Low intra-abdominal pressure in laparoscopic surgery: a systematic review and meta-analysis

BACKGROUND

Guidelines do not provide clear recommendations with regard to the use of low intra-abdominal pressure (IAP) during laparoscopic surgery. The aim of this meta-analysis is to assess the influence of low versus standard IAP during laparoscopic surgery on the key-outcomes in perioperative medicine as defined by the StEP-COMPAC consensus group.

MATERIALS AND METHODS

We searched the Cochrane Library, PubMed, and EMBASE for randomized controlled trials comparing low IAP (<10 mmHg) with standard IAP (10 mmHg or higher) during laparoscopic surgery without time, language, or blinding restrictions. According to the PRISMA guidelines, two review authors independently identified trials and extracted data. Risk ratio (RR), and mean difference (MD), with 95% CIs were calculated using random-effects models with RevMan5. Main outcomes were based on StEP-COMPAC recommendations, and included postoperative complications, postoperative pain, postoperative nausea and vomiting (PONV) scores, and length of hospital stay.

RESULTS

Eighty-five studies in a wide range of laparoscopic procedures (7349 patients) were included in this meta-analysis. The available evidence indicates that the use of low IAP (<10 mmHg) leads to a lower incidence of mild (Clavien-Dindo grade 1-2) postoperative complications (RR=0.68, 95% CI: 0.53-0.86), lower pain scores (MD=-0.68, 95% CI: -0.82 to 0.54) and PONV incidence (RR=0.67, 95% CI: 0.51-0.88), and a reduced length of hospital stay (MD=-0.29, 95% CI: -0.46 to 0.11). Low IAP did not increase the risk of intraoperative complications (RR=1.15, 95% CI: 0.77-1.73).

CONCLUSIONS

Given the established safety and the reduced incidence of mild postoperative complications, lower pain scores, reduced incidence of PONV, and shorter length of stay, the available evidence supports a moderate to strong recommendation (1a level of evidence) in favor of low IAP during laparoscopic surgery.

Measuring factors that influence the response of medical practitioners and social workers to problem drinkers: a pilot study

It is increasingly recognized that factors such as professionals' empathy, willingness to intervene, self-efficacy and role legitimacy influence the initial engagement of clients into treatment and the nature of any subsequent therapeutic relationship. These factors are difficult to measure using questionnaires, and for this reason qualitative research techniques are frequently used in this field of inquiry. The present methodological study is based on in-depth interviews conducted with 16 medical practitioners and 12 social workers, and attempts to overcome one of the main limitations associated with qualitative data-that is, the difficulty of reducing such complex material to a numerical value suitable for quantitative analysis. The interview technique and rating system described were most successful in achieving this in the case of self-efficacy and least successful in the case of empathy. Possible reasons for this are discussed. It is concluded that the technique described has the potential to elicit detailed data concerning the interactions of medical practitioners and social workers with problem drinkers, and that this material can be reliably rated in a manner that is not unduly time-consuming and burdensome to researchers.

Absorption, distribution, metabolism and excretion of intravenously and orally administered tetrabromobisphenol A [2,3-dibromopropyl ether] in male Fischer-344 rats

Tetrabromobisphenol A bis[2,3-dibromopropyl ether],2,2-bis[3,5-dibromo-4-(2,3-dibromopropoxy)phenyl]propane is a brominated flame retardant with substantial U.S. production. Due to the likelihood of human exposure to TBBPA-DBPE and its probable metabolites, studies regarding the absorption, distribution, metabolism, and excretion were conducted. Male Fischer-344 rats were dosed with TBBPA-DBPE (20mg/kg) by oral gavage or IV administration. Following a single oral administration of TBBPA-DBPE, elimination of [(14)C] equivalents in the feces was extensive and rapid (95% of dose by 36h). Following repeated daily oral doses for 5 or 10 days, route and rate of elimination was similar to single administrations of TBBPA-DBPE. After IV administration, fecal excretion of [(14)C] equivalents was much slower (27% of dose eliminated by 36h, 71% by 96h). Urinary elimination was minimal (<0.1%) following oral or IV administration. A single peak that co-eluted with the standard of TBBPA-DBPE was detected in extracts of whole blood following oral or IV administration. TBBPA-DBPE elimination from the blood was slow. Kinetic constants following IV dosing were-t(1/2beta): 24.8h; CL(b): 0.1mLmin(-1). Kinetic constants following oral dosing were: t(1/2alpha): 2.5h; t(1/2beta): 13.9h; CL(b): 4.6mLmin(-1). Systemic bioavailability was 2.2%. Liver was the major site of disposition following oral or IV administration. After oral administration, 1% of the dose was eliminated in bile in 24h (as metabolites). In in vitro experiments utilizing hepatocytes or liver microsomal protein, no detectable metabolism of TBBPA-DBPE occurred. These data indicate that TBBPA-DBPE is poorly absorbed from the gastrointestinal tract. Compound which is absorbed is sequestered in the liver, slowly metabolized, and eliminated in the feces.

A 12-year experience with prehospital cricothyrotomies

INTRODUCTION

Maintaining cricothyrotomy skills is difficult for air medical crewmembers because the procedure is performed infrequently. The purposes of this study were to review our program's experience with cricothyrotomies and use this pilot study to guide an industry-wide study.

METHODS

We conducted a retrospective review of all cricothyrotomies performed by our flight crew during the past 12 years. The flight logs were reviewed for patient demographics, scene information, clinical data, and procedure data.

RESULTS

During this period, 8833 patients were transported: 1589 required intubation (18%), and eight of the 1589 required a cricothyrotomy (0.5%). Five nurses (14% of the total employed during the study) and one physician attempted this procedure. All patients had at least one intubation attempt before the cricothyrotomy (average 3.6, range 1-6 attempts). Six (75%) patients had airway edema, four (50%) had an unstable trachea, and one patient (12.5%) had an airway obstruction. Five (62.5%) of the cricothyrotomy attempts were successful. The remaining three patients were managed with bag-valve mask ventilation. Three patients arrived at the receiving hospital with a perfusing rhythm.

CONCLUSION

Cricothyrotomy, rarely performed by our flight crews, is successful in 62.5% of cases. These preliminary data suggest current training practices should be re-evaluated. An industrywide survey is planned to determine the optimal training program.

