS). These were compared to the ACGME Resident Survey for 19 programs. Resident interviews and open response evaluation data informed content analysis on program experiences., Results: Institutional response rates were 63% for the internal learning environment survey and 96% for ACGME Resident Safety Survey. EM residents responded positively on the SPOS and PSS compared to other programs (ranked second highest scores on both scales). One-hundred percent of respondents agreed or strongly agreed on SPOS items: "Help is available from my department when I have a problem." "My department really cares about my well-being." "My department values my contribution to its well-being." Furthermore, EM had the highest overall training experience score (mean = 4.83) on the ACGME survey compared to the 18 other training programs. Qualitative responses suggest program strengths included supportive program leadership, positive working relationships with faculty, and emphasis on trainee wellness., Conclusions: Compared to other programs, EM has created a positive environment of safety and support as perceived by their residents. Internal surveys of the learning environment can help programs understand their culture for purposes of improvement and align with the ACGME survey.