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Patients with traumatic brain injury (TBI) are at an increased risk of developing complications from venous thromboembolisms (VTEs [blood clots]). Benchmarking by the American College of Surgeons Trauma Quality Improvement Program identified suboptimal use of prophylactic anticoagulation in patients with TBI. We hypothesized that institutional implementation of an anticoagulation protocol would improve clinical outcomes in such patients.A new prophylactic anticoagulation protocol that incorporated education, weekly audits, and real-time adherence feedback was implemented in July 2015. The trauma registry identified patients with TBI before (PRE) and after (POST) implementation. Multivariable regression analysis with risk adjustment was used to compare use of prophylactic anticoagulation, VTE events, and mortality.A total of 681 patients with TBI (368 PRE, 313 POST) were identified. After implementation of the VTE protocol, more patients received anticoagulation (PRE: 39.4%, POST: 80.5%, p0.001), time to initiation was shorter (PRE: 140 hours, POST: 59 hours, p0.001), and there were fewer VTE events (PRE: 19 [5.2%], POST: 7 [2.2%], p = 0.047). Multivariable analysis showed that POST patients were more likely to receive anticoagulation (odds ratio [OR] = 10.8, 95% confidence interval [CI] = 6.9-16.7, p0.001) and less likely to develop VTE (OR = 0.33, 95% CI = 0.1-1.0, p = 0.05).Benchmarking can assist institutions to identity potential clinically relevant areas for quality improvement in real time. Combining education and multifaceted protocol implementation can help organizations to better focus limited quality resources and counteract barriers that have hindered adoption of best practices.

This study uses data from the Place of Last Drink database and Google maps to assess the association of blood alcohol concentration with distance traveled and driver’s age among intoxicated drivers in Minnesota.

Purpose The purpose of this study was to determine the time to development, severity, and risk factors of incontinence-associated dermatitis (IAD) among critically ill patients with fecal incontinence. Subjects and setting Forty-five patients with a mean age of 49.4 ± 18.5 years (mean ± SD) in the surgical/trauma critical care unit (ICU) of 1 of 3 urban hospitals who were free of any perineal skin damage at study start participated in the study. The majority (76%) were male. Methods Surveillance of skin for IAD and chart review of data initially and daily. Results Incontinence-associated dermatitis developed in 36% of patients. The median time to onset of IAD was 4 days (range, 1-6). Eighty-one percent of patients still had IAD at discharge from the ICU and at the end of their surveillance (median time = 7 days, range, 1-19 days). The severity of erythema associated with IAD was mild, moderate, or severe for 13%, 11%, or 4% (means) of the time patients were observed. Denudement occurred 9% of the observed time. Frequent incontinence of loose or liquid stools and diminished cognitive awareness were significant independent risk factors for development of IAD sooner. Conclusion Incontinence-associated dermatitis develops in critically ill patients with fecal incontinence relatively quickly and does not resolve in most before their discharge from the ICU. Early monitoring and prevention of IAD, especially in patients with diminished cognition or with frequent leakage of loose or liquid feces, are recommended to promote skin health.

Injured patients are especially prone to developing complications. Using a multidisciplinary standardized approach to complication review is an effective method of evaluating quality improvement in patients on the trauma service. Collaboration between trauma surgeons and nurse clinicians is instrumental in improving the care of patients in each of the areas we identified. Using this consistently, quality improvement strategies can be put in place and tracked for outcomes. This has allowed for better quantification of the problem as well as any change that may result from applying this formal review process and subsequent intervention.

Title. Re-examination of risk factors for non-Clostridium difficile-associated diarrhoea in hospitalized patients. Aim. This paper is a report of a study to determine the incidence of non-Clostridium difficile-associated diarrhoea in hospitalized patients and to re-evaluate clinical characteristics and other risk factors related to non-C. difficile-associated diarrhoea. Background. Numerous factors are thought to be responsible for diarrhoea in hospitalized patients. Reports about the diarrhoeal effects of some medications administered concomitantly with tube feeding have stimulated reappraisal of the influence of tube feeding as a potential cause. Method. This study was a secondary analysis of data of 154 hospitalized patients collected during a prospective epidemiological study from 1992 to 1993. The secondary analysis was completed in 2006 in order to investigate unanswered questions of current importance. Findings. The sample was predominantly male and middle aged; approximately 50% were tube fed, and 25% were in an intensive care unit. The incidence of diarrhoea was 35%. Increased severity of illness as well as the combination of sorbitol-containing medication administration and tube feeding were found to be statistically significant factors in the development of diarrhoea. Conclusion. As diarrhoea in hospitalized patients appears to be multifactorial, use of an algorithm to systematically evaluate and manage related factors is recommended.

Walter Benjamin's esteem for Carl Schmitt is one of the most irritating incidents in the intellectual history of the Weimar Republic. It arouses astonishment to this day, connecting as it does Benjamin, a victim of Nazism, to Schmitt, who, with his distinction between friend and enemy, developed a Manichean definition of the political and took a public stance in support of National Socialism in the years after the Machtergreifung.' Yet this bizarre relationship, which for decades was repressed as inconceivable or dismissed as a mere chance episode, was no isolated incident. Although he was forbidden to teach after 1945 and his reputation remained tainted, Schmitt served as a kind of oracle for countless intellectuals and politicians in Germany and elsewhere before his death in 1985.2 It was even suggested that he "has more 'pupils' at universities in Ger