Definitive surgical trauma care live porcine session: a technique for training in trauma surgery

BACKGROUND

A new Definitive Surgical Trauma Care course was developed to educate surgeons in operative management of injuries. The course consists of an interactive CD-ROM and a live porcine animal laboratory.

METHOD

A five-hour session was conducted. Penetrating injuries to stomach, bowel, diaphragm, spleen, pancreas, kidney, ureter, inferior vena cava, liver, and heart were created by the senior surgeon and managed by the junior surgeon. Participants rated their expertise in 26 maneuvers pre- and post-lab. The evaluation scale used was: no prior experience; able to perform skill with assistance; proficient at procedure; able to teach procedure to another surgeon.

RESULTS

In 26 procedures, a maximum score of 78 was possible. There was an increase from pre- to post-session scores of 22.6 for PGY-4 residents (n = 3); 23.3 for PGY-5 residents (n = 4); 11.25 for fellows (n = 4); and 0 for attendings (n = 4).

CONCLUSION

The operative animal session had the greatest educational benefit among surgeons without formal training in trauma surgery. By exposing them to a range of trauma-induced surgical conditions, the DSTC course develops their operative repertoire and should increase their effectiveness in managing trauma patients.

Clinical practice guidelines and the cost of care. A growing alliance

Healthcare policy, medical practice, and cost of care are no longer considered distinct entities. Each is an integral factor in determining not only what, but how, patient care will be delivered. Clinical practice guidelines are the lynchpin that connects them. This paper addresses the various components of the clinical practice guideline--cost alliance.

OBJECTIVE

To examine the bidirectional influence of choice of care on costs and of cost of care on decision making.

METHODS

The literature was used to identify cost-related factors that influence development of guidelines and change in physician practice behavior. In a MEDLINE search with modifiers to the keywords "clinical practice guidelines," particular attention was paid to identifying surveys of practitioners. An analysis, prompted by a recently published guideline, of treating penetrating intraperitoneal colon injuries by different surgical approaches (primary repair versus diverting colostomy) exemplified how implementation of a guideline can affect the cost of care. Inpatient cost estimates, adjusted for medical inflation and cost-to-charge ratios and reported in 1999 U.S. dollars, were developed using data from 1996 and 1997 discharge databases from California and Massachusetts.

RESULTS

The results showed that a substantial savings in hospital costs was achieved when a primary repair surgical technique, as advocated by the guideline, was used. The effect of cost influences on the development of clinical practice guidelines was established by demonstrating the cyclical effect between usual and customary practices, guideline implementation, changing practice patterns, and the economic considerations influencing the process.

CONCLUSIONS

A growing, albeit uneasy, alliance between costs and clinical practice guidelines is evident.

Economic effects of managed care

There have been substantial changes in the way health care has been paid for in the last half of this century. The original contract between a physician and a patient has evolved to insurance companies paying usual and customary costs for physician services. Now, the medical care of a whole population is bid to organizations willing to insure the risk for managing the care of the population for a prospectively determined fee. The rising cost of health care has imposed new strategies to manage these escalating costs for physician, facilities, and patients. Despite the changes that have radically altered health care delivery, costs continue to rise. This fact ensures that there will be continuing evolution of strategies to decrease the rising rate of health care. Trauma care management traditionally has involved looking at the entire spectrum of the patient's disease process from the prehospital phase to his or her rehabilitation. The discipline that was necessary to identify each component of the system and quantify the cost associated with it has made trauma care a potential model for managed care. There are now systems of care in place that are fully dedicated to trauma. The facilities in them are verified by the American College of Surgeons or a similar professional body. These facilities are designated by a regulatory body, such as the state. It will become more common for payors to require that patients be enrolled in some trauma system of care because this will provide the most cost-effective management, especially for severely injured patients. Surgeons should clearly understand the historic and present strategies for cost-management and how they have evolved. A clear understanding of these forces will allow rational plans to be developed that will deliver the best, most cost effective care to trauma victims.

Helicopter air medical transport: ten-year outcomes for trauma patients in a New England program

BACKGROUND

Twenty-five years have passed since the introduction of the first civilian hospital-based air medical helicopter service. This study reviews the impact of a single air medical service during a decade of service on the survival of severely injured trauma patients.

METHODS

A retrospective database analysis was performed to determine program demographics and obtain outcome data. The outcomes of trauma patients were compared to mortality derived from a national database utilizing physiologic indices of severity.

RESULTS

Outcome analysis demonstrated an overall 13% reduction in mortality for air transported patients when compared to controls. Stratification based upon Trauma Score demonstrated a 35% reduction in mortality for victims transported directly from the scene with scene scores between four and 13, and essentially no difference in outcome for patients at Trauma Score extremes.

CONCLUSIONS

Rapid utilization of helicopter air medical transport can have a dramatic impact upon patient outcome, especially within a select group of scene transported trauma patients with Trauma Scores ranging from four to 13.

Violence in America: a public health crisis--domestic violence

Domestic violence is a major public health problem. It is important that physicians are aware of the extent and pervasiveness of this disease. It is important to identify potential victims of domestic violence when they are encountered in the hospital or office environment. A few, short, carefully asked questions can serve an important surveillance and diagnostic function. Once domestic violence is identified, a well thought out, sensitive, safe plan of action should be discussed with the victim. In this way, not only will the current event be well managed, but also the potential for mitigating further domestic violence events will be initiated. Through this document, EAST hopes to add its voice to that of other physician groups to serve as a catalyst for broad education on the subject of domestic violence as well as activating victim advocacy among physicians and others who come into contact with this problem in their patients.

Emergency medicine in France

The Essonne region of France is situated to the south of Paris. A population of more than 1 million, heavy commercial traffic, and industrial centers mandate first-rate prehospital and hospital emergency medicine. Medical education in France comprises 3 years of basic medical science, followed by 3 years of hospital rotations and a residency of variable length. Emergency medicine is struggling for recognition as a specialty. The ED at the hospital center in Corbeil-Essonnes, France, has 21,000 visits per year, accounting for 30% of hospital admissions. The physical plant is modern and well-organized, with 13 beds. Attention is paid to quality improvement. Prehospital emergency care also receives due attention. A two-tiered system of BLS ambulances run by the fire department and ALS ambulances run by hospitals provide 24-hour emergency coverage. Because of aggressive triage, only 65% of requests for service result in dispatch of an ambulance. Tasks for physicians involved in emergency medicine in France today include further development of firemen's medical skills, development and use of telemedicine, and accreditation of emergency medicine as a recognized specialty.

