scholarly journals A service evaluation examining the requirement for Level 2 critical care in a major trauma centre

2022 ◽  
Author(s):  
Paul Galea ◽  
Kirsten Joyce ◽  
Sarah Galea ◽  
Frank Loughnane
Keyword(s):  
Critical Care ◽  
High Risk ◽  
Hospital Mortality ◽  
Readmission Rate ◽  
Major Trauma ◽  
Service Evaluation ◽  
Secondary Outcome ◽  
Number Of Patients ◽  
Major Trauma Centre ◽  
Level 2

Critical care provision is fundamental in all developed health systems in which severe disease and injury is managed. This is especially true in major trauma centres and high-acuity establishments, where acutely unstable patients can be admitted at any time, requiring clinical monitoring and interventions appropriate for their burden of illness. This single-centre, prospective service evaluation applied validated scoring systems to a surgical population, sampling and following those considered “high-risk” through to discharge or death, alongside all intensive care unit (ICU) admissions during 2019. Primarily we aimed to quantify the number of patients objectively suitable for Level 2 critical care, conventionally provided in a high-dependency unit (HDU) setting. Secondary outcome measures included ICU readmission rate, in-hospital mortality, and delays to ICU admission and discharge. Of the “high-risk” surgical patients, more than eight per week were found to have peri-operative Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM) scores that would advocate critical care admission. Only one individual received scheduled peri-operative critical care. Post-operative mortality in this group was 6.1%, though none of these patients was admitted to ICU prior to death. There were 605 ICU admissions in 2019, with 32.1% of admitted days spent at the equivalent of Level 2 critical care, which could have been administered in a HDU if one was available. The ICU readmission rate was 6.45%. This data demonstrates substantial unmet critical care needs, with patients not uncommonly managed in clinically inappropriate areas for extended periods due to delays accessing ICU. A designated HDU may mitigate clinical risk from this subgroup, reducing morbidity and in-hospital mortality, and this methodology for assessing requirements could be used in other similar institutions.

scholarly journals 257 The Effect of the COVID-19 Pandemic on Mental Health Associated Trauma, Admissions and Fractures at a London Major Trauma Centre

2021 ◽  
Vol 108 (Supplement_6) ◽  
Author(s):  
M S Jamal ◽  
D Hay ◽  
K Al-Tawil ◽  
A Petohazi ◽  
V Gulli ◽  
...  
Keyword(s):  
Mental Health ◽  
Psychiatric Diagnosis ◽  
Major Trauma ◽  
Mental Health Problems ◽  
Demographic Data ◽  
Trauma Centre ◽  
Related Factors ◽  
Number Of Patients ◽  
Major Trauma Centre ◽  
The Impact

Abstract Aim Non-injury related factors have been extensively studied in major trauma and shown to have a significant impact on patient outcomes, with mental illness and associated medication use proven to have a negative effect on bone health and fracture healing. We report the epidemiological effect of COVID-19 pandemic on mental health associated Orthopaedic trauma, fractures, and admissions to our centre. Method We collated data retrospectively from the electronic records of Orthopaedic inpatients in an 8-week non-COVID and COVID period analysing demographic data, referral and admission numbers, orthopaedic injuries, surgery performed and patient co-morbidities including psychiatric history. Results here were 824 Orthopaedic referrals and 358 admissions (6/day) in the non-COVID period with 38/358 (10.6%) admissions having a psychiatric diagnosis and 30/358 (8.4%) also having a fracture. This was compared to 473 referrals and 195 admissions (3/day) in the COVID period with 73/195 (37.4%) admissions having a documented psychiatric diagnosis and 47/195 (24.1%) a fracture. 22/38 (57.9%) and 52/73 (71.2%) patients were known to mental health services, respectively. Conclusions Whilst total numbers utilising the Orthopaedic service decreased, the impact of the pandemic and lockdown disproportionately affected those with mental health problems, a group already at higher risk of poorer functional outcomes and non-union. The proportion of patients with both a fracture and a psychiatric diagnosis more than doubled and the number of patients presenting due to a traumatic suicide attempt almost tripled. It is imperative that adequate support is in place for vulnerable mental health patients, particularly as we are currently experiencing the “second wave” of COVID-19.

