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Hamill ME, Collin GR, Bath JL, Boone SM, Harvey EM, Tegge AN, Sprinkel WE, Toomey SA, Collier BR, Bower KL, Wang MM, Faulks ER, Matos MA, Hamill BE, Bean SL, Nussbaum MS, Parker SH. Impact of Standardized Multidisciplinary Critical Care Training on Confidence with Critical Illness and Attitudes Towards Interprofessional Education and Multidisciplinary Care. J Intensive Care Med 2024; 39:320-327. [PMID: 37812739 DOI: 10.1177/08850666231201528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Abstract
INTRODUCTION The Fundamental Critical Care Support Course (FCCS) is a standardized multidisciplinary program designed to educate participants on the basics of identification and management of patients with critical illness. Our objective was to evaluate the effect of FCCS participation on confidence in the assessment and management of critically ill patients and attitudes towards multidisciplinary education and interprofessional care in a multidisciplinary group of participants. METHODS Participants enrolled in the FCCS course from May 2018 to November 2019 were solicited to participate in a series of surveys evaluating their course experience and confidence in critical care. Attitudes towards multidisciplinary education and interprofessional care were evaluated using the Student Perceptions of Interprofessional Clinical Education-Revised Instrument version 2 (SPICE-R2) tool. A prospective pre- and post-design with a self-report survey including retrospective pre-training assessment and a 3-month follow-up was conducted. Statistical analysis was performed using descriptive statics and non-parametric methods. RESULTS 321 (97.9%) of the course participants enrolled in the study and completed the confidence survey and SPICE-R2 tool pre-course. Nurses (113, 35.4%) and physicians (110, 34.4%) made up the largest groups of participants, although physician assistants and paramedics were also well represented. Confidence in recognition and management of critical illness significantly improved across all studied domains after course completion, with the mean total confidence score improving from 32.96 pre-course to 41.10 post-course, P < 0.001. Attitudes towards multidisciplinary education and interprofessional care also improved (mean score 41.37 pre-course vs 42.71 post-course, P < 0.001), although pre-course numbers were higher than expected which limited the significance to only certain domains. DISCUSSION In a multidisciplinary group, completion of FCCS training led to increased confidence in all aspects of critical illness measured. A modest increase in attitudes regarding multidisciplinary education and interprofessional care was also demonstrated. Further study is needed to assess whether this increased confidence translates to improvements in patient care and outcomes.
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Affiliation(s)
- Mark E Hamill
- Department of Surgery, University of Nebraska Medical Center, 983280 Nebraska Medical Center, Omaha, NE, USA
- Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
- Carilion Clinic, Roanoke, VA, USA
| | - Gary R Collin
- Carilion Clinic, Roanoke, VA, USA
- Department of Surgery, VA Medical Center, Salem, VA, USA
| | | | - Sherry M Boone
- Carilion Clinic, Roanoke, VA, USA
- Department of Nursing, Waldron College of Health and Human Services, Radford University Carilion, Roanoke, VA, USA
| | | | - Allison N Tegge
- Department of Statistics, Virginia Tech, Blacksburg, VA, USA
| | | | | | - Bryan R Collier
- Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
- Carilion Clinic, Roanoke, VA, USA
| | - Katie L Bower
- Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
- Carilion Clinic, Roanoke, VA, USA
| | - Min M Wang
- Department of Basic Science Education, Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
| | - Emily R Faulks
- Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
- Carilion Clinic, Roanoke, VA, USA
| | - Miguel A Matos
- Department of Surgery, University of Nebraska Medical Center, 983280 Nebraska Medical Center, Omaha, NE, USA
- Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
- Carilion Clinic, Roanoke, VA, USA
| | | | | | - Michael S Nussbaum
- Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
- Carilion Clinic, Roanoke, VA, USA
| | - Sarah H Parker
- Department of Basic Science Education, Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
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2
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Whitehead PB, Haisch CE, Hankey MS, Mutcheson RB, Dewitt SA, Stewart CA, Stewart JD, Bath JL, Boone SM, Jileaeva I, Faulks ER, Musick DW. Studying moral distress (MD) and moral injury (MI) among inpatient and outpatient healthcare professionals during the COVID-19 pandemic. Int J Psychiatry Med 2023:912174231205660. [PMID: 37807925 DOI: 10.1177/00912174231205660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
BACKGROUND COVID-19 increased moral distress (MD) and moral injury (MI) among healthcare professionals (HCPs). MD and MI were studied among inpatient and outpatient HCPs during March 2022. OBJECTIVES We sought to examine (1) the relationship between MD and MI; (2) the relationship between MD/MI and pandemic-related burnout and resilience; and (3) the degree to which HCPs experienced pandemic-related MD and MI based on their background. METHODS A survey was conducted to measure MD, MI, burnout, resilience, and intent to leave healthcare at 2 academic medical centers during a 4-week period. A convenience sample of 184 participants (physicians, nurses, residents, respiratory therapists, advanced practice providers) completed the survey. In this mixed-methods approach, researchers analyzed both quantitative and qualitative survey data and triangulated the findings. RESULTS There was a moderate association between MD and MI (r = .47, P < .001). Regression results indicated that burnout was significantly associated with both MD and MI (P = .02 and P < .001, respectively), while intent to leave was associated only with MD (P < .001). Qualitative results yielded 8 sources of MD and MI: workload, distrust, lack of teamwork/collaboration, loss of connection, lack of leadership, futile care, outside stressors, and vulnerability. CONCLUSIONS While interrelated conceptually, MD and MI should be viewed as distinct constructs. HCPs were significantly impacted by the COVID-19 pandemic, with MD and MI being experienced by all HCP categories. Understanding the sources of MD and MI among HCPs could help to improve well-being and work satisfaction.
