Gina M. Berg

Background: The American College of Surgeons mandates eight trauma activation criteria for full trauma activations, yet many centers exceed this number to minimize undertriage. The association between trauma activation criteria and triage accuracy and resource use is poorly studied. Objective: To assess the relationship between the number of criteria for full trauma activation and rates of activation, undertriage, overtriage, mortality, and hospital length of stay. Methods: This multicenter retrospective cohort study analyzed survey and trauma registry data from 36 trauma centers across 16 U.S. states and the District of Columbia. Centers reported their activation criteria used for full trauma activation from 2017 to 2019, and outcomes were evaluated using multivariable negative binomial regression and weighted linear regression. Results: Among 218,832 patients, the number of trauma activation criteria per center ranged from 8 to 28, with a mean of 16.75 and an SD of 4.47. The number of criteria was not significantly associated with the proportion of full trauma activation (adjusted incidence rate ratio [aIRR] = 1.02 [95% CI 0.996, 1.05], p = .097), undertriage (aIRR = 0.98 [95% CI 0.96, 1.003], p = .081), mortality (aIRR = 1.00 [95% CI 0.99, 1.01]; p = .952), or length of stay ( b = −0.001 [95% CI −0.059, 0.058], p = .985). However, more criteria were significantly associated with greater overtriage (aIRR = 1.02 [95% CI 1.003, 1.03], p = .010). Conclusion: Increasing the number of trauma activation criteria was not linked to improved undertriage or clinical outcomes, but was associated with higher overtriage, suggesting a greater burden on trauma resources without clinical benefit.

Background Traumatic brain injury (TBI) patients requiring mechanical ventilation face a heightened risk of venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE). While early VTE prophylaxis (VTEp) has been shown to reduce thromboembolic complications, the optimal timing remains unclear, particularly in ventilated TBI patients, where concerns about intracranial hemorrhage progression exist. This study evaluates the association between VTEp timing and mechanical ventilation duration in TBI patients. Methods A retrospective cohort study was conducted using the American College of Surgeons Trauma Quality Program Participant Use File (ACS-TQIP-PUF) 2017–2021. Adult patients (≥ 15 years) with isolated TBI requiring mechanical ventilation were included. Patients were stratified by Modified Berne-Norwood Criteria (mBNC) into low, moderate, and high-risk categories for hemorrhagic progression. VTEp timing was categorized as very early (≤ 24 h), middle (24–72 h), and late (≥ 72 h). The primary outcome was the duration of mechanical ventilation, analyzed using multivariable linear regression models. Results Among 99,078 patients, very early VTEp was associated with a reduction of 3.7 days in ventilator duration and in low and 2.8 days in moderate-risk TBI patients (p < .01). High-risk patients receiving very early prophylaxis exhibited increased mortality (21.3% p < .01). Conclusion Very early VTEp (≤ 24 h) was associated with a reduction of 3.7 ventilator days in low-risk and 2.8 days in moderate-risk TBI patients, while high-risk patients demonstrated increased mortality (21.3%). These findings underscore the importance of personalized, risk-stratified prophylaxis strategies. However, given the retrospective design and absence of radiologic progression or cause-specific mortality data, prospective validation is required before implementing practice modifications. Levels of evidence Level III, retrospective/epidemiological.

Objective: Restrictive fluid management (RFM) for hemodynamically unstable trauma patients has reduced mortality rates. The objective was to determine whether RFM benefits geriatric hip fracture patients, who are usually hemodynamically stable. Design: Retrospective propensity-matched study. Setting: Five Level I trauma centers (January 1, 2018–December 12, 2018). Patients: Geriatric patients (65 years or older) with hip fractures were included in this study. Patients with multiple injuries, nonoperative management, and preoperative blood products were excluded. Intervention: Patients were grouped by fluid volume (normal saline, lactated Ringer, dextrose, electrolytes, and medications) received preoperatively or ≤24 hours of arrival; patients with standard fluid management (SFM) received ≥150 mL and RFM 2 days postoperatively), and mortality. Paired Student t-tests, Wilcoxon paired rank sum tests, and McNemar tests were used; an α value of < 0.05 was considered statistically significant. Results: There were 523 patients (40% RFM, 60% SFM); after matching, there were 95 patients per arm. The matched patients were well-balanced, including no difference in time from arrival to surgery. RFM and SFM patients received a median of 80 mL and 1250 mL of preoperative fluids, respectively (P < 0.001). Postoperative fluid volumes were 1550 versus 2000 mL, respectively, (P = 0.73), and LOSs were similar between the two groups (5 versus 5 days, P = 0.83). Mortality and complications, including acute kidney injuries, were similar. Delayed ambulation rates were similar overall. When stratified by preinjury ambulation status, SFM was associated with delayed ambulation for patients not walking independently before injury (P = 0.01), but RFM was not (P = 0.09). Conclusions: RFM seems to be safe in terms of laboratory results, complications, and disposition. SFM may lead to delayed ambulation for patients who are not walking independently before injury.

