Trauma Surgery & Acute Care Open最新文献

Abstract:

Background: Financial toxicity refers to financial hardship experienced because of illness or injury. Poverty is a known driver of community violence, but financial toxicity has not been studied in firearm violence survivors. The objective of our study was to explore the financial needs of firearm violence survivors enrolled in a hospital-based violence intervention program (HVIP). We hypothesized that survivors would report numerous financial needs.

Methods: This was a mixed-methods, retrospective study of firearm violence survivors enrolled in the Miami-Dade County HVIP from 2022 to 2023. Patients were eligible for enrollment if they were injured in shooting incidents that occurred in Miami-Dade police districts with high rates of group violence or gang-related violence. Social worker intake and longitudinal case records were reviewed. A qualitative thematic analysis of social worker notes was performed. Quantitative data were analyzed with descriptive statistics and χ² tests for association.

Results: 103 patients were enrolled in the program. The median age was 27 years. The majority of patients were black (82.5%) and male (83.5%). More patients were insured (59.2%) than uninsured (40.8%). Thematic analysis revealed 10 distinct financial needs, including assistance with victim crime compensation (75.7% of patients), medical bills (35.0%), wage loss (22.3%), insurance applications (14.6%), burial (13.6%), and emergency relocation (12.6%). Overall, financial needs were identified for 94 (91.3%) patients: 91 (88.3%) at initial program intake and 3 additional patients (2.9%) during longitudinal case management.

Conclusions: Survivors of firearm violence experience financial challenges after injury. Thus, financial support and assessment for financial toxicity should be included in firearm violence survivorship programs. Future investigations should use validated measures to study the financial toxicity of firearm violence survivors longitudinally.

Objectives: The goal of the current study was to assess the effectiveness of a peer integrated collaborative care intervention for postinjury outcomes.

Methods: Injury survivors ≥18 years of age were screened for post-traumatic stress disorder (PTSD) symptoms and severe postinjury concerns; screen-positive patients were randomized to the intervention versus enhanced usual care control conditions. The collaborative care intervention included peer support and care management. The intervention also included evidence-based pharmacotherapy and psychotherapeutic elements targeting PTSD. The COVID-19 pandemic interrupted recruitment between March and June 2020; in response to the COVID-19 pandemic, the peer component of the intervention went from in-person to virtual delivery. The primary outcomes were PTSD symptoms assessed with the Diagnostic and Statistical Manual of Mental Disorders fourth edition PTSD checklist, any severe postinjury concerns, and emergency department/inpatient utilization followed over the 12 months postinjury. Secondary outcomes included patient satisfaction with emotional healthcare.

Results: A total of 450 patients were randomized to the intervention (n=225) and control (n=225) conditions; 124 patients (28%) were recruited and completed all study assessments prior to the onset of the COVID-19 pandemic, while 326 patients (72%) were recruited after and/or had one or more study follow-ups occur postpandemic onset. Mixed model regression revealed no statistically significant comparisons for any of the primary outcomes. In exploratory models that examined the impact of COVID-19, significantly improved PTSD symptoms were present at 3 months pre-COVID-19 relative to post-COVID-19. Intervention patients consistently demonstrated higher satisfaction with emotional aspects of healthcare (F(5,1652)=2.87, p=0.01).

Conclusions: The intervention demonstrated no significant improvements in primary outcomes in the intent-to-treat sample. The peer integrated collaborative care intervention contributed to higher patient satisfaction with the emotional aspects of healthcare.

Level of evidence: Level II, randomized clinical trial.

Trial registration number: NCT03569878.

Background: Up to 20-40% of survivors of any traumatic injury develop post-traumatic stress disorder (PTSD) or depression after injury. Firearm injury survivors may be at even higher risk for adverse outcomes. We aimed to characterize PTSD and depression risk, pain symptoms, and ongoing functional limitations in firearm injury survivors early after hospital discharge.

Methods: Firearm injury survivors seen in the Trauma Quality of Life (TQOL) outpatient follow-up clinic 1-2 weeks after discharge were invited to participate in a survey assessing both mental and physical health outcomes. The survey included the Brief Pain Inventory (BPI), the Injured Trauma Survivor Screen (ITSS), the Beck Depression Inventory (BDI), the PTSD Checklist for DSM-5 (PCL-5), and the 12-item Short Form Survey Physical Health component (SF-12).

