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Background Despite current best practices, pressure injuries (PI) remain a devastating and prevalent hospital-acquired complication for patients with acute traumatic spinal cord injuries (SCIs). This study examined associations between risk factors for PI development in patients with complete SCI, such as norepinephrine dose and duration, and other demographic factors or lesion characteristics. Methods This case–control study included adults with acute complete SCIs ASIA-A, who were admitted to a level-one trauma center between 2014–18. A retrospective review was implement using data on patient and injury characteristics, including age, gender, level of SCI (cervical vs. thoracic), Injury Severity Score (ISS), length of stay (LOS) and mortality; presence/absence of PI during their acute hospital stay; and treatment factors such as spinal surgery, mean arterial pressure (MAP) targets, and vasopressor treatment. Multivariable logistic regression evaluated associations with PI. Results Eighty-two out of 103 eligible patients had complete data, and 30 (37%) developed PIs. Patient and injury characteristics, including age (Mean: 50.6; SD:21.3), location of SCI (48 cervical, 59%) and ISS (Mean 33.1; SD:11.8), did not differ between PI and non-PI groups. Logistic regression analysis revealed that male gender (OR:34.1; CI95:2.3–506.5, p = 0.010) and increased LOS (log-transformed; OR:20.5, CI95:2.8–149.9, p = 0.003) were associated with increased risk of PI. Having an order for a MAP > 80mmg (OR:0.05; CI95:0.01–0.30, p = 0.001) was associated with a reduced risk of PI. There were no significant associations between PI and duration of norepinephrine treatment. Conclusions Norepinephrine treatment parameters were not associated with development of PI, suggesting that MAP targets should be a focus for future investigations for SCI management. Increasing LOS should highlight the need for high-risk PI prevention and vigilance.

ObjectivesMilitary Forward Aeromedical Evacuation and civilian Helicopter Emergency Medical Services are widely used to conduct Primary Aeromedical Retrieval. Crew composition in Primary Aeromedical Retrieval missions varies considerably. The ideal composition is unknown. Thus, we conducted a descriptive systematic review on mortality and other outcomes for different Primary Aeromedical Retrieval crew compositions.MethodsMedline, Embase, and Cochrane Controlled Trials Register were searched up to January 2020. Results were reported per Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Studies of adult trauma air transported by different crews were included. Population, injury severity, crew composition, procedures, and outcomes, including mortality, were abstracted. Risk of bias was assessed using previously validated tools. A lack of reported effect measures precluded a quantitative analysis.ResultsSixteen studies met inclusion criteria (3 prospective studies, 1 case-control, and 12 retrospective). Overall, studies reported a mortality benefit associated with advanced health care providers. This was most apparent in patients with severe but survivable injuries. In this population, early rapid sequence induction, endotracheal intubation, mechanical ventilation, thoracostomies, blood products transfusion, and treatment of hemorrhagic shock are better performed by advanced providers and may improve outcomes. The quality of evidence reported a moderate risk of bias in the included studies.ConclusionsOverall, findings were divergent but showed a trend to decreased mortality in patients treated by advanced providers with interventions beyond the basic paramedic level. This trend was most significant in patients with severe but survivable injuries. These results should be cautiously interpreted because most studies were observational, had small sample sizes, and had a high potential for confounding factors.

Knee dislocations (KDs) are potentially devastating injuries, leading to loss of function or limb in often young patients. This retrospective database review aims to determine the relative incidence and risk factors for KDs presenting to North American Level I and II trauma centers. The National Trauma Data Bank (NTDB) was retrospectively interrogated using ICD-9-CM codes to identify KDs between 2010 and 2014 to derive KD incidence. KDs were stratified by age, sex, Injury Severity Score (ISS), Glasgow Coma Scale (GCS), drug and alcohol use, injury mechanism, open vs. closed KD, vascular injury and fracture. Each co-variate was tested against different mechanisms of injury, using Chi-squared tests and risk adjusted analyses to derive risk factors for KD. The same calculations were done for secondary outcomes (vascular and neurological injuries, compartment syndrome, amputation, and mortality). A total of 6454 KDs met the inclusion criteria (18/10,000 admissions). KDs occurred most commonly amongst men, aged 20–39, with an ISS score 1–14 and following motor vehicle collision (MVC). A vascular investigation was performed in 29%, with injury documented in 15% of KDs and 10.8% receiving a vascular procedure. Associated fractures were observed in 41.4% of KDs. Open injuries in 13.6%. Neurological injury documented in 6.2%, compartment syndrome in 2.7%, amputation in 3.8% (> 50% had vascular injury) and 2.8% died. MVC was the most common mechanism of injury (p

