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State regulations have decreased prescribed opioids with more than 25% of patients abstaining from opioids. Despite this, 2 distinct populations of patients exist who consume "high" or "low" amounts of opioids. The aim of this study was to identify factors associated with postoperative opioid use after common surgical procedures and develop an opioid risk score.Patients undergoing 35 surgical procedures from 7 surgical specialties were identified at a 620-bed tertiary care academic center and surveyed 1 week after discharge regarding opioid use and adequacy of analgesia. Electronic medical record data were used to characterize postdischarge opioids, complications, demographics, medical history, and social factors. High opioid use was defined as75th percentile morphine milligram equivalents for each procedure. An opioid risk score was calculated from factors associated with opioid use identified by backward multivariate logistic regression analysis.A total of 1,185 patients were enrolled between September 2017 and February 2019. Bivariate analyses revealed patient factors associated with opioid use including earlier substance use (p0.001), depression (p = 0.003), anxiety (p0.001), asthma (p = 0.006), obesity (p = 0.03), migraine (p = 0.004), opioid use in the 7 days before surgery (p0.001), and 31 Clinical Classifications Software Refined classifications (p0.05). Significant multivariates included: insurance (p = 0.005), employment status (p = 0.005), earlier opioid use (odds ratio [OR] 2.38 [95% CI 1.21 to 4.68], p = 0.01), coronary artery disease (OR 0.38 [95% CI 0.16 to 0.86], p = 0.02), acute pulmonary embolism (OR 9.81 [95% CI 3.01 to 32.04], p0.001), benign breast conditions (OR 3.42 [95% CI 1.76 to 6.64], p0.001), opioid-related disorders (OR 6.67 [95% CI 1.87 to 23.75], p = 0.003), mental and substance use disorders (OR 3.80 [95% CI 1.47 to 9.83], p = 0.006), headache (OR 1.82 [95% CI 1.24 to 2.67], p = 0.002), and previous cesarean section (OR 5.10 [95% CI 1.33 to 19.56], p = 0.02). An opioid risk score base was developed with an area under the curve of 0.696 for the prediction of high opioid use.Preoperative patient characteristics associated with high opioid use postoperatively were identified and an opioid risk score was derived. Identification of patients with a higher need for opioids presents an opportunity for improved preoperative interventions, the use of nonopioid analgesic therapies, and alternative therapies.

Background Unplanned ICU admissions (up-ICUad) are associated with poor outcomes. It is difficult to identify who is at risk for up-ICUad in trauma patients. This study aimed to identify injury patterns and comorbidities associated with up-ICUad and develop a predictive tool for who is at risk. Methods A retrospective study compared trauma patients admitted to the floor who experienced an up-ICUad to similar patients without an up-ICUad. Univariate analysis and multivariate logistic regression identified independent risk factors associated with up-ICUad. Based on those factors, a Risk Score (RS) was created and compared between the two groups. Results 2.15% of the 7206 patients experienced an up-ICUad. The up-ICUad group was older, experienced longer length of stay, and had higher mortality. Age, congestive heart failure, COPD, peptic ulcer disease, mild liver disease, CKD, and significant injuries to the thorax, spine, and lower extremities were independently associated with up-ICUad. A RS equation was created and was used for each patient. Conclusions Trauma patients are at increased risk for up-ICUad based on specific factors. These factors can be used to calculate a RS to determine who is at greatest risk for an up-ICUad which may be helpful for preventing up-ICUad.

BACKGROUND Acute care surgery (ACS) model of care delivery has many benefits. However, since the ACS surgeon has limited control over the volume, timing, and complexity of cases, traditional metrics of operating room (OR) efficiency almost always measure ACS service as "inefficient." The current study examines an alternative method-performance fronts-of evaluating changes in efficiency and tests the following hypotheses: (1) in an institution with a robust ACS service, performance front methodology is superior to traditional metrics in evaluating OR throughput/efficiency, and (2) introduction of an ACS service with block time allocation will improve OR throughput/efficiency. METHODS Operating room metrics 1-year pre-ACS implementation and post-ACS implementation were collected. Overall OR efficiency was calculated by mean case volumes for the entire OR and ACS and general surgery (GS) services individually. Detailed analysis of these two specific services was performed by gathering median monthly minutes-in block, out of block, after hours, and opportunity unused. The two services were examined using a traditional measure of efficiency and the "fronts" method. Services were compared with each other and also pre-ACS implementation and post-ACS implementation. RESULTS Overall OR case volumes increased by 5% (999 ± 50 to 1,043 ± 46: p 0.05). The alternative fronts chart demonstrated the more accurate picture with improved efficiency observed for GS, ACS, and combined. CONCLUSION In an institution with a busy ACS service, the alternative fronts methodology offers a more accurate evaluation of OR efficiency. The provision of an OR for the ACS service improves overall throughput/efficiency.

Background Care at verified trauma centers has improved survival and functional outcomes, yet determining the appropriate location of potential trauma centers is often driven by factors other than optimizing system-level patient care. Given the importance of transport time in trauma, we analyzed trauma transport patterns in a rural state lacking an organized trauma system and implemented a geographic information system to inform potential future trauma center locations. Study Design Data were collected on trauma ground transport during a 3-year period (2014 through 2016) from the Statewide Incident Reporting Network database. Geographic information system mapping and location-allocation modeling of the best-fit facility for trauma center verification was computed using trauma transport patterns, population density, road network layout, and 60-minute emergency medical services transport time based on current transport protocols. Results Location-allocation modeling identified 2 regional facilities positioned to become the next verified trauma centers. The proportion of the Vermont population without access to trauma center care within 60 minutes would be reduced from the current 29.68% to 5.81% if the identified facilities become verified centers. Conclusions Through geospatial mapping and location-allocation modeling, we were able to identify gaps and suggest optimal trauma center locations to maximize population coverage in a rural state lacking a formal, organized trauma system. These findings could inform future decision-making for targeted capacity improvement and system design that emphasizes more equitable access to trauma center care in Vermont.

OBJECTIVE: Risk factors for mortality in patients with subdural hematoma (SDH) include poor Glasgow Coma Scale (GCS), pupil non-reactivity, and hemodynamic instability on presentation. Little is published regarding prognosticators of SDH in the elderly. This study aims to examine risk factors for hospital mortality and withdrawal of life-sustaining measures in an octogenarian population presenting with SDH. METHODS: A prospectively collected multi-center database of 3,279 TBI admissions to 45 different U.S. trauma centers between 2017–2019 was queried to identify patients >79 years old presenting with SDH. Factors collected included baseline demographic data, past medical history, antiplatelet/anticoagulant use, and clinical presentation (GCS, pupil reactivity, injury severity scale [ISS]). Primary outcome data included hospital mortality/discharge to hospice care and withdrawal of life-sustaining measures. Multivariate logistic regression analyses were used to identify factors independently associated with primary outcome variables. RESULTS: A total of 695 patients were isolated for analysis. Of the total cohort, the rate of hospital mortality or discharge to hospice care was 22% (n=150) and the rate of withdrawal of life-sustaining measures was 10% (n=66). A multivariate logistic regression model identified GCS 80 years with SDH. Pre-existing CHF may further predict withdrawal of life-sustaining measures.

