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Trauma Center (trauma + center)

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Medical Sciences	96%

Kinds of Trauma Center

i trauma center

level i trauma center

Selected Abstracts

Current Practice, Demographics, and Trends of Critical Care Trained Emergency Physicians in the United States

ACADEMIC EMERGENCY MEDICINE, Issue 3 2010
Julie A. Mayglothling MD
Abstract Objectives:, Critical care medicine (CCM) is of growing interest among emergency physicians (EPs), but the number of CCM-trained EPs and their postfellowship practice is unknown. This study's purpose was to conduct a descriptive census survey of EPs who have completed or are currently in a CCM fellowship. Methods:, The authors created a Web-based survey, and requests to participate were sent to EPs who have completed or are currently in a CCM fellowship. Responses were collected over a 12-month period. Physicians were located via multiple whom electronic mailing lists, including the Emergency Medicine Section of the Society of Critical Care Medicine, Critical Care Section of the American College of Emergency Physicians, and the Emergency Medicine Residents' Association. The authors also contacted CCM fellowship coordinators and used informal networking. Data were collected on emergency medicine (EM) and other residency training; discipline, duration, and year of CCM fellowship; current practice setting; and board certification status, including the European Diploma in Intensive Care (EDIC). Results:, A total of 104 physicians completed the survey (97% response rate), of whom 73 had completed fellowship at the time of participation, and 31 of whom were in fellowship training. Of those who completed fellowship, 36/73 (49%) practice both EM and CCM, and 45/73 (62%) practice in academic institutions. Multiple disciplines of fellowship were represented: multidisciplinary (39), surgical (28), internal medicine (16), anesthesia (14), and other (4). Together, the CCM fellowships at the University of Maryland R Adams Cowley Shock Trauma Center and the University of Pittsburgh have trained 42% of all EM-CCM physicians, with 38 other institutions training from one to four fellows each. The number of EPs completing CCM fellowships has risen: from 1974 to 1989, 12 EPs; from 1990 to 1999, 15 EPs; and from 2000 to 2007, 43 EPs. Conclusions:, Emergency physicians are entering CCM fellowships in increasing numbers. Almost half of these EPs practice both EM and CCM. ACADAEMIC EMERGENCY MEDICINE 2010; 17:325,329 © 2010 by the Society for Academic Emergency Medicine [source]

Human-information interaction in time-critical settings: Information needs and use in the emergency room

PROCEEDINGS OF THE AMERICAN SOCIETY FOR INFORMATION SCIENCE & TECHNOLOGY (ELECTRONIC), Issue 1 2007
Aleksandra Sarcevic
Trauma centers are stressful, noisy, and dynamic places, with many people performing complex tasks, and with no technological aids to support their operations. This paper describes research that uses an emergency room as a natural laboratory for investigating information behavior and information sources of trauma team members. Data from interviews, focus groups, and videotaped trauma resuscitations revealed specific information needs in four distinct phases of a trauma event. The most commonly utilized information sources include the patient, vital signs monitor, x-rays images, and other team members. Additionally, data indicated inefficiencies in teamwork and communication. Results from this study can be used to derive system requirements for the design of decision and communication support systems for trauma teams. [source]

Effect of Normal Saline Infusion on the Diagnostic Utility of Base Deficit in Identifying Major Injury in Trauma Patients

ACADEMIC EMERGENCY MEDICINE, Issue 12 2006
Richard Sinert DO
Abstract Background Base deficit (BD) is a reliable marker of metabolic acidosis and is useful in gauging hemorrhage after trauma. Resuscitation with chloride-rich solutions such as normal saline (NS) can cause a dilutional acidosis, possibly confounding the interpretation of BD. Objectives To test the diagnostic utility of BD in distinguishing minor from major injury after administration of NS. Methods This was a prospective observational study at a Level 1 trauma center. The authors enrolled patients with significant mechanism of injury and measured BD at triage (BD-0) and at four hours after triage (BD-4). Major injury was defined by any of the following: injury severity score of ,15, drop in hematocrit of ,10 points, or the patient requiring a blood transfusion. Patients were divided into a low-volume (NS < 2L) and a high-volume (NS , 2L) group. Data were reported as mean (±SD). Student's t- and Wilcoxon tests were used to compare data. Receiver operating characteristic (ROC) curves tested the utility of BD-4 in differentiating minor from major injury in the study groups. Results Four hundred eighty-nine trauma patients (mean age, 36 [± 18] yr) were enrolled; 82% were male, and 34% had penetrating injury. Major-(20%) compared with minor-(80%) injury patients were significantly (p = 0.0001) more acidotic (BD-0 mean difference: ,3.3 mmol/L; 95% confidence interval [CI] =,2.5 to ,4.2). The high-volume group (n = 174) received 3,342 (±1,821) mL, and the low-volume group (n = 315) received 621 (±509) mL of NS. Areas under the ROC curves for the high-volume (0.63; 95% CI = 0.52 to 0.74) and low-volume (0.73; 95% CI = 0.60 to 0.86) groups were not significantly different from each other. Conclusions Base deficit was able to distinguish minor from major injury after four hours of resuscitation, irrespective of the volume of NS infused. [source]

Emergency Nurses' Utilization of Ultrasound Guidance for Placement of Peripheral Intravenous Lines in Difficult-access Patients