Integrating emergency medicine residents into a well-established helicopter program

INTRODUCTION

The institution of an emergency medicine residency in a university-affiliated Level 1 trauma center in July 1993 provided a challenge to develop a curriculum and on-line learning experience for emergency medicine residents in a well-established helicopter program. The purpose of this study was to survey flight crew members, emergency medicine at tending physicians, and emergency medicine residents on the anticipated roles and educational experience of integrating the emergency medicine residents from a new emergency medicine residency into the flight crew of a well-established helicopter program.

METHODS

A survey consisting of multiple choice, Likert scale, and open-ended questions was distributed to flight crew members (RN, RT, pilots, communication specialists, EM attendings, and EM residents [n=72]).

RESULTS

92% of surveys were returned. These surveys identified specific issues of concern and those areas believed to be of academic importance for the emergency medicine residents.

CONCLUSIONS

The results of this study allowed for the creation and implementation of a progressive flight experience for EM residents that incorporates increasing responsibility on the flight crew as experience is gained.

Hypercoagulability following multiple trauma

We sought evidence of hypercoagulability in 59 seriously injured trauma patients. An extended coagulation profile (consisting of tissue plasminogen activator antigen concentration, plasminogen activator inhibitor, serum antithrombin III, protein C antigen, functional protein C, protein S antigen, D-dimer, and prothrombin fragment 1.2) was compared to control values. Laboratory evidence of hypercoagulability was seen in 85% (n = 50) of the patients. Patients with an Injury Severity Score (ISS) > or = 16 (n = 36) had significantly elevated levels of D-dimer and decreased levels of functional protein C compared to patients with an ISS < or = 15 (n = 23). Functional protein C had a negative correlation (r = -0.44; p < 0.001) with the ISS. A hypercoagulable state exists immediately following severe trauma. Greater injury severity may increase this hypercoagulable state. Decreased levels of functional protein C best correlated with increased injury severity.

Accuracy of e-codes assigned to emergency department records

OBJECTIVE

To determine the accuracy of ICD-9-CM external-cause-of-injury codes (e-codes) assigned to the medical records of injured patients treated in an ED and released.

METHODS

A comparison was made of routine coding and expert recoding of medical records generated in the ED for a convenience sample of patients treated for injuries within 24 hours of injury occurrence and subsequently released from the ED. The medical record was handwritten and subsequently coded by three medical records coders (MRCs). The e-coded charts were sent to an external medical record consultant (expert), who was blinded to the codes previously assigned. The expert reading was used as the criterion standard. Accuracy was measured using a kappa statistic, and errors were described.

RESULTS

Of 126 available patient charts, 108 (85.7%) were assigned e-codes by MRCs. The expert assigned two codes to (double-coded) 67 patients, while the MRCs double-coded only one patient. The additional code was usually a "place of occurrence code." In 60 cases (55.6%), the expert code exactly matched the MRC code; kappa = 0.462. Of the 48 mismatches (44.4%), 20 (41.7%) were e-coded in the wrong category, 20 (41.7%) were e-coded in the correct category but with incorrect specificity of information, either too specific or not specific enough, and eight (16.6%) had combined coding errors.

CONCLUSION

The accuracy of e-codes assigned to ED records was moderate in this single institution analysis. Errors were predominantly related to the specificity of the code, but some e-codes were in the wrong category. There are implications for injury surveillance and research. E-code assignment must be standardized and applied uniformly to obtain accurate codes. Automation of e-coding could improve accuracy and consistency of codes. National and international epidemiologic studies of cause of injury among ED patients will be severely hampered until e-code assignment can be better standardized.

Emergency management of blunt testicular trauma

OBJECTIVE

Severe blunt testicular trauma is an infrequently reported consequence of injury, yet it is associated with significant sequelae. This case series evaluates the characteristics of patients with severe blunt testicular trauma, assesses the role of ultrasonography in their management, and offers an evaluation algorithm for use by both emergency and urology personnel.

METHODS

A retrospective review was conducted of ten patients who had severe blunt testicular injuries referred for urologic evaluation over a seven-year period at a level 1 trauma center. Attention was focused on ultrasonographic results, operative findings, and testicular salvage rates.

RESULTS

With the exception of two motorcycle crash victims, patients presented in a delayed fashion (mean 3.5 days; range 1-5 days). Most (6/10) patients had true testicular rupture, all were explored urgently, and there was a 100% testicular salvage rate. Of the eight patients who had preoperative ultrasonographic examination, two were reported to show testicular rupture, but on exploration only one in fact had a tunica albuginea tear. Six patients had ultrasonographic examinations that revealed nonspecific abnormalities but failed to show testicular rupture; three had testicular rupture.

CONCLUSIONS

Ultrasonography cannot be relied on to accurately diagnose rupture of the testis in high-risk patients. However, testicular rupture is universally associated with an abnormal ultrasonography scan, albeit commonly yielding nonspecific findings. A high level of suspicion is mandatory with high-energy transfer mechanisms. Since a significant delay in presentation is not unusual, early exploration is warranted in the setting of high risk and provides an excellent chance of testicular salvage. Injuries associated with normal testicular ultrasonography may be managed conservatively.

Mesenteric injury from blunt abdominal trauma

Mesenteric injury from blunt abdominal trauma is rare and can be difficult to diagnose. Twenty-seven cases were admitted over the past 5 years to our Level I trauma center. These cases have been retrospectively reviewed to better define the experience of patients with blunt mesenteric injury for the physician faced with making this diagnosis. It was found that the diagnosis of mesenteric injuries tends to be delayed in a certain subset of patients. Patients with a devascularizing, isolated injury or patients who are evaluated by abdominal CT scan (as opposed to DPL) tended to be more likely to experience a diagnostic delay. It was also found that motor vehicle accidents are the most common, though not the only, mechanism of injury and that the mesentery of the small bowel is injured approximately five times more frequently than the colonic mesenteries. These factors, however, did not result in earlier diagnostic decision making. To decrease the likelihood of a missed diagnosis, physicians should entertain the possibility of mesenteric injury in all patients presenting with blunt abdominal trauma, even if few clinical findings are initially present and/or an abdominal CT scan demonstrates no definitive intraabdominal injury.