BackgroundThe Brain Trauma Foundation (BTF) Guidelines for the Management of Severe Traumatic Brain Injury (TBI) include intracranial pressure monitoring (ICPM), yet very little is known about ICPM in older adults. Our objectives were to characterize the utilization of ICPM in older adults and identify factors associated with ICPM in those who met the BTF guidelines.MethodsWe analyzed data from the American Association for the Surgery of Trauma Geriatric TBI Study, a registry study conducted among individuals with isolated, CT-confirmed TBI across 45 trauma centers. The analysis was restricted to those aged ≥60. Independent factors associated with ICPM for those who did and did not meet the BTF guidelines were identified using logistic regression.ResultsOur sample was composed of 2303 patients, of whom 66 (2.9%) underwent ICPM. Relative to Glasgow Coma Scale (GCS) score of 13 to 15, GCS score of 9 to 12 (OR 10.2; 95% CI 4.3 to 24.4) and GCS score of DiscussionWorsening GCS, intraparenchymal/intraventricular hemorrhage, and skull fractures were associated with ICPM among older adults with TBI, yet utilization of ICPM remains low, especially among those meeting the BTF guidelines, and potential benefits remain unclear. This study highlights the need for better understanding of factors that influence compliance with BTF guidelines and the risks versus benefits of ICPM in this population.Level of evidencePrognostic and epidemiological, level III.

BackgroundUnplanned intensive care unit (ICU) readmission—ICU bounce back (ICUbb)—is associated with worse outcomes. Patients not requiring organ system support or intensive nursing are deemed ‘ICU discharge ready’ and transfer orders are placed. However, actual transfer only occurs when an appropriate, non-ICU bed is available. This is dependent on inherent system inefficiencies resulting in a naturally controlled experiment between when patients actually transfer: Early (24 hours) transfers, after order placement. This study leverages that natural experiment to determine if additional ICU time is protective against ICUbb. We hypothesize that Delayed transfer is protective against ICUbb.MethodsUsing a retrospective, cohort design, we queried a trauma research repository and electronic medical record during a 10-year period to capture traumatized patients admitted to the ICU. Patients were categorized into Early (24 hours) groups based on actual transfer time after order placement. Patient characteristics (age, Charlson Comorbidity Index (CCI)) and Injury Severity Score (ISS) were analyzed. Univariate and multivariate analyses were performed to compare ICUbb rates among Early and Unintended-Delayed groups.ResultsOf the 2004 patients who met the criteria, 1690 fell into the Early group, and 314 fell into the Delayed. The Early group was younger (mean age 52±23 vs. 55±22 years), had fewer comorbidities (median CCI score 1 (0, 3) vs. 2 (1, 3)), and was less injured (median ISS 17 (10–22) vs. 17 (13–25)), all pDiscussionDespite higher age, CCI score, and ISS, the Unintended-Delayed group experienced fewer ICUbb. After controlling for age, CCI and ISS, Delayed transfer reduced ICUbb risk by 78%. Specific care elements affording this protection remain to be elucidated.Level of evidenceLevel III.Study typeTherapeutic study.

Critically evaluate the current evidence in evaluation of the cervical spine following trauma. Little has changed in the evaluation of the cervical spine following penetrating trauma. Significant advances have been made in the evaluation following blunt trauma. Recent research has focused on evaluating the accuracy of recent generation-computed tomographic (CT) scanners in excluding (or identifying) significant cervical spine injury. Secondly, recent literature has evaluated the utility of magnetic resonance imaging (MRI) in the evaluation of the cervical spine injury following blunt trauma. Current evidence supports (1) in an adult patient if a high-quality CT scan, interpreted by a trained neuro-radiologist, does not demonstrate any abnormal findings, significant cervical spine injury can be excluded and the collar safely removed; (2) MRI adds little to the evaluation if the CT scan is negative; and (3) MRI scan is helpful if a CT is equivocal or to plan therapy when the CT demonstrates injury.

Acute care surgery (ACS) model of care delivery has many benefits. However, since the ACS surgeon has limited control over the volume, timing, and complexity of cases, traditional metrics of operating room (OR) efficiency almost always measure ACS service as "inefficient." The current study examines an alternative method-performance fronts-of evaluating changes in efficiency and tests the following hypotheses: (1) in an institution with a robust ACS service, performance front methodology is superior to traditional metrics in evaluating OR throughput/efficiency, and (2) introduction of an ACS service with block time allocation will improve OR throughput/efficiency.Operating room metrics 1-year pre-ACS implementation and post-ACS implementation were collected. Overall OR efficiency was calculated by mean case volumes for the entire OR and ACS and general surgery (GS) services individually. Detailed analysis of these two specific services was performed by gathering median monthly minutes-in block, out of block, after hours, and opportunity unused. The two services were examined using a traditional measure of efficiency and the "fronts" method. Services were compared with each other and also pre-ACS implementation and post-ACS implementation.Overall OR case volumes increased by 5% (999 ± 50 to 1,043 ± 46: p0.05) with almost all of the increase coming through ACS (27 ± 4 to 68 ± 16: p0.05). By traditional metrics, ACS had significantly worse median efficiency versus GS in both periods: pre (0.67 [0.66-0.71] vs. 0.80 [0.78-0.81]) and post (0.75 [0.53-0.77] vs. 0.83 [0.84-0.85]) (p0.05). As compared with the pre, GS efficiency improved significantly in post (p0.05), but ACS efficiency remained unchanged (p0.05). The alternative fronts chart demonstrated the more accurate picture with improved efficiency observed for GS, ACS, and combined.In an institution with a busy ACS service, the alternative fronts methodology offers a more accurate evaluation of OR efficiency. The provision of an OR for the ACS service improves overall throughput/efficiency.