scholarly journals 1651 Improving Surgical Admission Clerking in A Major Trauma Centre – The Role of a Standardised Clerking Proforma

2021 ◽  
Vol 108 (Supplement_6) ◽  
Author(s):  
M Arnaouti ◽  
M Foxall-Smith ◽  
D Mittapalli
Keyword(s):  
Major Trauma ◽  
Service Evaluation ◽  
Trauma Centre ◽  
P Value ◽  
Medication History ◽  
Allied Health Professionals ◽  
Essential Information ◽  
Major Trauma Centre ◽  
Good Patient Care ◽  
The Uk

Abstract Introduction High quality medical records are integral to Good Medical Practice in the UK, for provision of good patient care. This study assesses the effectiveness of a structured Surgical Assessment Proforma in improving documentation, within the Surgical Assessment Unit (SAU) of a major trauma centre. Method A four-phase prospective study was undertaken – using PDSA methodology. This included: initial clinician survey and proforma development, audit, re-audit post-implementation, and final user survey. Evaluation and proforma design utilised standards from the RCS(Eng) and the PRSB. Notes of all patients admitted to the SAU, over two separate one-week periods, were assessed for completeness of documentation. Statistical analysis employed T-Test, with a P value of < 0.05 considered significant. The study was considered service evaluation, and therefore exempt from ethical approval. Results Pre-Proforma Survey 100% of respondents felt a proforma would be beneficial. 77% believed key elements of clerking were missed within the previous system. Cycle 1 (n = 62) Of note, assessment categories lacking information were: Responsible Consultant, Medication History, Allergy Status and Differential Diagnosis. Cycle 2 (n = 119) Of 45 assessment criteria: 38 improved (23 significantly (P < 0.05)), 2 showed no change, 5 were reduced (2 significantly (P < 0.05)). Documentation rates in nine categories improved by over 50%. Post-Proforma Survey 73% of doctors and 86% of allied health professionals (AHPs) agreed documentation improved with proforma use. 66% of clinicians agreed proformas reduced omission of essential information and provided safe clerking guidance for doctors. 100% of AHPs agreed the proforma improved handover. Conclusions In a major trauma centre SAU, standardised proforma use improves completeness of clerking.

scholarly journals The effects of a UK lockdown on orthopaedic trauma admissions and surgical cases

2020 ◽  
Vol 1 (5) ◽  
pp. 137-143 ◽  
Author(s):  
Matthew Hampton ◽  
Matthew Clark ◽  
Ian Baxter ◽  
Richard Stevens ◽  
Elinor Flatt ◽  
...  
Keyword(s):  
Major Trauma ◽  
Fragility Fractures ◽  
Trauma Centre ◽  
Hand Injuries ◽  
Orthopaedic Trauma ◽  
Nerve Injuries ◽  
Number Of Patients ◽  
Major Trauma Centre ◽  
The Uk ◽  
The Impact

Aims The current global pandemic due to COVID-19 is generating significant burden on the health service in the UK. On 23 March 2020, the UK government issued requirements for a national lockdown. The aim of this multicentre study is to gain a greater understanding of the impact lockdown has had on the rates, mechanisms and types of injuries together with their management across a regional trauma service. Methods Data was collected from an adult major trauma centre, paediatric major trauma centre, district general hospital, and a regional hand trauma unit. Data collection included patient demographics, injury mechanism, injury type and treatment required. Time periods studied corresponded with the two weeks leading up to lockdown in the UK, two weeks during lockdown, and the same two-week period in 2019. Results There was a 55.7% (12,935 vs 5,733) reduction in total accident and emergency (A&E) attendances with a 53.7% (354 vs 164) reduction in trauma admissions during lockdown compared to 2019. The number of patients with fragility fractures requiring admission remained constant (32 patients in 2019 vs 31 patients during lockdown; p > 0.05). Road traffic collisions (57.1%, n = 8) were the commonest cause of major trauma admissions during lockdown. There was a significant increase in DIY related-hand injuries (26% (n = 13)) lockdown vs 8% (n = 11 in 2019, p = 0.006) during lockdown, which resulted in an increase in nerve injuries (12% (n = 6 in lockdown) vs 2.5% (n = 3 in 2019, p = 0.015) and hand infections (24% (n = 12) in lockdown vs 6.2% (n = 8) in 2019, p = 0.002). Conclusion The national lockdown has dramatically reduced orthopaedic trauma admissions. The incidence of fragility fractures requiring surgery has not changed. Appropriate provision in theatres should remain in place to ensure these patients can be managed as a surgical priority. DIY-related hand injuries have increased which has led to an increased in nerve injuries requiring intervention.