ACADEMIC EMERGENCY MEDICINE, Issue 12 2004
Larry Brannam MD
Objectives: Emergency nurses (ENs) typically place peripheral intravenous (IV) lines, but if repeated attempts fail, emergency physicians have to obtain peripheral or central access. The authors describe the patient population for which ultrasound (US)-guided peripheral IVs are used and evaluate the success rates for such lines by ENs. Methods: This was a prospective observational study of ENs in a Level I trauma center with a census of 75,000, performing US-guided IV line placement on difficult-to-stick patients (repeated blind IV placement failure or established history). ENs were trained on an inanimate model after a 45-minute lecture. Surveys were filled out after each US-guided IV attempt on a patient. ENs could decline to fill out surveys, which recorded the reason for use of US, type of patient, and success. Successful cannulation was confirmed by drawing blood and flushing fluids. Descriptive statistics were used to evaluated data. Results: A total of 321 surveys were collected in a five-month period no ENs declined to participate. There were 280 (87%) successful attempts. Twelve (29%) of the 41 failure patients required central lines, 9 (22%) received external jugular IVs, and 20 (49%) had peripheral IV access placed under US guidance by another nurse or physician. Twenty-eight percent (90) of all patients were obese, 18% (57) had sickle cell anemia, 10% (31) were renal dialysis patients, 12% (40) were IV drug abusers, and 19% (61) had unspecified chronic illness. The remainder had no reason for difficult access given. There were four arterial punctures. Conclusions: ENs had a high success rate and few complications with use of US guidance for vascular access in a variety of difficult-access patients. [source]

Ethnic differences in drinking outcomes following a brief alcohol intervention in the trauma care setting

ADDICTION, Issue 1 2010
Craig A. Field
ABSTRACT Background Evidence suggests that brief interventions in the trauma care setting reduce drinking, subsequent injury and driving under the influence (DUI) arrest. However, evidence on the effectiveness of these interventions in ethnic minority groups is lacking. The current study evaluates the efficacy of brief intervention among whites, blacks and Hispanics in the United States. Methods We conducted a two-group parallel randomized trial comparing brief motivational intervention (BMI) and treatment as usual with assessment (TAU+) to evaluate treatment differences in drinking patterns by ethnicity. Patients were recruited from a level 1 urban trauma center over a 2-year period. The study included 1493 trauma patients, including 668 whites, 288 blacks and 537 Hispanics. Hierarchical linear modeling was used to evaluate ethnic differences in drinking outcomes including volume per week, maximum amount consumed in 1 day, percentage days abstinent and percentage days heavy drinking at 6- and 12-month follow-up. Analyses controlled for age, gender, employment status, marital status, prior alcohol treatment, type of injury and injury severity. Special emphasis was given to potential ethnic differences by testing the interaction between ethnicity and BMI. Results At 6- and 12-month follow-up, BMI significantly reduced maximum amount consumed in 1 day (P < 0.001; P < 0.001, respectively) and percentage days heavy drinking (P < 0.05; P < 0.05, respectively) among Hispanics. Hispanics in the BMI group also reduced average volume per week at 12-month follow-up (,2 = 6.8, df = 1, P < 0.01). In addition, Hispanics in TAU+ reduced maximum amount consumed at 6- and 12-month follow-up (P < 0.001; P < 0.001) and volume per week at 12-month follow-up (P < 0.001). Whites and blacks in both BMI and TAU+ reduced volume per week and percentage days heavy drinking at 12-month follow-up (P < 0.001; P < 0.01, respectively) and decreased maximum amount at 6- (P < 0.001) and 12-month follow-up (P < 0.001). All three ethnic groups In both BMI and TAU+ reduced volume per week at 6-month follow-up (P < 0.001) and percentage days abstinent at 6- (P < 0.001) and 12-month follow-up (P < 0.001). Conclusions All three ethnic groups evidenced reductions in drinking at 6- and 12-month follow-up independent of treatment assignment. Among Hispanics, BMI reduced alcohol intake significantly as measured by average volume per week, percentage days heavy drinking and maximum amount consumed in 1 day. [source]

Pain Scores Improve Analgesic Administration Patterns for Trauma Patients in the Emergency Department

ACADEMIC EMERGENCY MEDICINE, Issue 3 2004
Paul A. Silka MD
Abstract Objective: To determine the efficacy of pain scores in improving pain management practices for trauma patients in the emergency department (ED). Methods: A prospective, observational study of analgesic administration to trauma patients was conducted over a nine-week period following educational intervention and introduction of verbal pain scores (VPSs). All ED nursing and physician staff in an urban Level I trauma center were trained to use the 0,10 VPS. Patients younger than 12 years old, having a Glasgow Coma Scale score (GCS) <8, or requiring intubation were excluded from analysis. Demographics, mechanism of injury, vital signs, pain scores, and analgesic data were extracted from a computerized ED database and patients' records. The staff was blinded to the ongoing study. Results: There were 150 patients studied (183 consecutive trauma patients seen; 33 patients excluded per criteria). Pain scores were documented for 73% of the patients. Overall, 53% (95% confidence interval [CI] = 45% to 61%) of the patients received analgesics in the ED. Of the patients who had pain scores documented, 60% (95% CI = 51% to 69%) received analgesics, whereas 33% (95% CI = 18% to 47%) of the patients without pain scores received analgesics. No patient with a VPS < 4 received analgesics, whereas 72% of patients with a VPS > 4 and 82% with a VPS > 7 received analgesics. Mean time to analgesic administration was 68 minutes (95% CI = 49 to 87). Conclusions: Pain assessment using VPS increased the likelihood of analgesic administration to trauma patients with higher pain scores in the ED. [source]

Trauma Team Activation Criteria as Predictors of Patient Disposition from the Emergency Department