As trauma surgeons, we focus on the immediate care and needs of the injured patient every day. Historically, trauma and injury research has focused on outcomes such as mortality, complications, and length of stay; and process metrics such as time to CT scan, resuscitation checklist frequencies, or venous thromboembolism prophylaxis rates. These outcomes are perceived by healthcare providers to be important, but patients likely have different perceptions of what outcomes are most important to measure and improve. True patient-centered outcomes research involves the healthcare providers, and the entire team of stakeholders including patients and the community. Understanding the process of stakeholder engagement and the barriers trauma researchers must overcome to effectively enter this field of research is important. This summary aims to inform the trauma research community on the basics of patient-centered outcomes research, priorities for funding from the Patient-Centered Outcomes Research Institute, resources for collaboration around patient-centered outcomes research, and a unique career development and training opportunity for early career trauma surgeons to develop a skill set in patient-centered outcomes research.

Screening for blunt cerebrovascular injuries (BCVIs) in asymptomatic high-risk patients has become routine. To date, the length of this asymptomatic period has not been defined. Determining the time to stroke could impact therapy including earlier initiation of antithrombotics in multiply injured patients. The purpose of this study was to determine the time to stroke in patients with a BCVI-related stroke. We hypothesized that the majority of patients suffer stroke between 24 hours and 72 hours after injury.Patients with a BCVI-related stroke from January 2007 to January 2017 from 37 trauma centers were reviewed.During the 10-year study, 492 patients had a BCVI-related stroke; the majority were men (61%), with a median age of 39 years and ISS of 29. Stroke was present at admission in 182 patients (37%) and occurred during an Interventional Radiology procedure in six patients. In the remaining 304 patients, stroke was identified a median of 48 hours after admission: 53 hours in the 144 patients identified by neurologic symptoms and 42 hours in the 160 patients without a neurologic examination and an incidental stroke identified on imaging. Of those patients with neurologic symptoms, 88 (61%) had a stroke within 72 hours, whereas 56 had a stroke after 72 hours; there was a sequential decline in stroke occurrence over the first week. Of the 304 patients who had a stroke after admission, 64 patients (22%) were being treated with antithrombotics when the stroke occurred.The majority of patients suffer BCVI-related stroke in the first 72 hours after injury. Time to stroke can help inform clinicians about initiation of treatment in the multiply injured patient.Prognostic/Epidemiologic, level III.

ObjectivesComparisons of risk-adjusted trauma mortality between high-income countries and low and middle-income countries (LMICs) can be used to identify specific patient populations and injury patterns for targeted interventions. Due to a paucity of granular patient and injury data from LMICs, there is a lack of such comparisons. This study aims to identify independent predictors of trauma mortality and significant differences between India and the USA.MethodsA retrospective cohort study of two trauma databases was conducted. Demographic, injury, physiologic, anatomic and outcome data were analyzed from India’s Towards Improved Trauma Care Outcomes project database and the US National Trauma Data Bank from 2013 to 2015. Multivariate logistic regression analyses were performed to determine significant independent predictors of mortality.Results687 407 adult trauma patients were included (India 11 796; USA 675 611). Patients from India were significantly younger with greater male preponderance, a higher proportion presented with physiologic abnormalities and suffered higher mortality rates (23.2% vs. 2.8%). When controlling for age, sex, physiologic abnormalities, and injury severity, sustaining an injury in India was the strongest predictor of mortality (OR 13.85, 95% CI 13.05 to 14.69). On subgroup analyses, the greatest mortality difference was seen in patients with lower Injury Severity Scores.ConclusionAfter adjusting for demographic, physiologic abnormalities, and injury severity, trauma-related mortality was found to be significantly higher in India. When compared with trauma patients in the USA, the odds of mortality are most notably different among patients with lower Injury Severity Scores. While troubling, this suggests that relatively simple, low-cost interventions focused on standard timely trauma care, early imaging, and protocolized treatment pathways could result in substantial improvements for injury mortality in India, and potentially other LMICs.Level of evidenceLevel 3, retrospective cohort study.

The data on the financial and operational impact of an Acute Care Surgery (ACS) service is equivocal. Multiple stakeholders, mostly surgeons and anesthesia health care providers, envision themselves as caretakers of a precious, expensive service line. Although previous studies have examined the impact of an ACS service model on the time to theater metric, there are no studies examining the impact of an ACS service on the operating room (OR) from the perspective of an OR manager. In this study, we examine the impact of an ACS service on operating room utilization and general surgery services using several OR management metrics: elective in-block utilization, after-hours utilization, and opportunity-unused time. Using these metrics to study one year pre- and one year post-ACS service implementation at our institution we were able to demonstrate more effective use of an OR (fixed cost) and a decrease in after-hours operating time for the non-ACS general surgeons (variable cost). We propose the use of such OR management metrics as an integral component of service line implementation analysis.

Introduction The United States (US) leads all high income countries in gunshot wound (GSW) deaths. However, as a result of two decades of reduced federal support, study of GSW has been largely neglected. In this paper we describe the current state of GSW hospitalizations in the US using population-based data. Patients and methods We conducted an observational study of patients hospitalized for GSW in the National (Nationwide) Inpatient Sample (NIS) 2004 −2013. Our primary outcome is mortality after admission and we model its associations with gender, race, age, intent, severity of injury and weapon type, as well as providing temporal trends in hospital charges. Results Each year approximately 30,000 patients are hospitalized for GSW, and 2500 die in hospital. Men are 9 times as likely to be hospitalized for GSW as women, but are less likely to die. Twice as many blacks are hospitalized for GSW as non-Hispanic whites. In-hospital mortality for blacks and non-Hispanic whites was similar when controlled for other factors. Most GSW (63%) are the result of assaults which overwhelmingly involve blacks; accidents are also common (23%) and more commonly involve non-Hispanic whites. Although suicide is much less common (8.3%), it accounts for 32% of all deaths; most of which are older non-Hispanic white males. Handguns are the most common weapon reported, and have the highest mortality rate (8.4%). During the study period, the annual rate of hospitalizations for GSW remained stable at 80 per 100,000 hospital admissions; median inflation-adjusted hospital charges have steadily increased by approximately 20% annually from $30,000 to $56,000 per hospitalization. The adjusted odds for mortality decreased over the study period. Although extensively reported, GSW inflicted by police and terrorists represent few hospitalizations and very few deaths. Conclusions The preponderance GSW hospitalizations resulting from assaults on young black males and suicides among older non-Hispanic white males have continued unabated over the last decade with escalating costs. As with other widespread threats to the public wellbeing, federally funded research is required if effective interventions are to be developed.