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Affiliation(s)
| | | | | | - Ryan B Mutcheson
- Virginia Polytechnic Institute and State University, Blacksburg, VA, USA
| | | | | | | | | | | | - Ilona Jileaeva
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
| | | | - David W Musick
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
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Gates RS, Lollar DI, Collier BR, Smith J, Faulks ER, Gillen JR. Enoxaparin titrated by anti-Xa levels reduces venous thromboembolism in trauma patients. J Trauma Acute Care Surg 2022; 92:93-97. [PMID: 34561398 DOI: 10.1097/ta.0000000000003418] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Trauma is a major risk factor for the development of a venous thromboembolism (VTE). After observing higher than expected VTE rates within our center's Trauma Quality Improvement Program data, we instituted a change in our VTE prophylaxis protocol, moving to enoxaparin dosing titrated by anti-Xa levels. We hypothesized that this intervention would lower our symptomatic VTE rates. METHODS Adult trauma patients at a single institution meeting National Trauma Data Standard criteria from April 2015 to September 2019 were examined with regards to VTE chemoprophylaxis regimen and VTE incidence. Two groups of patients were identified based on VTE protocol-those who received enoxaparin 30 mg twice daily without routine anti-Xa levels ("pre") versus those who received enoxaparin 40 mg twice daily with dose titrated by serial anti-Xa levels ("post"). Univariate and multivariate analyses were performed to define statistically significant differences in VTE incidence between the two cohorts. RESULTS There were 1698 patients within the "pre" group and 1406 patients within the "post" group. The two groups were essentially the same in terms of demographics and risk factors for bleeding or thrombosis. There was a statistically significant reduction in VTE rate (p = 0.01) and deep vein thrombosis rate (p = 0.01) but no significant reduction in pulmonary embolism rate (p = 0.21) after implementation of the anti-Xa titration protocol. Risk-adjusted Trauma Quality Improvement Program data showed an improvement in rate of symptomatic pulmonary embolism from fifth decile to first decile. CONCLUSION A protocol titrating prophylactic enoxaparin dose based on anti-Xa levels reduced VTE rates. Implementation of this type of protocol requires diligence from the physician and pharmacist team. Further research will investigate the impact of protocol compliance and time to appropriate anti-Xa level on incidence of VTE. LEVEL OF EVIDENCE Therapeutic/care management, Level IV.