scholarly journals Prehospital critical care is associated with increased survival in adult trauma patients in Scotland

2020 ◽  
Vol 37 (3) ◽  
pp. 141-145 ◽  
Author(s):  
Alistair Maddock ◽  
Alasdair R Corfield ◽  
Michael J Donald ◽  
Richard M Lyon ◽  
Neil Sinclair ◽  
...  
Keyword(s):  
Multivariate Analysis ◽  
Critical Care ◽  
Major Trauma ◽  
Injury Severity ◽  
Prehospital Care ◽  
National Registry ◽  
Trauma Centre ◽  
Trauma Patients ◽  
Data Set ◽  
Major Trauma Centre

BackgroundScotland has three prehospital critical care teams (PHCCTs) providing enhanced care support to a usually paramedic-delivered ambulance service. The effect of the PHCCTs on patient survival following trauma in Scotland is not currently known nationally.MethodsNational registry-based retrospective cohort study using 2011–2016 data from the Scottish Trauma Audit Group. 30-day mortality was compared between groups after multivariate analysis to account for confounding variables.ResultsOur data set comprised 17 157 patients, with a mean age of 54.7 years and 8206 (57.5%) of male gender. 2877 patients in the registry were excluded due to incomplete data on their level of prehospital care, leaving an eligible group of 14 280. 13 504 injured adults who received care from ambulance clinicians (paramedics or technicians) were compared with 776 whose care included input from a PHCCT. The median Injury Severity Score (ISS) across all eligible patients was 9; 3076 patients (21.5%) met the ISS>15 criterion for major trauma. Patients in the PHCCT cohort were statistically significantly (all p<0.01) more likely to be male; be transported to a prospective Major Trauma Centre; have suffered major trauma; have suffered a severe head injury; be transported by air and be intubated prior to arrival in hospital. Following multivariate analysis, the OR for 30-day mortality for patients seen by a PHCCT was 0.56 (95% CI 0.36 to 0.86, p=0.01).ConclusionPrehospital care provided by a physician-led critical care team was associated with an increased chance of survival at 30 days when compared with care provided by ambulance clinicians.

Outcomes in Traumatic Brain Injury for Patients Presenting on Antiplatelet Therapy

2015 ◽  
Vol 81 (2) ◽  
pp. 128-132 ◽  
Author(s):  
John David Cull ◽  
Lauren M. Sakai ◽  
Imran Sabir ◽  
Brent Johnson ◽  
Andrew Tully ◽  
...  
Keyword(s):  
Hospital Mortality ◽  
Antiplatelet Therapy ◽  
Injury Severity ◽  
Head Injuries ◽  
Hospital Length Of Stay ◽  
Secondary Outcome ◽  
Secondary Outcome Measure ◽  
Number Of Patients ◽  
Blunt Head Trauma ◽  
Significant Difference