Trauma surgery moves fast. Clinical decisions and treatment of injured patients must occur expeditiously, or patients suffer. Trauma research also moves fast, and new high-quality studies about treatment of injured patients frequently reshape the field and our understanding of best practices. Historically, medicine relied on the dissemination of best practices through publication of manuscripts and the endorsement of trusted physicians to change practices. However, implementation of research has proven to be slow. When research does not reach the bedside, patients are not offered proven therapies or are treated with dated or ineffective therapies. Implementation science, or the rigorous studying of the timely uptake of evidence into routine practice, is the next vital frontier in surgery,1 with the potential to have a profound positive effect on the care provided to our patients. The purpose of this paper is to describe the principles of implementation science and propose their wider use in trauma care. This paper is published as an initiative of the Coalition for National Trauma Research (CNTR) to further advance high-quality research and promote sustainable research funding to improve the care of injured patients, commensurate with the burden of disease in the USA. We will review definitions of implementation, dissemination, and de-implementation, as well as research frameworks, study design, and funding opportunities. Implementation science is an umbrella term that includes implementation research, dissemination research, and de-implementation research. The key with implementation science is focusing on “how to do it” rather than “what to do.” As a result, the outcomes of interest are not those typically considered in outcomes research such as mortality or morbidity. To study implementation, we assume that the “best practice” treatment is already known. Implementation science focuses on how to obtain sustained use of the best practice treatment in real-world settings. Implementation research is the study …

High-quality clinical trials are needed to advance the care of injured patients. Traditional randomized clinical trials in trauma have challenges in generating new knowledge due to many issues, including logistical difficulties performing individual randomization, unclear pretrial estimates of treatment effect leading to often unpowered studies, and difficulty assessing the generalizability of an intervention given the heterogeneity of both patients and trauma centers. In this review, we discuss alternative clinical trial designs that can address some of these difficulties. These include pragmatic trials, cluster randomization, cluster randomized stepped wedge designs, factorial trials, and adaptive designs. Additionally, we discuss how Bayesian methods of inference may provide more knowledge to trauma and acute care surgeons compared with traditional, frequentist methods.

BACKGROUND: The Acute Care Surgery (ACS) model has been widely adopted by hospitals across the United States, with ACS services managing emergency general surgery (EGS) patients previously treated by general surgery (GS) services. We evaluated the operational and financial impact of an ACS service model on general surgeons at an academic medical center. METHODS: Using WiseOR® (Palo Alto, CA), we compared surgical case volumes for the GS service two years before (October, 2013 - September, 2015) and two years after (October, 2015 - September, 2017) implementation of an ACS service at the University of Vermont Medical Center. From financial reports, we obtained monthly wRVUs, clinical FTEs, net patient revenue, and payer mix for the GS service and compared the two years before and after ACS model implementation. RESULTS: There was a significant reduction in the average number of cases performed by the GS service following ACS service implementation (monthly mean ± SD, 139.1 ± 16.0 vs. 116.7 ± 14.0, p < 0.001). The normal-hours caseload remained stable, while a significant decrease in after-hours cases accounted for the reduction in overall volume. Despite the reduction in operative volume, the decrease in mean monthly wRVU/FTE for the GS service when comparing the pre- and post- ACS periods did not reach statistical significance (614.9 ± 82.9 vs. 576.3 ± 62.1, p = 0.08). There was a significant increase in average monthly clinic-derived wRVU/FTE for the GS service (106.3 ± 13.5 vs. 120.5 ± 16.4, p = 0.007). CONCLUSIONS: Shifting EGS patient management from the GS to ACS service did not negatively impact the productivity of the GS service. BACKGROUND

Traumatized patients are at risk of developing deep vein thrombosis (DVT) and DVT prophylaxis is the standard of care. The Centers for Medicare and Medicaid Services classifies DVT as a hospital-acquired condition and can deny payment for treatment of DVT and, in addition, place financial penalties on hospitals with higher than acceptable rates of DVT, unless the DVT was preexisting. We sought to determine the rate of preexisting chronic DVT among symptomatic traumatized inpatients at our ACS-verified Level 1 trauma center.Retrospective review of all traumatized patients admitted for48 hours over a 7-year study period ending December 2016. Patients who had undergone lower extremity duplex ultrasound (LEDUS) were reviewed further to evaluate the results of these tests. Patients were classified as having either no DVT, acute DVT, or chronic (preexisting) DVT based on sonographic characteristics. Incidence, patient demographics, injury severity and outcomes were compared for patients with and without DVT and also for patients with acute and chronic DVT.Five thousand five hundred forty-three patients met inclusion criteria. Of those, 391 (7.0%) had undergone at least one LEDUS for suspicion of DVT. Deep vein thrombosis was diagnosed in 64 (16%) of the patients undergoing LEDUS and thus 1.1% of the entire population had symptomatic DVT diagnosed during admission. Of the 64 patients with DVT, sonographic characteristics classified 56 (87.5%) as "acute." 6 (9%) as "chronic" (preexisting) and 2 (3.5%) as "indeterminate." Among the six patients found to have a preexisting DVT only three (50%) acknowledged a history of DVT.In the absence of routine DVT surveillance almost 10% of traumatized patients diagnosed with DVT likely have chronic preexisting DVT that is unknown to the patient in 50% of cases. This has significant financial implications for hospitals.Epidemiologic/Prognostic, level III.

The abdomen, including pelvis, is injured in 10 to 15% of significantly injured patients: 80% by blunt and 20% by penetrating mechanisms. Abdominal injuries can be subtle and hence missed. The majority of injuries, if detected early, can be treated, and hence, delay in diagnosis or underappreciation of the severity of intra-abdominal injury is responsible for significant preventable morbidity and even mortality. The initial management is the same as any trauma patient, with the greatest threats to life addressed first. If the patient is in shock and the source is intra-abdominal, urgent laparotomy is indicated along with damage control resuscitation. If the patient remains in shock in the operating room, abbreviated damage control laparotomy should be pursued. In stable patients with penetrating mechanism, if the penetration extends into the peritoneal cavity, operative exploration to identify and address any injury is the safest approach; however, more selective approaches are increasingly being pursued. In stable patients with blunt mechanism, a thorough evaluation, usually including IV contrast-enhanced CT (CECT) is pursued to diagnose, and equally importantly, exclude intra-abdominal injury. High-quality IV CECT has a very high negative predictive value for intra-abdominal injuries. In stable patients, injuries to spleen, liver, and kidney, irrespective of grade, are managed nonoperatively with or without angioembolization. Lower-grade pancreatic injuries are managed nonoperatively or with drainage, whereas higher-grade injuries (involving major ducts) usually require resection. Majority of gastrointestinal hollow viscus injuries are managed with repair, resection with anastomosis or diversion. Delays as short as 8 hours in definitive management of such injuries increase morbidity and mortality. Intra and retro peritoneal genitourinary injuries are repaired and extraperitoneal ones are managed without surgery. Retroperitoneal hematomas are managed based on mechanism, stability, and location. Abdominal trauma is associated with a host of complications that need to be detected early and managed appropriately to prevent delayed morbidity and mortality. This review contains 5 figures, 6 tables, and 60 references. Key Words: abdomen, complications, damage control, diaphragm, hollow viscus, trauma, solid organ, retroperitoneum