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Affiliation(s)
- Rebecca S Gates
- From the Carilion Clinic, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
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Shahmanyan D, Lawrence JC, Lollar DI, Hamill ME, Faulks ER, Collier BR, Chestovich PJ, Bower KL. Early feeding after percutaneous endoscopic gastrostomy tube placement in trauma and surgical intensive care patients: A retrospective cohort study. JPEN J Parenter Enteral Nutr 2021; 46:1160-1166. [PMID: 34791680 DOI: 10.1002/jpen.2303] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Critically ill patients experience frequent interruptions in enteral nutrition(EN). For ventilated patients who undergo percutaneous endoscopic gastrostomy tube(PEG) placement, post-procedure fasting time varies from 1-24hrs, depending on the surgeon's preference. There is no evidence to support prolonged fasting after PEG placement. This study's purpose was to determine if there is an increased complication rate associated with reduced fasting time after PEG. METHODS 150 adult ventilated trauma and surgical ICU patients at a level I trauma center underwent PEG placement March 2015-May 2018 by one of 6 surgical intensivists. Retrospective review revealed variable post-PEG fasting practices among them: 1 started EN at 1hr, 2 at 4hrs, 2 at 6hrs, and 1 at 24hrs. Time to initiation of EN and complication rates were assessed. Patients were divided into early feeding(<4hrs) and prolonged fasting(≥4hrs) groups. RESULTS Median post-procedure fasting time was 5.5hrs. Complications included bleeding(2), infection(1), tube leak(1), feeding intolerance(1) and aspiration(0). The overall complication rate was 3.3%, with feeding intolerance rate 0.7% and aspiration rate 0%. There was no difference in complication rate for early feeding(3.1%) as compared to delayed feeding(3.4%) (OR 0.92, 95%CI 0.10-8.52, p = 0.7). CONCLUSION Complication rates following PEG placement in ventilated trauma and surgical ICU patients are low and do not change with early feeding <4hr compared to prolonged fasting ≥4hr. Early feeding after PEG is probably safe. With this data, a randomized controlled trial is underway that will provide evidence to support a more consistent practice, thus mitigating a source of EN interruption in a population vulnerable to malnutrition. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Davit Shahmanyan
- Virginia Tech Carilion School of Medicine and Research Institute, 2 Riverside Circle, Roanoke, VA, 24016
| | - Jeffrey C Lawrence
- Carilion Clinic, Department of Surgery, 1906 Belleview Ave., Roanoke, VA, 24014
| | - Daniel I Lollar
- Virginia Tech Carilion School of Medicine and Research Institute, 2 Riverside Circle, Roanoke, VA, 24016.,Carilion Clinic, Department of Surgery, 1906 Belleview Ave., Roanoke, VA, 24014
| | - Mark E Hamill
- Virginia Tech Carilion School of Medicine and Research Institute, 2 Riverside Circle, Roanoke, VA, 24016.,Carilion Clinic, Department of Surgery, 1906 Belleview Ave., Roanoke, VA, 24014
| | - Emily R Faulks
- Virginia Tech Carilion School of Medicine and Research Institute, 2 Riverside Circle, Roanoke, VA, 24016.,Carilion Clinic, Department of Surgery, 1906 Belleview Ave., Roanoke, VA, 24014
| | - Bryan R Collier
- Virginia Tech Carilion School of Medicine and Research Institute, 2 Riverside Circle, Roanoke, VA, 24016.,Carilion Clinic, Department of Surgery, 1906 Belleview Ave., Roanoke, VA, 24014
| | - Paul J Chestovich
- University of Nevada, Las Vegas, Department of Surgery, 1707 W. Charleston Blvd., Suite 160, Las Vegas, NV, 89102
| | - Katie L Bower
- Virginia Tech Carilion School of Medicine and Research Institute, 2 Riverside Circle, Roanoke, VA, 24016.,Carilion Clinic, Department of Surgery, 1906 Belleview Ave., Roanoke, VA, 24014
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Shahmanyan D, Joy MT, Collier BR, Faulks ER, Hamill ME. A case of burn evisceration with full-thickness injury to abdominal wall, bowel, bladder, and three extremities. Surg Case Rep 2021; 7:220. [PMID: 34585274 PMCID: PMC8479039 DOI: 10.1186/s40792-021-01302-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 09/15/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Severe electrical burns are a rare cause of admission to major burn centers. Incidence of electrical injury causing full-thickness injury to viscera is an increasingly scarce, but severe presentation requiring rapid intervention. We report one of few cases of a patient with full-thickness electrical injury to the abdominal wall, bowel, and bladder. CASE REPORT The patient, a 22-year-old male, was transferred to our institution from his local hospital after sustaining a suspected electrical burn. On arrival the patient was noted to have severe burn injuries to the lower abdominal wall with evisceration of multiple loops of burned small bowel as well as burns to the groin, left upper, and bilateral lower extremities. In the trauma bay, primary and secondary surveys were completed, and the patient was taken for CT imaging and then emergently to the operating room. On exploration, the patient had massive full-thickness burns to the lower abdominal wall, five full-thickness burns to small bowel, and intraperitoneal bladder rupture secondary to full-thickness burn. The patient underwent damage-control laparotomy including enterectomies, debridement of bladder coagulative necrosis, and layered closure of bladder injury followed by temporary abdominal closure with vacuum dressing. The patient also underwent right leg escharotomy and partial right foot fasciotomies. The patient was subsequently transferred to the nearest burn center for continued resuscitation and comprehensive burn care. CONCLUSION Severe electrical burns can be associated with devastating visceral injuries in rare cases. Though uncommon, these injuries are associated with very high mortality rates. The authors assert that rapid evaluation and initial stabilization following ATLS guidelines, damage-control laparotomy, and goal-directed resuscitation in concert with transfer to a major burn center are essential in effecting a successful outcome in these challenging cases.