In patients with adhesive small bowel obstruction (aSBO), the decision to operate as well as the timing and technique of surgery have significant impacts on clinical outcomes. Trends in the management of aSBO have not been described at the population level and guideline adherence is unknown. We sought to evaluate the secular trends in the management of aSBO in a large North American population. We used administrative data to identify patients admitted to hospital for their first episode of aSBO over 2005–2014. We evaluated temporal trends in admission for aSBO and in management practices using Cochran-Armitage tests. Multivariable logistic regressions were used to assess trends when controlling for potential confounders. Patients (40,800) were admitted with their first episode of aSBO. The mean age was 68.5 years and 55% of patients were female. The population-based rate of admission for aSBO decreased over the study period, from 39.1 to 38.1 per 100,000 persons per year. There was a significant increase in the proportion of patients who underwent surgery for aSBO (19 to 23%, p

This review describes the evolution of quality improvement in trauma from the creation of the Committee on Trauma’s (COT) Optimal Hospital Resources for Care of the Injured Patient in 1976 to the National Trauma DataBank (NTDB) to the American College of Surgeons’ (ACS) Trauma Quality Improvement Program (TQIP). The national standardization of data collection for trauma patients through the National Trauma Data Standard (NTDS) and TQIP has allowed trauma centers to benchmark with their peers and focus quality improvement initiatives on areas of opportunity. TQIP provides enrolled hospitals with the data and educational resources they need to improve trauma care. This review describes the development of ACS TQIP and quality benchmarking in trauma. The ACS COT began its journey to improve the quality of trauma care by establishing standards for the optimal care of injured patients and verifying that centers had the necessary equipment, personnel, and processes in place. The standardization of data collection for seriously injured patients nationally now has allowed trauma centers to meaningfully measure patient outcomes. ACS TQIP has further advanced trauma care by providing participating centers with the resources they need to achieve quality improvement in trauma.

Background: Clinical handover between emergency medical services (EMS) and the hospital trauma team can be subject to errors that may negatively affect patient care. Thus far, there has been limited evaluation of the quality of EMS handover. As such, we sought to characterize handover practices from EMS to the trauma team, identify areas for improvement, and determine if there is a need for standardization of current handover practices. Aim Statement: Identify areas for improvement in handover from EMS to the trauma team, specifically examining handover content, structure, and discordances between different team members regarding handover expectations. Measures & Design: Data were prospectively collected over a nine week period by a trained observer at Canada's largest level one trauma centre. A randomized scheduled was used to capture a representative breadth of handovers. Data collected included outcome measures such as duration of handover, structure of the handover, and information shared, process measures such as questions and interruptions from the trauma team, and perceptions of the handover from nurses, trauma team leaders (TTLs) and EMS according to a bidirectional Likert scale. Evaluation/Results: Of 410 trauma team activations, 79 verbal handovers were observed. Information was often missing regarding airway (present 22%), breathing (54%), medications (59%), and allergies (54%). Handover structure lacked consistency beyond the order of identification and mechanism of injury. Only 28% of handovers had a dedicated question and answer period. Of all questions asked, 35% were questioning previously given information. EMS returned to categories of information unprompted in 84% of handovers. The majority of handovers (61%) involved parallel conversations between team members while EMS was speaking, which was associated with a greater number of interrupting questions from the trauma team (3.15 vs. 1.82, p =.001). There was a statistically significant disparity between the self-evaluation of EMS handovers and the perceived quality determined by nurses and trauma team leaders. Discussion/Impact: At our trauma centre, we have identified the need for handover standardization due to poor information content, a lack of structure and active listening, significant information repetition, and discordant expectations between EMS, nurses, and TTLs. We intend to use our results to guide the development of a co-constructed framework integrating the perspectives of all team members on the trauma team.