Results: 306 patients were seen in the TQOL Clinic, and 175 responded to the survey. The mean age was 32 years (SD=12), 81% were male, and 79% were black. On the ITSS, 69% and 48% of patients screened risk positive for PTSD and depression, respectively. Patients reported mild depression symptoms with an average BDI score of 14.3 (SD=11.8) and elevated PTSD symptoms with an average PCL-5 score of 43.8 (SD=12.8). Patients with severe BPI scores were more likely to screen positive for depression and PTSD. Respondents scored >2 SD below the US national average on the SF-12 for physical quality of life (M=28.7). 12% of patients were at risk across all four domains of pain, PTSD, depression, and physical function.

Conclusion: Early after discharge, over two-thirds of firearm injury survivors were at risk for the development of PTSD, nearly half were at risk of depression, and physical function was significantly decreased. Trauma centers need to prioritize early, outpatient multidisciplinary care to treat and prevent the development of poor chronic physical and mental health for firearm injury survivors.

Level of evidence: III.

Background: Burnout negatively impacts healthcare professionals' well-being, leading to an increased risk of human errors and patient harm. There are limited assessments of burnout and associated stressors among acute care and trauma surgery teams.

Methods: Acute care and trauma surgery team members at a US academic medical center were administered a survey that included a 2-item Maslach Burnout Inventory and 21 workplace stressors based on the National Academy of Medicine's systems model of clinician burnout and professional well-being. Stressors were summarized and presented to participants in focus groups. Contextual inquiries (CIs) were conducted to gather additional information about key stressors. Qualitative data were used to generate an affinity model, which participants then validated and used to prioritize top stressors. Participants rated stressors by level of impact and level of effort, and improvement recommendations were made based on these results.

Results: 74% (n=14/19) acute care and trauma surgery team members reported high burnout. Key stressors included inadequate staffing, organizational culture, excessive workload, and inefficient workflows. Attending faculty (surgeons) classified the following key priorities for improvement: (i) improve throughput and patient flow, (ii) provide better information technology support, and (iii) improve rewards and support. Non-faculty (advanced practice providers (APPs), nurses, staff) classified the following for improvement: (i) align APP job responsibilities, (ii) improve lack of recognition from leadership, and (iii) robust and consistent APP training.

Conclusions: A contextual design approach to studying burnout using surveys, focus groups, CIs, modeling, and validation and prioritization is a feasible method for identifying key stressors and improvements that may enable more impactful and appropriately targeted interventions. Results indicate high levels of burnout among acute care and trauma surgery team members, requiring prioritized attention to operational and relationship issues necessary to care for patients. Efforts to improve surgery teams' workflows, auxiliary support, compensation, and relationships with leadership may address burnout.

Level of evidence: Level V.

Background: Operative mortality for high-grade liver injury (HGLI) remains 42% to 66%, with near-universal mortality after retrohepatic caval injury. The objective of this study was to evaluate mortality and complications of operative and nonoperative management (OM and NOM) of HGLI at our institution, characterized by a trauma surgery-liver surgery collaborative approach to trauma care.

Methods: This was an observational cohort study of adult patients (age ≥16) with HGLI (The American Association for Surgery of Trauma (AAST) grades IV and V) admitted to an urban level I trauma center from January 2010 to November 2021. Data were obtained from the electronic medical record and state trauma registry. Patients were categorized by management strategy: immediate OM or planned NOM. The primary outcome was 30-day mortality.

Results: Our institution treated 179 patients with HGLI (78% blunt, 22% penetrating); 122 grade IV (68%) and 57 grade V (32%) injuries. All abdominal gunshot wounds and 49% of blunt injuries underwent initial OM; 51% of blunt injuries were managed initially by NOM. Procedures at the initial operation included hepatorrhaphy±packing (66.4%), nonanatomic resection (5.6%), segmentectomy (9.3%), and hepatic lobectomy (7.5%). Thirty-day mortality in the OM group was substantially lower than prior reports (23.4%). Operative mortality attributable to the liver injury was 15.7%. 19.4% of patients failed NOM with one death (1.4%).

Conclusion: We report an operative mortality of 23.4% for HGLI in a trauma care system characterized by a collaborative approach by trauma surgeons and liver surgeons.

Level of evidence: III.