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Affiliation(s)
- Davit Shahmanyan
- Department of Surgery, Virginia Tech Carilion School of Medicine, 3 Riverside Circle, Roanoke, VA, 24016, USA.,Department of Surgery, University of California San Francisco - Fresno, 155 N Fresno Street, Fresno, CA, 93701, USA
| | - Matthew T Joy
- Department of Surgery, Virginia Tech Carilion School of Medicine, 3 Riverside Circle, Roanoke, VA, 24016, USA
| | - Bryan R Collier
- Department of Surgery, Virginia Tech Carilion School of Medicine, 3 Riverside Circle, Roanoke, VA, 24016, USA
| | - Emily R Faulks
- Department of Surgery, Virginia Tech Carilion School of Medicine, 3 Riverside Circle, Roanoke, VA, 24016, USA
| | - Mark E Hamill
- Department of Surgery, Virginia Tech Carilion School of Medicine, 3 Riverside Circle, Roanoke, VA, 24016, USA. .,Department of Surgery, University of Nebraska Medical Center, 983280 Nebraska Medical Center, MSB 4553, Omaha, NE, 68198-3280, USA.
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Walker BS, Collier BR, Tegge AN, Lollar DI, Bower KL, Faulks ER, Gillen JR, Matos MA, Nussbaum MS, Hamill ME. Trauma Outreach to Primary Care Physicians Regarding the Risks Associated With Beers Criteria Medications in Geriatric Patients. Am Surg 2020; 88:1314-1316. [PMID: 32812808 DOI: 10.1177/0003134820942175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Benjamin S Walker
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA.,22391 Department fo Medicine, Carilion Roanoke Memorial Hospital, Roanoke, VA, USA
| | - Bryan R Collier
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA.,22391 Department of Surgery, Carilion Roanoke Memorial Hospital, Roanoke, VA, USA
| | - Allison N Tegge
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA.,Department of Statistics, Virginia Tech, Blacksburg, VA, USA
| | - Daniel I Lollar
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA.,22391 Department of Surgery, Carilion Roanoke Memorial Hospital, Roanoke, VA, USA
| | - Katie L Bower
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA.,22391 Department of Surgery, Carilion Roanoke Memorial Hospital, Roanoke, VA, USA
| | - Emily R Faulks
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA.,22391 Department of Surgery, Carilion Roanoke Memorial Hospital, Roanoke, VA, USA
| | - Jacob R Gillen
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA.,22391 Department of Surgery, Carilion Roanoke Memorial Hospital, Roanoke, VA, USA
| | - Miguel A Matos
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA.,22391 Department of Surgery, Carilion Roanoke Memorial Hospital, Roanoke, VA, USA
| | - Michael S Nussbaum
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA.,22391 Department of Surgery, Carilion Roanoke Memorial Hospital, Roanoke, VA, USA
| | - Mark E Hamill
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA.,22391 Department of Surgery, Carilion Roanoke Memorial Hospital, Roanoke, VA, USA
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Plaster AL, Faulks ER, Gillen JN, Tegge AN, Matos MA, Lollar DI, Bower KL, Nussbaum MS, Collier BR, Hamill ME. Different Perceptions Exist Between Health Care Providers and the General Population Regarding the Importance of Findings on Additional Imaging for Trauma Consults. Am Surg 2020; 86:830-836. [PMID: 32731746 DOI: 10.1177/0003134820940249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Approximately one-third of additional imaging for trauma consults results in the discovery of new injuries. No studies have addressed the perception of these findings in non-health care providers. Our hypothesis was that significant differences in perception of the importance of injuries would exist between health care providers (HCPs) and the general population. METHODS Six standardized scenarios were developed detailing common new injury findings on additional imaging in trauma consults. Demographics as well as information regarding the significance of findings, potential for change in care, and the importance of patient notification were collected. Surveys were electronically distributed to HCPs in our system and the public. Data analysis was performed with generalized linear modeling. RESULTS A total of 339 public and 129 HCP surveys were returned. HCPs included attending staff, residents, and advanced care providers from a variety of specialties. Significant differences in perception were found in traumatic brain injury, spine fractures, and rib fractures, with HCPs rating most findings as less clinically important than the general population, while rating patient notification as more important. Perceived importance decreased with increased age in the general population. Increasing HCP age or length in practice did not significantly affect perception of clinical importance, except for rib fractures. DISCUSSION Differences in perception exist regarding the significance of additional injuries between HCPs and the general population. Perceptions of the general population also change with age. Decisions to pursue additional imaging in trauma patients should include consideration of these differences in perception to help support quality patient-centered care.