An increasing number of patients are presenting to trauma units with head injuries on antiplatelet therapy (APT). The influence of APTon these patients is poorly defined. This study examines the outcomes of patients on APT presenting to the hospital with blunt head trauma (BHT). Registries of two Level I trauma centers were reviewed for patients older than 40 years of age from January 2008 to December 2011 with BHT. Patients on APT were compared with control subjects. Primary outcome measures were in-hospital mortality, intracranial hemorrhage (ICH), and need for neurosurgical intervention (NI). Hospital length of stay (LOS) was a secondary outcome measure. Multivariate analysis was used and adjusted models included antiplatelet status, age, Injury Severity Score (ISS), and Glasgow coma scale (GCS). Patients meeting inclusion criteria and having complete data (n = 1547) were included in the analysis; 422 (27%) patients were taking APT. Rates of ICH, NI, and in-hospital mortality of patients with BHT in our study were 45.4, 3.1, and 5.8 per cent, respectively. Controlling for age, ISS, and GCS, there was no significant difference in ICH (odds ratio [OR], 0.84; 95% confidence interval [CI], 0.61 to 1.16), NI (OR, 1.26; 95% CI, 0.60 to 2.67), or mortality (OR, 1.79; 95% CI, 0.89 to 3.59) associated with APT. Subgroup analysis revealed that patients with ISS 20 or greater on APT had increased in-hospital mortality (OR, 2.34; 95% CI, 1.03 to 5.31). LOS greater than 14 days was more likely in the APT group than those in the non-APT group (OR, 1.85; 95% CI, 1.09 to 3.12). The effects of antiplatelet therapy in patients with BHT aged 40 years and older showed no difference in ICH, NI, and in-hospital mortality.

scholarly journals Helicopter emergency medical service dispatch in older trauma: time to reconsider the trigger?

2021 ◽  
Vol 29 (1) ◽  
Author(s):  
J. E. Griggs ◽  
◽  
J. W. Barrett ◽  
E. ter Avest ◽  
R. de Coverly ◽  
...  
Keyword(s):  
Critical Care ◽  
Major Trauma ◽  
Road Traffic ◽  
Trauma System ◽  
Trauma Centre ◽  
Trauma Patients ◽  
Emergency Medical ◽  
Major Trauma Centre ◽  
Head Injured ◽  
Injured Patients

Abstract Background Helicopter Emergency Medical Services (HEMS) respond to serious trauma and medical emergencies. Geographical disparity and the regionalisation of trauma systems can complicate accurate HEMS dispatch. We sought to evaluate HEMS dispatch sensitivity in older trauma patients by analysing critical care interventions and conveyance in a well-established trauma system. Methods All trauma patients aged ≥65 years that were attended by the Air Ambulance Kent Surrey Sussex over a 6-year period from 1 July 2013 to 30 June 2019 were included. Patient characteristics, critical care interventions and hospital disposition were stratified by dispatch type (immediate, interrogate and crew request). Results 1321 trauma patients aged ≥65 were included. Median age was 75 years [IQR 69–89]. HEMS dispatch was by immediate (32.0%), interrogation (43.5%) and at the request of ambulance clinicians (24.5%). Older age was associated with a longer dispatch interval and was significantly longer in the crew request category (37 min [34–39]) compared to immediate dispatch (6 min [5–6] (p = .001). Dispatch by crew request was common in patients with falls < 2 m, whereas pedestrian road traffic collisions and falls > 2 m more often resulted in immediate dispatch (p = .001). Immediate dispatch to isolated head injured patients often resulted in pre-hospital emergency anaesthesia (PHEA) (39%). However, over a third of head injured patients attended after dispatch by crew request received PHEA (36%) and a large proportion were triaged to major trauma centres (69%). Conclusions Many patients who do not fulfil the criteria for immediate HEMS dispatch need advanced clinical interventions and subsequent tertiary level care at a major trauma centre. Further studies should evaluate if HEMS activation criteria, nuanced by age-dependant triggers for mechanism and physiological parameters, optimise dispatch sensitivity and HEMS utilisation.

scholarly journals P118: Pulmonary Embolism Severity Index (PESI) score as a predictor for readmission in acute pulmonary embolism in emergency department?