ACADEMIC EMERGENCY MEDICINE, Issue 1 2004
Michael A. Kohn MD
Many trauma centers use mainly physiologic, first-tier criteria and mechanism-related, second-tier criteria to determine whether and at what level to activate a multidisciplinary trauma team in response to an out-of-hospital call. Some of these criteria result in a large number of unnecessary team activations while identifying only a few additional patients who require immediate operative intervention. Objectives: To separately evaluate the incremental predictive value of individual first-tier and second-tier trauma team activation criteria for severe injury as reflected by patient disposition from the emergency department (ED). Methods: This was a prospective cohort study in which activation criteria were collected prospectively on all adult patients for whom the trauma team was activated during a five-month period at an urban, Level 1 trauma center. Severe injury disposition ("appropriate" team activation) was defined as immediate operative intervention, admission to the intensive care unit (ICU), or death in the ED. Data analysis consisted of recursive partitioning and multiple logistic regression. Results: Of the 305 activations for the mainly physiologic first-tier criteria, 157 (51.5%) resulted in severe injury disposition. The first-tier criterion that caused the greatest increase in "inappropriate" activations for the lowest increase in "appropriate" activations was "age > 65." Of the 34 additional activations due to this criterion, seven (20.6%) resulted in severe injury disposition. Of the 700 activations for second-tier, mechanism-related criteria, 54 (7.7%) resulted in ICU or operating room admissions, and none resulted in ED death. The four least predictive second-tier criteria were "motorcycle crash with separation of rider,""pedestrian hit by motor vehicle,""motor vehicle crash with rollover," and "motor vehicle crash with death of occupant." Of the 452 activations for these four criteria, only 18 (4.0%) resulted in ICU or operating room admission. Conclusions: The four least predictive second-tier, mechanism-related criteria added little sensitivity to the trauma team activation rule at the cost of substantially decreased specificity, and they should be modified or eliminated. The first-tier, mainly physiologic criteria were all useful in predicting the need for an immediate multidisciplinary response. If increased specificity of the first-tier criteria is desired, the first criterion to eliminate is "age > 65." [source]

Utility of an Initial D-dimer Assay in Screening for Traumatic or Spontaneous Intracranial Hemorrhage

ACADEMIC EMERGENCY MEDICINE, Issue 9 2001
Mark E. Hoffmann MD
Abstract Objective: To evaluate the sensitivity of a D-dimer assay as a screening tool for possible traumatic or spontaneous intracranial hemorrhage. If adequately sensitive, the D-dimer assay may potentially permit omission of a more expensive computed tomography (CT) scan of the head when such hemorrhage is clinically suspected. Methods: Prospective, consecutive, blinded study of patients (age > 16 years) requiring a CT scan of the head for suspected intracranial hemorrhage over a five-month period at a university, Level I trauma center. All study patients had a serum D-dimer assay obtained prior to their CT scans. Sensitivity and specificity, with 95% confidence intervals (95% CIs), of the enzyme-linked immunosorbent assay (ELISA) D-dimer assay for the detection of intracranial hemorrhage were calculated. Results: Of the 319 patients entered in the study, 25 (7.8%) had a CT scan positive for intracranial hemorrhage. Patients with intracranial hemorrhage were more likely to have a positive D-dimer assay (chi-square ? 13.075, p < 0.001). The D-dimer assay had 21 true-positive and four false-negative tests, resulting in a sensitivity of 84.0% (95% CI ? 63.7% to 95.5%) and a specificity of 55.8% (95% CI ? 55.5% to 55.9%). The four false-negative cases included one small intraparenchymal hemorrhage, one small subarachnoid hemorrhage, one moderate-sized intraparenchymal hemorrhage with mid-line shift, and one large subdural hematoma requiring emergent surgery. Conclusions: Due to the catastrophic nature of missing an intracranial hemorrhage in the emergency department, the D-dimer assay is not adequately sensitive or predictive to use as a screening tool to allow routine omission of head CT scanning. [source]

A Combination of Midazolam and Ketamine for Procedural Sedation and Analgesia in Adult Emergency Department Patients

ACADEMIC EMERGENCY MEDICINE, Issue 3 2000
Carl R. Chudnofsky MD
Abstract Objective: To describe the clinical characteristics of a combination of midazolam and ketamine for procedural sedation and analgesia in adult emergency department (ED) patients. Methods: This was a prospective, observational trial, conducted in the ED of an urban level II trauma center. Patients , 18 years of age requiring procedural sedation and analgesia were eligible, and enrolled patients received 0.07 mg/kg of intravenous midazolam followed by 2 mg/kg of intravenous ketamine. Vital signs were recorded at regular intervals. The adequacy of sedation, adverse effects, patient satisfaction, and time to reach discharge alertness were determined. Descriptive statistics were calculated using statistical analysis software. Results: Seventy-seven patients were enrolled. Three were excluded due to protocol violations, three due to lack of documentation, and one due to subcutaneous infiltration of ketamine, leaving 70 patients for analysis. The average age was 31 years, and 41 (59%) were female. Indications for procedural sedation and analgesia included abscess incision and drainage (66%), fracture/joint reduction (26%), and other (8%). The mean dose of midazolam was 5.6 ± 1.4 mg and the mean dose of ketamine was 159 ± 42 mg. The mean time to achieve discharge criteria was 64 ± 24 minutes. Fivepatients experienced mild emergence reactions, but there were no episodes of hallucinations, delirium, or other serious emergence reactions. Eighteen (25%) patients recalled dreaming while sedated; twelve (17%) were described as pleasant, two (3%) unpleasant, three (4%) both pleasant and unpleasant, and one (1%) neither pleasant nor unpleasant. There were four (6%) cases of respiratory compromise, two (3%) episodes of emesis, and one (1%) case of myoclonia. All of these were transient and did not result in a change in the patient's disposition. Only one (1%) patient indicated that she was not satisfied with the sedation regimen. Conclusions: The combination of midazolam and ketamine provides effective procedural sedation and analgesia in adult ED patients, and appears to be safe. [source]