Innovation Concept: Effective communication for ad hoc teams is critical to successful management of multisystem trauma patients, to improve situational awareness and to mitigate risk of error. OBJECTIVES 1. Improve communication of ad hoc teams. 2. Identify system gaps. INNOVATION Team in situ simulations provide a unique opportunity to practice communication and assess systems in the real environment. Our trauma team consists of residents and staff from emergency services, general surgery, orthopedics, anaesthesia, nursing and respiratory therapy. Methods: A team of subject matter experts (SME's) from trauma, nursing, emergency medicine and simulation co-developed curriculum in response to a needs assessment that identified gaps in systems and team communication. The simulation occurred in the actual trauma bay. The on-call trauma team was paged and expected to manage a simulated multisystem trauma patient. Once the team arrived, they participated in a briefing, manikin-based simulation and a communication and system focused debriefing. Curriculum, Tool, or Material: Monthly scenarios consisted of management of a blunt trauma patient, emergency airway and massive hemorrhage protocol. Teams were assessed on communication skills and timeliness of interventions. Debriefing consisted of identification of system gaps and latent safety threats. Feedback was given by each discipline followed by SME's. Information was gathered from participant evaluations (5-point Likert scale and open ended questions) and group debrief. Feedback was themed and actions taken to co-create interventions to communication gaps and latent safety threats. As a result, cricothyroidotomy trays were standardized throughout the hospital to mitigate confusion, time delay and unfamiliarity during difficult airway interventions. Participants felt the exercise was an effective means of practicing interprofessional communication and role clarity, and improved their attitude towards the same. Conclusion: In situ simulation-based education with ad hoc trauma teams can improve interprofessional communication and identify latent safety threats for the management of multisystem trauma patients.

Background: Massive hemorrhage protocols (MHPs) streamline the complex logistics required for prompt care of the bleeding patient, but their uptake has been variable and few regions have a system to measure outcomes from these events. Aim Statement: We aim to implement a standardized MHP with uniform quality improvement (QI) metrics to increase uptake of evidence-based MHPs across 150-hospitals in Ontario between 2017 and 2021. Measures & Design: We performed ongoing PDSA cycles; 1) stakeholder analysis by surveying the Ontario Regional Blood Coordinating Network (ORBCoN), 2) problem characterization and Ishikawa analysis for key QI metrics based on areas of MHP variability in 150 Ontario hospitals using a web-based survey, 3) creation of a consensus MHP via a modified Delphi process, 4) problem characterization at ORBCoN for the design of a freely available toolkit for provincial implementation by expert working groups, 5) design of 8 key QI metrics by a modified Delphi process, and 6) identification of process measures for QI data collection by implementation metrics. Evaluation/Results: PDSA1-2; 150-hospitals were surveyed. 33% of hospitals lacked MHPs, mostly in smaller sites. Major areas for QI were related to activation criteria, hemostatic agents, protocolized hypothermia management, variable MHP naming, QI metrics and serial blood work requirements. PDSA3; 3 Delphi rounds were held to reach 100% expert consensus for 42 statements and 8 CQI metrics. Major areas for modification were protocol name, laboratory resuscitation targets, cooler configurations, and role of factor VIIa. PDSA4; adaptable toolkit is under development by the steering committee and expert working groups. Implementation is scheduled for Spring 2020. PDSA5; the 8 CQI metrics are: TXA administration < 1 h, RBC transfusion < 15 min, call to transfer for definitive care < 60 min, temp >35°C at end of protocol, Hgb kept between 60-110g/L, transition to group-specific RBC by 90 min, appropriate activation defined by ≥6 units RBC in the first 24 hours, and any blood component wastage. Discussion/Impact: MHP uptake, content, and tracking is variable. A standardized MHP that is adaptable to diverse settings decreases complexity, improves use of evidence-based practices, and provides a platform for continuous QI. PDSA6 will occur after implementation; we will complete an implementation survey, and design a pilot and feasibility study for prospective tracking of patient outcomes using existing prospectively collected inter-hospital and provincial databases.