CJEM ◽  
2018 ◽  
Vol 20 (S1) ◽  
pp. S98-S99
Author(s):  
D. Prajapati ◽  
D. Suryanarayan ◽  
E. S. Lang
Keyword(s):  
Emergency Department ◽  
Pulmonary Embolism ◽  
High Risk ◽  
Readmission Rate ◽  
Significant Risk ◽  
Severity Index ◽  
Low Risk ◽  
Secondary Outcome ◽  
Patient Disposition ◽  
Discharged Patients

Introduction: Pulmonary Embolism (PE) management in Emergency Department (ED) confers a substantial cost burden representing opportunities for improvements in decision-making. The Pulmonary Embolism Severity Index (PESI) is a validated tool to prognosticate patients with PE supporting admit versus (vs.) discharge decisions from the ED. Despite existing evidence, PESI is under-used in patients with PE. We sought to evaluate PESI scores and patient disposition from 4 EDs within Calgary to determine discordance between them and the effect of the discordance on readmission and mortality. Methods: Retrospective review of adult patients 18 years, diagnosed with PE between January-June 2016 at 4 EDs in Calgary Health Region. Patients were divided into high-risk PESI (score>85) and low-risk PESI (score 0-85). Chi-Square (2) test was used for comparison between the groups. Primary outcome measure was rate of discordance between PESI risk and disposition decision and identify factors driving the discordance. Secondary outcome measures included comparing 30-day readmission rate, 30-day and 90-day mortality between the discordant PESI groups. Results: 365 patients were diagnosed with PE in the study period with 60% being admitted and 40% discharged. The median PESI score in admitted patients was 85 (26-172) vs. 68 (20-163) in discharged patients. 51% of admitted patients had a low-risk PESI score and 24% of the discharged patients were high-risk PESI. 30-day readmission rate was 22.9% vs 5.3% (p=0.002) in discharged patients with high-risk PESI vs. discharged patients with low-risk PESI. Hypoxemia was the most common (62%) justification for admission in low-risk PESI groups. Among discharged patients we noted an 8.6% 90-day mortality in the high-risk vs. 0% in the low-risk PESI groups. Conclusion: Discharging a PE patient from the ED with a high PESI score carries a significant risk of ED revisit and readmission. Hypoxia was the reason for admission in majority of low risk PE patients.

scholarly journals Value of early critical care transthoracic echocardiography for patients undergoing mechanical ventilation: a retrospective study

BMJ Open ◽  
2021 ◽  
Vol 11 (10) ◽  
pp. e048646
Author(s):  
Hao Jiang ◽  
Wen Xu ◽  
Wenjing Chen ◽  
Lingling Pan ◽  
Xueshu Yu ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Critical Care ◽  
Intensive Care ◽  
Propensity Score ◽  
Hospital Mortality ◽  
Transthoracic Echocardiography ◽  
Secondary Outcome ◽  
Favourable Effect ◽  
Icu Admission ◽  
Mimic Iii

ObjectivesTo evaluate whether early intensive care transthoracic echocardiography (TTE) can improve the prognosis of patients with mechanical ventilation (MV).DesignA retrospective cohort study.SettingPatients undergoing MV for more than 48 hours, based on the Medical Information Mart for Intensive Care III (MIMIC-III) database and the eICU Collaborative Research Database (eICU-CRD), were selected.Participants2931 and 6236 patients were recruited from the MIMIC-III database and the eICU database, respectively.Primary and secondary outcome measuresThe primary outcome was in-hospital mortality. Secondary outcomes were 30-day mortality from the date of ICU admission, days free of MV and vasopressors 30 days after ICU admission, use of vasoactive drugs, total intravenous fluid and ventilator settings during the first day of MV.ResultsWe used propensity score matching to analyse the association between early TTE and in-hospital mortality and sensitivity analysis, including the inverse probability weighting model and covariate balancing propensity score model, to ensure the robustness of our findings. The adjusted OR showed a favourable effect between the early TTE group and in-hospital mortality (MIMIC: OR 0.78; 95% CI 0.65 to 0.94, p=0.01; eICU-CRD: OR 0.76; 95% CI 0.67 to 0.86, p<0.01). Early TTE was also associated with 30-day mortality in the MIMIC database (OR 0.71, 95% CI 0.57 to 0.88, p=0.001). Furthermore, those who had early TTE had both more ventilation-free days (only in eICU-CRD: 23.48 vs 24.57, p<0.01) and more vasopressor-free days (MIMIC: 18.22 vs 20.64, p=0.005; eICU-CRD: 27.37 vs 28.59, p<0.001) than the control group (TTE applied outside of the early TTE and no TTE at all).ConclusionsEarly application of critical care TTE during MV is beneficial for improving in-hospital mortality. Further investigation with prospectively collected data is required to validate this relationship.

