77.13 Trauma Education in a State of Emergency: A Curriculum-based Analysis

Posted on December 22, 2014

S. D. Waterford1, M. Williams4, P. M. Fisichella3, A. Lebenthal2,3  1Massachusetts General Hospital,Department Of General Surgery,Boston, MA, USA 2Brigham And Women’s Hospital,Division Of Thoracic Surgery,Boston, MA, USA 3Boston VA Healthcare System,Department Of Surgery,Boston, MA, USA 4Oakwood Southshore Medical Center,Department Of General Surgery,Trenton, MI, USA

Introduction:  Trauma is the leading cause of death among persons aged 1-44 in the United States and is the 5th leading cause of death overall. It accounts for more lost years of life than atherosclerosis and cancer combined. Trauma education in American medical schools has received little attention. In this pilot project, we sought to quantify the number of curricular hours devoted to each of the 5 leading causes of death in the United States.

Methods:  We performed a review of the pre-clinical curriculum at a northeastern Medical School with full LCME accreditation and hospital affiliations with three adult and one pediatric American College of Surgeons verified Level I trauma centers. We tabulated the total number of hours devoted to education of the 5 leading cause of death in the United States and we included class lectures as well as small group case-based meetings with a faculty preceptor. We then compared the total number of curricular hours devoted to trauma to other major causes of death in the United States. For the statistical analysis we used standard ANOVA with a p < 0.05 significance threshold.

Results: Of the leading 5 causes of death, heart disease was the most covered topic with 128 hours of dedicated curriculum time (Table I).  Chronic respiratory disease was the second most discussed topic with 80 hours of dedicated curriculum time.  The number of hours of curriculum time devoted to heart disease, chronic lower respiratory diseases, malignant diseases, and cerebrovascular diseases far exceeded that devoted to trauma. This was statistically significant for all 5 leading causes of death except cerebrovascular disease.  In the first two pre-clinical years of curriculum 6.5 hours were dedicated to trauma. Six hours of tutorial time was devoted to a single trauma case, involving an accidental blunt trauma. A half hour lecture on orthopedic fractures concluded the total time allocation. No lectures were given on the basic management of trauma patients.

Conclusion: A pilot study comparing curricular hours of the 5 leading causes of death demonstrated a statistically significant discrepancy in the allocated time devoted to trauma education compared to other causes. Based on these preliminary data, we advocate a broader multi-institutional study to further ascertain the amount and quality of trauma education in American medical schools.

77.14 Improvement of an Acute Care Surgery Medical Student Rotation:Use of Feedback & Loop Closure

Posted on December 22, 2014

J. R. Cherry-Bukowiec1, D. A. Machado-Aranda1, K. To1, K. Raghavendran1, M. J. Englesbe1, L. M. Napolitano1  1University Of Michigan,Surgery,Ann Arbor, MI, USA

Introduction:

The unpredictable and sometimes chaotic environment present in an Acute Care Surgery Services (Trauma, Burn, Surgical Critical Care, Non-Trauma Emergency Surgery) can cause high levels of anxiety and stress that could impact a medical students’ experience during their M3 surgical clerkship. This negative perception perhaps is a determinant influence in diverting talented students into other medical subspecialties. We sought out to objectively identify potential areas of improvement through direct feedback and implement programmatic changes to address these areas. We hypothesized that as the changes were made students perception of the rotation would improve.

Methods:

Review of end of clerkship M3 Trauma Burn Surgery Rotation evaluations and comments was performed for the 2010-2011 academic year. Trends in negative feedback were identified and categorized into 5 areas for improvement: Logistics, Student Expectations, Communication, Team Integration, and Feedback. (Table 1.) A plan was designed and implemented for each category. Feedback on improvements to the rotation was monitored via surveys and during monthly end of rotation face-to-face student feedback sessions with the rotation faculty facilitator and surgery clerkship director. Data was compiled and reviewed

Results:

Perceptions of the rotation markedly improved within the first month of the changes, and continued to improve over the study time frame (2011-2013) in all five categories. We also observed an increase in the number of students who rotated through the ACS service selecting a surgical residency in the NRMP Match from a low of 8% in 2009-2010 prior to any interventions, to 25% after full implementation of improvement measures in 2011-2012.

Conclusion:
A systematic approach using direct feedback from students to address service specific issues improves perceptions of students on the educational value of a busy Trauma –Burn Acute Care Surgery Service and may have a positive influence on students considering surgical careers to pursue a surgical specialty.

77.15 Medical Student Perceptions of the Operating Room in Acute Care Surgery

Posted on December 22, 2014

D. A. Machado-Aranda1, J. Cherry-Bukowiec1, K. To1, M. Englesbe2, L. M. Napolitano1, K. Raghavendran1  1University Of Michigan,Division Of Acute Care Surgery/Department Of Surgery,Ann Arbor, MI, USA 2University Of Michigan,Division Of Transplant Surgery/Department Of Surgery,Ann Arbor, MI, USA

Introduction: Declining medical student interest in surgical careers has been a worrisome trend in the last few years. A repetitive criticism in modern surgical education is the decreased value of educational experiences in the operative room. The unpredictable and intimidating atmosphere in the operating theater of Acute Care Surgery (ACS), including Trauma, Burns, Surgical Critical Care and Emergency Surgery Services, can lead to an poor perception among medical students, creating a negative experience that could divert talented students from choosing a career in ACS. However tools to evaluate teaching in the operating room remain poorly developed. We set out to interrogate this ACS operative perception in order to maximize its educational value and convert it into a positive experience.  

Methods: Third-year medical students (M3) rotating through a four-week long course in ACS from the 2013-2014 academic years were the subject of this study.  A tool (OR-card) was created to deconstruct the phases within the operative process (preoperative, intra-operative and postoperative debriefs) and capture potential areas of improvement.

