摘要:

PurposeThe surgical resident experience with trauma has changed. Many residents are exposed to predominantly nonoperative patient care experiences while on trauma rotations. Data from a large multicenter study were analyzed to estimate surgical resident exposure to trauma laparotomy, diagnostic peritoneal lavage (DPL), and focused abdominal sonography for trauma (U/S).MethodsCenters completed a self-report questionnaire on their institutional demographics, admissions, and procedure for a 2-year period (1998–1999).ResultsA total of 82 trauma centers that provide resident teaching were included. The included centers represent over 247,000 trauma admissions. The majority of trauma centers (65.9%) had > 80% blunt injury. Although all centers performed laparotomies, other results were more variable. For U/S, 24.2% performed none at all and 47.0% performed fewer than two U/S examinations per month. For DPLs, 3.8% performed none and 66.7% performed fewer than two per month. Assuming 1 night of 4 on call, the average surgical resident training at a trauma center performing > 80% blunt trauma has the potential to participate in only 15 trauma laparotomies, 6 diagnostic peritoneal lavages, and 45 ultrasound examinations per year. In addition, the resident will care for an average of 500 blunt trauma patients before performing a splenectomy or liver repair.ConclusionSurgical resident experience on most trauma services is heavily weighted to nonoperative management, with a relatively low number of procedures, little experience with DPL, and highly variable experience with ultrasound. These data have serious implications for resident training and recruitment into the specialty.

ISSN:0022-5282    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

BackgroundA Level I trauma center must provide immediate availability general (trauma) surgical expertise. In the current practice few patients require a general surgical procedure. The expertise of subspecialists may also be required and frequently these patients will require subspecialty operative care. We hypothesized that trauma surgeons would receive less reimbursement than their subspecialty colleagues despite a greater commitment of time and effort in taking care of the multiply-injured patient.MethodsThree fellowship trained trauma surgeons were specifically hired to cover the trauma service for the year 2000. Professional billings, contribution to margin (reimbursement minus direct costs) of the trauma surgeons and subspecialists were obtained from the hospital financial information system. A surrogate for effort was assessed by the number of attending notes in the chart. A surrogate for complexity of care was assessed by the length of notes in the chart. Weekly time sheets assessed the percentage of time involved in the care of trauma patients.ResultsThere were 344 patients cared for exclusively on the trauma service for the year 2000. The billing generated per patient was $1005 for the trauma surgeon, $5904 for the subspecialists, and $27,554 for the hospital. Orthopedics and radiology generated more professional billing on the trauma patients than the trauma surgeons. The trauma surgeons spent 52% of their weekly clinical activity in the care of trauma patients, yet this activity accounted for only 16% of their billings (the rest came from general surgery and ICU care). The effort and complexity of care provided by the trauma surgeons was significantly greater than the subspecialists.ConclusionThe Level I trauma service is a conduit for patients coming into the hospital that provides a significant remuneration to the subspecialty services. Trauma surgeons are able to bill much less than many of their subspecialty colleagues despite expending significantly greater amounts of time and effort in the care of these patients. Strategies for improved reimbursement for trauma surgeons must be devised or trauma surgery will suffer the same fate as other areas of surgery, losing our brightest and best to more financially sound subspecialty services such as radiology and orthopedics.

ISSN:0022-5282    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

BackgroundThe guidelines for Level I trauma center verification require 1,200 admissions per year. Several studies looking at the relationship between hospital volume and outcomes after injury have reached conflicting conclusions. The goal of our study was to examine the relationship between patient volume and outcomes (mortality and length of hospital stay) in California’s trauma centers.MethodsData for patients ≥ 18 years old admitted after injury (n = 98,245) to a Level I or II trauma center (n = 38) in 1998 and 1999 were obtained from the Patient Discharge Data of the State of California. Hospital volume was derived from the annual number of admissions per center, and covariates including age, sex, mechanism of injury, Injury Severity Score, and trauma center designation were analyzed.ResultsHospital volume was not a significant predictor of death or length of hospital stay. More severely injured patients appeared to have worse outcomes at the highest volume centers.ConclusionIn our study, hospital volume was not a good proxy for outcome. Low-volume centers appeared to have outcomes that were comparable to centers with higher volumes. Perhaps institutional outcomes rather than volumes should be used as a criterion for trauma center verification.