The Efficacy of Factor VIIa in Emergency Department Patients With Warfarin Use and Traumatic Intracranial Hemorrhage

ACADEMIC EMERGENCY MEDICINE, Issue 3 2010
Daniel K. Nishijima MD
Abstract Objectives:, The objective was to compare outcomes in emergency department (ED) patients with preinjury warfarin use and traumatic intracranial hemorrhage (tICH) who did and did not receive recombinant activated factor VIIa (rFVIIa) for international normalized ratio (INR) reversal. Methods:, This was a retrospective before-and-after study conducted at a Level 1 trauma center, with data from 1999 to 2009. Eligible patients had preinjury warfarin use and tICH on cranial computed tomography (CT) scan. Patients before (standard cohort) and after (rFVIIa cohort) implementation of a protocol for administering 1.2 mg of rFVIIa in the ED were reviewed. Glasgow Coma Scale (GCS) score, Revised Trauma Score (RTS), Injury Severity Score (ISS), INR, and Marshall score were collected. Outcome measures included mortality, thromboembolic complications, and INR normalization. Results:, Forty patients (median age = 80.5 years, interquartile range [IQR] = 63.5,85) were included (20 in each cohort). Age, GCS score, ISS, RTS, initial INR, and Marshall score were similar (p > 0.05) between the two cohorts. Survival was identical between cohorts (13 of 20, or 65.0%, 95% confidence interval [CI] = 40.8% to 84.6%). There were no differences in rate of thromboembolic complications in the standard cohort (1 of 20, 5.0%, 95% CI = 0.1% to 24.9%) than the rFVIIa cohort (4 of 20, 20.0%, 95% CI = 5.7% to 43.7%; p = 0.34). Time to normal INR was earlier in the rFVIIa cohort (mean = 4.8 hours, 95% CI = 3.0 to 6.7 hours) than in the standard cohort (mean = 17.5 hours, 95% CI = 12.5 to 22.6; p < 0.001). Conclusions:, In patients with preinjury warfarin and tICH, use of rFVIIa was associated with a decreased time to normal INR. However, no difference in mortality was identified. Use of rFVIIa in patients on warfarin and tICH requires further study to demonstrate important patient-oriented outcomes. ACADEMIC EMERGENCY MEDICINE 2010; 17:244,251 © 2010 by the Society for Academic Emergency Medicine [source]

Assessment of trauma nurse knowledge related to forensic practice

JOURNAL OF FORENSIC NURSING, Issue 4 2008
Kelli Eldredge RN
Abstract Assessment of forensic practice specific to the trauma setting was the purpose of this pilot study. Thirty-eight trauma nurses from a level II trauma center completed a questionnaire related to their knowledge of forensic practice. Although 58% of nurses had some education related to forensics, emergency department nurses were significantly more knowledgeable about existence of protocols than were intensive care unit nurses. Most respondents indicated a willingness to incorporate forensic principles into practice. Forensic education and standardization of protocols would enhance clinical practice in the trauma setting. [source]

Management of critically ill children with traumatic brain injury

PEDIATRIC ANESTHESIA, Issue 6 2008
GILLES A. ORLIAGUET MD PhD
Summary The management of critically ill children with traumatic brain injury (TBI) requires a precise assessment of the brain lesions but also of potentially associated extra-cranial injuries. Children with severe TBI should be treated in a pediatric trauma center, if possible. Initial assessment relies mainly upon clinical examination, trans-cranial Doppler ultrasonography and body CT scan. Neurosurgical operations are rarely necessary in these patients, except in the case of a compressive subdural or epidural hematoma. On the other hand, one of the major goals of resuscitation in these children is aimed at protecting against secondary brain insults (SBI). SBI are mainly because of systemic hypotension, hypoxia, hypercarbia, anemia and hyperglycemia. Cerebral perfusion pressure (CPP = mean arterial blood pressure , intracranial pressure: ICP) should be monitored and optimized as soon as possible, taking into account age-related differences in optimal CPP goals. Different general maneuvers must be applied in these patients early during their treatment (control of fever, avoidance of jugular venous outflow obstruction, maintenance of adequate arterial oxygenation, normocarbia, sedation,analgesia and normovolemia). In the case of increased ICP and/or decreased CPP, first-tier ICP-specific treatments may be implemented, including cerebrospinal fluid drainage, if possible, osmotic therapy and moderate hyperventilation. In the case of refractory intracranial hypertension, second-tier therapy (profound hyperventilation with PaCO2 < 35 mmHg, high-dose barbiturates, moderate hypothermia, decompressive craniectomy) may be introduced, after a new cerebral CT scan. [source]

Traumatic occupational injuries in Hispanic and foreign born workers

AMERICAN JOURNAL OF INDUSTRIAL MEDICINE, Issue 4 2010
Linda Forst MD
Abstract Background Hispanic and foreign-born workers suffer high rates of occupational fatality. Reasons for this are not well understood. Our aim was to gather information about the details related to severe, non-fatal occupational injuries in this vulnerable population. Methods Eight years of data were obtained from an urban trauma center. In addition, medical consultations of individuals admitted for an occupational injury during an 8-month period are reported. Results Hispanics were more highly represented than expected; their number of injuries steadily rose. Hispanics were more likely to be injured by machinery and hand tools. Workers reported hazardous working conditions, lack of workers compensation, short time in current employment, and not working in their usual job. Conclusion Trauma systems can provide a glimpse of risk factors for severe injuries in vulnerable workers. We recommend greater use of this data source, follow backs, long-term follow up of individuals, and improvement of surveillance of vulnerable working populations. Am. J. Ind. Med. 53:344,351, 2010. © 2009 Wiley-Liss, Inc. [source]

