Trauma Surgery & Acute Care Open最新文献

When we think about leadership in trauma and acute care surgery, we are often reminded of the direct impact we can have beyond immediate patient care. Leadership is not just about making decisions; it's about fostering growth within our institutions, among our colleagues and beyond the four walls of our centers. Importantly, leadership and its influence extend throughout the hospital and impact our trainees, mentees, colleagues, and peers alike. As guest speakers at the 2024 American Association for the Surgery of Trauma Annual Meeting Lunch Session entitled "Directorships, Leadership Roles, and Taking the Lead: Everything I Wish I Knew", KB, JWS and DMS all shared their journeys and thoughts on the complexities, hardships, and rewards of leadership in their roles as clinicians, educators, researchers, and surgeon administrators. This work represents a summary of the lunch panel and provides insights for surgeons seeking to navigate similar paths in academic surgical leadership.

Background: Culturally responsive care is a core recommendation to reduce health disparities. Language barriers contribute to misunderstandings, dissatisfaction, and worse outcomes. This is exacerbated in trauma when communication is constrained by time, complexity, and competing priorities. We hypothesized that Spanish-speaking trauma patients (SSP) would have less accurate comprehension of care (CC) and discharge instructions compared with English-speaking patients (ENG).

Methods: We retrospectively reviewed discharges from a level 1 trauma center (October 2021 to March 2022) who were aged ≥18, primarily ENG or SSP, discharge Glasgow Coma Scale score ≥14, and without memory loss. Patients were surveyed <48 hours from discharge to assess CC. Patients self-rated CC on a Likert scale and answered open-ended questions on CC and discharge instructions. Charts were reviewed to assess and rate concordance of CC with actual care and ENG and SSP cohorts compared.

Results: We included 46 patients (21 SSP, 25 ENG). Mean age was 48.3 years SSP, 43.3 years ENG; 47% SSP were female versus 32% ENG (p=0.28). 56% SSP had ≥high school diploma versus 72% ENG (p=0.34). Self-rated CC was similar, with both groups rating high understanding of their care and follow-up. SSP were less likely to accurately report diagnoses, home medications, and follow-up appointments than ENG. When corrected for health literacy, differences remained between groups in accuracy of diagnoses despite having high confidence in their CC.

Conclusions: Though both SSP and ENG self-rated their comprehension of their care highly, there were significant differences between groups' accuracy. Increased use of certified medical interpreters throughout hospitalization may improve language disparities in patient comprehension.

Level of evidence: Therapeutic/care management, level IV.

Background: Traumatic brain injury (TBI) remains a major healthcare burden, especially among older adults. Existing triage protocols, such as the Brain Injury Guidelines, may not be universally applicable due to institutional and implementation barriers. We evaluated the impact of a novel, evidence-based TBI triage tool-developed by a multidisciplinary team using high-risk and low-risk criteria-on hospital resource utilization at a high-volume Level 1 trauma center. The triage tool stratified patients into high-risk or low-risk pathways based on age, clinical criteria, and radiographic findings. We hypothesized that implementation would reduce intensive care unit (ICU) patient days and repeat head CT scans.

Methods: We conducted a retrospective pre-post implementation study at an American College of Surgeons-verified Level 1 trauma center. The pre-implementation group included patients retrospectively categorized as low-risk from January to November 2021. The post implementation group included patients prospectively triaged as low-risk from January 2023 to June 2024. The triage tool was created through consensus from all relevant clinical stakeholders. Patient demographics, clinical outcomes, and hospital resource use were compared using Fisher's exact test, χ², and Mann-Whitney U tests.

Results: A total of 145 patients were included (62 pre-implementation, 83 post implementation). Groups were well matched by demographics and clinical factors. Post implementation, 188 ICU-patient-days were projected to be saved, and ICU length of stay was significantly reduced (median (IQR): 1 (0-2) vs 0 (0-0) days; p<0.001). 38 repeat CT head scans were avoided, with overall scan frequency reduced (median (IQR): 2 (2-2) vs 2 (1-2); p<0.001). There were no neurosurgical interventions, in-hospital deaths, or 30-day readmissions in either group.

Conclusion: Implementation of a multidisciplinary, risk-based TBI triage tool significantly reduced unnecessary ICU stays and repeat head CTs without observed adverse patient outcomes in the low-risk cohort. This approach represents a scalable, value-based model for improving TBI care and optimizing resource utilization.

Level of evidence: Level III.

Introduction: In trauma care, there is a need to increase communication to ensure evidence-informed, best practice care guidelines are easily accessible to all providers to yield consistency of care. Clinical guidance use is one way to address this need while employing a patient-centered team approach.

Methods: During year 2 of the Design for Implementation: The Future of Trauma Research & Clinical Guidance conference series, participants gathered in person and virtually to further develop the minimum viable product (MVP) created during year 1. Professional facilitators used the purpose-to-practice framework to help structure and guide further consensus building.

Results: 70 in-person and up to 65 virtual attendees participated. 65 responses were collected on the MVP reflection and initial feedback survey. Themes were developed surrounding the pillars of 'Purpose', 'Principles', 'Participants', and 'Practices' while looking at the 'Structure' for 'Sustainability'. The 'Purpose' pillar addressed the importance of rigorous, standardized implementation guidance. 'Principles' exemplified the necessity of a collaborative approach and included all relevant stakeholders. Similarly, the central theme emphasized by the 'Participants' pillar was the inclusiveness of all members of the trauma team. 'Practices' dove into the deliverables of the initiative, including up-to-date decision-making support and logistics regarding guidance storage, management, and maintenance. Regarding 'Structure', the most highly ranked idea was developing a steering committee whose purpose would be primarily to prioritize strategic initiatives.