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Affiliation(s)
- Andrew L Plaster
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA.,San Antonio Uniformed Services Health Education Consortium, JBSA Fort Sam Houston, TX, USA
| | - Emily R Faulks
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA.,22391 Department of Surgery, Carilion Roanoke Memorial Hospital, Roanoke, VA, USA
| | - Jacob N Gillen
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA.,22391 Department of Surgery, Carilion Roanoke Memorial Hospital, Roanoke, VA, USA
| | - Allison N Tegge
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA.,Department of Statistics, Virginia Tech, Blacksburg, VA, USA
| | - Miguel A Matos
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA.,22391 Department of Surgery, Carilion Roanoke Memorial Hospital, Roanoke, VA, USA
| | - Daniel I Lollar
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA.,22391 Department of Surgery, Carilion Roanoke Memorial Hospital, Roanoke, VA, USA
| | - Katie L Bower
- 22391 Department of Surgery, Carilion Roanoke Memorial Hospital, Roanoke, VA, USA
| | - Michael S Nussbaum
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA.,22391 Department of Surgery, Carilion Roanoke Memorial Hospital, Roanoke, VA, USA
| | - Bryan R Collier
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA.,22391 Department of Surgery, Carilion Roanoke Memorial Hospital, Roanoke, VA, USA
| | - Mark E Hamill
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA.,22391 Department of Surgery, Carilion Roanoke Memorial Hospital, Roanoke, VA, USA
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Boone SM, Collier BR, Faulks ER, Locklear TM, Bower KL, Lollar DI, Dhiman N, Nussbaum MS, Hamill ME. Tracheostomy and Gastrostomy in Geriatric Trauma Associated With High Postdischarge Mortality. Crit Care Explor 2020; 2:e0156. [PMID: 32766554 PMCID: PMC7365707 DOI: 10.1097/cce.0000000000000156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES Identify 5-year mortality rates in trauma patients greater than 18 years old who undergo tracheostomy and/or gastrostomy tube placement. DESIGN Retrospective convenience sample with two cohorts. SETTING Academic level 1 trauma center. PATIENTS Hospitalized patients admitted to the trauma service from July 2008 to December 2012 who underwent tracheostomy and/or gastrostomy tube placement. INTERVENTIONS Patients were placed into two cohorts: adult 18-64 and geriatric greater than or equal to 65; mortality data were obtained from the National Death Index. MEASUREMENTS AND MAIN RESULTS The primary outcome was 5-year mortality of both cohorts as well as those admitted who did not receive tracheostomy or gastrostomy. Univariate analysis was performed using Fisher exact and Wilcoxon signed-rank tests. Kaplan-Meier curves were plotted to examine mortality up to 5 years after discharge. CONCLUSIONS Five-year postdischarge mortality is significantly higher in geriatric patients undergoing tracheostomy and/or gastrostomy after traumatic injury. Fifty percent die within the first 28 weeks following discharge and 93% die within 2 years.
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Affiliation(s)
- Sherry M Boone
- Department of Surgery, Division of Trauma and Surgical Critical Care, Carilion Clinic, Roanoke, VA
| | - Bryan R Collier
- Department of Surgery, Division of Trauma and Surgical Critical Care, Carilion Clinic, Roanoke, VA
- Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, VA
| | - Emily R Faulks
- Department of Surgery, Division of Trauma and Surgical Critical Care, Carilion Clinic, Roanoke, VA
- Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, VA
| | | | - Katie L Bower
- Department of Surgery, Division of Trauma and Surgical Critical Care, Carilion Clinic, Roanoke, VA
- Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, VA
| | - Daniel I Lollar
- Department of Surgery, Division of Trauma and Surgical Critical Care, Carilion Clinic, Roanoke, VA
- Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, VA
| | - Nitasha Dhiman
- Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, VA
| | - Michael S Nussbaum
- Department of Surgery, Division of Trauma and Surgical Critical Care, Carilion Clinic, Roanoke, VA
- Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, VA
| | - Mark E Hamill
- Department of Surgery, Division of Trauma and Surgical Critical Care, Carilion Clinic, Roanoke, VA
- Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, VA