Results: A total of 12 students were included in the initial sample.  Close to 30 OR-cards were collected.  All students (100%) correctly identified and named the operative procedure and its indication.  However, only 66.6% could enumerate pertinent preoperative workup.  Conversely, 83.3% could review principles of anatomy and physiology important for the operation, and 83.3% had a clear postoperative plan. Importantly, despite the unpredictable nature of ACS, only 16.6% of operations changed from the proposed surgery.  Using an analogue scale where a “10” was exact to discussion and “1” was completely different from discussion, students' appreciation score was an 8.3 ±  2.4.  Best memorable learning experiences were Anatomical Review (66.6%), Participation (50%), Individual Skill (50%) and Operative Surgical Principles (50%).  Finally, the highest sources of information for students were residents (83.3%) followed by surgical attending (33.3%), whereas no traditional references were used (textbooks, peer-reviewed publications or atlases). 

Conclusions: Despite the unscheduled nature of ACS operations, medical students were able to greatly follow through the different phases of the majority of emergency surgical interventions.  Potential areas of improvement include understanding of pertinent preoperative workup, strengthening anatomical review, and inviting more participation within the intervention.  Finally, attending surgeons should assume their critical role as teachers within the OR, as students are greatly depending on sources that are still in-training (residents).

77.01 Do Trauma Nurses Know (and Trust) their Physician Colleagues?

Posted on December 22, 2014

N. Ho1, G. Kurosawa1, A. Wei1, E. Lim1, S. Steinemann1,2  1University Of Hawaii,John A. Burns School Of Medicine,Honolulu, HI, USA 2The Queen’s Medical Center,Honolulu, HI, USA

Introduction:  

Efficient teamwork requires knowledge of members’ capabilities and task domains. In modern trauma teams, multiple levels of “physician” practitioners (medical students, residents, fellows, attendings and physicians’ assistants – “PAs”) may create confusion. We hypothesized that trauma nurses (TRNs) lack detailed knowledge of team members’ abilities, and that TRNs and surgeons may have discordant perceptions of responsibilities during resuscitations.

Methods:  

A survey was conducted at a Level II Trauma Center which includes medical students, residents, surgical critical care fellows (Fellows) and PAs on the trauma team. TRNs enrolled in a trauma refresher course gave informed consent to participate and were asked their knowledge of the education, clinical training and need for supervision of team members. TRNs then ranked, on a 7-point Likert-type scale, their perception of responsibility for 17 resuscitation tasks.  TRN perceptions were compared (via two sample t tests) to those of attending trauma surgeons.

Results:

42 TRNs (100%) and 9 surgeons (90%) participated. Only 4% of TRNs knew the minimum clinical years training of first-year residents (PGY1s), Fellows and PAs. 90% of TRNs underestimated the clinical experience of PAs by an average of 2-fold; 61% underestimated the experience of PGY1s and Fellows.

88% of TRNs correctly identified the need for medical student, PGY1 and PA supervision for specific procedures or patient conditions.  However, 92% of TRNs thought mid-level residents should be supervised for tube thoracostomy, a procedure typically performed by mid-level residents without direct supervision.

TRNs and attending surgeons differed in perception of responsibility for most resuscitation tasks with both groups assigning significantly more responsibility to their own profession (Table).

Conclusion:

Our study demonstrates a gap in TRN understanding of the education and experience of surgical trainees and PAs, and a perceived need for additional procedural supervision of mid-level residents. Both TRNs and attending trauma surgeons maintained “ownership” of a number of trauma resuscitation tasks. This could conceivably result in inefficiency and duplication of diagnostic procedures or interventions.  Further education regarding trauma team members’ training and ability, and attention to nontechnical “teamwork” skills (e.g. pre-briefing, role assignments, communication) may be warranted to reduce redundancy and confusion.

75.15 Decreased Traumatic Brain Injury Severity After Improvements in Vehicle Safety Regulations.

Posted on December 22, 2014

B. W. Bonds1,2, M. J. Bradley3,4, S. S. Cai2, D. M. Stein1,2  3Naval Medical Research Center,Regenerative Medicine,Silver Spring, MD, USA 4Walter Reed Army Medical Center,Washington, DC, USA 1R Adams Cowley Shock Trauma Center,Trauma Surgery,Baltimore, MD, USA 2University Of Maryland,School Of Medicine,Baltimore, MD, USA

Introduction:  Motor vehicle collisions (MVC) are one of the main mechanisms for traumatic brain injury (TBI) in the United States.  In 2009, regulations modifying side impact crash testing from the National Highway Traffic Safety Administration were announced which effectively mandated the inclusion of side impact airbags on all vehicles as well as structural reinforcements aimed at minimizing sidewall intrusion.  We sought to determine any effect these changes have had on the mortality, frequency and severity of TBI following MVC. 

Methods:  Data was retrospectively collected over ten years (2004-2013) on all patients admitted to a level one trauma center with a TBI following MVC. Patients were reviewed for severity of brain injury, post-resuscitation Glasgow Coma Scale (GCS), and mortality.  The incidence of mild (GCS 13-15), moderate (GCS 9-12), and severe TBI (GCS ≤ 8) was calculated five years before (2004-08) and after (2009-13) the new regulations with a p-value < 0.05 considered significant.

Results: Over ten years, 2144 patients were admitted with a TBI secondary to a MVC. There were no significant demographic differences between patients admitted before or after 2009 (Age 39.67 vs 41.15 p = 0.086, Male 61.75% vs 64.07% p = 0.286, ISS 28.85 vs 28.87  p = 0.979, Brain AIS 3.76 vs 3.81 p = 0.119). While incidence of TBI from all causes increased by 15.59% since 2009, MVC as the mechanism of injury leading to hospital admission has declined by 4.70% (25.11% vs 20.41%, p < 0.0001). Severity of head injury also shifted with a reduction in the proportion of severe TBI (42.18% vs 37.09%, p = 0.0343) and an expansion of mild-moderate TBI (3.61% and 1.48% increase respectively).  Early mortality (< 24 hrs of admission) decreased from 51.02% to 33.09% (p = 0.0034), while overall mortality was unchanged (Table 1). 

Conclusion: Further work is needed to show a causal relationship, but since the widespread implementation of improved vehicle safety regulations there has been a significant reduction in severe TBI and proportionately higher rates of mild-moderate TBI after MVC. While overall mortality in this study was unchanged following 2009, those patients critically injured showed a significant improvement in early mortality. 