Clinical management of blunt trauma patients with unilateral rib fractures: a randomized trial

Optimal pain management is essential in blunt trauma patients sustaining significant chest trauma. The purpose of this randomized prospective trial was to measure the difference in pulmonary function in nonintubated patients with unilateral multiple rib fractures receiving two modalities of pain relief: systemic narcotic medications alone or local anesthetics given by intrapleural catheter (IPCs). Forty-two patients were randomized to receive systemic narcotic medications or IPCs for pain control. The patients with IPCs statistically had more compromised pulmonary function as measured by forced vital capacity (FVC) on admission; however, they tended toward a greater objective improvement of FVC on discharge. When analyzing a cohort of severely impaired patients (initial FVC < 20%), half of the systemic medication patients compared to only 10% of the IPC group failed and required another mode of therapy. Catheter complications were minor and did not contribute to overall morbidity. The IPC patients had fewer failures than the systemic medication patients.

The quantity of cause-of-injury information documented on the medical record: an appeal for injury prevention

OBJECTIVE

To determine how much information about the cause of injury (available at the time of ED treatment) is documented on the medical record. This information is used by medical records coders to assign e-codes.

METHODS

Quantitative "stages of information" were defined: stage 1 = the maximum amount of information available from the patient, as collected by a trained research assistant; stage 2 = the amount of information obtained by the care provider during the patient interview; and stage 3 = the amount of information the care provider documented in the medical record. Comparisons were made between the three stages; subgroup analyses compared amounts of information loss between the stages for levels of care provider and cause-of-injury information categories.

RESULTS

Information was obtained from 109 patients. Only 46% of the cause-of-injury information available during the ED visit was recorded on the medical record. Incomplete history taking (obtaining 68% of the available information) and failure to document (writing 67% of the information obtained during the patient interview) contributed equally to the loss of information. The most information was obtained about who had received the injury (72%) and the least amount of information was in the category of where the injury had occurred (14%). Attending physicians collected the most information (74%) but documented significantly less (65%) than did physician assistants (70%) or medical students (81%). Medical students collected the least (65%) but documented the most, resulting in the students' medical records' being the most complete (52%) for cause-of-injury information.

CONCLUSION

Emergency providers obtain significantly less cause-of-injury information than is available from the patient. Also, these providers' handwritten medical records contain significantly less cause-of-injury information than was obtained during the patient interview.

Isolated free fluid on abdominal computerized tomographic scan: an indication for surgery in blunt trauma patients?

A retrospective study of 792 patients who sustained blunt traumatic injury and underwent abdominopelvic computerized tomographic scan (CT) evaluation was performed. Patients who had free intraperitoneal fluid without evidence of solid visceral organ damage served as the study population. Sixty-six (8.3%) of patients were identified as having free fluid without evidence of solid organ injury. Pelvic fractures occurred in 14 of the 66 (21.2%) patients. Splenic injuries requiring laparotomy were not diagnosed initially on CT scan of the abdomen in four (6%) patients. Mesenteric or small bowel injuries occurred in six (9%) patients. Nine (13.6%) of the patients expired. Thirty-five patients (53%) had no sequelae of intra-abdominal injuries and required no surgical intervention. If patients with pelvic fractures are excluded, 10 (19.2%) of the patients required operative intervention for their injuries. It is our conclusion that free fluid as the only significant finding on CT scan in blunt trauma patients may be a harbinger of significant intra-abdominal injury, and that these patients need to be closely observed to decrease morbidity associated with these potential injuries.

Prospective evaluation of craniofacial pressure in four different cervical orthoses

INTRODUCTION

Cervical collars play a role in the long-term treatment of cervical spine injuries. Pressure ulcers are one of the potential complications. We previously reported on three patients who developed pressure ulcers of the scalp while wearing cervical collars. The pressure exerted by different collars was measured to determine whether this was a significant factor in the clinical problem we observed.

METHODS

Four brands of cervical collars (Stifneck, Philadelphia, Newport, and Miami J) were tested in 20 normal volunteers. Pressure was measured at the occiput, mandible, and chin. Opinions on comfort were also collected.

RESULTS

The Stifneck collar exceeds capillary closing pressure (CCP) for most contact points. The Philadelphia collar exposes the wearer to high pressures when supine compared with the upright position (p < 0.001). The Newport and Miami J collars exerted pressure well below CCP. The subjective comfort (scale from 0 (poor) to 5 (best)) ratings were: Stifneck = 0.85, Philadelphia = 3.00, Newport = 3.80, and Miami J = 3.45.

CONCLUSIONS

We recommend use of "patient-friendly" collars such as the Newport or Miami J because of their favorable skin pressure patterns and superior patient comfort. These collars should potentially reduce the incidence of soft-tissue complications and improve patient compliance.

An efficient system for controlled distal colorectal irrigation

We have found this setup to be most useful. For those surgeons who incorporate rectal irrigation as part of their treatment plan for patients with rectal injuries, we would recommend trial of this simple yet effective technique. The more senior anesthesia and nursing staff who have suffered through the vagaries of widespread fecal contamination from the beginning to the end of the operation rapidly become advocates of this procedure.

Personality types of flight crew members in a hospital-based helicopter program

PURPOSE

To determine the personality preferences of flight crew members in a hospital-based helicopter emergency medical service (HEMS) using the Myers-Briggs Type Indicator (MBTI), and to differentiate and compare these preferences between crew specialties and a historical control population.

METHODS

A prospective cohort study was conducted of all active crew members (nurses, respiratory therapists and pilots) in a hospital-based flight program. Data collected included the results of the MBTI, gender, age and years of flight experience.

RESULTS

Crew members were represented by 14 of 16 possible MBTI personality types, with three types predominating. For each crew specialty, extroversion preferences predominated over introversion, and perceiving characteristics predominated over judging characteristics. Differences existed by crew specialty for the sensing-intuition and thinking-feeling dimensions.