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Walker BS, Collier BR, Bower KL, Lollar DI, Faulks ER, Matos M, Nussbaum MS, Hamill ME. The Prevalence of Beers Criteria Medication Use and Associations with Falls in Geriatric Patients at a Level 1 Trauma Center. Am Surg 2020. [DOI: 10.1177/000313481908500842] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The Beers Criteria for Potentially Inappropriate Medication (PIM) use is a list of medications with multiple risks in older patients. Approximately 24 per cent use rate is reported in prior studies. Our objective was to determine the local PIM use and subsequent fall risk in geriatric trauma patients. We conducted a retrospective analysis of PIM use in all geriatric patients evaluated at our Level 1 trauma center between 2014 and 2017. Patients were identified from our trauma database. Pre-admission medication use was determined through medication reconciliation from our electronic medical record (EMR). Patients not undergoing medication reconciliation were excluded. After initial analysis, patients were stratified by age into three groups: 65 to 74, 75 to 84, and ≥85 years. Multivariate logistic regression analyses were used to calculate odds ratios of falls for specific PIMs. In all, 2181 patients met the inclusion criteria. Overall, 71.2 per cent of geriatric trauma patients were prescribed at least one PIM—73.1 per cent of falls compared with 68.6 per cent for other mechanisms. Specific PIM use varied by age group. PIMs associated with fall risk in all patients included antipsychotics, benzodiazepines, and diclofenac. For those aged 65 to 74 years, antihistamines, diclofenac, proton pump inhibitors, and promethazine were associated. In those aged 75 to 84 years, alprazolam, antipsychotics, benzodiazepines, cyclobenzaprine, diclofenac, and muscle relaxants were implicated. No significant associations were found for patients aged ≥85 years. PIM use at our trauma center seems to be rampant and well above the national average. Geriatric falls were associated with using ≥1 PIM and multiple specific PIMs implicated. We are designing a targeted educational program for local primary care physicians (PCPs) that will attempt to decrease geriatric PIM use.
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Affiliation(s)
- Benjamin S. Walker
- From the Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Bryan R. Collier
- From the Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Katie L. Bower
- From the Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Daniel I. Lollar
- From the Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Emily R. Faulks
- From the Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Miguel Matos
- From the Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Michael S. Nussbaum
- From the Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Mark E. Hamill
- From the Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
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Howe KL, Collier BR, Bath JL, Lagoy JC, Criss TW, Faulks ER, Lollar DI, Bower KL, Locklear TM, Matos MA, Nussbaum MS, Hamill ME. The two faces of intentional self-inflicted injury: High in-hospital mortality, low postdischarge mortality, but high readmission rates. Surgery 2019; 166:580-586. [DOI: 10.1016/j.surg.2019.04.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 04/18/2019] [Accepted: 03/06/2019] [Indexed: 10/26/2022]
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Walker BS, Collier BR, Bower KL, Lollar DI, Faulks ER, Matos M, Nussbaum MS, Hamill ME. The Prevalence of Beers Criteria Medication Use and Associations with Falls in Geriatric Patients at a Level 1 Trauma Center. Am Surg 2019; 85:877-882. [PMID: 31560307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The Beers Criteria for Potentially Inappropriate Medication (PIM) use is a list of medications with multiple risks in older patients. Approximately 24 per cent use rate is reported in prior studies. Our objective was to determine the local PIM use and subsequent fall risk in geriatric trauma patients. We conducted a retrospective analysis of PIM use in all geriatric patients evaluated at our Level 1 trauma center between 2014 and 2017. Patients were identified from our trauma database. Pre-admission medication use was determined through medication reconciliation from our electronic medical record (EMR). Patients not undergoing medication reconciliation were excluded. After initial analysis, patients were stratified by age into three groups: 65 to 74, 75 to 84, and ≥85 years. Multivariate logistic regression analyses were used to calculate odds ratios of falls for specific PIMs. In all, 2181 patients met the inclusion criteria. Overall, 71.2 per cent of geriatric trauma patients were prescribed at least one PIM-73.1 per cent of falls compared with 68.6 per cent for other mechanisms. Specific PIM use varied by age group. PIMs associated with fall risk in all patients included antipsychotics, benzodiazepines, and diclofenac. For those aged 65 to 74 years, antihistamines, diclofenac, proton pump inhibitors, and promethazine were associated. In those aged 75 to 84 years, alprazolam, antipsychotics, benzodiazepines, cyclobenzaprine, diclofenac, and muscle relaxants were implicated. No significant associations were found for patients aged ≥85 years. PIM use at our trauma center seems to be rampant and well above the national average. Geriatric falls were associated with using ≥1 PIM and multiple specific PIMs implicated. We are designing a targeted educational program for local primary care physicians (PCPs) that will attempt to decrease geriatric PIM use.