Prevention of Venous Thromboembolism in High-Risk Patients

Hematology ◽  
2006 ◽  
Vol 2006 (1) ◽  
pp. 462-466 ◽  
Author(s):  
William H. Geerts
Keyword(s):  
Critical Care ◽  
Venous Thromboembolism ◽  
High Risk ◽  
Major Trauma ◽  
Bleeding Risk ◽  
Audit And Feedback ◽  
Cord Injury ◽  
Risk Patients ◽  
High Bleeding Risk ◽  
Critical Care Patients

Abstract The prevention of venous thromboembolism (VTE) in patients recovering from major trauma, spinal cord injury (SCI), or other critical illness is often challenging. These patient groups share a high risk for VTE, they often have at least a temporary high bleeding risk, and there are relatively few thromboprophylaxis trials specific to these populations. A systematic literature review has been conducted to summarize the risks and prevention of VTE in these three groups. It is concluded that routine thromboprophylaxis should be provided to major trauma, SCI and critical care patients based on an individual assessment of their thrombosis and bleeding risks. For patients at high risk for VTE, including those recovering from major trauma and SCI, prophylaxis with a low molecular weight heparin (LMWH) should commence as soon as hemostasis has been demonstrated. For critical care patients at lower thrombosis risk, either LMWH or low-dose heparin is recommended. For those with a very high risk of bleeding, mechanical prophylaxis should be instituted as early as possible and continued until pharmacologic prophylaxis can be initiated. The use of prophylactic inferior vena caval filters is strongly discouraged because their potential benefit has not been shown to outweigh the risks or substantial costs. Implementation of thromboprophylaxis in these patients requires a local commitment to this important patient safety priority as well as a highly functional delivery system, based on the use of pre-printed orders, computer prompts, regular audit and feedback, and ongoing quality improvement efforts.

scholarly journals Implementation of an ERAS program in patients undergoing thoracic surgery at a third-level university hospital. An ambispective cohort study

2020 ◽  
Author(s):  
Soledad Bellas-Cotán ◽  
Rubén Casans-Francés ◽  
Cristina Ibáñez ◽  
Ignacio Muguruza ◽  
Luis E. Muñoz-Alameda
Keyword(s):  
Cohort Study ◽  
Length Of Stay ◽  
Thoracic Surgery ◽  
Surgical Complications ◽  
Readmission Rate ◽  
University Hospital ◽  
Secondary Outcome ◽  
Logistic Analysis ◽  
Number Of Patients ◽  
Eras Protocol

ABSTRACTObjetiveTo analyze the effects of the implementation of an ERAS program in patients undergoing pulmonary resection in a tertiary university hospital on the rates of complications and readmission and the length of stay.Methodsambispective cohort study, with a prospective arm of patients undergoing thoracic surgery within an ERAS program versus a retrospective arm of patients before the implementation of the protocol. We recluited 50 patients per arm. The primary outcome was the number of patients with 30-day surgical complications. Secondary outcome included ERAS adherence, no-surgical complications, mortality, readmission, reintervention rates, pain and hospital lenght of stay. We performed a multivariate logistic analysis to study the association of coutcomes with ERAS adherence.ResultsWe found no difference between the two groups in surgical complications [Standard 18 (36%) vs 12 (24%], p =0.19]. ERAS group was significantly lower only in its readmission rate [Standard 15 (30%) vs 6 (12%], p =0.03]. In multivariate analyses, ERAS adherence was the only factor associated with a reduction in surgical complications [OR (95%CI) = 0.02 (0.00, 0.59), p = 0.03] and length of stay [HR (95%CI) = 18.5 (4.39, 78.4), p < 0.001].ConclusionsERAS program was able to decrease the readmission rate at our centre significantly. The adherence to the ERAS protocol influenced the reduction of surgical complications and length of stay.

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