CONCLUSIONS

A personality typology has been established for individual and group preferences within one hospital-based HEMS program. This data begins to develop a data base and an investigative protocol for understanding some of the human factors regarding flight programs. Future research should focus on expanding the data base and exploring specific crew interactions based on additional diagnostic and evaluative methodologies.

The response of scene call volume to prehospital education

INTRODUCTION

Transport of injured patients directly from a scene to a trauma center improves survival of patients and shortens their length of stay in the hospital. This paper studies the relationship between education presentations to prehospital personnel and scene call volume. The education sessions emphasize safety issues and how, when, and why to call for air medical transport.

METHODS

The town and date of scene flights were compared to the town and date of flight nurse presentations and aircraft demonstrations. The length of time from a presentation to a scene call for each town was determined, and a cumulative frequency graph was drawn. Epidemiologic curves of presentations and calls were drawn for each town. Based on these graphs, observations of a relationship were obtained.

RESULTS

There were 65 scene calls to 27 towns that had no education programs. There were 880 scene calls to 90 towns that had 235 education programs. There were 21 towns that received a total of 41 presentations and never initiated a scene call. The results show that scene call requests are more likely to occur within three months of a presentation. Individual town analysis shows variability of response to education programs.

CONCLUSION

Prehospital provider education programs increase scene call volume, but this effect seems to last for three months. On a town-by-town basis there are many other determinants of scene call volume.

Continuous quality improvement applied to a scientific assembly: the history of the Eastern Association for the Surgery of Trauma

INTRODUCTION

The purpose of this study was to measure the quality of the research presented at the Eastern Association for the Surgery of Trauma (EAST) for the first 5 years.

METHODS

Abstracts from the scientific assemblies of EAST, 1988-1992, were reviewed. Five elements were identified for each abstract, the research question, the research design, the sampling method, the validity of the conclusions, and if the research question was answered. These were identified because of their significant impact on the quality of the research presented in the abstract format.

RESULTS

Two hundred two abstracts were reviewed. There was a significant improvement in research design, in the sampling method, in the validity of the conclusions, and in the proportion of research questions answered. There was an initial improvement in the presence of a research question, but it was not sustained.

CONCLUSION

The results clearly demonstrate an improvement in the quality of the abstracts chosen for presentation at the scientific assembly of the Eastern Association for the Surgery of Trauma. Further improvements can be made by adding the category of 'research question' or 'purpose' and requiring a structured abstract.

Recidivism in a helicopter emergency medical service

This study was designed to determine the frequency of recidivism (patients using a service more than once for the same or different disease episodes) in a helicopter emergency service, with the premise that high levels of recidivism may constitute grounds for improving quality of care or patient education programs. A retrospective chart review was performed on records from June 1985 to September 1990. Patients were included if they required helicopter transport on more than one occasion for either different disease episodes (true recidivists) or for multiple transports during a single hospital admission. Twenty-one (0.6%) of the 3,543 patients transported were true recidivists and 20 (0.6%) patients required secondary transport during the same admission. Of the latter group, 17 secondary transports were within 24 hours of admission. This study showed that recidivism in this helicopter emergency service is low. Patients who were air transported more than once for the same illness or injury within a 24-hour period occurred in less than 1% of transports, well within the helicopter program's pre-established less than 2% threshold.

The prevalence of occupational injuries in EMTs in New England

OBJECTIVE

To characterize the prevalence and morbidity of injuries to emergency medical technicians EMTs) in New England [United States].

DESIGN

A survey was mailed to a 2% random sample of all registered EMTs in the six New England States. The identity of the EMTs remained anonymous, and a second mailing was used to improve return rate. The EMTs were requested to recall events that occurred during the previous six months.

RESULTS

A total of 439 of the 786 (56%) surveys were returned representing 13,875 hours of duty time in the six-month period. Seventy-one percent of the EMTs were male with a mean age of 35 years. Sixty-six percent were basic-EMTs. Injury attack rates (number of injuries/100 EMTs/6 months) were: stress, 11.2; back, 10.5; extremity, 9.8; assault, 8.4; ambulance collision, 4.1; hearing loss, 2.5; and eye injury, 1.4. Twelve percent of the EMTs were injured more than once in the six-month period. The paramedics more frequently were involved in ambulance collisions, suffered from stress, and were less likely to injure their back. There were minor interstate differences. Disability due to back injury affected 2.5% of those surveyed, four EMTs lost duty time secondary to an assault, and 0.5% of the EMTs were out of work due to stress.

CONCLUSIONS

This survey begins to characterize the occupational risks of EMTs. The prevalence of back injuries, assault, stress, and extremity injuries seems to be too high. Educational programs and preventive interventions should be designed to minimize back injuries, stress, and assault. There is a need for more research nationwide in order to better characterize these injuries.

The effect of quality assurance on flight nurse documentation

This study was developed to evaluate if a structured quality assurance program has an effect on nursing documentation. A randomized, retrospective audit of records was conducted from 1985 to 1989, and in November 1987, a structured QA program was initiated for flight nurses. Each chart was audited for completeness of 69 elements from seven categories: administrative information, patient history, physical exam, management plan, vital signs, medications and intravenous access. A comparison of audit results was conducted before and after the QA program was initiated. A total of 224 charts were audited, 123 before the QA program and 101 after. There was statistically significant improvement in 4 of 13 administrative, 5 of 7 history, 21 of 31 physical exam, 2 of 6 management, 2 of 2 vital signs, 0 of 4 medication, and 0 of 6 intravenous access elements. Twenty-five of 35 categories that did not show improvement had initial completion rates greater than 90 percent. The significant improvement in documentation by flight nurses after a formal QA program was initiated lead the authors to conclude that QA benefits air medical programs by providing a mechanism to improve documentation.

