Mental health symptoms and engagement in a stepped-care mental health service among patients with a violent versus nonviolent injury

BACKGROUND

Few studies have examined mental health symptom trajectories and engagement in mental health follow-up in relation to mechanism of injury. This study examined differences in engagement between survivors of nonviolent and violent injury in the Trauma Resilience and Recovery Program (TRRP), a stepped-care, technology-enhanced model that provides evidence-based mental health screening and treatment to patients admitted to our Level I trauma service.

METHODS

This study analyzed data from 2,527 adults enrolled in TRRP at hospital bedside between 2018 and 2022, including 398 patients (16%) with a violent injury and 2,129 patients (84%) with a nonviolent injury. Bivariate and hierarchical logistic regression analyses examined relations between injury type (violent vs. nonviolent) engagement in TRRP and mental health symptoms at 30 day follow-up.

RESULTS

Engagement in services at bedside was similar across survivors of violent and nonviolent traumatic injury. Patients with violent injury had higher levels of posttraumatic stress disorder and depressive symptoms 30 days postinjury but were less likely to engage in mental health screening. Among patients who screened positive for posttraumatic stress disorder and depression, patients with violent injury were more likely to accept treatment referrals.

CONCLUSION

Patients with a violent traumatic injury have higher levels of mental health needs yet face greater barriers to accessing mental health services following their injury relative to those with a nonviolent injury. Effective strategies are needed to ensure continuity of care and access to mental health care to promote resilience and emotional and functional recovery.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

793 "Minimally Invasive" Skin Grafting with Enzymatic Debridement and Autologous Skin Cell Suspension

Introduction

Minimally invasive surgery has become standard of care across numerous subspecialties. However, burn surgery has lagged behind; as the mainstay of treatment still involves excision with a knife and a split thickness skin graft (STSG) with a painful donor site. Enzymatic debridement with bromelain and autologous skin cell spray (ASCS) have independently been STSG use and decrease the donor site size. Due to constraints with the time course of these products only being available via studies before one was FDA approved, these technologies have not been utilized together in the United States until recently. Little literature exists regarding their use in combination. The current study characterizes a series of patients who received “minimally invasive” skin grafts with enzymatic debridement and ASCS as proof of concept.

Methods

This was a retrospective study of a single academic burn center’s experience using bromelain and ASCS together. Data collection included demographics, injury characteristics, length of stay, complications, and measurements of donor sites, STSGs, and ASCS treatment. Donor site size:total area treated with ASCS and/or STSG was calculated. Length of stay (LOS) was qualitatively compared to expected using a factor of 1.1days:%TBSA, and O/E LOS ratio was calculated. Data was reported in medians with interquartile ranges. Patients with 1-30%TBSA qualified for the bromelain study and were treated according to protocol. Those deemed to have enough residual dermis were treated with ASCS, while 3rd degree areas received meshed split thickness skin patch grafts with ASCS overspray.

Results

Eleven patients were included in the study. Four patients received ASCS alone, while 7 patients received a meshed STSG on portions of their burn. Median burn size was 13% TBSA (IQR:5,20), while DPT+FT size was 9% TBSA (IQR:5,16). Patients had a median of 1067 sq cm (IQR:772,2183) of burn operatively treated with ASCS, and 351 sq cm (IQR:0,457) treated with meshed autograft. Donor site size (ASCS and STSG) was 225 sq cm (IQR:72,315), and ratio of donor site are to total treatment area was 0.0125 (IQR:0.01,0.32), suggesting an expansion of 80:1. Median LOS was 11 days (IQR:7,21), 0.84 days per %TBSA (IQR:0.5,1.16). Expected LOS was 14.3 days, with an O/E ratio of 0.77. Two patients developed infection; one required reoperation with STSG on half of his burned areas (5% TBSA).

Conclusions

Enzymatic debridement and ASCS can be used to treat burn injury with a “minimally invasive” approach. Donor sites were much smaller than expected had they been treated with a conventional meshed STSG on deep 2nd degree and 3rd degree areas. The data also suggests that length of stay was lower than expected. Further study is needed to determine which subsets of patients and burn wounds are optimal for this combination of technologies.

54 Cost of Dakin’s Solution vs. Mafenide Soaks in Acute Burn Care

Introduction

The cost of health care in the United States is extremely high, with burn care being no exception to this rule. A 2016 study found that burn care costs are twice as much as the cost of non-burn related inpatient admissions, necessitating the need for cost savings. As one such measure, the authors no longer routinely use mafenide solution for burn care, and now use 0.0125% Dakin’s as a default topical irrigant, due to lower cost and less cytotoxicity. The aim of this analysis is to investigate the cost savings from using Dakin’s Solution (0.125%, 0.25%, and 0.50% strengths) versus the theoretical cost of using an equivalent amount of 5% mafenide.

