Trauma Surgery & Acute Care Open最新文献

Introduction: Developing and implementing trauma clinical guidance is integral to providing quality care to all trauma patients while maintaining a minimum standard of treatment. A mixed-methods novel consensus-building approach was used to identify the current barriers to developing and implementing trauma clinical guidance and highlight the priority areas for change to better support end users.

Methods: As part of year 1 of the Design for Implementation: The Future of Trauma Clinical Guidance and Research Conference Series, preconference participant surveys and hybrid, professionally facilitated, structured dialogue were used to define the ideal future state of trauma clinical guidance development and dissemination. Novel to this context, in-person and virtual "user stories", a form of structured focus group, were generated, and a "minimum viable product" (MVP), a form of brokered dialogue, was developed. Descriptive statistics and thematic analysis were used to evaluate preconference survey and "user story" results.

Results: 72 in-person and up to 35 virtual attendees participated. The majority (92%) of in-person attendees and nearly half (48%) of virtual attendees completed the preconference survey. Participants identified barriers along the continuum of clinical guidance development, dissemination, and adoption. Areas for improvement centered around the creation, storage, and use of guidance. Across the survey and user stories, participants expressed the need for clinical guidance that is comprehensive, evidence-based, coordinated, and easily accessible by all clinicians both domestically and abroad. The MVP targeted the risks and objectives to improved guidance. A prominent theme throughout this consensus-building assessment was the imperative for collaboration between professional societies for clinical guidance development and dissemination.

Discussion: Trauma clinical guidance must be current, consolidated, and coordinated with patient-centered outcomes prioritized. Next steps include turning the MVP produced into a prototype and refining it to inform a national redesign of trauma clinical guidance.

Level of evidence: Level III.

Acute extremity compartment syndrome (CS) is a serious medical complication triggered by factors such as trauma, vascular injury, or prolonged compression, resulting in elevated intracompartmental pressure (ICP) and tissue ischemia. Diagnosis remains challenging, mainly relying on the subjective evaluation of clinical symptoms. Different animal models have been used to study pathophysiology and evaluate diagnostic and therapeutic approaches. The aim of this review is to summarize and compare different animal CS models to provide insight for the development of more authentic and clinically relevant CS model. A comprehensive search of two databases was conducted. English-language animal studies focusing on CS were included. Human studies, non-acute extremity CS, and review papers were excluded. Data extraction and analysis focused on animal species, CS models, and clinically relevant assessment methods of CS. After screening, 90 studies met the inclusion criteria. Small animal (n=36, 40%) and canine models (n=31, 34.4%) were the most used animal species. A fluid infusion model (n=48, 53.3%) was the predominant induction method, followed by the ischemia-reperfusion (n=29, 32.2%) and the internal/external mechanical pressure models. Five studies used a combination CS model to achieve a more comprehensive representation of the clinical pathophysiology. Various diagnostic modalities were employed; ICP measurement (n=74, 82.2%) and evaluation of tissue oxygenation (n=10, 11.1%) were the most frequent device-based assessments. Biomarkers assessing muscle cell damage (n=15, 16.7%), antioxidant status (n=18, 20%) and inflammation (n=16, 17.8%) were analyzed as well as physical examination (n=12, 13.3%) and neuromuscular testing (n=10, 11.1%). There are a variety of validated animal species models, which can be considered depending on the research objectives. This review helps researchers evaluate model strengths and drawbacks before deciding on an experimental design.

Introduction: Trauma clinical guidance (guidelines, protocols, algorithms, etc) has been shown to improve patient outcomes; however, it is only used in about half of the patients to whom it applies. Guidance implementation is affected by intrinsic factors (eg, guidance format) as well as extrinsic factors (eg, the clinical environment). Recommendations and frameworks have been created to aid in the development of implementable guidance. We hypothesize that existing trauma clinical guidance lacks elements important for implementation.

Methods: The Framework for Guideline Implementability by Gagliardi, which consists of 22 elements arranged into eight domains, was used to evaluate trauma clinical guidance. A sample of 20 pieces of guidance, crafted by 11 professional organizations, were reviewed. Data were extracted to identify the presence or absence of each implementability element.

Results: All guidance provided a clear objective and 85% allowed for individualized application of recommendations based on clinical scenario. Approximately half of the guidance included formatting elements, such as graphic aids, to enhance usability, and 50% incorporated formal evidence grading. Patient-friendly tools accompanied 10% of guidance, and few discussed implementation strategies (25%) or quality metrics (30%) to evaluate guidance implementation.

Discussion: Clinical guidance exists on a spectrum, from narrative (eg, written documents) to executable tools (eg, automated decision support based on patient context). While integration of computable guidance into clinical workflows may be the ultimate goal in high-resource settings, there are other more feasible and even cost-free modifications developers may integrate into new guidance to improve implementation across settings.

Conclusion: Utilization of trauma clinical guidance is crucial for improving healthcare quality. To achieve this, guidance developers might leverage the elements in the new TRAUMA (Transparency, Robust inclusivity, Adaptability, Usability, Measurability, Accessibility) framework that enhance implementability. Future research is needed to validate this theoretical new framework's impact on clinical implementation and patient outcomes.

Level of evidence: IV.