Highlights • Atrophic visceral myopathy (AVM) is a rare cause of intestinal pseudo-obstruction. • More commonly presenting in youth, it can sometimes present acutely in previously asymptomatic patients. • General surgeons and practitioners should consider AVM in their workup of large bowel obstruction. • AVM is associated with hypothyroidism, and hormone repletion and/or motility agents may be of benefit., Purpose Atrophic visceral myopathy is a pathological diagnosis characterized by atrophy of the smooth muscle layers of the viscera with intact ganglia. Rarely, it can present acutely as an intestinal pseudo-obstruction. We describe a rare case report and explore how this diagnosis can be distinguished from other forms of intestinal obstruction. Case description A 60-year-old male with a past medical history of hypothyroidism presented to the emergency department with a two-day history of worsening abdominal distention and pain associated with nausea and vomiting. Upon evaluation patient was found to have tachycardia, with abdominal distention and localized tenderness with peritonitis. Computed tomography demonstrated large bowel obstruction, likely caused by sigmoid volvulus. The patient underwent emergent laparotomy. Intra-operatively, the entire colon was found to be extremely dilated and redundant. With a working diagnosis of recurrent sigmoid volvulus causing intermittent large bowel obstruction, a sigmoid colectomy and primary anastomosis was performed. Pathology revealed atrophic visceral myopathy, with an extremely thin colonic wall and atrophic circumferential and longitudinal muscularis propria without inflammation or fibrosis. The ganglion cells and myenteric plexus were unaffected. Post-operatively, the patient developed prolonged ileus requiring nasogastric decompression and parenteral nutrition. The ileus resolved with pro-kinetic agents, and patient was discharged home on post-operative day fifteen. Conclusions Atrophic visceral neuropathy is a rare cause of intestinal pseudo-obstruction. While often presenting with chronic obstruction in younger populations, we present a rare late-onset acute presentation that may have been secondary to underlying hypothyroidism.

The trauma pandemic is one of the leading causes of death worldwide but especially in rapidly developing economies. Perhaps, a common cause of trauma-related mortality in these settings comes from the rapid expansion of motor vehicle ownership without the corresponding expansion of national prehospital training in developed countries. The resulting road traffic injuries often never make it to the hospital in time for effective treatment, resulting in preventable disability and death. The current article examines the development of a medical first responder training program that has the potential to reduce this unnecessary morbidity and mortality.An intensive training workshop has been differentiated into two progressive tiers: acute trauma training (ATT) and broad trauma training (BTT) protocols. These four-hour and two-day protocols, respectively, allow for the mass education of laypersons-such as police officials, fire brigade, and taxi and/or ambulance drivers-who are most likely to interact first with prehospital victims. Over 750 ATT participants and 168 BTT participants were trained across three Indian educational institutions at Jodhpur and Jaipur. Trainees were given didactic and hands-on education in a series of critical trauma topics, in addition to pretraining and post-training self-assessments to rate clinical confidence across curricular topics. Two-sample t-test statistical analyses were performed to compare pretraining and post-training confidence levels.Program development resulted in recruitment of a variety of career backgrounds for enrollment in both our ATT and BTT workshops. The workshops were run by local physicians from a wide spectrum of medical specialties and previously ATT-trained police officials. Statistically significant improvements in clinical confidence across all curricular topics for ATT and BTT protocols were identified (P 0.0001). In addition, improvement in confidence after BTT training was similar in Jodhpur compared with Jaipur.These results suggest a promising level of reliability and reproducibility across different geographic areas in rapidly developing settings. Program expansion can offer an exponential growth in the training rate of medical first responders, which can help curb the trauma-related mortality in rapidly developing economies. Future directions will include clinical competency assessments and further progressive differentiation into higher tiers of trauma expertise.

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.

Kidneys perform a multitude of essential functions within the human body. Of these the most important are (1) maintaining pH through regulation of acid/base levels and (2) excreting end products of metabolism. As for most organ-systems, these functions are especially important for healing following trauma and/or surgery and decline with age. Acute Kidney Injury (AKI) is one of the common forms of organ failures seen in the ICU and elderly patients are more prone to it. The causes maybe classified as Prerenal (inadequate perfusion), renal (inherent kidney disease) and post-renal (urinary obstruction). Preventing AKI should be an important concern in all critically ill patients but especially important in the elderly patients since the development of AKI can significantly increase in-hospital mortality. Once AKI has set in a systematic and step-wise approach of diagnosis and management is key to avoiding adverse outcomes.

This is a recommended algorithm of the Western Trauma Association for the management of penetrating neck trauma that has penetrated the platysma muscle of the neck. Because of the paucity of recent prospective randomized trials on the evaluation and management of penetrating neck injury, the current algorithm and recommendations are based on available published prospective cohort, observational, and retrospective studies and the expert opinion of the Western Trauma Association members. The algorithm (Fig. 1.) and accompanying text represents a safe and reasonable approach to this difficult injury type and attempts to incorporate the advent of recent advances in radiographic screening and selective or expectant management practice. We recognize that there will be variability in decision making, local resources, institutional consensus, and patient-specific factors that may require deviation from the algorithm presented. This annotated algorithm is meant to serve as a basis from which protocols at individual institutions can be developed or serve as a quick bedside reference for clinicians. The algorithm contains letters A through J, which correspond to the lettered text. Their

OBJECTIVES Limited transthoracic echocardiography (LTTE) has been introduced as a hemodynamic tool for trauma patients. The aim of this study was to evaluate the utility of LTTE during the evaluation of nonsurviving patients who presented to the trauma bay with traumatic cardiac arrest. METHODS Approval by the Institutional Review Board was obtained. All nonsurviving patients with traumatic cardiac arrest who reached the trauma bay were evaluated retrospectively for 1 year. Comparisons between groups of patients in whom LTTE was performed as part of the resuscitation effort and those in whom it was not performed were conducted. RESULTS From January 2012 to January 2013, 37 patients did not survive traumatic cardiac arrest while in the trauma bay: 14 in the LTTE group and 23 in the non-LTTE group. When comparing the LTTE and non-LTTE groups, both were similar in sex distribution (LTTE, 86% male; non-LTTE, 74% male; P = .68), age (34.8 versus 24.1 years; P= .55), Injury Severity Score (41.0 versus 38.2; P= .48), and percentage of penetrating trauma (21.6% versus 21.7%; P = .29). Compared with the non-LTTE group, the LTTE group spent significantly less time in the trauma bay (13.7 versus 37.9 minutes; P = .01), received fewer blood products (7.1% versus 31.2%; P = .789), and were less likely to undergo nontherapeutic thoracotomy in the emergency department (7.14% versus 39.1%; P < .05). The non-LTTE group had a mean of $3040.50 in hospital costs, compared with the mean for the LTTE group of $1871.60 (P = .0054). CONCLUSIONS In this study, image-guided resuscitation with LTTE decreased the time in the trauma bay and avoided nontherapeutic thoracotomy in nonsurviving trauma patients. Limited TTE could improve the use of health care resources in patients with traumatic cardiac arrest.