Relationship of age, injury severity, injury type, comorbid conditions, level of care, and survival among older motor vehicle trauma patients,

RESEARCH IN NURSING & HEALTH, Issue 3 2005
Linda J. Scheetz
Abstract The purpose of this secondary data analysis was to compare age, injury severity, injury types, selected comorbidities, level of care (at trauma center [TC] and non,trauma center [NTC] hospitals), and survival among older motor vehicle trauma patients (N,=,1,478). Patients admitted to both levels of care had similar comorbid conditions. TC patients had a higher injury severity, whereas NTC patients had a greater proportion of soft tissue injuries. Results of logistic regression analyses subsequent to group comparisons revealed that higher injury severity was associated with TC admission. The likelihood of TC admission of severely injured patients decreased in the presence of spinal, internal, and head injuries. Internal injuries, liver, renal, and cardiovascular diseases were associated with non-survival while hypertension was associated with survival. Special attention is needed when triaging older trauma patients because their injuries may be covert, thus putting them at risk for admission to a level of care that may be inappropriate given the extent of their injuries. © 2005 Wiley Periodicals, Inc. Res Nurs Health 28: 198,209, 2005 [source]

Patterns of Maxillofacial Injuries As a Function of Automobile Restraint Use,

THE LARYNGOSCOPE, Issue 4 2000
M. Scott Major MD
Abstract Objective To determine the pattern and severity of maxillofacial injuries sustained in a motor vehicle accident (MVA) resulting from automobile restraint use. Design Retrospective database review of patients injured in a MVA who were admitted to the level I trauma center at the University of Louisville Hospital in Louisville, Kentucky. Methods Demographic data, drug and alcohol impairment screening, and comorbidity data were obtained from database searches of trauma records. Forty-four patients had an airbag deployed, 34 patients wore seat belts, and 94 patients were unrestrained. All maxillofacial Abbreviated Injury Scale (AIS) ratings were compared among the three groups. Results Twenty-two of the 44 patients (50%) in the airbag group sustained only facial injuries. Fifteen of them had lacerations; four others had only facial abrasions. Three of the airbag patients had moderate facial injuries (AIS = 2); none required operative management. The airbag group had a mean AIS rating of 1.13, the seat belt group a mean AIS of 1.29, and the unrestrained group a mean AIS of 1.46. Patients using either seat belts (mean age, 40.5 y) or airbags (mean age, 44.9 y) were older than the unrestrained group (mean age, 39.6 y). Drug and/or alcohol impairment was significantly greater in the unrestrained group (mean, 38%) compared with the seat belt group (mean, 26%) and the airbag group (mean 11%). Conclusions Use of airbags is associated with less severe maxillofacial injuries compared with either a seat belt alone or no restraint. There is an inherent risk of minor maxillofacial injuries with airbag usage, but the severity of injury is distinctly reduced. [source]

A Comparison of GlideScope Video Laryngoscopy Versus Direct Laryngoscopy Intubation in the Emergency Department

ACADEMIC EMERGENCY MEDICINE, Issue 9 2009
Timothy F. Platts-Mills MD
Abstract Objectives:, The first-attempt success rate of intubation was compared using GlideScope video laryngoscopy and direct laryngoscopy in an emergency department (ED). Methods:, A prospective observational study was conducted of adult patients undergoing intubation in the ED of a Level 1 trauma center with an emergency medicine residency program. Patients were consecutively enrolled between August 2006 and February 2008. Data collected included indication for intubation, patient characteristics, device used, initial oxygen saturation, and resident postgraduate year. The primary outcome measure was success with first attempt. Secondary outcome measures included time to successful intubation, intubation failure, and lowest oxygen saturation levels. An attempt was defined as the introduction of the laryngoscope into the mouth. Failure was defined as an esophageal intubation, changing to a different device or physician, or inability to place the endotracheal tube after three attempts. Results:, A total of 280 patients were enrolled, of whom video laryngoscopy was used for the initial intubation attempt in 63 (22%) and direct laryngoscopy was used in 217 (78%). Reasons for intubation included altered mental status (64%), respiratory distress (47%), facial trauma (9%), and immobilization for imaging (9%). Overall, 233 (83%) intubations were successful on the first attempt, 26 (9%) failures occurred, and one patient received a cricothyrotomy. The first-attempt success rate was 51 of 63 (81%, 95% confidence interval [CI] = 70% to 89%) for video laryngoscopy versus 182 of 217 (84%, 95% CI = 79% to 88%) for direct laryngoscopy (p = 0.59). Median time to successful intubation was 42 seconds (range, 13 to 350 seconds) for video laryngoscopy versus 30 seconds (range, 11 to 600 seconds) for direct laryngoscopy (p < 0.01). Conclusions:, Rates of successful intubation on first attempt were not significantly different between video and direct laryngoscopy. However, intubation using video laryngoscopy required significantly more time to complete. [source]

Guardian Availability in Children Evaluated in the Emergency Department for Blunt Head Trauma