Factors associated with outcome in blunt aortic injury: a population-based study

A population-based study was conducted for two contiguous states representing a population of 9.1 million to determine whether age, injury severity score, major complications, and preexisting conditions contribute to the outcome of patients diagnosed with blunt traumatic aortic injury. A secondary analysis reviewed patients with blunt aortic injury admitted over a six-year period to a trauma center located in one of the states to examine other more detailed factors related to mortality. Age was the only variable that correlated statistically with mortality in both populations analyzed. (Region P = .004; trauma center P = .0012) The severity of injury showed a tendency for decreased survival with increasing injury severity score. The elderly (age > or = 55) in both data sets sustained higher mortality from blunt aortic injury. In the trauma center population, the elderly had more delay in diagnosis than the younger patient population.

The effect of the new trauma DRGs on reimbursement

Reimbursement for trauma care based on prospective payment has not been satisfactory. The Health Care Financing Administration introduced four new Multiple Significant Trauma (MST) DRGs in 1991 with the intention of covering patients who have had at least two body sites injured. To determine the effect if any on reimbursement, a sample of patients who were assigned the new DRGs over a 5-month period were analyzed. The analysis compared the calculated reimbursement for these 49 patients based on their total accumulated charges, DRG weights, and the average Medicare dollar blend along with the additional weight factor specific for the study facility. This analysis was compared with an additional analysis determining the reimbursement performed on the same patient sample but with DRG weights determined from DRGs derived from the 1989 DRG GROUPER/FINDER. During the 5-month study period, 5.5% of the patients discharged from the hospital has sustained at least one injury covered by ICD-9-CM codes. Of these, 49 (3.9%) were classified into one of the four new MST DRGs. The majority of patients were male (75.5%), the mean age was 31.8 years, and the total charges accumulated were $1,809,192.23. The calculated DRG-based reimbursement was $1,183,495.40, or 65.5% of the total charges. In the second part of the study, using the DRGs available in 1989 for the same sample of patients, the DRG-based reimbursement was $691,437.72, or only 38.2% of the accumulated charges.(ABSTRACT TRUNCATED AT 250 WORDS)

Delayed hemorrhagic pericardial effusion: case reports of a complication from severe blunt chest trauma

The rare occurrence of delayed hemorrhagic pericardial effusion requiring treatment is reported following significant blunt chest trauma (AIS greater than or equal to 3) in three patients from 12 to 15 days after injury. Cardiomegaly was suspected on serial chest roentgenograms, and the pericardial effusion was confirmed by echocardiography. Two of three patients required systemic anticoagulation early after their admission to the hospital. It is currently unknown whether the number of delayed hemorrhagic pericardial effusions is increasing with the use of certain anticoagulation treatment regimens.

The changing perspectives of trauma care. The Sinkler Memorial Lecture

Trauma and the management of injuries have changed considerably over the past century. A sound understanding of the factors that generate injuries and sophisticated systems that can be accessed immediately are now in place in most of the United States. The concept of a team approach to the management of multiple system injuries using specialists from all disciplines has resulted in the reduction of morbidity and mortality. Although many of the challenges of managing the trauma patient have been overcome, there are still a number of exciting areas that lend themselves to ongoing research. These changing perspectives allow for many exciting challenges for the trauma team.

Evaluating the compliance of universal precautions by aeromedical personnel before and after an educational seminar on infectious diseases

STUDY OBJECTIVE

To measure the compliance of an aeromedical crew with universal precautions and demonstrate what effect education has on utilization.

DESIGN

Blinded time-series design.

SETTING

Helicopter emergency medical service.

TYPE OF PARTICIPANTS

Aeromedical crew consisting of flight nurses, respiratory therapists, and doctors.

INTERVENTIONS

A mandatory educational seminar on universal precautions as required by the Centers for Disease Control.

MEASUREMENTS AND MAIN RESULTS

Before the educational seminar the flight crew utilized gloves in 42% of patient contacts and goggles 0% of the time. At that time, masks and gowns were not available. The nurses used gloves in 28/72 (39%) of patients, respiratory therapists in 27/71 (38%) of patients, and doctors in 12/19 (63%) of patients. The overall compliance after the education seminar was 61% for gloves and 0% for goggles. The nurses used gloves in 20/36 (56%) of patients, the respiratory therapist in 23/34 (68%) of patients, and the doctors in 11/16 (69%) of patients.

CONCLUSIONS

The use of gloves and goggles as preventive measures to protect the aeromedical crew from the potential hazards of body fluid contact and transmission of disease during their treatment of patients is low. Compliance increased after an educational seminar on universal precautions but still remained low. Other modalities, such as quality assurance measures, continuing education, policies, and peer pressure, in addition to education, are necessary.

An objective method to measure and manage occult pneumothorax

Of 457 patients with multisystem injuries undergoing abdominal computed tomographic (CT) scan, 26 patients were found to have 31 pneumothoraces. None of these were apparent on prior roentgenograms of the chest. Each pneumothorax was quantified by measuring its maximal width in millimeters and the number of 10 millimeter CT sections on which it appeared. Serial roentgenograms of the chest and patient charts were reviewed. The major factor determining the clinical course and management of these pneumothoraces was size. Seventeen per cent of pneumothoraces measuring less than 5 X 80 millimeters (group 1) and 85 per cent of those measuring greater than or equal to 5 X 80 millimeters (group 2) had tube thoracostomy performed. The percentage of pneumothoraces in each group with positive pressure ventilation was 55 and 77 per cent, respectively. Our results suggest that such occult pneumothoraces may be managed with close observation if they measure less than 5 X 80 millimeters, whether or not the patient is to receive positive pressure ventilation. Larger pneumothoraces and those associated with more than two rib fractures may require early treatment.

The integration of a helicopter emergency medical service in a mass casualty response system

Since 1985, the state of Connecticut has been served by a hospital-based, advanced life support (ALS) helicopter air medical service. The service is stationed at a 1,000-bed, Level 1, trauma center that is responsible for its operation. Connecticut statute requires the hospital to file operations reports with the Office of Emergency Medical Services, which reports to the Connecticut Department of Public Health. Operations include response to requests for transportation of severely ill or injured patients from the scene of an incident, and patient transport from one hospital to a higher level, definitive-care hospital. This service also was charged to develop a disaster response plan to be integrated into the overall state plan for disaster responses. The helicopter disaster response involves all six New England states and three hospital-based emergency medical helicopter programs that operate in the New England states. This approach has allowed for joint planning and multi-agency, simulated drills. The helicopter emergency medical service has responded to 15 simulated emergencies (drills) and seven actual mass casualty incidents from May, 1985 to June, 1989. In Connecticut, the planning process conducted by the Department of Public Health and the Office of State EMS produced a coordinated, multi-jurisdictional, mass-casualty response plan.