We hypothesize that limited transthoracic echocardiogram (LTTE) is a useful tool to guide therapy during the initial phase of resuscitation in trauma patients.All highest-level alert patients with at least one measurement of systolic blood pressure less than 100 mm Hg, a mean arterial pressure less than 60 mm Hg, and/or a heart rate greater than 120 beats per minute who arrived to the trauma bay (TB) were randomized to have either LTTE performed (LTTEp) or not performed (non-LTTE) as part of their initial evaluation. Images were stored, and results were reported regarding contractility (good vs. poor), fluid status (empty inferior vena cava [hypovolemic] vs. full inferior vena cava [not hypovolemic]), and pericardial effusion (present vs. absent). Time from TB to operating room, intravenous fluid administration, blood product requirement, intensive care unit admission, and mortality were examined in both groups.A total of 240 patients were randomized. Twenty-five patients were excluded since they died upon arrival to the TB, leaving 215 patients in the study. Ninety-two patients were in the LTTEp group with 123 patients in the non-LTTE group. The LTTEp and non-LTTE groups were similar in age (38 years vs. 38.8 years, p = 0.75), Injury Severity Score (ISS) (19.2 vs. 19.0, p = 0.94), Revised Trauma Score (RTS) (5.5 vs. 6.0, p = 0.09), lactate (4.2 vs. 3.6, p = 0.14), and mechanism of injury (p = 0.44). Strikingly, LTTEp had significantly less intravenous fluid than non-LTTE patients (1.5 L vs. 2.5 L, p0.0001), less time from TB to operating room (35.6 minutes vs. 79.1 min, p = 0.0006), higher rate of intensive care unit admission (80.4% vs. 67.2%, p = 0.04), and a lower mortality rate (11% vs. 19.5%, p = 0.09). Mortality differences were particularly evident in the traumatic brain injury patients (14.7% in LTTEp vs. 39.5% in non-LTTE, p = 0.03).LTTE is a useful guide for therapy in hypotensive trauma patients during the early phase of resuscitation.Therapeutic study, level II.

Intra-abdominal hypertension and its more dangerous manifestation, abdominal compartment syndrome, occur when the space available within the abdominal cavity is less than the combined total volume of the contents, leading to an increase in intra-abdominal pressure, which in turn causes systemic organ system dysfunction. Any patient undergoing complex abdominal wall reconstruction is prone to develop this complication. Careful preoperative preparation and modification of intraoperative technique can prevent the condition from occurring. Postoperative monitoring is critical in early detection and rapid therapy. Mild cases maybe treated with nonoperative therapy, but for more severe cases, operative decompression with or without subsequent reconstruction has to be performed to prevent poor outcomes.

BACKGROUND Variability exists in the approach to cervical spine (c-spine) clearance after significant trauma. Using concurrently gathered data on more than 9,000 such patients, the current study develops an evidence-based and readily adoptable algorithm for c-spine clearance aimed at timely removal of collar, optimal use of imaging, and appropriate spine consultations. METHODS Prospective study of adult blunt trauma team alert (TTA) patients presenting at a Level I trauma center who underwent screening computed tomography (CT) to diagnose/rule out c-spine injury (January 2008 to May 2014). Regression analysis comparing patients with and without c-spine injury-fracture and/or ligament-was used to identify significant predictors of injury. The predictors with the highest odds ratio were used to develop the algorithm. RESULTS Among 9,227 patients meeting inclusion criteria, c-spine injury was identified in 553 patients (5.99%). All 553 patients had a c-spine fracture, and of these, 57 patients (0.6% of entire population and 10.31% of patients with injury) also had a ligamentous injury. No patient with a normal CT result was found to have an injury. The five greatest predictors of ligament injury that follow were used to develop the algorithm: (1) CT evidence of ligament injury; (2) fracture pattern "not" isolated transverse/spinous process; (3) neurologic symptoms; (4) midline tenderness; and (5) Glasgow Coma Scale score

Trauma is the leading cause of death in the first four decades of life, and the fifth leading cause overall.1 In the early phase of hospital treatment, most of these patients die, succumb to neurologic injury, or hemorrhage.2 The insult of blood loss results in an inability for the oxygen supply to meet the demands of the body. Trauma and hypovolemia trigger multiple compensatory mechanisms, which include activation of the sympathetic nervous system, cardiac adjustments, hormonal changes, renal volume, and electrolyte alterations that act to preserve oxygenation and tissue blood flow. Some microcirculatory beds are rerouted to sustain flow to essential organs. In the hospital setting, hemorrhage is controlled and trauma-hemorrhage victims are resuscitated with intravenous crystalloid fluids to restore oxygen delivery. Despite these salvage mechanisms, victims may develop irretrievable loss of capillary bed perfusion (the no-reflow phenomenon), immune suppression, and systemic inflammation.2 After resuscitation, there may be ischemia-reperfusion injury that may precipitate further tissue damage, immunosuppression, sepsis, multiple organ failure, and death.3 Injury and blood loss manifest clinically with tachycardia, tachypnea, hypoxia, and hypotension. Persistent hypovolemia causes hypoperfused tissues and cellular hypoxia resulting in increased anaerobic cellular activity and increased levels of lactate.3,4 The endpoints of resuscitation are determined by a combination of clinical, laboratory, and invasive monitoring. Blood pressure, heart rate, and urine output, base deficit, and lactate are all used to monitor the extent of hemorrhagic shock.5 The role of the L-Arginine (L-Arg)-nitric oxide (NO) pathway in the regulation of tissue perfusion and modulation of the inflammatory response continues to evolve. L-Arg is an amino acid that may have antioxidant and immunomodulatory activity.6 NO is a downstream product of L-Arg oxidation formed by NO synthetase (NOS). The enzyme exists in an inducible form, which is activated by immunologic and inflammatory responses and a constitutive form that continuously produces low levels of NO, mainly in the vascular endothelium.7,8 Some studies have suggested that the augmentation of the L-Arg-NO pathway by the infusion of L-Arg can restore the depressed cardiac output and improve tissue hypoperfusion seen after trauma and hemorrhage.9–11 Other studies suggest that augmenting this pathway by providing L-Arg or NO donors may attenuate systemic and regional inflammation and improve outcomes after shock with or without the preceding trauma.12–14 Our previous study demonstrated increased survival of swine receiving L-Arg before lethal hemorrhagic shock, trauma, and resuscitation (unpublished data). The mechanism of these salutary effects of L-Arg have yet to be systematically demonstrated. The major aim of this study was to demonstrate that the beneficial effects seen after L-Arg administration in the setting of hemorrhagic shock are due to metabolism through the NO pathway.