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Gerrish AW, Hamill ME, Locklear TM, Bower KL, Lollar DI, Faulks ER, Matos M, Nussbaum MS, Collier BR. Trauma Recidivism Postdischarge Mortality: Important Differences Exist between the Adult and Geriatric Populations. Am Surg 2019; 85:685-689. [PMID: 31405408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Trauma recidivists are a high-risk patient population. The effects of recidivism on Geriatric trauma mortality have not been investigated. Our hypothesis is that trauma recidivism is associated with high postdischarge mortality after the initial index admission in both the geriatric and adult trauma populations. The trauma registry of our Level I trauma center was queried for patients evaluated between 2008 and 2012. Patients were stratified adult (18-64) and geriatric (≥65) groups and matched with mortality data from the National Death Index. Unique patients were identified and recidivists flagged. Statistical analysis was performed based on characteristics from the index admission using nonparametric tests, and Kaplan-Meier curves were plotted to examine postdischarge mortality after index admission for recidivists. A total of 8716 records met inclusion criteria; 800 recidivist records were identified representing 369 unique patients. Recidivists presented between 2 and 7 times. Recidivists were more likely to be male, required ICU admission and mechanical ventilation, had a longer median length of stay, were less likely to discharge home, and had a higher postdischarge mortality. Stratifying into adult and geriatric groups demonstrated significant differences in injury severity, injury patterns, length of stay, race, gender, mechanism, and postdischarge mortality. Recidivists demonstrated a higher postdischarge mortality in both groups with the geriatric group approaching 46 per cent. Trauma recidivists represent an at-risk group with significantly higher postdischarge mortality. Group characteristics differ significantly between the adult and geriatric recidivist populations. Further research is needed to identify modifiable risk factors in these populations to minimize risks of morbidity and mortality.
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Plaster AL, Hamill ME, Lollar DI, Love KM, Faulks ER, Freeman DW, Benson AD, Nussbaum MS, Collier BR. The Utility of Additional Imaging in Trauma Consults with Mild to Moderate Injury. Am Surg 2018. [DOI: 10.1177/000313481808401143] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Limiting CT imaging in the ED has gained interest recently. After initial trauma workup for consultations in the ED, additional CT imaging is frequently ordered. We assessed the benefits of this additional imaging. Our hypothesis was that additional imaging in lower acuity trauma consults results in the diagnosis of new significant injuries with a change in treatment plan and increased Injury Severity Score (ISS). The registry at our Level I trauma center was queried from November 2015 to November 2016 for trauma consults initially evaluated by ED physicians. Patients with mild to moderate injuries were included. Injury findings before and after additional imaging were determined by chart review and pre- and postimaging ISS were calculated. Blinded trauma surgeons assessed the findings for clinical significance and changes in treatment. Four hundred and twenty-one patients were evaluated, 41 were excluded. One hundred and forty patients (37%) underwent additional CT imaging. Forty-seven patients (34%) had additional injuries found, with 16 (12%) increasing their ISS (mean 0.54, SD 1.66). Ninety-three per cent of cases resulted in at least one physician finding the new injuries clinically significant; however, agreement was low (κ = 0.095). For 70 per cent, at least one physician felt the findings warranted a change in treatment plan (κ = 0.405). Additional imaging in ED trauma consults resulted in the identification of new injuries in 1/3 of our patient sample. This suggests that current efforts to limit the use of CT imaging in trauma patients may result in significant injuries going undiscovered and undertreated. Further research is needed to determine the risk of attempts to limit imaging.
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Plaster AL, Hamill ME, Lollar DI, Love KM, Faulks ER, Freeman DW, Benson AD, Nussbaum MS, Collier BR. The Utility of Additional Imaging in Trauma Consults with Mild to Moderate Injury. Am Surg 2018; 84:1825-1831. [PMID: 30747641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Limiting CT imaging in the ED has gained interest recently. After initial trauma workup for consultations in the ED, additional CT imaging is frequently ordered. We assessed the benefits of this additional imaging. Our hypothesis was that additional imaging in lower acuity trauma consults results in the diagnosis of new significant injuries with a change in treatment plan and increased Injury Severity Score (ISS). The registry at our Level I trauma center was queried from November 2015 to November 2016 for trauma consults initially evaluated by ED physicians. Patients with mild to moderate injuries were included. Injury findings before and after additional imaging were determined by chart review and pre- and postimaging ISS were calculated. Blinded trauma surgeons assessed the findings for clinical significance and changes in treatment. Four hundred and twenty-one patients were evaluated, 41 were excluded. One hundred and forty patients (37%) underwent additional CT imaging. Forty-seven patients (34%) had additional injuries found, with 16 (12%) increasing their ISS (mean 0.54, SD 1.66). Ninety-three per cent of cases resulted in at least one physician finding the new injuries clinically significant; however, agreement was low (κ = 0.095). For 70 per cent, at least one physician felt the findings warranted a change in treatment plan (κ = 0.405). Additional imaging in ED trauma consults resulted in the identification of new injuries in 1/3 of our patient sample. This suggests that current efforts to limit the use of CT imaging in trauma patients may result in significant injuries going undiscovered and undertreated. Further research is needed to determine the risk of attempts to limit imaging.