Choledocholithiasis is commonly treated initially with endoscopic sphincterotomy, followed by cholecystectomy to definitively address the underlying problem of cholelithiasis. While the benefits of early cholecystectomy have been realized in other populations, the preferred timing for this subset of patients is less well established. We performed a large, population-based analysis to determine the frequency, benefits, and practice variance in regard to early cholecystectomy on a provincial level. Patients undergoing endoscopic sphincterotomy followed by cholecystectomy in British Columbia, Canada, from January 2001 to December 2011 were identified using fee-code billing data. Multiple databases were linked to obtain information on demographics, admissions, procedures, mortality, and census geographic data. Regression analysis was performed for length of stay (LOS) and additional procedures. Outcome data were risk adjusted for age, gender, comorbidities, socioeconomic status, and year of procedure. Variability of early cholecystectomy crude rates across census areas was determined using a funnel plot. There were 4287 eligible patients. Of these, 1905 (44.4%) underwent early cholecystectomy, defined as surgery within 14 days of sphincterotomy. Median interval to cholecystectomy was 2 days for the early cholecystectomy group and 61 days for delayed. There was a significant difference in hospital LOS favoring early cholecystectomy for patients with documented gallstone disease (p

The optimal timing of tracheostomy placement in acutely brain-injured patients, who generally require endotracheal intubation for airway protection rather than respiratory failure, remains uncertain. We systematically reviewed trials comparing early tracheostomy to late tracheostomy or prolonged intubation in these patients. We searched 5 databases (from inception to April 2015) to identify randomized controlled trials comparing early tracheostomy (≤10 days of intubation) with late tracheostomy (>10 days) or prolonged intubation in acutely brain-injured patients. We contacted the principal authors of included trials to obtain subgroup data. Two reviewers extracted data and assessed risk of bias. Outcomes included long-term mortality (primary), short-term mortality, duration of mechanical ventilation, complications, and liberation from ventilation without a tracheostomy. Meta-analyses used random-effects models. Ten trials (503 patients) met selection criteria; overall study quality was moderate to good. Early tracheostomy reduced long-term mortality (risk ratio [RR] 0.57. 95 % confidence interval (CI), 0.36–0.90; p = 0.02; n = 135), although in a sensitivity analysis excluding one trial, with an unclear risk of bias, the significant finding was attenuated (RR 0.61, 95 % CI, 0.32–1.16; p = 0.13; n = 95). Early tracheostomy reduced duration of mechanical ventilation (mean difference [MD] −2.72 days, 95 % CI, −1.29 to −4.15; p = 0.0002; n = 412) and ICU length of stay (MD −2.55 days, 95 % CI, −0.50 to −4.59; p = 0.01; n = 326). However, early tracheostomy did not reduce short-term mortality (RR 1.25; 95 % CI, 0.68–2.30; p = 0.47 n = 301) and increased the probability of ever receiving a tracheostomy (RR 1.58, 95 % CI, 1.24–2.02; 0

Background Traumatic brain injury (TBI) is a heterogeneous syndrome with a broad range of outcome. We developed a simple model for long-term outcome prognostication after severe TBI. Methods Secondary data analysis of a large multicenter randomized trial. Patients were grouped according to 6-month extended Glasgow outcome scale (eGOS): poor-outcome (eGOS ≤ 4; severe disability or death) and acceptable outcome (eGOS > 4; no or moderate disability). A prediction decision tree was built using binary recursive partitioning to predict poor or acceptable 6-month outcome. Comparison to two previously published and validated models was made. Results The decision tree included the predictors of head Abbreviated Injury Scale (AIS) severity, the Marshall computed tomography score, and pupillary reactivity. All patients with a head AIS severity of 5 were predicted to have a poor outcome. In patients with head AIS severity

Introduction: BACKGOUND In the modern era of terrorism and senseless violence, it is essential that hospital staff have expertise in implementation of a mass casualty incident (MCI) plan. OBJECTIVES 1. To assess current gaps in implementation of an academic urban hospital code orange plan using live simulation and tabletop exercise. 2. To identify and educate front-line staff to champion a hospital-wide MCI plan. INNOVATION Historically, in order to limit resource utilization and impact on patient care, disaster response training of front-line staff involved tabletop exercises only. The tenets of experiential learning suggest that learner engagement through realistic active practice of skills achieves deeper uptake of new knowledge. We enhanced the traditional tabletop approach through novel use of live actor patients presenting to an academic, urban emergency department (ED) during a hospital-wide MCI simulation. Methods: To assess the current code orange plan, an interprofessional, committee comprising expert leaders in trauma, emergency preparedness, emergency medicine and simulation integrated tabletop and live simulation to stage a MCI based on a mock incident at a new subway station. ED staff, the trauma team and champions from medicine, surgery and critical care participated along with support departments such as Patient Flow, Patient Transport, Environmental Services and the Hospital Emergency Operations Centre. Ten live actor patients and eight virtual patients presented to the ED. The exercise occurred in situ in the ED. Other participating departments conducted tabletop exercises and received live actor patients. Results: CURRICULUM Staff decanted the ED and other participating units using their current knowledge of hospital code orange policy. Live and virtual patients were triaged and managed according to severity of injuries. Live actor patients were assessed, intervened and transported to their designated unit. Virtual patients were managed through verbal discussion with the simulation controllers. An ED debrief took place using a plus/delta approach followed by a hospital-wide debrief. Conclusion: CONCLUSION An interprofessional hospital-wide MCI simulation revealed important challenges such as communication, command and control and patient-tracking . The exercise ignited enthusiasm and commitment to longitudinal practice and improvement for identified gaps.