ISSN:0022-5282    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

BackgroundThe development of trauma systems reduces preventable mortality and the measurement of standardized complications creates further opportunity for improvement in morbidity. The annual incidence of complications in a trauma population has been previously reported but the frequency change over time in a single institution is not well studied.MethodsAll patients who were hospitalized for more than 24 hours, who died, were admitted to the Intensive Care Unit (ICU) or Intermediate Care Unit (IMU), or were inter-facility transfers prospectively evaluated for 12 consecutive years. A total of 13,382 patients were studied (range, 862–1234 patients per year). Complication events were collected using 135 standardized definitions including disease and provider outcomes.ResultsThe overall incidence of complications has remained stable over time. Provider events, disease events, and patients developing three or more complications have remained unchanged as well. Specific disease complications including pneumonia, deep vein thrombosis (DVT), and small bowel obstruction have fallen over time. Improvements in provider errors have also occurred.ConclusionThis data suggests that most complications have a finite threshold despite the use of a stable trauma staff, implementation of standardized protocols, and emphasis on consistency of practice. Further reductions will require new research for disease-related treatment and new strategies for consistency and error reduction rather than our current models of continuous quality improvement.

ISSN:0022-5282    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

BackgroundMissed injuries (MIs) adversely affect patient outcome and damage physician/institutional credibility. The primary and secondary surveys are designed to identify all of a patient’s injuries and prioritize their management; however, MIs are prevalent in severely injured and multisystem trauma patients, especially when the patient’s condition precludes completion of the secondary survey. We hypothesized that implementation of a routine tertiary trauma survey (TS) would reduce the incidence of MIs in a Level I trauma center.MethodsIn mid 1999, a TS form was created and TS documentation was mandated on all trauma intensive care unit (TICU) patients within 24 hours of admission. Patient data, including TS documentation and injury patterns, were concurrently recorded in an institutional trauma registry. Data were compared for patients admitted in 1997 to 1998 (PRE period) and 2000 to 2001 (POST period) using &khgr;2or Student’sttest.ResultsMIs decreased from 2.4% to 1.5% overall, and from 5.7% to 3.4% in TICU patients, after TS implementation. Patients with MIs were slightly older (49 vs. 45 years;p> 0.05) and had higher Injury Severity Scores (21 vs. 10;p< 0.05) than patients without MIs. Sixty percent of MI patients had brain injuries, 56% were admitted to the TICU, and 26% went directly from the emergency department to the operating room. The large majority of MIs in the POST period were detected in patients not undergoing timely TS.ConclusionICU patients—particularly brain injury victims and those undergoing emergent surgical procedures—appear to be at highest risk for MI. Implementation of a standardized TS decreased MIs by 36% in our Level I trauma center, and more timely TS would likely have further reduced MIs. A TS should be routine in trauma centers.

ISSN:0022-5282    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

BackgroundUncertainty about the definition and diagnosis of blunt cardiac injury (BCI) leads to unnecessary hospitalization and cost while trying to rule it out. The purpose of this study was to examine whether the combination of two simple tests, electrocardiography (ECG) and serum troponin I (TnI) level, may serve as reliable predictors of BCI or the absence of it.MethodsOver a period of 30 months (September 1999–February 2002), 333 consecutive patients with significant blunt thoracic trauma were followed prospectively. Serial ECG and TnI tests were performed routinely and echocardiography was performed selectively. Clinically significant BCI (SigBCI) was defined as the presence of cardiogenic shock, arrhythmias requiring treatment, or posttraumatic structural deficits.ResultsSigBCI was diagnosed in 44 patients (13%). Of 80 patients with abnormal ECG and TnI, 27 (34%) developed SigBCI. Of 131 with normal serial ECG and TnI, none developed SigBCI. Of patients with abnormal ECG only or TnI only, 22% and 7%, respectively, developed SigBCI. The positive and negative predictive values were 29% and 98% for ECG, 21% and 94% for TnI, and 34% and 100% for the combination of ECG and TnI. The admission ECG or TnI was abnormal in 43 of 44 patients with SigBCI. Only one patient had initially normal ECG and TnI and developed abnormalities 8 hours after admission. Forty-one patients without other significant injuries stayed 1 to 3 days in the hospital only to rule out SigBCI and could have been discharged earlier. Besides ECG and TnI, other independent risk factors of SigBCI were an Injury Severity Score > 15, the presence of significant skeletal trauma, and history of cardiac disease.ConclusionThe combination of normal ECG and TnI at admission and 8 hours later rules out the diagnosis of SigBCI. In the absence of other reasons for hospitalization, such patients can be safely discharged.