Resuscitation end point markers such as lactate and base deficit (BD) are used in trauma to identify and treat a state of compensated shock. Lactate and BD levels are also elevated by alcohol. In blunt trauma patients with positive blood alcohol levels, lactate may be a poor indicator of injury. Retrospective data were collected on 1083 blunt trauma patients with positive blood alcohol levels admitted a Level I trauma center between 2003 and 2006. Patients were stratified by Injury Severity Score, age, gender, and Glasgow Coma Score. Logistic regression analyses were used to assess lactate and BD as independent risk factors for mortality. Seventy-four per cent of patients had an abnormal lactate level compared with 28 per cent with abnormal BD levels. In patients with mild injury, lactate levels were abnormal in more than 70 per cent of patients compared with less than 20 per cent of patients with abnormal BD levels. Linear regression showed lactate is not a significant predictor of mortality. Regardless of Injury Severity Score, lactate appeared to be more often abnormal than BD in the setting of alcohol ingestion. Additionally, because BD, and not lactate, was shown to be an independent predictor of mortality, lactate may not be a reliable marker of end point resuscitation in this patient population.

Limited transthoracic echocardiogram (LTTE) represents an attractive alternative to formal transthoracic echocardiogram (TTE), because it does not require an echocardiogram machine. Our hypothesis is that trauma attendings can learn LTTE effectively with minimal training.Seven attendings at a Level I trauma center received didactic and hands-on training in LTTE and performed this test on hypotensive patients to evaluate for contractility, fluid status, and pericardial effusion. Therapy to improve perfusion (administration of fluids, ionotropes, or vasopressors) was guided by LTTE findings. Perfusion status was determined by serum lactate level before and 6 hours after LTTE. Findings were compared with cardiology-performed TTE.Range of postresidency training was 1 year to 29 years. LTTE teaching entailed 70 minutes of didactics and 25 minutes of hands-on. In all, 52 LTTEs were performed; two patients were excluded due to blunt trauma arrest. Age ranged from 22 years to 89 years with an average of 55 years. Admission diagnosis was blunt trauma (n = 34), penetrating trauma (n = 3), and intra-abdominal sepsis (n = 13). Average time for LTTE was 4 minutes 38 seconds. Cardiology-performed TTE was obtained in all patients, and correlation with LTTE was 100%. A total of 37 patients received intravenous fluid, 9 received vasopressors, and 4 received ionotropes as guided by LTTE findings, with lactate reduction in all patients (p0.00001). Attendings scored a mean of 88% in a written test after training.Trauma attendings can successfully learn LTTE with minimal training and use the technique as a resuscitation tool in the hypotensive patient.

Quantitative bronchoalveolar lavage (BAL) is used to diagnose ventilator-associated pneumonia (VAP). We prospectively compared semiquantitative (SQ) and quantitative (Qu) culture of BAL for VAP diagnosis. Ventilated patients suspected of VAP underwent bronchoscopic BAL. BAL fluid was examined by both Qu (colony-forming units [CFUs]/mL) and SQ culture (none, sparse, moderate, or heavy) and results were compared. VAP was defined as 105CFU/mL or greater on Qu culture. Over 36 months, 319 BALs were performed. Sixty-three of 319 (20%) showed diagnostic growth by Qu culture identifying a total of 81 organisms causing VAP. All 63 specimens showed growth of some organism(s) on SQ culture with 79 of 81 causative organisms identified and two ( Pseudomonas, one; Corynebacterium, one) not identified. The remaining 256 specimens did not meet the threshold for VAP by the Qu method. Among these, 79 did not show any growth on SQ culture. Among the 240 specimens showing some growth on SQ culture, a total of 384 organisms were identified. VAP rates in relation to strength of growth on SQ culture were: sparse, 10 of 140 (7%); moderate, 24 of 147 (16%); and heavy, 45 of 97 (46%). Sensitivity (Sn), specificity (Sp), positive (PPV), and negative (NPV) predictive values of SQ culture of BAL fluid for the diagnosis of VAP were 97, 21, 21, and 97 per cent, respectively. Nonquantitative culture of BAL fluid is fairly accurate in ruling out VAP (high Sn and NPV). It however has poor Sp and PPV and using this method will lead to unnecessary antimicrobial use with its attendant complications of toxicity, cost, and resistance.

Since the promulgation of emergency department (ED) thoracotomy40 years ago, there has been an ongoing search to define when this heroic resuscitative effort is futile. In this era of health care reform, generation of accurate data is imperative for developing patient care guidelines. The purpose of this prospective multicenter study was to identify injury patterns and physiologic profiles at ED arrival that are compatible with survival.Eighteen institutions representing the Western Trauma Association commenced enrollment in January 2003; data were collected prospectively.During the ensuing 6 years, 56 patients survived to hospital discharge. Mean age was 31.3 years (15-64 years), and 93% were male. As expected, survival was predominant in those with thoracic injuries (77%), followed by abdomen (9%), extremity (7%), neck (4%), and head (4%). The most common injury was a ventricular stab wound (30%), followed by a gunshot wound to the lung (16%); 9% of survivors sustained blunt trauma, 34% underwent prehospital cardiopulmonary resuscitation (CPR), and the presenting base deficit was25 mequiv/L in 18%. Relevant to futile care, there were survivors of blunt torso injuries with CPR up to 9 minutes and penetrating torso wounds up to 15 minutes. Asystole was documented at ED arrival in seven patients (12%); all these patients had pericardial tamponade and three (43%) had good functional neurologic recovery at hospital discharge.Resuscitative thoracotomy in the ED can be considered futile care when (a) prehospital CPR exceeds 10 minutes after blunt trauma without a response, (b) prehospital CPR exceeds 15 minutes after penetrating trauma without a response, and (c) asystole is the presenting rhythm and there is no pericardial tamponade.