Evaluation of liver function tests in screening for intra-abdominal injuries

STUDY OBJECTIVES

To determine the utility of serum glutamic oxaloacetic transaminase (SGOT) and serum glutamic pyruvic transaminase (SGPT) in predicting intra-abdominal injury in blunt trauma patients.

DESIGN

Descriptive review of 309 blunt trauma admissions during study period.

SETTING

A 1,000-bed Level I trauma center in a major metropolitan area.

TYPE OF PARTICIPANTS

Consecutive adult blunt trauma admissions to the trauma service.

INTERVENTIONS

Serum levels of study enzymes were measured at initial evaluation and subsequent hospitalization. Results of all intra-abdominal evaluations were recorded.

MAIN RESULTS

Significantly greater numbers of patients with SGOT and/or SGPT elevated to more than 130 IU/L had associated intra-abdominal injuries as compared with patients with enzyme elevations of less than 130 IU/L (52% versus 8%). All 18 patients with liver injuries had one or both enzymes elevated to more than 130 IU/L. Higher enzyme levels were more frequently associated with liver injury.

CONCLUSIONS

Elevation of serum levels of the study enzymes is a marker for intra-abdominal injury. Levels in excess of 130 IU/L are relative indicators of abdominal computed tomography scan. Levels of less than 130 IU/L are unlikely to be associated with liver injury.

Quality assurance in the Connecticut Helicopter Emergency Medical Service

Quality Assurance (QA) is a vital aspect of the Connecticut Helicopter Emergency Medical Service (HEMS). The program has three components: 1. scene flight audit, 2. random chart audit, and 3. biweekly patient care QA conferences. The scene flight audit identifies patients who, in retrospect, may not have required helicopter transportation. These patients are identified by the following criteria: trauma score greater than 12 and injury severity score less than 16, emergency department deaths, discharged within 24 hours, medical patients. Patient care QA involves review of all flights. A random chart audit is a method of peer review of the written flight record for completeness. The scene flight audit was from 6/85 to 12/87, with 17/107 (16%) in group one, 0/137 (0%) in group two, 5/29 (17%) in group three, and 8/54 (15%) in group four not justified. There were four audit review periods, each with a feedback mechanism to share results with providers. Each audit resulted in a decrease in the number of non-justified flights. There were 57 patient care QA conferences with 231 cases presented. Technical errors and policy issues decreased over time. Random review of five charts/month were reported quarterly. Omitted elements of standard documentation decreased over time. QA can be accomplished in HEMS. Monitored areas should include appropriateness of flights, proper documentation, and patient care review. A QA program improves appropriateness of flights, medical record keeping, and care given.

Interhospital transport audit criteria for helicopter emergency medical services

A quality assurance audit of all interhospital patient transports from 17 June 1985 through 31 December 1989 by Connecticut's critical care helicopter system was performed to determine the number of medically appropriate and justified flights. There were 1,839 transports reviewed using nationally established criteria. Flights not fulfilling any of these criteria (n = 401) were reviewed in detail by a panel consisting of medical and nursing representatives. During this case by case review, additional acceptable criteria for transport were developed. The audit determined that 1,792 (97%) of interhospital transfers were justified for helicopter emergency medical transport. The use of these national criteria along with the proposed additional criteria is recommended to health care personnel in the decision to transport a patient to a tertiary care hospital by air. In addition, these criteria should be prospectively utilized by aeromedical flight programs for quality assurance review of appropriateness of helicopter interhospital requests.

A prospective analysis of a two-year experience using computed tomography as an adjunct for cervical spine clearance

The role of CT scanning as an adjunct to plain roentgenograms of the cervical spine was reviewed in acutely injured blunt trauma patients. Following institution of a protocol to evaluate the cervical spine in all blunt trauma patients, 179 patients underwent CT scanning of their cervical spine. This was performed for patients whose x-ray findings were positive, for patients with plain x-ray films suggestive of a pathologic condition, for patients with plain x-ray films that did not reveal all of the cervical vertebrae, and for patients who had persistent pain or neurologic deficits despite normal plain x-ray films. Of 123 patients not able to have their cervical spine cleared by normal roentgenograms, 93% were cleared within 24 hours of admission based on CT scans. There were no missed injuries in this setting. A false-positive rate of 28% and a false-negative rate of 1.5% were found for plain roentgenograms. Computed tomographic scans detected 98% of the injuries in our study and when combined with a three-view plain x-ray series of the cervical spine, 100% of cervical spine injuries were detected. Computed tomographic scanning as an adjunct to plain x-ray films of the cervical spine is a highly accurate and expedient modality to clear the cervical spine of blunt trauma patients.

Intraperitoneal femoral venous catheter insertion with free blood return in presence of tense hemoperitoneum

The authors report a case of intraperitoneal insertion of a femoral venous catheter, with blood return, in a patient with hemoperitoneum. In such patients, skin puncture at or below the inguinal ligament is important. Aspiration of unusually dark blood and medial catheter location should raise the possibility of intraperitoneal catheter placement.

Roles of a helicopter emergency medical service in mass casualty incidents

The Connecticut helicopter emergency medical service (HEMS) has responded to 12 mass casualty incidents (MCI) in two years. Eight were drills and four were actual events. An MCI response plan was instituted prior to the onset of the HEMS program. All MCIs were reviewed to determine actual victims, knowledge of MCI prior to lift-off, and roles of the HEMS. The actual roles were compared with the pre-established roles. The four actual MCIs (building explosion, hotel fire, bus rollover and plane crash) were reviewed. Sixty-seven victims were involved. Prenotification occurred in one MCI. The roles of the HEMS in each MCI were: triage (n = 4), medical treatment (n = 4), transport (n = 3), augmented response (n = 1), and air surveillance (n = 0). The roles of HEMS response to MCI should be well-defined prior to an event. Air medical benefits include response within a large geographic area, highest level of prehospital medical care, identification of trauma receiving hospitals, and facilitation of transport.