BACKGROUND: The Pediatric Emergency Care Applied Research Network (PECARN) traumatic brain injury algorithm is used to identify children at low risk of clinically significant traumatic brain injuries to reduce computed tomography (CT) exposure. Adapting PECARN rules based on population-specific risk stratification has been suggested to improve diagnostic accuracy. OBJECTIVE: This study sought to identify center-specific patient variables, beyond PECARN rules, that may enhance the identification of patients requiring neuroimaging. METHODS: This single-center, retrospective cohort study was conducted from July 1, 2016, to July 1, 2020, in a Southwestern U.S. Level II pediatric trauma center. The inclusion criteria were adolescents (10–15 years), Glasgow Coma Scale (13–15), with a confirmed mechanical blow to the head. Patients without a head CT were excluded. Logistic regression was performed to identify additional complicated mild traumatic brain injury predictor variables beyond the PECARN. RESULTS: There were 136 patients studied; 21 (15%) presented with a complicated mild traumatic brain injury. Relative to motorcycle collision or all-terrain vehicle trauma (odds ratio [OR] 211.75, 95% confidence interval, CI [4.51, 9931.41], p < .001), an unspecified mechanism (OR 42.0, 95% CI [1.30, 1350.97], p = .03) and consult activation (OR 17.44, 95% CI [1.75, 173.31], p = .01) were significantly associated with complicated mild traumatic brain injury. CONCLUSIONS: We identified additional factors associated with complex mild traumatic brain injury, including motorcycle collision and all-terrain vehicle trauma, unspecified mechanism, and consult activation that are not in the PECARN imaging decision rule. Adding these variables may aid in determining the need for appropriate CT scanning.

Background: Only a fraction of pediatric trauma patients are treated in pediatric-specific facilities, leaving the remaining to be seen in centers that must decide to admit the patient to a pediatric or adult unit. Thus, there may be inconsistencies in pediatric trauma admission practices among trauma centers. Objective: Describe current practices in admission decision making for pediatric patients. Methods: An email survey was distributed to members of three professional organizations: The American Association for the Surgery of Trauma, Society of Trauma Nurses, and Pediatric Trauma Society. The survey contained questions regarding pediatric age cutoffs, institutional placement decisions, and scenario-based assessments to determine mitigating placement factors. Results: There were 313 survey responses representing freestanding children's hospitals (114, 36.4%); children's hospitals within general hospitals (107, 34.2%), and adult centers (not a children's hospital; 90, 28.8%). The mean age cutoff for pediatric admission was 16.6 years. The most reported cutoff ages were 18 years (77, 25.6%) and 15 years (76, 25.2%). The most common rationales for the age cutoffs were “institutional experience/tradition” (139, 44.4%) and “physician preference” (89, 28.4%). Conclusion: There was no single widely accepted age cutoff that distinguished pediatric from adult trauma patients for admission placement. There was significant variability between and within the types of facilities, with noted ambiguity in the definition of a “pediatric” patient. Thresholds appear to be based primarily on subjective criteria such as traditions or preferences rather than scientific data. Institutions should strive for objective, evidence-based policies for determining the appropriate placement of pediatric patients.