ISSN:0022-5282    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

BackgroundFocused assessment with sonography for trauma (FAST) as a screening tool in the evaluation of blunt abdominal trauma will lead to underdiagnosis of abdominal injuries and may have an impact on treatment and outcome in trauma patients.MethodsFrom October 2001 to June 2002, a protocol for evaluating hemodynamically stable trauma patients with suspected blunt abdominal injury (BAI) admitted to our institution was implemented using FAST examination as a screening tool for BAI and computed tomographic (CT) scanning of the abdomen and pelvis as a confirmatory test. At the completion of the secondary survey, patients underwent a four-view FAST examination (Sonosite, Bothell, WA) followed within 1 hour by an abdominal/pelvic CT scan. The FAST examination was considered positive if it demonstrated evidence of free intra-abdominal fluid. Clinical, laboratory, and imaging results were recorded at admission, and FAST examination results were compared with CT scan findings, noting the discordance.ResultsPatients with suspicion for BAI were evaluated according to protocol (n = 372). Thirteen cases were excluded for inadequate FAST examinations, leaving 359 patients for analysis. There were 313 true-negative FAST examinations, 16 true-positives, 22 false-negatives, and 8 false-positives. Using CT scanning as the confirmatory test for hemoperitoneum, FAST examination had a sensitivity of 42%, a specificity of 98%, a positive predictive value of 67%, a negative predictive value of 93%, and an accuracy of 92%; &khgr;2analysis showed significant discordance between FAST examination and CT scan (5.85%,p< 0.001). Six patients with false-negative FAST examinations required laparotomy for intra-abdominal injuries; 16 patients required admission for nonoperative management of injury. Of the 313 true-negative FAST examinations, 19 patients were noted to have intra-abdominal injuries without hemoperitoneum and 11 patients were noted to have retroperitoneal injuries.ConclusionUse of FAST examination as a screening tool for BAI in the hemodynamically stable trauma patient results in underdiagnosis of intra-abdominal injury. This may have an impact on treatment and outcome in trauma patients. Hemodynamically stable patients with suspected BAI should undergo routine CT scanning.

ISSN:0022-5282    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveThe purpose of this study was to prospectively evaluate the utility of dynamic computed tomographic (CT) scanning as a diagnostic tool and adjunct to physical examination in the identification of surgically significant penetrating zone II neck injuries.MethodsAll patients older than 14 years of age who suffered penetrating zone II neck injuries were eligible for entry into the study protocol at an urban Level I trauma center. All patients that presented with signs of surgically significant injury on physical examination underwent immediate neck exploration. Patients that did not show signs of surgically significant injury were entered into the study protocol and underwent soft tissue dynamic CT scan (1/2-cm cuts, 250-mL oral contrast) of the neck after initial resuscitation. After CT scan, all patients entered into the study protocol underwent esophagography. After completion of radiologic assessment, all study protocol patients underwent surgical exploration of the neck. The patient’s surgical team was blinded to results of the CT scan and esophagography before and during surgical exploration of the neck.ResultsDuring a 42-month period from May 1997 to March 2001, 42 patients were entered into the study protocol. Thirty-six (86%) of the injuries were secondary to stab wounds and the rest were caused by gunshot wounds. Surgical exploration revealed four esophageal injuries, of which two (50%) were missed by CT scan. Esophagography missed the identical esophageal injuries, as did CT scan. Both of the missed esophageal injuries were secondary to stab wounds. Seven internal jugular vein injuries were diagnosed intraoperatively, of which four (57%) were diagnosed by CT scan. During the study period, all patients with carotid artery and tracheal injuries were diagnosed by physical examination and thus underwent immediate surgical exploration without study entry.ConclusionDynamic CT scan contributes minimally to the sensitivity of physical examination in the diagnosis of surgically significant penetrating zone II neck injury. Diagnosis of esophageal injuries with dynamic CT scan appears no better than esophagography. CT scan has greater sensitivity than physical examination for the diagnosis of jugular venous injuries; however, the majority of these injuries do not require identification or surgical intervention.