Discussion: Clinical guidance needs to be current and readily available to all providers. The next steps of this initiative include developing a steering committee and subcommittees to sustain momentum.

Level of evidence: VII.

The second Design for Implementation (DFI): The Future of Trauma Research and Clinical Guidance Conference gathered experts from diverse sectors to advance trauma clinical guidance design and implementation. Building on the previous year's minimum viable product, this conference progressed from conceptualization to design phase, focusing on creating scalable, sustainable solutions for trauma clinical guidance. Participants explored innovative approaches addressing critical challenges in trauma care, including interorganizational collaboration, resource-adaptable guidance, and patient-centered design. The conference highlighted the integration of artificial intelligence (AI) to enhance guidance development and maintain clinical expertise and ethical standards. A key advancement was the refinement of a central repository containing 258 guidance documents in the form of an app with improved accessibility features. Discussions emphasized the importance of implementation science principles, advocating for leadership engagement, maintaining academic recognition for guidance contributions, and continuous outcome tracking. The proposed 12-step guidance development process integrates AI capabilities and preserving clinician expertise. Patient voices and lived experiences were emphasized as essential elements in developing trauma-informed systems, with powerful testimonials from trauma survivors illustrating the critical need for comprehensive support services. Participants agreed that practical guidance must be contextually relevant, properly vetted, and integrate seamlessly with electronic health records. The conference concluded with plans to secure sustainable funding, formalize partnerships, and engage broader communities. The DFI series will continue in February 2026, focusing on testing and implementing innovative solutions to advance trauma care and improve patient outcomes.

Introduction: Forward military field hospitals often operate in battle zone environments where access to specialized personnel, such as radiologists, is limited, complicating the accuracy of diagnostic imaging. Chest radiographs are crucial for assessing thoracic injuries and other conditions, but their interpretation frequently falls to non-radiologist personnel. This study evaluates the effectiveness of an artificial intelligence (AI)-assisted model in enhancing the diagnostic accuracy of chest radiographs in such resource-limited settings.

Methods: Nine board-certified military physicians from various non-radiology specialties interpreted 159 anonymized chest radiographs, both with and without the support of AI. The AI model, INSIGHT CXR, generated automated descriptions for 80 radiographs, whereas 79 were interpreted without AI support. A linear mixed-effects model was used to assess the difference in diagnostic accuracy between the two conditions. Secondary analyses examined the effects of radiograph type and physician specialty on diagnostic performance.

Results: AI support increased mean diagnostic accuracy by 9.4% (p<0.001) from pretest to post-test, representing a 23.15% relative improvement. This improvement was consistent across both normal and abnormal findings, with no significant differences observed based on radiograph type or physician specialty. These findings suggest that AI tools can serve as effective support in field hospitals, improving diagnostic precision and decision-making in the absence of radiologists.

Conclusions: This study highlights the potential for AI-assisted radiograph interpretation to enhance diagnostic accuracy in military field hospitals. If AI tools are proven reliable, they could be integrated into the workflow of forward field hospitals, improving the quality of care for injured personnel. Immediate benefits may include faster diagnoses, increased personnel readiness, optimized performance, and cost savings, leading to better outcomes in combat operations.

Level of evidence: II. Diagnostic Test.

Objectives: Patients with traumatic intracranial hemorrhage (ICH) often undergo early stability CT scans to evaluate for progression of bleeding. The factors associated with progression after initiating venous thromboembolism (VTE) chemoprophylaxis (CP) remain poorly described. This study aimed to determine the rate of and factors associated with ICH progression following CP initiation.

Methods: This retrospective observational study included adult (≥16 years) polytrauma patients with blunt or penetrating traumatic brain injury (TBI) admitted between September 2016 and December 2021. Progression was defined as a radiographic increase in ICH following VTE CP initiation, determined by neurosurgery or radiology faculty. Postprophylaxis CT scans were obtained based on clinical deterioration. Associated factors, neurosurgical intervention rates, and outcomes were evaluated.

Results: Among 1390 included patients, ICH progression occurred in 3% (43) following CP initiation. Patients with progression were older (55 vs 45 years) and had higher injury severity scores (33 vs 27; p<0.05). Rates of pneumonia (49% vs 21%) and sepsis (19% vs 9%) were higher in the progression group (p<0.05). There was no difference between groups in time to prophylaxis initiation (40 vs 38 hours), survival (88% vs 92%), or VTE incidence (0% vs 4%; all p=NS). Factors associated with progression included midline shift (21% vs 6%), subdural hematoma (47% vs 26%), and prior progression on 6-hour stability CT (64% vs 34%; p<0.05). Multivariate analysis confirmed these findings. Among progression patients, 9% required intervention after CP, with only two requiring craniotomy.

Conclusions: ICH progression is rare (3%) after VTE CP initiation. Associated factors align with spontaneous progression, suggesting that ICH progression is independent of early VTE prophylaxis (<48 hours). These findings support the safety of early VTE CP as the standard of care for mitigating VTE risk in TBI patients with TBI.

Level of evidence: Level III, retrospective study with up to two negative criteria.