ACADEMIC EMERGENCY MEDICINE, Issue 1 2009
James F. Holmes MD
Abstract Background:, Enrolling children in research studies in the emergency department (ED) is typically dependent on the presence of a guardian to provide written informed consent. Objectives:, The objectives were to determine the rate of guardian availability during the initial ED evaluation of children with nontrivial blunt head trauma, to identify the reasons why a guardian is unavailable, and to compare clinical factors in patients with and without a guardian present during initial ED evaluation. Methods:, This was a prospective study of children (<18 years of age) presenting to a single Level 1 trauma center after nontrivial blunt head trauma over a 10-month period. Physicians documented patient history and physical examination findings onto a structured data form after initial evaluation. The data form contained data points regarding the presence or absence of the patient's guardian during the initial ED evaluation. For those children for whom the guardian was not available during the initial ED evaluation, the physicians completing the data forms documented the reasons for the absence. Results:, The authors enrolled 602 patients, of whom 271 (45%, 95% confidence interval [CI] = 41% to 49%) did not have a guardian available during the initial ED evaluation. In these 271 patients, 261 had reasons documented for lack of guardian availability, 43 of whom had multiple reasons. The most common of these was that the guardian did not ride in the ambulance (51%). Those patients without a guardian available were more likely to be older (mean age, 11.4 years vs. 7.6 years; p < 0.001), be victims of a motor vehicle collision (MVC; 130/268 [49%] vs. 35/328 [11%]; p < 0.001), have a Glasgow Coma Scale (GCS) score <14 (21/269 [7.8%] vs. 11/331 [3.3%]; p = 0.02), and undergo cranial computed tomography (CT) scanning (224/271 [83%] vs. 213/331 [64%]; p < 0.001). Multivariate analysis identified similar independent risk factors for lack of guardian presence. Conclusions:, Nearly one-half of children with nontrivial blunt head trauma evaluated in the ED may not have a guardian available during their initial ED evaluation. Patients whose guardians are not available at the time of initial ED evaluation are older and have more severe mechanisms of injury and more serious head trauma. ED research studies of pediatric trauma patients that require written informed consent from a guardian at the time of initial ED evaluation and treatment may have difficulty enrolling targeted sample size numbers and will likely be limited by enrollment bias. [source]

Advanced Statistics: Developing a Formal Model of Emergency Department Census and Defining Operational Efficiency

ACADEMIC EMERGENCY MEDICINE, Issue 9 2007
Thomas J. Flottemesch PhD
Background: Emergency department (ED) crowding has been a frequent topic of investigation, but it is a concept without an objective definition. This has limited the scope of research and progress toward the development of consistent and meaningful operational responses. Objectives: To develop a straightforward model of ED census that incorporates concepts of ED crowding, daily patient surge, throughput time, and operational efficiency. Methods: Using 2005,2006 patient encounter data at a Level 1 urban trauma center, a set of three stylized facts describing daily patterns of ED census was observed. These facts guided the development of a formal, mathematical model of ED census. Using this model, a metric of ED operational efficiency and a forecast of ED census were developed. Results: The three stylized facts of daily ED census were 1) ED census is cyclical, 2) ED census exhibits an input-output relationship, and 3) unexpected shocks have long-lasting effects. These were represented by a three-equation system. This system was solved for the following expression, Censust = A(·) + B(·) cos(vT +,) + a(et), that captured the time path of ED census. Using nonlinear estimation, the parameters of this expression were estimated and a forecasting tool was developed. Conclusions: The basic pattern of ED census can be represented by a straightforward expression. This expression can be quickly adapted to a variety of inquiries regarding ED crowding, daily surge, and operational efficiency. [source]

Assessment of Teacher Interruptions on Learners during Oral Case Presentations

ACADEMIC EMERGENCY MEDICINE, Issue 6 2007
Glen Yang BA
Background:Studies have only recently begun to investigate the effects of interruptions on physicians in the emergency department (ED). Objectives:To determine the frequency and nature of interruptions by the training physician that occur when medical trainees do oral case presentations (OCPs) in the ED. Methods:This was an observational study. Learner OCPs to attending emergency physicians were observed in the ED of an urban Level 1 trauma center at a major teaching hospital. A single investigator followed attending physicians blinded to the study objective in a nonrandomized convenience sampling of all ED shifts, recording information regarding teacher interruptions during new patient presentations. Learners completed a brief questionnaire after each OCP. Results:A total of 196 OCPs were observed. The mean (±SD) duration of OCPs was 3.30 (±1.85) minutes, and the mean (±SD) number of interruptions was 0.75 (±0.60) per minute and 2.49 (±1.95) per OCP. The number of interruptions (per OCP) and duration of OCP varied by learner level of training, with more experienced learners giving shorter presentations and being interrupted less often. Frequency (per minute) of interruptions did not vary by learner level. In 40.3% of OCPs, attending physicians interrupted to give an assessment and/or a plan before the learner had done so, but 8.3% of interrupted learners believed that teacher interruptions were "disruptive" to their OCP. Conclusions:Attending emergency physicians frequently interrupt learners during new patient OCPs, with the number of interruptions varying by learner level of training. Teacher interruptions appear to have minimal, if any, detrimental effect on the perceived effectiveness of OCPs as a learning experience. [source]

Trauma Center Utilization for Children in California 1998,2004: Trends and Areas for Further Analysis