 

75.16 Communication At The Interface Of Surgery & Critical Care: Finding Ways To Enhance Patient Safety

Posted on December 22, 2014

L. Gotlib Conn1, B. Haas3, B. H. Cuthbertson1,4, A. Amaral1,4, N. Coburn2,5, S. Goddard4, L. Nusdorfer4, A. B. Nathens1,2  1Sunnybrook Research Institute,Evaluative Clinical Sciences/Trauma, Emergency And Critical Care Research Program,Toronto, ONTARIO, Canada 2Sunnybrook Health Sciences Centre,Surgery,Toronto, ONTARIO, Canada 3University of Toronto,Critical Care Medicine,Toronto, Ontario, Canada 4Sunnybrook Health Sciences Centre,Critical Care Medicine,Toronto, ONTARIO, Canada 5Sunnybrook Research Institute,Odette Cancer Research Program,Toronto, ONTARIO, Canada

Introduction:
Ineffective communication between providers in the ICU is associated with a higher rate of errors and harmful effects on provider and patient family relations. Improving communication across providers may significantly enhance patient safety and improve provider-family interactions. To identify opportunities for improvement, we explored communication behaviors and practices between surgical and critical care teams treating trauma/surgical patients in a closed ICU.

Methods:
We conducted a qualitative ethnographic study of communication practices and behaviors of trauma, general surgery, neurosurgery and critical care teams in 3 academic ICUs, totaling 50 hours of observation. Additional data were derived from focused interviews (n=46) with surgeons, intensivists, surgical residents, intensive care fellows and ICU nurses. Data were collected and analyzed iteratively to the point of theoretical saturation.

Results:

Observed communication between surgical and ICU teams focused on negotiating contested boundaries of expertise, patient ownership, and decisional authority. Participants described features of effective communication involving successful negotiation of these boundaries leading to collaborative patient care. Ineffective communication involved poor boundary negotiation leading  to provider frustration and inter-team conflict (figure). Several discrete communication behaviors and practices between surgical and critical care teams were identified; specific behaviors and practices were closely associated with either enhanced or suboptimal communication across teams. In addition, multiple structures and processes of care currently in place were identified as barriers to effective communication between teams, creating delays and gaps in information transfer impacting the quality of patient care. 

Conclusion:

Opportunities exist to improve collaborative communication between surgery and critical care teams.  In addition to targeting specific structures and processes of care, interventions aimed to elucidate competing cultures of care, strengthen provider relationships, and mitigate negative behaviors should be evaluated to address interdisciplinary collaboration with a view to enhancing surgical patient safety in the closed ICU.
 

73.11 Does Obesity Affect Outcomes in Adult Burn Patients?

Posted on December 22, 2014

J. J. Ray1, S. S. Satahoo1, C. J. Allen1, J. P. Meizoso1, C. M. Thorson1, L. F. Teisch1, J. E. Sola2, K. G. Proctor1, L. R. Pizano1, N. Namias1, C. I. Schulman1  1University Of Miami,Divisions of Trauma, Surgical Critical Care, and Burns,Miami, FL, USA 2University Of Miami,Division of Pediatric and Adolescent Surgery,Miami, FL, USA

Introduction: It is recognized that negative outcomes are associated with obesity in trauma, but less is known about outcomes in burn patients. We aim to bridge this gap to better understand the association of obesity to clinical and economic outcomes in the burn population. We hypothesize that obesity is an independent predictor of adverse events.

Methods: The National Inpatient Sample was queried for adult patients (age ≥ 18 years) with an “emergency,” “urgent,” or “trauma center” admission from 2005-2009, and ICD-9 codes for burn injury. Patients with isolated injuries to the internal organs and eyes (941-946.5, 948-949.5) were excluded as were those with missing data for total body surface area (TBSA) burn and/or burn degree. Demographics, disease severity, length of stay (LOS), discharge disposition, hospital costs and outcomes were reviewed. Parametric data are represented as mean±standard deviation and non-parametric data as median(interquartile range). Univariate and multivariate analysis logistic regression models were performed.

Results: In 14,602 patients, 3.3% were obese (body mass index>30). The rate of obesity increased significantly over the study period (2005: 1.7%, 2006: 2.0%, 2007: 2.8%, 2008: 4.6%, 2009: 5.2%, p<0.001). On univariate analysis, there were no significant differences between obese and non-obese patients in terms of race, TBSA burn, degree of burn, need for mechanical ventilation, or household income. Significant differences were noted in incidence of wound infection (7.2%vs5.0%), urinary tract infection (UTI) (7.2%vs4.6%), deep vein thrombosis (DVT) in TBSA burn ≥ 10% (3.1 vs 1.1%), pulmonary embolism (PE) in TBSA burn ≥ 10% (2.3%vs0.6%), discharge to home (57.7%vs66.6%), high disease severity (91.8%vs73.5%), LOS [6(8) vs 5(9)] and hospital costs [$10,122.12($19,825.21) vs $7892.07($17.191.96)] (all p <0.05). Significant predictors of adverse events (UTI, wound infection, DVT, or PE) included: obesity (15.2%vs10.1%), TBSA ≥ 20% (14.6%vs9.6%), age (53±20y vs 45±18y) and black race (13.0%vs9.9%). These remained significant on multivariate analysis using a logistic regression model (area under receiver operator curve= 0.703) (Table).

Conclusion: In burn patients, obesity is an independent predictor of adverse events along with TBSA ≥ 20, age, and black race. Our findings highlight the potential clinical and economic impact of the obesity epidemic on burn patients nationwide.

 

73.12 Cultural Divergence: Trauma Mechanisms and Outcomes Transcend Racial Similarities

Posted on December 22, 2014

N. Kamagate1, T. Wood1, U. Pandya1, M. S. O’Mara1  1Grant Medical Center/Ohio University,Trauma And Acute Care Surgery/Ohio University Heritage College Of Osteopathic Medicine,Columbus, OHIO, USA

Introduction:   Race has been associated with outcomes in trauma patients. However, growing populations of 1st and 2nd generation African immigrants has brought up questions as to whether it is culture or race that influences these outcomes.   We hypothesize that the cultural background of patients instead of racial type, impacts cause, course and outcomes in trauma patients.