Background: The Pediatric Trauma Society (PTS) is a multidisciplinary organization, with scientific presentations at its annual meeting addressing trauma care from prehospital through rehabilitation. Objective: The purpose of this study was to identify and describe the scholarly areas of focus of presentations at the annual meeting over the society's first 5 years and evaluate research dissemination. Methods: Data were collected on abstracts presented between 2014 and 2018, including titles, authors, and abstract classification. PubMed and Google Scholar searches identified abstracts that resulted in publications. Journal impact factors were identified. Results: Over 5 years, 491 of 635 (77.3%) abstracts were accepted. The number of submitted and accepted abstracts increased, but the acceptance rate was stable (range = 72.1%–81.2%, p = NS [nonsignificant]). The most frequently accepted categories included “Epidemiology,” “Abdominal or Thoracic Trauma,” and “Neurosurgery or Traumatic Brain Injury (TBI),” whereas “Trauma Nursing” and “Quality Improvement” were less common. Among the 2014–2016 abstracts, 55.4% of podium and 24.3% of poster presentations were published. Abstracts categorized as “Epidemiology,” “Education & Injury Prevention,” and “Neurosurgery or TBI” were commonly presented but uncommonly published. The median journal impact factor of publications was 2.1 and 2.0 for podium and poster presentations, respectively (ranging from 0.11 to 10.25). Conclusion: Most of the scholarly effort presented at the PTS remains unpublished. Published work is mainly in low-impact factor journals. Mentorship in the publication process and encouragement of multidisciplinary collaboration within the society are needed to address limitations in the number and potential impact of the scientific content of the annual meeting. This type of analysis is relevant not only to the PTS but also to any professional society seeking to improve its impact.

Background: Since the national stay-at-home order for COVID-19 was implemented, clinicians and public health authorities worldwide have expressed growing concern about the potential repercussions of drug and alcohol use due to social restrictions. We explored the impact of the national stay-at-home orders on alcohol or drug use and screenings among trauma admissions. Methods: This was a retrospective cohort study at six Level I trauma centers across four states. Patients admitted during the period after the onset of the COVID-19 restrictions (defined as March 16, 2020-May 31, 2020) were compared with those admitted during the same time period in 2019. We compared 1) rate of urine drug screens and blood alcohol screens; 2) rate of positivity for drugs or alcohol (blood alcohol concentration ≥ 10 mg/dL); 3) characteristics of patients who were positive for drug or alcohol, by period using chi-squared tests or Fisher’s exact tests, as appropriate. Two-tailed tests with an alpha of p < 0.05 was used on all tests. Results: There were 4762 trauma admissions across the study period; 2602 (55%) in 2019 and 2160 (45%) in 2020. From 2019 to 2020, there were statistically significant increases in alcohol screens (34% vs. 37%, p = 0.03) and drug screens (21% vs. 26%, p < 0.001). Overall, the rate of alcohol positive patients significantly increased from 2019 to 2020 (32% vs. 39%, p = 0.007), while the rate of drug positive patients was unchanged (57% vs. 52%, p = 0.13). Of the 1025 (22%) patients who were positive for alcohol or drugs, there were significant increases in a history of alcoholism (41% vs. 26%, p < 0.001), and substance abuse (11% vs. 23%, p < 0.001) in the 2020 period. No other statistically significant differences were identified among alcohol or drug positive patients during COVID-19 compared to the same period in 2019. Conclusions: Our first wave of COVID-19 data suggests that trauma centers were admitting significantly more patients who were alcohol positive, as well those with substance use disorders, potentially due to the impact of social restrictions and guidelines. Further longitudinal research is warranted to assess the alcohol and drug positive rates of trauma patients over the COVID-19 pandemic.

Introduction. Difficulties with the electronic health record (EHR) are known to be associated with high physician burnout. Usability studies can evaluate and identify usability issues with the EHR at the end user level. This study was conducted to determine physician perspectives and usability issues of local EHR systems. Methods. Survey and focus group methodology were employed. Participants were resident physicians who were members of a resident council in the Midwest. Survey data collected included demographics and perceptions. Focus group data included participants identification of usability principle violations and potential impact to end user. Results. There were 15 survey respondents (across 11 residency programs) who reported use of three different EHR systems: Cerner®, Meditech, and Computerized Patient Record System (CPRS). Satisfaction was greatest with Cerner® as well as most reported level of experience. Focus group respondents reported a variety of usability violations which lead to provider confusion, increased time, alert fatigue, and potential patient safety issues. Discussion. Violations of usability principles can result in disruption of physician workflow processes and lead to increased documentation time as well as fatigue. These issues have been associated with increased provider burnout. Continuous usability assessments should be conducted at the end user level to promote the development of more effective and efficient EHR interface designs.