Background The Accreditation Council for Graduate Medical Education resident work hour limitations were implemented in July, 2003. Effects on faculty are not well understood.

Both acute pancreatitis and severe trauma induce a systemic sterile inflammatory process which leads to a high incidence of remote organ dysfunction and death. Several attributes of these two entities make them ideal for evaluation of the effects of mediator-directed therapy. The rationale and evidence for mediator-directed therapy in pancreatitis and trauma are reviewed. In pancreatitis, organ dysfunction and death are best prevented using strategies designed to limit the inflammatory response, particularly IL-1a and IL-10. By contrast, the sequelae of a post-traumatic systemic inflammatory response are best mitigated using strategies designed to limit neutrophil adhesion.

The objective of this study was to define risk factors for and the clinical course of recurrent or tertiary peritonitis. Intensive supportive care of patients with life-threatening intraabdominal infections has led to the emergence of a new clinical syndrome, tertiary peritonitis, defined as the persistence or recurrence of intraabdominal infection following apparently adequate therapy of primary or secondary peritonitis. We undertook a retrospective study of 59 patients admitted with intraabdominal infection to a surgical intensive care unit (ICU). Tertiary peritonitis developed in 74% (44/59) of patients. Despite comparable premorbid health status, source of peritonitis, and admission APACHE II scores, patients with tertiary peritonitis had a significantly longer ICU stay (21.8 +/- 14.9 vs. 8.5 +/- 7.9 days), more advanced organ dysfunction reflected in higher organ dysfunction scores (13.3 +/- 5.1 vs. 7.7 +/- 3.3), and higher ICU mortality (64% vs. 33%) than patients with uncomplicated secondary peritonitis. The most common infecting organisms in patients with tertiary peritonitis were Enterococcus, Candida, Staphylococcus epidermidis, and Enterobacter. Infectious foci were rarely amenable to percutaneous drainage and were found to be poorly localized at laparotomy. Recurrent, or tertiary, peritonitis is a common complication of intraabdominal infection in patients admitted to an ICU. It differs from uncomplicated secondary peritonitis in its microbial flora and lack of response to appropriate surgical and antibiotic therapy. Like nosocomial pneumonia in the critically ill patient, the syndrome appears to be more a reflection than a cause of adverse outcome.

Progress in the care of the critically ill patient with life-threatening infection has been hampered by inconsistent, often confusing terminology. The clinical syndrome of sepsis-familiar to all yet definable by none-describes a highly heterogeneous group of disorders with different causes and differing prognoses. The imminent availability of mediator-directed therapy has created a sense of urgency to develop better methods for delineating discrete clinical syndromes and to modulate the host response, which may bring both benefit and harm, depending on the clinical circumstances. The term systemic inflammatory response syndrome (SIRS) was introduced several years ago to describe the familiar clinical syndrome of sepsis, independent of its cause. SIRS can result from trauma, pancreatitis, drug reactions, autoimmune disease, and a host of other disorders; when it arises in response to infection, sepsis is said to be present. SIRS describes a dynamic process that has adaptive survival value for the host. The maladaptive consequence of this process in the critically ill patient is the development of progressive but potentially reversible remote organ dysfunction-the multiple organ dysfunction syndrome. The development of cogent conceptual frameworks for classification of the septic response in critically ill patients is more than a question of linguistic pedantry. Optimal therapy presupposes identification of an homogeneous patient population with a characteristic disease process and a predictable response to an intervention. Although progress has been made in identifying such groups of critically ill patients, the disappointing results of clinical trials of agents that so clearly demonstrate efficacy in animal models indicates that considerable work remains.