Methods:   25470 patients admitted to a level one trauma center over an 8-year period were retrospectively evaluated. Patients were separated into 3 groups: 1) Caucasian, 2) non-immigrant African Americans, and 3) African first or second generation immigrants.  Demographic, injury mechanism and severity, and outcome variables were evaluated.

Results:  Patient demographics and injury severity were not different.  The mechanism of injury in the immigrant population was different (see table), with immigrant patients having a majority of motor vehicle collisions.  MVCs were the most frequent in the nonimmigrant and Caucasian groups as well, but those two groups had much higher incidence of penetrating injury (non-immigrant African Americans) and falls (Caucasians).  There was also a decreased mortality in the immigrant group (2.8%), which was significantly (p < 0.0001) lower than both the non-immigrant (4.4%) and Caucasian groups (3.1%).

Conclusion:  There is more to trauma outcomes than race.  Cultural background is a significant predictor of injury cause and of survival in trauma patients.

 

73.13 Failure-to-Rescue from Complication after Blunt Traumatic Injury: Is Socioeconomic Status a Factor?

Posted on December 22, 2014

M. Arafeh1, S. Selvarajah1, E. B. Schneider1, J. Canner1, C. K. Zogg1, A. H. Haider1  1Johns Hopkins University School Of Medicine,Center For Surgical Trials And Outcomes Research, Department Of Surgery,Baltimore, MD, USA

Introduction:  Variations in in-hospital mortality rates by socioeconomic status (SES) following trauma have been consistently demonstrated, but mechanisms underlying this disparity are poorly understood. We sought to evaluate the impact of SES on the occurrence of post-traumatic complications and subsequent failure-to-rescue (FTR). 

Methods:  A retrospective analysis of the 2006-2011 Nationwide Emergency Department Sample (NEDS) was performed. Patients aged 18-64 years presenting to Level I or II trauma centers with blunt traumatic injury were identified. SES was determined using a pre-defined NEDS variable classifying patients into quartiles of median household income by zip code. A nationally representative weighted population subset was used, approximating a 20% stratified sample of U.S. hospital-based emergency departments. [t1] Complications associated with FTR as defined by the Agency for Healthcare Research & Quality (AHRQ) were identified using ICD-9 diagnosis codes. Multivariable logistic regression was performed to determine the odds of FTR (defined as mortality following a specified complication) comparing patients from the lowest SES (Q1) with patients from the highest SES (Q4), adjusting for age, gender, insurance status, injury severity, comorbidities,  trauma level, and teaching status. 

 

Results: Of 412,534 cases that met inclusion criteria, 22,398 (5.4%) patients had one or more complication. Overall, proportionally more patients in Q1 (n=13,964; 5.8%) developed complications compared with patients in Q4 (n=8,474; 5.0%), p=0.002. Of patients who developed complications, the average patient age was 44 years (SE=0.252); 76.8% were males with equal distribution between Q1 and Q4 (p=0.799). FTR was proportionally more common among patients in Q1 compared to Q4 (19.5% vs. 15.4%; p=0.004). After adjusting for relevant covariates, the odds of FTR were 31% higher among patients in Q1 compared to Q4 (AOR=1.31 [95% CI=1.067-1.620], p=0.012). 

 

Conclusion: Among patients who develop complications, FTR is significantly increased following blunt traumatic injury in the lowest SES quartile (Q1) compared to the wealthiest patients (Q4). Further research will be necessary to discern factors associated with higher complication and greater FTR rates among patients with low SES.
 

73.14 A National Estimation of LGB Patients Seeking Surgical Care in the ED

Posted on December 22, 2014

R. Y. Shields1, N. Nagarajan1, B. Lau1, C. Zogg1, L. Kodadek1, A. Robinson2, D. German2, A. Ranjit1, S. Peterson1, A. Haider1  1Johns Hopkins University School Of Medicine,Baltimore, MD, USA 2Johns Hopkins Bloomberg School Of Public Health,Baltimore, MD, USA

Introduction:

Widespread health and healthcare disparities for lesbian, gay, and bisexual (LGB) patients have been well documented in a variety of ambulatory settings. However, no information of specific treatments, outcomes, or risks in the emergency department (ED) or surgical settings exists for this population. Using the ED as a point of entry, we aimed to estimate the number of LGB patients who seek emergent surgical care annually by extrapolating from existing population data.

 

Methods:

A review was done to find studies that surveyed sexual orientation. We searched MEDLINE/PubMed, Embase, CINAHL, and Scopus using controlled vocabulary and relevant free text which included: LGB*, homosexual*, health care. We included studies that reported proportion of LGB individuals, conducted within the United States, and published between 1980-2013. Studies that reported sexual behavior or attraction, did not use standardized question formats, or had high rates of missing data were not included. We extracted relevant data from these studies to determine estimated LGB proportions in the general population. Using national estimates of ED visits from the HCUP National Emergency Department Sample (NEDS) and ICD-9 codes to identify patients needing surgical consultations, we calculated a nationally-representative number (and corresponding 95% CI) of LGB individuals seeking surgical care in the ED.

Results:

We reviewed 405 potentially relevant papers, of which 3 satisfied our inclusion criteria (Table). Combining their results, we estimated that 2.78% (95% CI: 2.73-2.84) of the U.S. population identify as LGB. Data from the 2011 NEDS estimated a total of 131,048,605 ED visits. Of the 131 million ED visits, 14 million required emergent surgical care. Assuming that 2.78% of the ED visits were by self-identifying LGB individuals, there were approximately 3.64 million (95% CI: 3.57 – 3.72 million) encounters with LGB patients in the ED in 2011. Of these, 389,200 (95% CI: 382,200 – 397,600) required a surgical consult.

Conclusion:

Every year, millions of patients who self-identify as LGB seek care in EDs across the country, a significant proportion of whom require surgical care. It is likely that this is a conservative estimate given widespread underreporting of LGB status. It is impossible to further examine potential disparities facing LGB patients seeking surgical care without routine collection of sexual orientation information, a priority for the Institute of Medicine and The Joint Commission. Additional research is needed to develop effective education and training for surgeons and surgical residents to address LGB patients. 