ACADEMIC EMERGENCY MEDICINE, Issue 4 2007
N. Ewen Wang MD
Abstract Background: While it is known that trauma systems improve the outcome of injury in children, there is a paucity of information regarding trauma system function amid changes in policies and health care financing that affect emergency medical systems for children. Objectives: To describe the trends in the proportion of pediatric trauma patients acutely hospitalized in trauma-designated versus non,trauma-designated hospitals. Methods: This was a retrospective observational study of a population-based cohort obtained by secondary analysis of a publicly available data set: the California Office of Statewide Health Planning and Development Patient Discharge Database from 1998 to 2004. Patients were included in the analysis if they were 0,19 years old, had International Classification of Disease, Ninth Revision (ICD-9) diagnostic codes and E-codes indicative of trauma, had an unscheduled admission, and were discharged from a general acute care hospital (N= 111,566). Proportions of patients hospitalized in trauma-designated hospitals versus non,trauma-designated hospitals were calculated for Injury Severity Score and death. Injury Severity Scores were calculated from ICD-9 codes. Primary outcomes were hospitalization in a trauma center and death two or more days after hospitalization. Results: Over the study period, the proportion of children aged 0,14 years with acute trauma requiring hospitalization and who were cared for in trauma-designated hospitals increased from 55% (95% confidence interval [CI] = 54% to 56%) in 1998 to 66% (95% CI = 65% to 67%) in 2004 (p < 0.01). For children aged 15,19 years, the proportion increased from 55% (95% CI = 54% to 57%) in 1998 to 74% (95% CI = 72% to 75%) in 2004 (p < 0.0001). When trauma discharges were stratified by injury severity, the proportion of children with severe injury who were hospitalized in trauma-designated hospitals increased from 69% (95% CI = 66% to 72%) in 1998 to 84% (95% CI = 82% to 87%) in 2004, a rate higher than in children with moderate injury (59% [95% CI = 58% to 61%] in 1998 and 75% [95% CI = 74% to 76%] in 2004) and mild injury (51% [95% CI = 50% to 52%] in 1998 and 63% [95% CI = 62% to 64%] in 2004) (p < 0.0001 for each injury severity category and both age groups). Of the hospitalized children who died two or more days after injury (n= 502), 18.1% died in non,trauma-designated hospitals (p < 0.002 for children aged 0,14 years; p = 0.346 for children aged 15,19 years). Conclusions: An increasing majority of children with trauma were cared for in trauma-designated hospitals over the study period. However, 23% of children with severe injuries, and 18.1% of pediatric deaths more than two days after injury, were cared for in non,trauma-designated hospitals. These findings demonstrate an important opportunity for improvement. If we can characterize those children who do not access the trauma system despite severe injury or death, we will be able to design clinical protocols and implement policies that ensure access to appropriate regional trauma care for all children in need. [source]

The Effect of Emergency Department Expansion on Emergency Department Overcrowding

ACADEMIC EMERGENCY MEDICINE, Issue 4 2007
Jin H. Han MD
Abstract Objectives: To examine the effects of emergency department (ED) expansion on ambulance diversion at an urban, academic Level 1 trauma center. Methods: This was a pre-post study performed using administrative data from the ED and hospital electronic information systems. On April 19, 2005, the adult ED expanded from 28 to 53 licensed beds. Data from a five-month pre-expansion period (November 1, 2004, to March 1, 2005) and a five-month postexpansion period (June 1, 2005, to October 31, 2005) were included for this analysis. ED and waiting room statistics as well as diversion status were obtained. Total ED length of stay (LOS) was defined as the time from patient registration to the time leaving the ED. Admission hold LOS was defined as the time from the inpatient bed request to the time leaving the ED for admitted patients. Mean differences (95% confidence interval [CI]) in total time spent on ambulance diversion per month, diversion episodes per month, and duration per diversion episode were calculated. An accelerated failure time model was performed to test if ED expansion was associated with a reduction in ambulance diversion while adjusting for potential confounders. Results: From pre-expansion to postexpansion, daily patient volume increased but ED occupancy decreased. There was no significant change in the time spent on ambulance diversion per month (mean difference, 10.9 hours; 95% CI =,74.0 to 95.8), ambulance diversion episodes per month (two episodes per month; 95% CI =,4.2 to 8.2), and duration of ambulance diversion per episode (0.3 hours; 95% CI =,4.0 to 3.5). Mean (±SD) total LOS increased from 4.6 (±1.9) to 5.6 (±2.3) hours, and mean (±SD) admission hold LOS also increased from 3.0 (±0.2) to 4.1 (±0.2) hours. The proportion of patients who left without being seen was 3.5% and 2.7% (p = 0.06) in the pre-expansion and postexpansion periods, respectively. In the accelerated failure time model, ED expansion did not affect the time to the next ambulance diversion episode. Conclusions: An increase in ED bed capacity did not affect ambulance diversion. Instead, total and admission hold LOS increased. As a result, ED expansion appears to be an insufficient solution to improve diversion without addressing other bottlenecks in the hospital. [source]

Trauma Team Activation Criteria as Predictors of Patient Disposition from the Emergency Department

Playground Injuries in Children: A Review and Pennsylvania Trauma Center Experience

JOURNAL FOR SPECIALISTS IN PEDIATRIC NURSING, Issue 1 2001
Lisa Marie Bernardo
ISSUES AND PURPOSE. To describe patient demographics, injury characteristics, and circumstances of playground injuries in children admitted to Pennsylvania trauma centers and to identify injury prevention strategies. DESIGN AND METHODS. Retrospective, descriptive study of 234 children ages 1 to 18 years sustaining playground-related injuries and whose hospital data were entered into the Pennsylvania Trauma Outcome Study. RESULTS. Most of the injuries occurred between April and September (77%), and noon to 6 P.M. (69%). Falls from playground equipment constituted the highest proportion of incidents (73%). Of 421 injuries (M = 1.8/patient), most were upper extremity (n = 117) and head (n = 110) injuries. PRACTICE IMPLICATIONS. Nurses can advocate for playground safety by teaching children to play safely and recommending age-appropriate equipment and protective surfacing. [source]

Validation of Length of Hospital Stay as a Surrogate Measure for Injury Severity and Resource Use Among Injury Survivors