ISSN:0022-5282    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

BackgroundThe past century has seen improvement in trauma care, with a resulting decrease in therapeutically preventable deaths. We hypothesize that further major reduction in injury mortality will be obtained through injury prevention, rather than improvements in therapy.MethodsSeven hundred fifty-three deaths in an American College of Surgeons–verified, Level I trauma center were reviewed as they occurred. Deaths were classified as therapeutically not preventable, possibly preventable, or preventable. These charts were also reviewed for factors that might have prevented or lessened the severity of the injury.ResultsMean age was 43, mean Glasgow Coma Scale score was 5, mean Revised Trauma Score was 4, mean Injury Severity Score was 41, and mean probability of survival was 0.25 (according to TRISS). Forty-six percent underwent cardiopulmonary resuscitation in the field, 52% died within 12 hours, 74% died within 48 hours, and 86% died within 7 days. Primary causes of death included central nervous system injury in 51%, irreversible shock in 21%, multiple injuries (shock plus central nervous system injury) in 9%, multiple organ failure/sepsis and other causes in 3%, and pulmonary embolus in 0.1%. Seven hundred one (93%) were classified as not preventable with a change in therapy, 32 (4.2%) were classified as potentially preventable with a change in therapy, and 20 were classified as preventable with a change in therapy (2.6%). Forty-six percent had cardiopulmonary resuscitation performed before or immediately on arrival to the hospital. Another 23% had vital signs present on arrival, but had a Glasgow Coma Scale score of ≤ 4. Of the 546 unintentionally injured patients, 58% had an identifiable factor that contributed to the presence and/or severity of the injury (intoxication, restraint and helmet use), with 28% of patients having a positive blood alcohol level. Of the 206 patients with intentional injuries, 44% were intoxicated at the time of their death. Commensurate with driving-while-intoxicated prevention program(s), the percentage of intoxicated patients significantly (p= 0.03) decreased from 45% to 34% over the same 7-year period.ConclusionDramatically improving therapy (no errors, cure for multiple organ failure, sepsis, and pulmonary embolus) in a modern trauma system would decrease trauma mortality by 13%. In contrast, more than half of all deaths are potentially preventable with preinjury behavioral changes. Injury prevention is critical to reducing deaths in the modern trauma system.

ISSN:0022-5282    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

BackgroundThe goal of gene therapy for cultured keratinocyte grafts is to accelerate growth and wound healing following engraftment without producing long-term complications from the delivered gene. We studied a Green Fluorescent Protein-Adenoviral construct (GFP-ADV) to determine the characteristics of gene expression in human cultured keratinocyte grafts.MethodsTwelve GFP-ADV grafts and twelve control grafts were transplanted to the flanks of 24 athymic mice. Mouse flanks were monitored with fluorescence-filtered microscopy and, on Day 21, were sectioned and stained with anti-human MHC Class I with H&E counterstaining. Real-time PCR was performed on graft biopsies for adenoviral DNA.ResultsFluorescence decreased from Days 3 to 5 resulting in no difference between GFP-ADV and control grafts from days 5 to 10. All grafts were positive for human MHC Class I with an epithelial architecture by H&E. Day 21 GFP-ADV grafts were negative for adenoviral DNA.ConclusionThe delivered gene was transiently expressed without the persistence of viral DNA, demonstrating the potential of adenoviral gene delivery for the improvement of wound healing without long-term adverse effects to the graft.

ISSN:0022-5282    

出版商:OVID    

年代:2003

数据来源: OVID