73.15 Perioperative Complications of Traumatic Open Femur Fracture ORIF in the Elderly

Posted on December 22, 2014

N. N. Branch1,2, A. Obirieze2, R. H. Wilson1,2  1Howard University College Of Medicine,Washington, DC, USA 2Howard University Hospital,Surgery,Washington, DC, USA

Introduction: Elderly patients 65 years and older represent an increasing proportion of the population, and they are typically more susceptible to open femoral fractures.  However, factors such as bone quality, nutritional status and comorbidites may affect treatment approaches and outcomes.  We aim to assess 30 day perioperative complications associated with open reduction and internal fixation of open femoral fractures in the elderly.

Methods: A retrospective analysis of the National Trauma Data Bank (NTDB) from 2007-2010 utilizing ICD-9 codes was conducted.  Cases ≥ 18 years old, who underwent open reduction and internal fixation (ORIF) of the femur at a level I or level II trauma center were included.  Patients were then stratified by age, with those 18-24 years serving as the reference group. Univariate, bivariate, and multivariate analyses were performed.

Results: 9,406 patients met the inclusion criteria, with the majority being white (61%), males (73%), between 25-44 years old (41%) with a mean age of 29 years.  Patient with private insurance (25%) and injury via motor vehicle collisions (34%) were most common. Elderly patients comprised 9.5% of the total population of which 85% were White and 62% were female. Elderly patients were 85% more likely to have fixation after hospital day 2 (OR: 1.85 CI: 1.49-2.29 p<0.001), 94% more likely to have an organ/space surgical site infection (OR: 1.94 CI: 1.32-2.37 p=0.001), and more than seven times more likely to die (OR: 7.58 CI: 3.71-15.49 p<0.001). All patients were over three times more likely to die if they had at least one perioperative complication (OR: 3.6 CI: 2.48-5.24 p<0.001).  All age groups were more likely to have at least one perioperative complication compared to those 18-24 years with the elderly having the greatest odds at 67% (OR: 1.67 CI: 1.25-2.21 p<0.001), followed by ages 45-64 (OR: 1.47 CI: 1.22-1.78 p<0.001), and ages 25-44 (OR: 1.30 CI: 1.10-1.55 p=0.002).

Conclusion: While the elderly represent a small proportion of open femoral fracture cases they are more likely to have a perioperative complication including infections.  Moreover elderly patients are the group most likely to suffer the most profound complication of all; perioperative death as compared to their younger counterparts.  While direct causality cannot be identified with this study, it is probable that a reduction of overall complications in this patient population could improve perioperative mortality.

73.16 PEDESTRIAN CRASH INJURIES IN LAS VEGAS: ALCOHOL USE AND OTHER FACTORS INCREASE RISK OF INJURY

Posted on December 22, 2014

D. R. Fraser1, N. D. Fulkerson1, A. A. Chavez1, N. K. Ingalls1, E. A. Snavely2, B. S. Penalosa1, J. J. Fildes1, D. A. Kuhls1  2University Medical Center,Trauma,Las Vegas, NV, USA 1University Of Nevada School Of Medicine,Surgery/Trauma,Las Vegas, NV, USA

Introduction: Las Vegas is ranked the13th most dangerous metropolitan area for walking, according to Transportation for America. Approximately 5,000 pedestrians die each year on U.S. roadways, creating a public health concern for pedestrian safety. To effectively target injury prevention, we analyzed demographic, environmental, temporal and alcohol consumption factors associated with being struck by a vehicle while navigating the streets of Las Vegas on foot.

Methods: We conducted a retrospective analysis of injuries resulting from auto pedestrian crashes (APC) at our Level I Trauma Center in Las Vegas from 2009-2013 (n=1126). Demographic, injury, environmental and hospital utilization data were analyzed in SPSS 22 using chi square, Mann Whitney U and logistic regression tests with significance set at p<0.05.

Results: Overall, 29% of injured pedestrians were labeled as having suspected alcohol use on admission; this did not vary by racial groups and was reported higher during the weekdays. These patients with suspected alcohol use were 4.3 times more likely to be admitted at night and experienced a longer hospital length of stay (HLOS). Injury severity did not vary with the time of day or day of the week but injury patterns varied: severe extremity injury (Abbreviated Injury Scale (AIS) of 3+) occurred during weekdays (p<0.001) and more severe facial injuries occurred at night. Additionally, patients admitted at night had a lower Glasgow Coma Scale (GCS) and Revised Trauma Score (RTS) compared to those admitted during the day. Seasonal variation included more night admissions for spring, summer and fall. During the summer, APC patients were 2.2 times more likely to occur at night. Friday pedestrian injuries were higher compared to Sunday, Monday and Tuesday. Predictors of low GCS (3-8) included increased age, Asian and Other race groups. Compared to the White group, Asian and Other groups were 2.46 and 3.6 times more likely to have a low admission GCS. Older age, New Injury Severity Score (NISS) and suspected alcohol use were significant predictors of HLOS.

Conclusion: In Las Vegas, there are demographic, temporal and social factors that contribute to APCs. Pedestrians who engage in alcohol use during the summer months have an increased likelihood of being involved in a crash at night and during the weekdays. Patients injured during the night had a decreased Revised Trauma Score (RTS), indicating an initial assessment of more serious injury. Age, NISS and suspected alcohol use were associated with increased HLOS. Increased incidence of pedestrian injuries occurred on Friday compared with earlier days in the week. Injury prevention efforts should focus on alcohol consumption, seasonal and diurnal variations that contribute to pedestrian safety. A prospective study that analyzes pedestrian behaviors and other factors may help elucidate other factors that place pedestrians at risk and contribute to high rate of APCs in Las Vegas.

