How Translators Affect the Experience and Healthcare of Primary Spanish-Speaking Patients in the Trauma Department

Background and Objective: The trauma bay is a fast-paced environment where comprehension of medical jargon is difficult even for native English-speaking patients. For Spanish-speaking patients, the presence, and use of the translating tools in hospitals may change the course and/or quality of their care, especially in a trauma setting. Our objective was to gather information and perspectives of Spanish-speaking patients in the trauma bay and subsequent hospitalization. This pilot study determined if there were constant themes. Methods: In this pilot qualitative study, we successfully recruited three adult primary Spanish-speaking patients admitted to the trauma service for at least twenty-four hours in July 2021 at an urban academic level I trauma center. Spanish only in-person semi-structured interviews were used to gather patient’s perspectives, with data supplemented from electronic health records and trauma registries. The interview was transcribed in Spanish, translated to English, coded, and analyzed using thematic analysis. Results: Although recruitment occurred at both hospitals, this study includes only three patients admitted at IU Health Methodist. All three were males aged 22-37 years from Latin America. Blunt injuries occurred in two with injury severity scores (ISS) ranging from 5-11 while the third had penetrating injuries with an ISS of 10. Several themes have emerged. All patients felt they did not have autonomy or empowerment in their care. It was found that the healthcare team decided who received a translator. Two of the patients had a lack of understanding in their traumatic injuries. One patient relied on his partner for translating, even though a translator was provided. Conclusions: These results suggest that Spanish-speaking trauma patients lack autonomy, empowerment, and understanding their medical conditions. Further interviews need to be conducted in order to strengthen the perspective of a Spanish-speaking trauma patient’s care.

The Utility of Serial Hemoglobin Monitoring in Non-Operative Management of Blunt Splenic Injury

Background The Eastern Association for the Surgery of Trauma (EAST) states there is not enough evidence to recommend a particular frequency of measuring Hgb values for non-operative management (NOM) of blunt splenic injury (BSI). This study was performed to compare the utility of serial Hgb (SHgb) to daily Hgb (DHgb) in this population. Methods We conducted a retrospective chart review of patients with BSI between 2013 and 2019. Demographics, comorbidities, lab values, clinical decisions, and outcomes were gathered through a trauma database. Results A total of 562 patients arrive in the trauma bay with BSI. In the NOM group, 297 were successful and 37 failed NOM. Of those that failed NOM, 8 (21.6%) changed to OM due to a drop in Hgb. 5 (62.5%) were hypotensive first, 2 (25%) were no longer receiving SHgb, and 1 (12.5%) had a repeat CT scan and was embolized. DHgb patients were not significantly different from SHgb patients in injury severity, length of stay, the largest drop in Hgb, and incidence of failing NOM. Patients taking aspirin were more likely to fall below 7 g/dl at 48 and 72 hours into admission. Conclusions These results suggest that that trending SHgb may not influence clinical decision-making in NOM of BSI. Besides taking aspirin, risk factors for who would benefit from SHgb were not identified. Patients who received DHgb had similar injuries and outcomes than patients who received SHgb. Prospective studies are needed to evaluate the clinical utility of SHgb compared to DHgb.

Defining adverse events during trauma resuscitation: a modified RAND Delphi study

BackgroundThe majority of preventable adverse event (AEs) in trauma care occur during the initial phase of resuscitation, often within the trauma bay. However, there is significant heterogeneity in reporting these AEs that limits performance comparisons between hospitals and trauma systems. The objective of this study was to create a taxonomy of AEs that occur during trauma resuscitation and a corresponding classification system to assign a degree of harm.MethodsThis study used a modified RAND Delphi methodology to establish a taxonomy of AEs in trauma and a degree of harm classification system. A systematic review informed the preliminary list of AEs. An interdisciplinary panel of 22 trauma experts rated these AEs through two rounds of online surveys and a final consensus meeting. Consensus was defined as 80% for each AE and the final checklist.ResultsThe Delphi panel consisted of 22 multidisciplinary trauma experts. A list of 57 evidence-informed AEs was revised and expanded during the modified Delphi process into a finalized list of 67 AEs. Each AE was classified based on degree of harm on a scale from I (no harm) to V (death).DiscussionThis study developed a taxonomy of 67 AEs that occur during the initial phases of a trauma resuscitation with a corresponding degree of harm classification. This taxonomy serves to support a standardized evaluation of trauma care between centers and regions.Level of evidenceLevel 5.