Methods

This study was a retrospective review that characterized a single cohort of burn patients treated with Dakin’s solution in the pre and post operative setting. Graft loss was recorded and defined as >25% loss. As a default, 0.125% Dakin’s was used, and concentration was potentially escalated based on attending judgement of wound characteristics. We qualitatively compared length of stay (LOS) index to expected for length of stay index using 1.1 hospital days per %TBSA and using 2019 NBR statistics of 3 days per %TBSA for survivors. Using costs of $37.29 (0.0125%), $40.69 (0.25%), and $38.11 (0.5%) per liter of Dakin’s versus $165.05 per liter for 5% mafenide, we looked at potential savings per patient and for the entire cohort. Average cost, median cost, and total cost of both Dakin’s solution and Mafenide were calculated. Mann Whitney Test was used to compare costs of Dakin’s versus theoretical cost of mafenide.

Results

The total number of cases analyzed was 39 (n=39). The median burn size was 4% TBSA (IQR:1,6) and the median LOS was 3 days (IQR:2,8) The average cost for Dakins per patient was $721.61 versus $3172.98 had mafenide been used, p< 0.001. When all of the Dakins use was amalgamated, this represents a potential cost savings of $2451.37 per patient and $95603.43 for the entire cohort. LOS index was 0.68 with the conservative measure and 0.25 using 2019 NBR data. Only 2 patients had unplanned readmissions within 30 days. None of the patients suffered graft loss.

Conclusions

Use of Dakin’s solution as an alternative to mafenide results in a significant potential cost savings compared to 5% mafenide. The patients treated with Dakins in this study spent less time in the hospital than expected compared to national averages. In addition to lower strength Dakin’s dilutions being well established as less cytotoxic, this study suggests it can save money for the burn center. Future studies should directly compare the two topicals to determine if true differences in infection, healing, or length of stay that might offset or augment cost savings emerge.

Leadership skills curriculum development for residents and fellows: A needs-assessment

BACKGROUND

Non-technical skills (NTS) curricula have demonstrated success in surgical residencies. The purpose of this study is to examine the need for a structured leadership curriculum at our institution.

METHODS

A needs-assessment survey analyzing the importance of leadership domains, previously validated by Kazley et al. was delivered to 240 general surgery staff. Respondent groups were broken down into: Attendings, Residents, and Multi-Disciplinary. Statistical analyses were conducted using Cronbach's Alpha (α = 0.9259) and Fisher's exact test (pre-set p-value = 0.05). The importance of each competency was compared among groups and importance was defined as >75% important and very important responses.

RESULTS

Nineteen of 33 competencies were important for all groups, including 3 with 100% importance: interpersonal communication, team-work, and problem-solving. Several competencies showed statistically significant differences among groups.

CONCLUSION

A diverse range of surgery staff agreed that 19 leadership domains are important to teach residents, with some variance among respondent groups.

Understanding the makeup of a growing field: A committee on trauma survey of the national network of hospital-based violence intervention programs

BACKGROUND

Among Hospital Based Violence Intervention programs (HVIPs), little is known about variation in services provided, funding sources, or populations served.

STUDY DESIGN

Twenty-eight member programs of Health Alliance for Violence Intervention participated in a survey administered by the American College of Surgeons Committee on Trauma. Questions were quantitative and qualitative. For qualitative analysis, questions pertaining to the domains were assessed for common themes and assessed across all subject domains.

RESULTS

All programs enroll patients injured by community violence, some by intimate partner violence (IPV), trafficking, and rarely by child or elder abuse. Programs with more funding (≥$300,000 per year) were more likely federally, state, or city funded. Lower funded programs (≤$300,000 per year) were funded by foundations or philanthropy. In both qualitative and quantitative analysis, barriers to starting or sustaining HVIPs included funding, and lack of risk reduction and mental health resources. Successful programs had stable funding, adequate staffing, and buy in from hospitals and staff.

CONCLUSION

HVIPs serve diverse populations in variable models. There is opportunity to expand the reach of HVIPs, and the experience if existing programs is an invaluable resource.

Health literacy and child health outcomes: a systematic review of the literature

OBJECTIVES

To review the relationship between parent and child literacy and child health outcomes and interventions designed to improve child health outcomes for children or parents with low literacy skills.

METHODS

We searched Medline and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) for articles published from 1980 through 2008 and included studies that reported original data, measured literacy and >or=1 health outcome, and assessed the relationship between literacy and health outcomes. Health outcomes included health knowledge, health behaviors, use of health care resources, intermediate markers of disease status, and measures of morbidity. Two abstractors reviewed each study for inclusion. Included studies were abstracted into evidence tables and were assessed by using an 11-item quality scale.

RESULTS

We reviewed 4182 new titles and abstracts published since 2003. Fifty-eight articles were retained for full review, and 13 met the inclusion criteria. Eleven articles from the systematic review from 1980 to 2003 met the inclusion criteria, giving us a total of 24 articles. Children with low literacy generally had worse health behaviors. Parents with low literacy had less health knowledge and had behaviors that were less advantageous for their children's health compared with parents with higher literacy. Children whose parents had low literacy often had worse health outcomes, but we found mixed results for the relationship of literacy to the use of health care services. Interventions found that improving written materials can increase health knowledge, and combining good written materials with brief counseling can improve behaviors including adherence. The average quality of the studies was fair to good.

CONCLUSIONS

Child and parent literacy seems associated with important health outcomes. Future research can help us understand under what circumstances this relationship is causal, how literacy and health outcomes are related in noncausal pathways, the relative importance of parent and child literacy, and what interventions effectively reduce health literacy-related disparities.