73.01 Strategies for Securing Funding for Global Health in Trauma and Acute Care Surgery

Posted on December 22, 2014

J. Puyana1, N. Carney1, A. Sanchez3, A. Rubiano1, A. Garcia3, C. Ordoñez3, A. Peitzman1  1University Of Pittsburgh,Trauma & Acute Care Surgery,Pittsburgh, PA, USA 2Oregon Health And Science University,Informatics,Portland, OR, USA 3Universidad Del Valle,Surgery,Cali, Valle, Colombia

Introduction: International programs promoting global health-“surgery” in low and middle-income countries (LMICs) continue to sprout across many academic centers in the United States. This development has been driven in part by the enormous and ever growing interest voiced by medical students and young surgical residents to engage in “global surgery” activities. This interest has resulted from an increasing awareness of the impact of trauma and suboptimal acute care surgery as major burdens of disease around the world. We have created an innovative "cross sectional" strategy combining clinical research training, capacity building and clinical mentoring overseas in order to strengthen the academic components of such international activities. This strategy has secured continuous funding by NIH sponsored global health programs over an 8 year period. This approach has opened a new realm of opportunities by identifying long term funding mechanisms that directly impact trauma care under a number of programs not originally targeted for trauma/injury research initiatives

Methods:

After obtaining an initial D43 training grant aimed at supporting capacity building in injury research, our multidisciplinary team identified other NIH sponsored programs in the following areas: Informatics training for global health, Brain disorders in the developing world: Research across the lifespan, Global Health Research Training eCapacity and Mobile Health: Technology and Outcomes in LMICs.

Results:

Funding has been procured from four of these five programs ($US 2.5 Million). We generated research projects including the development of mobile technology based trauma information tools, web based platforms for trauma registries in underserved areas and a multicenter clinical trial in the form of pilot R21 for capacity building in traumatic brain injury. Seven students obtained a Master’s degree and one a PhD. All these students have returned to their country of origin. There has been an incremental increase in the number of contributions from LMIC trainees to several trauma/injury related academic societies. Trainee – initiated research endeavors have generated, 30 manuscripts published in peer review journals, 7 manuscripts submitted for publication, 6 publications in textbooks and 45 abstracts. This research output in trauma and acute care surgery is unprecedented in most LMICs.

Conclusion:

A multidisciplinary collaboration between health professionals from the US and LMIC has resulted in significant trauma research contributions relevant to LMICs and opened the doors for bilateral exchange and mutual benefit in both clinical and research areas. Furthermore, a new modality of global surgery is emerging supported by long term relationships with strong academic platforms that have the potential for expanding other global health ventures and providing new avenues for the development of true academic careers in global surgery.

 

73.02 The Utility of the Verbal Autopsy Technique to Assess Pre-hospital Trauma-mortality Burden

Posted on December 22, 2014

J. S. Qureshi1, G. Mulima2, S. Zadrozny1, B. Cairns1, A. G. Charles1  1University Of North Carolina At Chapel Hill,Chapel Hill, NC, USA 2Kamuzu Central Hospital,Lilongwe, , Malawi

Introduction:
Trauma, particularly Road Traffic Injury (RTI), is a leading cause of global death and disability. Africa has one of the highest RTI related mortality in the world, at 28.3 deaths per 100 000 population, however, this may be underestimated as only 7% of cause of death information is obtained from population based vital registration systems. We herein compare pre-hospital to in-hospital trauma-mortality burden using a validated verbal autopsy tool in an urban sub-Saharan African setting.

Methods:
A modified World Health Organization (WHO) VA tool was administered at the Kamuzu Central Hospital (KCH) morgue in Lilongwe, Malawi to family members of deceased from outside the hospital (referred to as ‘brought in dead’; BID) over three months. These results were compared to validated VA assessment of inpatient deaths to compare differences in disease burden in these two settings.

Results:
The top five categories of mortality were the same for both the inpatient population studied in the validation phase and the BID population. According to Physician Coded Verbal Autopsy (PCVA), infectious diseases remained the highest cause of mortality in BID patients followed by injury, gastrointestinal disease, cancer and cardiovascular disease. However, injury constituted a higher percentage of deaths in the BID population than in the inpatient population, particularly road traffic injury. (Table: Burden of Traumatic Injury in Brought-In-Dead Patients)

Conclusion:
Global burden of trauma-mortality is underestimated in resource poor settings if only hospital registries are used. Verbal autopsy provides a novel adjunct to traditional hospital-based trauma registries to assess community trauma burden, particularly road traffic injuries. Our study reveals that road traffic injury constitutes the majority of prehospital trauma death in a resource poor urban setting. Efforts to improve prehospital care are imperative to reduce the burden of trauma mortality.
 

73.03 Design and Implementation of an Electronic Trauma Registry: A Partnership with the Panamerican Trauma Society

Posted on December 22, 2014

M. B. Aboutanos1, S. Jayaraman1, L. V. Mata1, E. B. Rodas2, C. A. Ordoñez4, F. Mora6, C. Morales5, M. Quiodettis3, M. Duong1, R. Ivatury1  1Virginia Commonwealth University,Acute Care Surgical Services/ Depart. Surgery,Richmond, VA, USA 2Hospital Vicente Corral Moscoso And Hospital Universitario Del Rio,Surgery,Cuenca, AZUAY, Ecuador 3Hospital Santo Tomas,Trauma,Panama, , Panama 4Hospital Universitario Del Valle And Fundacion Valle De Lili,Trauma,Cali, , Colombia 5San Vicente De Paul,Cirugia,Medellin, , Colombia 6Cinterandes Foundation Mobile Surgical Program,Cuenca, , Ecuador

Introduction:

Injury is a major cause of death and disability in low and middle income countries (LMICs). A major impediment to trauma system development is lack of basic injury data. We aimed to create an injury surveillance system that could be implemented at every level of health facilities in LMICs and which would allow communication across facilities to track injury morbidity and mortality, allow monitoring, evaluation and auditing of trauma care and identify opportunities for intervention. 

Methods:

A multi-disciplinary team of program staff, statistician and information technology staff was created and led by a trauma surgeon with previous experience with paper registries in Central America. The team created an electronic trauma registry for low-resource settings that can be used on and offline, in English and Spanish, and covers trauma care from the prehospital trauma setting, initial trauma management, through hospitalization until discharge. The registry consists of two tiers: an essential element tier with 25 variables and a comprehensive tier with 250 variables, uses ICD-10 codes with a built-in search box and calculates injury severity scores (AIS, ISS, RTS and OIS).  An integrated quality control system limits incorrect data entry and a report generator allows for pre-specified basic reports and advanced customizable reporting. Specific user roles can be established to control accessibility and facilitate access from any network. A pilot program was implemented with concomitant training in: basic epidemiology and injury surveillance, use of a standardized trauma assessment form, registry access and data entry, analysis and report generation, periodic auditing and quality improvement.