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Woriax HE, Hamill ME, Gilbert CM, Reed CM, Faulks ER, Love KM, Lollar DI, Nussbaum MS, Collier BR. Is the Face an Air Bag for the Brain and Torso?—The Potential Protective Effects of Severe Midface Fractures. Am Surg 2018. [DOI: 10.1177/000313481808400840] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We investigated the patterns of injury associated with major midface trauma. Our hypothesis is that midface injuries are associated with a decrease in certain traumatic brain injuries as well as major torso injuries. The registry of our Level I trauma center was queried for all adult patients treated over 25 years from 1989 to 2013. Patients with midface fractures were identified based on the ICD-9 code. Associated injuries were defined based both on individual ICD-9 codes as well as the Barell Injury Matrix. Injury etiology was defined based on e-codes. Univariate analysis was performed using chi-squared test, Fisher's exact test, and Wilcoxon test. A total of 29,152 patients were identified. Excluding pediatric patients, those with exclusively penetrating trauma, and patients with incomplete data, 20,971 patients were included for subsequent analysis. Midface fractures were identified in 752 patients. Patients with Le Fort fractures were more likely to be male, have a higher Injury Severity Score, a lower arrival Glasgow Coma Scale, and more likely to require intensive care unit admission and mechanical ventilation, with a longer hospital length of stay. Patients with midface fractures had significantly fewer subdural hematomas, subarachnoid hemorrhages, spine fractures, and were less likely to have associated abdominal and pelvic injuries. Patients with midface fractures were more likely to require facial reconstruction procedures and craniotomy. Patients presenting with midface fractures after blunt trauma have a distinctly different pattern of injuries. One potential mechanism for this is a deceleration effect, where midface impact and resulting fractures dissipate some of the energy.
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Affiliation(s)
- Hannah E. Woriax
- Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Mark E. Hamill
- Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Carol M. Gilbert
- Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Christopher M. Reed
- Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
- Department of Surgery, Duke University, Durham, North Carolina
| | - Emily R. Faulks
- Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Katie M. Love
- Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Daniel I. Lollar
- Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Michael S. Nussbaum
- Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Bryan R. Collier
- Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
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Woriax HE, Hamill ME, Gilbert CM, Reed CM, Faulks ER, Love KM, Lollar DI, Nussbaum MS, Collier BR. Is the Face an Air Bag for the Brain and Torso?-The Potential Protective Effects of Severe Midface Fractures. Am Surg 2018; 84:1299-1302. [PMID: 30185304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
We investigated the patterns of injury associated with major midface trauma. Our hypothesis is that midface injuries are associated with a decrease in certain traumatic brain injuries as well as major torso injuries. The registry of our Level I trauma center was queried for all adult patients treated over 25 years from 1989 to 2013. Patients with midface fractures were identified based on the ICD-9 code. Associated injuries were defined based both on individual ICD-9 codes as well as the Barell Injury Matrix. Injury etiology was defined based on e-codes. Univariate analysis was performed using chi-squared test, Fisher's exact test, and Wilcoxon test. A total of 29,152 patients were identified. Excluding pediatric patients, those with exclusively penetrating trauma, and patients with incomplete data, 20,971 patients were included for subsequent analysis. Midface fractures were identified in 752 patients. Patients with Le Fort fractures were more likely to be male, have a higher Injury Severity Score, a lower arrival Glasgow Coma Scale, and more likely to require intensive care unit admission and mechanical ventilation, with a longer hospital length of stay. Patients with midface fractures had significantly fewer subdural hematomas, subarachnoid hemorrhages, spine fractures, and were less likely to have associated abdominal and pelvic injuries. Patients with midface fractures were more likely to require facial reconstruction procedures and craniotomy. Patients presenting with midface fractures after blunt trauma have a distinctly different pattern of injuries. One potential mechanism for this is a deceleration effect, where midface impact and resulting fractures dissipate some of the energy.
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Grim R, Parma CM, Faulks ER, Wesner VS, Ahuja V. Reducing iatrogenic pneumothorax (PAI 06) central line placement at a community teaching hospital background. J Am Coll Surg 2014. [DOI: 10.1016/j.jamcollsurg.2014.07.490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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