A Survey of Residency Directors in Academic Trauma Centers for Policies on Airway Management in The Trauma Ward

Background Despite its presence as a critical procedure in the trauma setting, airway management is not performed uniformly, varying between institutions, particularly with personnel involved in decision-making. Past literature has noted a trend in which emergency medicine physicians assumed greater responsibility for primary management of airways in the trauma ward. In addition, many institutions have adopted tiered activation systems for traumas in order to improve patient care, deploying resources more effectively. In this study, a survey of residency directors was deployed to assess trends in airway management. Methods A validated survey was distributed to residency directors in anesthesiology, general surgery and emergency medicine in 190 Level I trauma centers in the United States. Questions assessed personnel management, complication tracking and difficult airway prediction factors, amongst other considerations for airway management in the trauma bay. Results Respondents completed the survey at a rate of 23.8% of those solicited. A majority of respondents indicated that emergency medicine physicians are primary airway managers in the trauma bay and that their institutions utilize tiered trauma activation systems at 77.4% and 95.6% respectively. Anesthesia providers were immediately available in 81% of respondent institutions with inconclusive data regarding protocols for delineating anesthesia involvement in difficult airways. More than a third of respondents indicated their institution either does not track airway complications or they did not know if complications were tracked. Finally, nine different criteria were used in varying degrees by respondents’ institutions to predict the presence of a difficult airway, including such factors as head/face trauma, airway fluid and obesity. Conclusion The trend towards airway management by emergency medicine physicians in the trauma bay continues, with anesthesia personnel available in many situations to assist in complicated patients. Complication tracking for airway management remains inconsistent, as does the criteria for prediction of the presence of difficult airways.

Trauma resource pit stop: increasing efficiency in the evaluation of lower severity trauma patients

BackgroundOvertriage of trauma patients is unavoidable and requires effective use of hospital resources. A ‘pit stop’ (PS) was added to our lowest tier trauma resource (TR) triage protocol where the patient stops in the trauma bay for immediate evaluation by the emergency department (ED) physician and trauma nursing. We hypothesized this would allow for faster diagnostic testing and disposition while decreasing cost.MethodsWe performed a before/after retrospective comparison after PS implementation. Patients not meeting trauma activation (TA) criteria but requiring trauma center evaluation were assigned as a TR for an expedited PS evaluation. A board-certified ED physician and trauma/ED nurse performed an immediate assessment in the trauma bay followed by performance of diagnostic studies. Trauma surgeons were readily available in case of upgrade to TA. We compared patient demographics, Injury Severity Score, time to physician evaluation, time to CT scan, hospital length of stay, and in-hospital mortality. Comparisons were made using 95% CI for variance and SD and unpaired t-tests for two-tailed p values, with statistical difference, p<0.05.ResultsThere were 994 TAs and 474 TRs in the first 9 months after implementation. TR’s preanalysis versus postanalysis of the TR group shows similar mean door to physician evaluation times (6.9 vs. 8.6 minutes, p=0.1084). Mean door to CT time significantly decreased (67.7 vs. 50 minutes, p<0.001). 346 (73%) TR patients were discharged from ED; 2 (0.4%) were upgraded on arrival. When admitted, TR patients were older (61.4 vs. 47.2 years, p<0.0001) and more often involved in a same-level fall (59.5% vs. 20.1%, p<0.0001). Undertriage was calculated using the Cribari matrix at 3.2%.DiscussionPS implementation allowed for faster door to CT time for trauma patients not meeting activation criteria without mobilizing trauma team resources. This approach is safe, feasible, and simultaneously decreases hospital cost while improving allocation of trauma team resources.Level of evidenceLevel II, economic/decision therapeutic/care management study.

REBOA Use, Practices, Characteristics, and Implementations Across Various US Trauma Centers

Background Hemorrhage accounts for >30% of trauma-related mortalities. Use of resuscitative endovascular balloon occlusion of the aorta (REBOA) for temporary hemostasis in the civilian population remains controversial. We aim to investigate REBOA practices through analysis of surgeon and trauma center characteristics, implementation, patient characteristics, and overall opinions. Methods An anonymous 30-question standardized online survey on REBOA use was administered to active trauma surgeon members of the Eastern Association for the Surgery of Trauma. Results A total of 345 responses were received, and 130/345 (37.7%) reported REBOA being favorable, 42 (12.2%) reported REBOA unfavorably, and 173 (50.1%) were undecided. The majority of respondents (87.6%) reported REBOA performance in the trauma bay. 170 (49.3%) of respondents reported having deployed REBOA at least once over the past 2 years. 80.0% reported blunt trauma being the most common mechanism of injury in REBOA patients. Resuscitative endovascular balloon occlusion of the aorta deployment in zone 3 of the aorta was significantly higher in patients reported to suffer a pelvic fracture or pelvic hemorrhage, whereas REBOA deployment in zone 1 was significantly higher among patients reported to suffer hepatic, splenic, or other intra-abdominal hemorrhage ( P < .05). Conclusion Among survey respondents, frequency of REBOA use was low along with knowledge of clear indications for use. While current REBOA usage among respondents appeared to model current guidelines, additional research regarding REBOA indications, ideal patient populations, and outcomes is needed in order to improve REBOA perception in trauma surgeons and increase frequency of use.