Results:

The registry and a standardized trauma patient assessment form were implemented across nine hospitals in three member countries of the Panamerican Trauma Society: Ecuador, Colombia and Panama. Implementation included sessions for a total of 62 hospital staff including clinicians, hospital administrators and data entry personnel. Since implementation, 28,698 injured patients have been entered into the registry across the nine sites: 6,911 at five hospitals in Ecuador; 20,795 across three hospitals in Colombia; and 992 in Santo Tomas Hospital in Panama. Site-specific analysis is under way.

Conclusion:
LMIC governments practice with significant resource constraints and yet need to develop high quality trauma and emergency systems. This injury registry was created through highly innovative collaboration between clinicians and health informatics experts and can be used capture reliable and accurate data, determine the burden of injury morbidity and mortality and identify opportunities to improve trauma and emergency care. Investment in such information infrastructure has potential to improve resource allocation and facilitate trauma system development in LMICs.
 

73.04 Trauma Training Among Physicians in Haiti

Posted on December 22, 2014

J. K. Bagley4, C. M. McCullough4, M. E. Quinn4, J. Srinivasan1, V. DeGennaro2,3, J. Sharma1  1Emory University School Of Medicine,Department Of Surgery,Atlanta, GA, USA 2University Of Florida,Department Of Medicine, College Of Medicine,Gainesville, FL, USA 3Project Medishare For Haiti,Port Au Prince, , Haiti 4Emory University School Of Medicine,Atlanta, GA, USA

Introduction:  The burden of trauma is disproportionally greater in low and middle-income countries (LMIC) such as Haiti. As a follow up to a previous survey in Haiti’s Central Plateau, this study was designed with the goal of addressing the current state of trauma training among practitioners in hospitals throughout Haiti.

Methods:  A survey was designed to globally assess the needs of trauma-related care in Haiti, comprised of 13 sections containing a total of 260 questions. A total of 14 questions were prepared with the goal of quantifying trauma training among physicians staffing Emergency Departments (ED) and general surgeons. Medical directors, hospital administrators, surgeons, and physicians staffing the ED were questioned via interpreter to complete the survey based on interviewee knowledge and availability. Formal trauma training was defined as having taken a course in Advanced Trauma Life Support (ATLS) or ATLS-equivalent.

Results: The survey was administered at 11 major hospitals in 9 (of 10) Departments in Haiti. Of 10 hospitals for which the survey is complete, two had ED physicians with trauma training. At those two facilities, an average of 40% of all ED physicians had trauma training. 3 hospitals had general surgeons with trauma training. At those three facilities, 50% of all general surgeons had trauma training. 2 hospitals have offered ATLS or an ATLS-equivalent course to hospital staff. 9 hospitals have access to in-service training by visiting medical teams or hospital staff, and 2 of those indicate trauma as a previous topic of training. 

Conclusion: Formal training in trauma care is infrequent or absent in many large hospitals in Haiti, despite an increased burden of disease compared to high-income counties. Though ATLS has not been correlated to outcomes in injury-related care in LMIC, we believe that formal, applied trauma training would be of benefit to victims of injury in Haiti.  This information was gathered with the cooperation of the Haitian Ministry of Health in efforts to improve hospital care and outcomes of trauma victims.

 

73.05 Creating an mHealth solution to improve prehospital trauma care in urban Bangladesh

Posted on December 22, 2014

J. T. Farrell1, M. Swaroop2, M. Bhuiyan4, R. R. Chakraborty3, K. Rakshand5, B. M. Jaffe1  4Bangabandhu Sheikh Mujib Medical University,Dhaka, , Bangladesh 5JAAGO Foundation,Dhaka, , Bangladesh 1Tulane University School Of Medicine,New Orleans, LA, USA 2Northwestern University, Feinberg School Of Medicine,Division Of Trauma & Critical Care,Chicago, IL, USA 3Chittagong Medical College Hospital,Chittagong, , Bangladesh

Introduction:

Currently no organized Emergency Medical System exists in Bangladesh and the mortality of road traffic accidents in Bangladesh is estimated to be between 12,000-20,000 people annually. Studies show that well-trained and rapidly dispatched lay first responders have a significant impact on improving health outcomes and reducing mortality. To improve trauma outcomes in Bangladesh, a non-profit social enterprise called CriticaLink has been developed to fill the gap in pre-hospital care by training first responders in preparation for the launch of a mobile health application (mHealth app) using GPS and a location based emergency response system with implementation of an emergency number.

Methods:

Volunteers were recruited through partnerships with several large youth volunteer organizations in Bangladesh, including JAAGO’s Volunteer for Bangladesh. Volunteers were trained in 1-2 day first responder courses developed by members of the Tulane University team based on published recommendations from the International Red Cross, Red Crescent and other first responder curriculums published in peer-reviewed journals.  The training course was further modified after analysis of qualitative and quantitative feedback from the trainees in the CriticaLink program. 

Results:

During the pilot phase of the CriticaLink First Responder System, over 585 volunteers have registered and more than 200 have been selected and trained to serve on one of seven location-based teams in Dhaka.  Each team consists of two team leaders and certified First Responders who will respond to emergencies in seven of Dhaka’s most populated areas (Dhanmondi, Gulshan/Banani, Uttara, Mirpur, Mohammadpur, Old Dhaka, and Lalbagh).  In order to connect First Responders with accident victims, an emergency number, call center, and dispatch system has been established to report accidents in Dhaka. The mHealth app, created on an Android platform, will serve as both a dispatch and patient data collection tool for First Responders. 

Conclusion:

The combination of well-trained first responders and an innovative location-based mHealth dispatch system has the potential to significantly improve trauma outcomes in urban Bangladesh. The location data will also be important to help focus accident prevention efforts.  Once the pilot phase is formally launched in Dhaka, the system will be prospectively evaluated with the possibility to extend CriticaLink to other cities, not only in Bangladesh, but in any country lacking a formal Emergency Medical System.