We hypothesized that flexion extension (FE) films do not facilitate the diagnosis or treatment of ligamentous injury of the cervical spine after blunt trauma. From January 2000 to December 2008 we reviewed all patients who underwent FE films and compared five-view plain films (5view) and cervical spine CTC with FE in the diagnosis of ligamentous injury. There were 22,929 patients with blunt trauma and of these, 271 patients underwent 303 FE films. Average age was 39.6 years, Injury Severity Score was 10.8, Glasgow Coma Score was 14.1, lactate was 2.6 mmol/L, and hospital length of stay was 6 days. Compared with FE, 5view and CTC had a sensitivity of 80 per cent (8 of 10), positive predictive value of 47.1 per cent (8 of 17), specificity of 96.55 per cent (252 of 261), and negative predictive value of 99.21 per cent (252 of 254). For purposes of analysis, incomplete and ambiguous FE films were listed as negative; however, 20.5 per cent (62 of 303) were incomplete and 9.2 per cent (28 of 303) were ambiguous. Management did not change for the 2 patients with missed ligament injuries. The 303 studies cost $162,105.00 to obtain. FEs are often incomplete and unreliable making it difficult to use them to base management decisions. They do not facilitate treatment and may lead to increased cost and prolonged cervical collars.

To retrospectively determine the frequency and importance of a small amount of isolated pelvic free fluid seen at multidetector computed tomography (CT) in male patients who have blunt trauma without an identifiable cause.Institutional review board approval was obtained, and the requirement for informed consent was waived for this HIPAA-compliant study. One thousand male patients with blunt trauma who underwent abdominopelvic CT at a level 1 trauma center between January 2004 and June 2006 were entered into this study. The CT images of the 1000 patients were reviewed independently by two abdominal radiologists. CT scan assessment included evaluation for presence or absence of pelvic free fluid, any traumatic or nontraumatic cause of the free fluid, pelvic free fluid attenuation and volume measurements, and determination of the location of pelvic free fluid. Interobserver agreement was determined with kappa statistics, and the Student t test was used to assess differences in the mean volume and mean attenuation of the pelvic free fluid in the patients with and those without injury.Pelvic free fluid was identified in 10.2% (102 of 1000) of patients. A small amount of isolated pelvic free fluid without any identifiable cause was identified in 4.8% (48 of 1000) of patients by reader 1 and in 5.0% (50 of 1000) of patients by reader 2 (kappa value, 0.76) and was located at or below the level of the third sacral vertebral body in all 49 patients with isolated pelvic free fluid. The mean volume and mean attenuation of the small amount of isolated pelvic free fluid were 2.3 mL +/- 1.5 (standard deviation) and 8.1 HU +/- 3.9, respectively. None of the patients in this group had an undiagnosed bowel and/or mesenteric injury.In male patients with blunt trauma, a small amount of isolated pelvic free fluid with attenuation equal to that of simple fluid and located in the deep region of the pelvis likely is not a sign of bowel and/or mesenteric injury.

The purpose of this study was to compare flexion-extension (FE) plain films with MRI as the gold standard in the diagnosis of ligamentous injury (LI) of the cervical spine after trauma. A retrospective review of patients sustaining blunt trauma from January 2000 to December 2008 (n = 22929) who had both FE and MRI of the cervical spine was performed. Two hundred seventy-one patients had 303 FE films. Forty-nine also had MRI. The average Injury Severity Score was 15.6 ± 10.2, Glasgow Coma Scale was 13.8 ± 3.5, lactate 2.2 ± 1.7 mmol/L, and hospital stay of 8 ± 11.2 days. FE failed to identify all eight LIs seen on MRI. FE film sensitivity was 0 per cent (zero of eight), specificity 98 per cent (40 of 41), positive predictive value 0 per cent (zero of one), and negative predictive value 83 per cent (40 of 48). Although classified as negative for purposes of analysis, FE was incomplete 20.5 per cent (62 of 303) and ambiguous 9.2 per cent (28 of 303) of the time. The charge of FE is $535 so $48150 (90 incomplete/ambiguous films) could have been saved by eliminating these films. FE should no longer be used to diagnose LI. Given the rare incidence of these injuries, MRI should be used when there is high clinical suspicion of injury.

We evaluated the benefit of a central venous line (CVL) protocol on bloodstream infections (BSIs) and outcome in a trauma intensive care unit (ICU) population. We prospectively compared three groups: Group 1 (January 2003 to June 2004) preprotocol; Group 2 (July 2004 to June 2005) after the start of the protocol that included minimizing CVL use and strict universal precautions; and Group 3 (July 2005 to December 2006) after the addition of a line supply cart and nursing checklist. There were 1622 trauma patients admitted to the trauma ICU during the study period of whom 542 had a CVL. Group 3 had a higher Injury Severity Score (ISS) compared with both Groups 2 and 1 (28.3 ± 13.0 vs 23.5 ± 11.7 vs 22.8 ± 12.0, P = 0.0002) but had a lower BSI rate/1000 line days (Group 1:16.5; Group 2:15.0; Group 3: 7.7). Adjusting for ISS group, three had shorter ICU length of stay (LOS) compared with Group 1 (12.11 ± 1.46 vs 18.16 ± 1.51, P = 0.01). Logistic regression showed ISS ( P = 0.04; OR, 1.025; CI, 1.001-1.050) and a lack of CVL protocol ( P = 0.01; OR, 0.31; CI, 0.13-0.76) to be independent predictors of BSI. CVL protocols decrease both BSI and LOS in trauma patients. Strict enforcement by a nurse preserves the integrity of the protocol.

Background: Poor follow-up by patients with trauma results in a lack of knowledge of postdischarge health-related issues. This study reports on postdischarge health-related issues discovered by a program of active postdischarge contact or follow-up. Methods. All patients discharged home from the trauma service were followed up in the following manner: within 4 weeks of discharge, telephonic follow-up was attempted three times followed by scanning of electronic records. Failing that, other physicians (specialists or primary care) were contacted. Once contact was established, the patient, family member, or physician was questioned about the general well-being, any specific health-related issue, and the resolution. Results: During the 13-month study period ending September 2007, a total of 1,353 patients met entry criteria. Contact was established with 692 (51%). Of these, 116 (17%) were found to have significant health issues: (1) severe uncontrolled pain, 45; (2) missed injury, 17 (spine fractures, 4; clavicle or hand or foot fractures, 6; facial bone fractures, 3; soft tissue, 3; hematuria, 1); (3) wound infections, 17; (4) other infections, 17 (urinary, 8; pulmonary, 7; blood stream, 2) (5) venous thromboembolism, 10; and (6) other, 9 (psychiatric, 6; nontraumatic, 3). One patient died at home within 24 hours of discharge. The issues were significant enough for the patients to seek medical care (outpatient, 39; emergency department visits, 52; hospitalization, 24). Conclusion: A significant proportion of patients with trauma have moderate to severe health-related issues postdischarge that are often not found by the trauma team or the trauma registry. Active follow-up can identify the nature of the medical issues and help in designing system changes to reduce or eliminate them.