ACADEMIC EMERGENCY MEDICINE, Issue 2 2010
Craig D. Newgard MD
Abstract Objectives:, While hospital length of stay (LOS) has been used as a surrogate injury outcome when more detailed outcomes are unavailable, it has not been validated. This project sought to validate LOS as a proxy measure of injury severity and resource use in heterogeneous injury populations. Methods:, This observational study used four retrospective cohorts: patients presenting to 339 California emergency departments (EDs) with a primary International Classification of Diseases, Ninth Revision (ICD-9), injury diagnosis (years 2005,2006); California hospital injury admissions (a subset of the ED population); trauma patients presenting to 48 Oregon EDs (years 1998,2003); and injured Medicare patients admitted to 171 Oregon and Washington hospitals (years 2001,2002). In-hospital deaths were excluded, as they represent adverse outcomes regardless of LOS. Duration of hospital stay was defined as the number of days from ED admission to hospital discharge. The primary composite outcome (dichotomous) was serious injury (Injury Severity Score [ISS] , 16 or ICD-9 ISS , 0.90) or resource use (major surgery, blood transfusion, or prolonged ventilation). The discriminatory accuracy of LOS for identifying the composite outcome was evaluated using receiver operating characteristic (ROC) analysis. Analyses were also stratified by age (0,14, 15,64, and ,65 years), hospital type, and hospital annual admission volume. Results:, The four cohorts included 3,989,409 California ED injury visits (including admissions), 236,639 California injury admissions, 23,817 Oregon trauma patients, and 30,804 Medicare injury admissions. Composite outcome rates for the four cohorts were 2.1%, 29%, 27%, and 22%, respectively. Areas under the ROC curves for overall LOS were 0.88 (California ED), 0.74 (California admissions), 0.82 (Oregon trauma patients), and 0.68 (Medicare patients). In general, the discriminatory value of LOS was highest among children, tertiary trauma centers, and higher volume hospitals, although this finding differed by the injury population and outcome assessed. Conclusions:, Hospital LOS may be a reasonable proxy for serious injury and resource use among injury survivors when more detailed outcomes are unavailable, although the discriminatory value differs by age and the injury population being studied. ACADEMIC EMERGENCY MEDICINE 2010; 17:142,150 © 2010 by the Society for Academic Emergency Medicine [source]

Are All Trauma Centers Created Equally?

ACADEMIC EMERGENCY MEDICINE, Issue 7 2010
A Statewide Analysis
ACADEMIC EMERGENCY MEDICINE 2010; 17:701,708 © 2010 by the Society for Academic Emergency Medicine Abstract Objectives:, Prior work has shown differences in mortality at different levels of trauma centers (TCs). There are limited data comparing mortality of equivalently verified TCs. This study sought to assess the potential differences in mortality as well as discharge destination (discharge to home vs. to a rehabilitation center or skilled nursing facility) across Level I TCs in the state of Ohio. Methods:, This was a retrospective, multicenter, statewide analysis of a state trauma registry of American College of Surgeons (ACS)-verified Level I TCs from 2003 to 2006. All adult (>15 years) patients transferred from the scene to one of the 10 Level I TCs throughout the state were included (n = 16,849). Multivariable logistic regression models were developed to assess for differences in mortality, keeping each TC as a fixed-effect term and adjusting for patient demographics, injury severity, mechanism of injury, and emergency medical services and emergency department procedures. Outcomes included in-hospital mortality and discharge destination (home vs. rehabilitation center or skilled nursing facility). Adjusted odds ratios (ORs) for each TC were also calculated. Results:, Considerable variability existed in unadjusted mortality between the centers, from 3.8% (95% confidence interval [CI] = 3.7% to 3.9%) to 24.2% (95% CI = 24.1% to 24.3%), despite similar patient characteristics and injury severity. Adjusted mortality had similar variability as well, ranging from an OR of 0.93 (95% CI = 0.47 to 1.84) to an OR of 6.02 (95% CI= 3.70 to 9.79). Similar results were seen with the secondary outcomes (discharge destination). Conclusions:, There is considerable variability in the mortality of injured patients at Level I TCs in the state of Ohio. The patient differences or care processes responsible for this variation should be explored. [source]

On-call Specialists and Higher Level of Care Transfers in California Emergency Departments

ACADEMIC EMERGENCY MEDICINE, Issue 4 2008
Michael D. Menchine MD
Abstract Objectives:, To survey California emergency department (ED) medical directors' impressions of on-call specialist availability and higher level of care (HLOC) transfer needs and difficulties and changes since the passage of the Emergency Medicine Treatment and Active Labor Act (EMTALA) final rule in 2003. Methods:, The authors conducted a survey of all California ED medical directors from February to June 2006 with regard to the composition of the ED on-call panel and need for HLOC transfer. ED demographic data were obtained from the California Office of Statewide Health Planning and Development. Results:, Overall response rate was 243 of 347 (70%). More than 80% of respondent EDs reported having internal medicine, obstetrics/gynecology (OB/GYN), and pediatrics on call. However, fewer than 60% of EDs reported cardiac surgery, otolaryngology, neurosurgery, plastic surgery, or vascular surgery on call. Specialists were less likely to be on call in rural EDs. On-call coverage was rated worse than 3 years ago for 10 of 16 specialties. Rural EDs were more likely, and trauma centers and teaching hospitals were less likely to transfer at least one patient daily for HLOC. ED medical directors reported that the ability to transfer for HLOC has worsened over the past 3 years for all specialties. Respondents indicated that more than 40% of ear, nose, and throat (ENT), orthopedics, plastic surgery, and mental health HLOC transfers take more than 3 hours. Conclusions:, This survey of California ED medical directors suggests ED on-call specialist availability and the ability to transfer for HLOC have worsened since the passage of the EMTALA final rule in 2003. [source]