A comparison of ground paramedics and aeromedical treatment of severe blunt trauma patients

This study compared a hospital-based aeromedical program to a ground paramedic service in order to determine whether the element of prehospital time or prehospital care is the major contributor towards improved survival. One hundred twenty-six severe blunt trauma patients were studied. There were 93(73.81%) transported by air and 33(26.19%) transported by ground. Utilizing the TRISS methodology, the air patients had a probability of survival of 2.23 SD better than the national norm, and the ground patients had a -2.69 SD below the national norm. The air patients had a higher percentage of intubated patients (42% vs 3%) and use of PASG(56% vs 30%). There was no significant difference in the prehospital times of either the air or ground services once they had arrived at the scene. Since the scene time of both services is similar, the improved survival of the air patients may be due to the technical intervention procedures performed.

Evaluation of an alcohol education package for non-specialist health care and social workers

A quasi-experimental non-equivalent control group design was used to assess the influence of a two-day experiential alcohol education package for non-specialist health care and social workers. Four pairs of teams took part in the study: general practice; accident and emergency; medicine for the elderly; and social work. The dual foci of the evaluation were agents' knowledge and attitudes, and these were assessed using a modified version of the Alcohol and Alcohol Problems Perception Questionnaire (AAPPQ). For both variables, the one-month follow-up scores of the education teams were significantly higher than those of the comparisons, although the effect was stronger in the case of therapeutic attitudes than knowledge. There were also significant differences in improvement in attitude scores, with significant effects being observed in the general practice, medicine for the elderly and social work teams but not the accident and emergency. At 6 months, the level of fall-off in improvement varied and this, along with the pattern of change evident in the five components which comprise the AAPPQ attitude scale, was examined and discussed in relation to previous research in this field of inquiry.

The impact of emergency medical helicopters on prehospital care

Emergency medical helicopter services have grown exponentially over the past seventeen years. These services offer rapid transport by flight crews to tertiary care centers with a higher level of medical capabilities. An impact because of helicopters on survival has been well-documented for trauma patients. Assessing usage for other critical care patients remains to be delineated further.

Impact of pre-trauma center care on length of stay and hospital charges

The purpose of this paper is to identify factors associated with improved utilization of health care resources in the treatment of patients with injury. A prospective cohort study was conducted of all trauma patients admitted to a trauma center from April 15, 1987 to February 28, 1988. Altogether, 877 patients were entered into the study: 673 (76.7%) scene patients, and 204 (23.3%) interhospital transfers. The mean length of stay (LOS) for scene patients was 12 days, with mean charges of $8,781, whereas the mean LOS of interhospital transfers was 18 days, with mean charges of $16,734. When controlled for confounding variables, the scene patients had significantly shorter LOS and charges than matched interhospital transfers. This difference was more pronounced for the air-transported patients than for ground-transported patients. The elderly utilize more resources than young patients when matched for severity of injury. It is beneficial to the patients and the health care system to have severely injured trauma patients transported directly to a trauma center from the scene of an injury. Helicopter emergency medical services can enhance the ability of a trauma care system to decrease health care costs.

A critical care helicopter system in trauma

Civilian helicopters and emergency medical services in the United States have been in existence for approximately 15 years. The rapid growth of this type of health care delivery coupled with an increasing number of accidents has prompted professional and lay scrutiny of these programs. Although they have a demonstrated history of benefit to patients, the type and severity of injuries to patients who are eligible for helicopter transportation need further definition. The composition of the medical crews and the benefits that particular crew members bring to the patients require ongoing evaluation. Significant questions regarding the number of pilots in a helicopter and in a program remain to be answered. This article reviews the role of emergency medical air transport services in providing care to trauma patients, staff training and evaluation, and safety criteria and offers recommendations to minimize risks to patients and crews.

Airway intubation in injured patients at the scene of an accident

Trauma patients requiring intubation at the scene of the accident were entered into a study from June 1985 to June 1987 to determine: 1) the success rate of intubation by flight crews and 2) factors important in managing the difficult airway at the scene. One hundred thirty-six patients were reviewed. The success rate of trauma patients intubated in the field was 92.6%. The success rate of each procedure was, orotracheal 87%, and nasotracheal 77.6%. Six out of the 10 patients unsuccessfully intubated had vomiting or blood in the oropharynx which was cited as the reason for failure of intubation. All 24 patients requiring medications (paralytics and sedatives) for intubation were successfully intubated. Trismus and combativeness were the indications for medication usage. An aeromedical crew (MD, RN, RT) can successfully intubate trauma patients at the scene of the accident. Severe facial injuries with vomiting and blood in the oropharynx are factors in intubation failure. The use of muscle relaxants and sedatives facilitates difficult intubations.

Incidence, costs, and DRG-based reimbursement for traumatic brain injured patients: a 3-year experience

A 3-year prospective study was conducted to establish the incidence of traumatic brain injury (TBI) and related characteristics of age, sex, length of stay (LOS), intensive care unit LOS (ICU/LOS), direct hospital charges, and reimbursement using a prospective DRG-based reimbursement system. The study identified TBI patients using ICD-9-Codes. The mean LOS for the two groups of patients with intracranial injury differed (p less than 0.05). Those with such an injury accompanied by a fracture stayed 1.8 days less in the ICU and 6.0 days less overall. Direct hospital charges for all TBI patients were $14,138,036 (mean, $11,645). Using Medicare weights and hospital-specific rates/DRG, the DRG reimbursement was $6,689,293. Thirty-day outliers (those who stayed ten times the geometric mean length of stay) provided an additional $526,389 leaving a total non-reimbursable figure of $6,922,354, or 49% of total charges. Of the 71 DRGs assigned to the study population, 15 reimbursed more than the actual charges. The severity of TBI victims and the complexity of caring for them in a Level I trauma center generates hospital charges of which only half are reimbursed through an all-payor DRG system. Strategies to correct what could be a financial disincentive are: documenting the uniqueness of this population to justify additional reimbursement, calculating a more precise mean LOS for TBI-related DRGs to more accurately identify outliers, and calculating DRG rates for TBI diagnoses derived from a representative sample at varying severity levels and hospitalized in facilities with and without rehabilitation services.