73.06 Trauma Registries in Kenya: Improving Care with Mobile Technology

Posted on December 22, 2014

F. Paruk1, I. Botchey1, A. Hyder1, K. Stevens2  1Johns Hopkins University Bloomberg School Of Public Health,International Health / Health Systems,Baltimore, MD, USA 2Johns Hopkins University School Of Medicine,Surgery,Baltimore, MD, USA

Introduction:

An assessment of Kenya’s trauma care capacity highlighted the need for a better understanding of the burden of injury and a need for standardized, quality trauma care training for clinical staff. 

Trauma registries play an integral role in injury surveillance, identification of gaps in care, and in monitoring and evaluation of trauma care.  Success in establishing and maintaining trauma registries is limited in low-resource settings. Efforts are being made to establish hospital based trauma registries at multiple sites in Kenya. Challenges include: lack of clinical skills necessary for trauma care, missing data, errors in transcription, backlog of data entry, and lack of reliable software for data management and export. 

We aimed To educate clinical staff in trauma care skills while piloting a new mHealth injury surveillance tool.  Goals were to successfully train hospital staff to care for the injured, improve data quality, reduce feedback time, enable data sharing, identify immediate gaps in care, and improve efficiency of the entire process.  The data ultimately would highlight areas for immediate and long-term improvements in trauma care. 

An educational curriculum including trauma skills and injury surveillance skills was developed and implemented at 4 hospitals in Kenya in 2013 and 2014.  Using a free app-based program, a paper surveillance tool was adapted for mobile devices, and designed for real-time upload to a web-based database upon completion of each entry.

Methods:

Existing trauma care clinical skills and data collection methods in the Kenyan setting were assessed through literature review, focus group discussions, and site-visits.  Data collection software for trauma registry data was selected, taking into consideration cost, ease of programming, functionality and feedback to the end-user. 

Data is analyzed at regular intervals and feedback given to hospitals. 

Results:

Preliminary results of the training program demonstrated improvement in data quality: missing and erroneous data was decreased upon implementation of training and mobile data collection, and adherence to trauma care protocols has improved.  Vitals signs recorded on trauma patients at one site went from 29% pre-electronic data collection to 98%.  Feedback from end users was positive, with increased efficiency of the process from data collection to analysis. 

Conclusion:

In addition to expected outcomes, the use of mobile technology has decreased human resource requirements, while increasing interest and awareness for the program.  Electronic data collection has expanded from one site to four sites over the past year with further potential to scale-up to the injury surveillance and standardize trauma training in Kenya.

 

72.03 Does Community Consultation Reach Patients Likely to be Enrolled in EFIC Studies?

Posted on December 22, 2014

W. C. Beck1, B. A. Cotton1, C. E. Wade1, J. M. Podbielski1, L. Vincent1, D. J. Del Junco1, J. B. Holcomb1, J. A. Harvin1  1University Of Texas Health Science Center At Houston,Houston, TX, USA

Introduction:  Exception from informed consent (EFIC) allows subjects to be randomized prior to obtaining individual or representative consent. EFIC requires extensive community notification through processes such as in-person Community Consultation (CC), random-digit dialing, and announcements in radio, television and print media. The objective of this study was to assess whether a recently conducted trial performed under EFIC reached relevant and affected communities through the CC process alone.

Methods:  A randomized transfusion trial at our center was conducted under EFIC. We held CC meetings with local organizations at 15 sites across the catchment area, which encompasses over 200 zip codes. Zip codes including and adjacent to the CC meeting locations were defined as CC ZIPCODE. We identified all zip codes in which patients were either injured or declared resident.

Results: There were 1695 patients screened and 107 patients randomized. Among the randomized group, 18% were injured in CC ZIPCODE (12% among screened). 24% of randomized patients had home zip code in CC ZIPCODE area (19% among screened). When CC ZIPCODE included either injury location or home address, 25% of patients were from CC ZIPCODE areas (22% among screened). CC ZIPCODE patients were more likely to be non-white (56 vs. 40%, p=0.129), penetrating mechanism (48 vs. 26%, p=0.034) and transported by ground (49 vs. 27%, p=0.036) than their counterparts. There were no differences in study group allocation, transfusion volumes or mortality.

Conclusion: In this EFIC trial, 25% of patients were injured or lived in areas where CC was performed. While CC cannot reach all potential patients in emergency research settings, we have demonstrated that high-risk areas can be identifiedand targeted to cover patients likely to be screened and enrolled for such studies. Our CC process was able to over-sample and engage communities at risk for health and healthcare disparities.

68.06 Isolated Lumbar Transverse Process Fractures: Roadmap to Potentially Serious Injuires

Posted on December 22, 2014

M. Khalil1, P. Rhee1, T. Orouji Jokar1, N. Kulvatunyou1, A. A. Haider1, T. O’Keeffe1, A. Tang1, G. Vercruysse1, L. Gries1, R. S. Friese1, B. Joseph1  1University Of Arizona,Trauma/Surgery/Medicine,Tucson, AZ, USA

Introduction:

Isolated transverse process fractures (iTPF) of the lumbar spine have been shown to be associated with development of non-spine associated injuries (NSAI). However; the level of lumbar spine fracture associated with type of NSAI remains unknown.  The aim of this study was to determine the association between level of lumbar iTPF and type of NSAI.

Methods:

We performed a 3-year retrospective analysis of all patients with spine fractures at our level 1 trauma center. Patients with lumbar iTPF were included. Patients were stratified based on the level of lumbar spine fracture. Outcome measure was development of NSAI. We defined NSAI as abdominal injury (solid or hollow viscus), thoracic injury, pelvic or sacral fracture, or extremity fracture. Multivariate regression analysis was performed to identify association between location of fracture and development of NSAI.   

Results:

A total of 198 patients with lumbar iTPF were included of which, 67.2% (n=132) patients developed NSAI. L3 (48%) and L4 (35.9%) were the most common location of iTPF. L5 iTPF had 83.6% sensitivity and 89.8% negative predictive value (NPV) for predicting pelvic/sacral fracture.  L2 iTPF predicted the development of solid organ injury with 78% sensitivity. 

Conclusion:

Level of isolated lumbar transverse process fracture determines the type of NSAI. The presence of L2 iTPF was independently associated with solid organ injury while L5 iTPF was associated with pelvic/sacral fractures. Level of lumbar iTPF can serve as a roadmap for clinicians in assessment of trauma patients.  

 

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