Background: Prothrombin complex concentrate (PCC) is recommended as a therapy to be considered for the reversal of warfarin's effects. Few published data are available on the use of PCC for this indication in traumatically injured patients. Objective: To determine whether the addition of PCC to standard approaches to warfarin reversal more rapidly corrects the international normalized ratio (INR) in injured patients. Methods: A retrospective analysis was performed in trauma patients who were on warfarin preinjury from January 2007 to September 2009 at North Memorial Medical Center. Data were collected from medical records and the trauma registry. Patients were separated based on whether or not they received PCC. The groups were compared on the basis of demographics, units of fresh frozen plasma (FFP), vitamin K use, units of PCC, number of patients achieving an INR of 1.5 or less, time to an INR of 1.5 or less, mortality, intensive care unit (ICU) and hospital length of stay, and the incidence of thromboembolic events during hospitalization. Results: Thirty-one patients were included in the analysis; 13 patients who received a total mean (SD) dose of 2281 (1053) units (25.6 [12.2] units/kg) of PCC (Profilnine SD) were compared to 18 patients who did not receive PCC. There was no significant difference between groups in FFP units received or the number of patients who received vitamin K. Most patients in both groups achieved an INR of 1.5 or less (92% PCC vs 89% no PCC). However, the mean time to achieve an INR of 1.5 or less was 16:59 (20:53) hours in the PCC group versus 30:03 (23:10) hours in the no PCC group (p = 0.048). There were 3 deaths in the PCC group and no deaths in the no PCC group (p = 0.06). ICU and hospital length of stay and number of thromboembolic events did not differ significantly between the 2 groups. Conclusions: PCC, when added to FFP and vitamin K, resulted in a more rapid time to reversal of the INR.

Background: The initial care of critically injured patients has profound effects on ultimate outcomes. The "golden hour" of trauma care is often provided by rural hospitals before definitive transfer. There are, however, no standardized methods for providing educational feedback to these hospitals for the purposes of performance improvement. We hypothesized that an outreach program would stimulate peer review and identify systematic deficiencies in the care of patients with injuries. Methods: We developed a quality improvement program aimed at providing educational feedback to hospitals that referred patients to our American College of Surgeons-verified level I trauma center. We traveled to each referral center to provide feedback on the initial treatment and ultimate outcome of patients that were transferred to us. These feedback sessions were presented in the format of case presentations and case discussions. Results: The outreach program was presented at each hospital every 3 months to 6 months. Nine hospitals were included in our program. We received 334 patients in transfer from these hospitals during the study period. Formal peer review that focused on trauma patients increased from 14% of hospitals to 100% of hospitals after institution of the program. Eighty-five percent of hospitals thought that the care of patients with injuries was improved as a result of the program. Eighty-five percent of hospitals developed process improvement initiatives as a result of the program. Conclusions: A formal outreach program can stimulate peer review at rural hospitals, provide continuing education in the care of patients with injuries, and foster process improvements at referring hospitals.

Severely bleeding trauma patients requiring massive transfusion (MT) often experience poor outcomes. Our purpose was to determine the potential role of near infrared spectrometry derived tissue hemoglobin oxygen saturation (StO2) monitoring in early prediction of MT, and in the identification of those MT patients who will have poor outcomes.Data from a prospective multi-institution StO2 monitoring study were analyzed to determine the current epidemiology of MT (defined as transfusion volume/=10 units packed red blood cells in 24 hours of hospitalization). Multivariate logistic regression was used to develop prediction models.Seven US level I trauma centers (TC) enrolled 383 patients. 114 (30%) required MT. MT progressed rapidly (40% exceeded MT threshold 2 hours after TC arrival, 80% after 6 hours). One third of MT patients died. Two thirds of deaths were due to early exsanguination and two thirds of early exsanguination patients died within 6 hours. One third of the early MT survivors developed multiple organ dysfunction syndrome. MT could be predicted with standard, readily available clinical data within 30 minutes and 60 minutes of TC arrival (area under the receiver operating characteristic curve = 0.78 and 0.80). In patients who required MT, StO2 was the only consistent predictor of poor outcome (multiple organ dysfunction syndrome or death).MT progresses rapidly to significant morbidity and mortality despite level I TC care. Patients who require MT can be predicted early, and persistent low StO2 identifies those MT patients destined to have poor outcome. The ultimate goal is to identify these high risk patients as early as possible to test new strategies to improve outcome. Further validation studies are needed to analyze appropriate allocation and study appropriate use of damage control interventions.

Near-infrared spectroscopy (NIRS) can continuously and noninvasively monitor tissue oxygen saturation (StO2) in muscle and may be an indicator of shock severity. Our purpose was to evaluate how well StO2 predicted outcome in high-risk torso trauma patients presenting in shock.The primary outcome in this prospective study was multiple organ dysfunction syndrome (MODS). StO2 data were obtained upon hospital arrival and for 24 hours along with other known predictors of hypoperfusion and clinical outcomes. Clinicians were blinded to StO2 measurements.Seven Level I trauma centers enrolled 383 patients, 50 of whom developed MODS. Minimum StO2 performed similarly to maximum base deficit (BD) in discrimination of MODS patients. The sensitivity for both measures (StO2 cutoff = 75%; BD cutoff = 6 mEq/L) was 78%, the specificity was 34% to 39%, the positive predictive value was 18% to 20% and the negative predictive value was 88% to 91%. StO2 and BD were also comparable in predicting death.NIRS-derived muscle StO2 measurements perform similarly to BD in identifying poor perfusion and predicting the development of MODS or death after severe torso trauma, yet have the additional advantages of being continuous and noninvasive.