Trauma Surgery & Acute Care Open最新文献

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.

Abstract:

Background: Trauma video review (TVR) is an evolving technology that can be used to measure technical and non-technical aspects of trauma care leading to meaningful improvements. Only 30% of centers currently use TVR, with non-users citing medicolegal concerns, staff discomfort with recording, and resource constraints as barriers to implementation. Multiple studies have shown established TVR programs are well-perceived by staff. Little is known about perceptions prior to, and after implementation of a new program.

Objective: This study evaluated changes in TVR perceptions following implementation of a new program.

Methods: A 15-question survey was distributed to emergency department and trauma surgery providers at a level I trauma center prior to, and 1 year after, implementation of TVR. A 5-point Likert scale was used to evaluate perceptions of the value of TVR, measures of team dynamics, and staff discomfort with recording.

Results: A total of 106 pre-implementation and 82 post-implementation responses were recorded. Perceptions in several domains improved post-implementation including team leader effectiveness (3 (3-4) to 4 (3-4); p=0.002), communication (3 (3-4) to 4 (3-4); p<0.001), and self confidence in role (4 (3-4) to 4 (4-5); p=0.001). Staff discomfort with recording decreased post-implementation (3 (2-4) to 2 (2-3); p=0.002).

Conclusion: Our study shows that perceptions of TVR changed favorably after implementation, particularly perceptions of team dynamics and provider discomfort with recording. These results can be used to mitigate staff concerns about TVR and encourage the development of new programs.

Level of evidence: IV.

Summary:

Introduction: In critical care, there is often a lack of understanding regarding patient preferences toward end-of-life care. Goals of care discussions are poorly defined and inhibited by clinician apprehension, prognostic uncertainty, and discomfort from both sides. In the delivery of bad news, protocol-based discussions have proven beneficial, yet no such protocol exists for goals of care discussions in the intensive care unit (ICU). We therefore assembled a multidisciplinary team to define a specific protocol dedicated to leading goals of care discussions in the ICU setting.

Safe-goals protocol: S: set upA: acknowledgmentF: family understandingE: events of hospital courseG: get to know the patientO: optionsAL: active listening and discussionS: steps going forward.

Conclusion: This protocol provides a framework for leading goals of care conversations in the ICU. Specific training should be incorporated and better emphasized in the modern medical education.

The Trauma Survivors Network (TSN), a program of the American Trauma Society (ATS), has a unique history spanning decades with a vision to continue expanding and strengthening services to support survivors and families impacted by traumatic injury. Since the COVID-19 pandemic, the ATS has adapted TSN services to provide both virtual and in-person services for trauma survivors, increasing equity and inclusion for many survivors to access TSN services for the first time. The recent policy changes in the American College of Surgeons Committee on Trauma New Standards for Care of the Injured Patient provide an impetus for the TSN to grow and expand services in support of a diverse group of trauma survivors and their loved ones. This paper highlights the collateral impact of traumatic injury, the history and ongoing growth of the TSN and its services to date, the challenges encountered in establishing and maintaining the TSN program, and the equity and inclusion that the TSN offers internationally to support a diverse range of survivors with various forms of trauma and polytrauma.

Background: Patients with cervical spinal cord injuries (CSCIs) have a high incidence of respiratory complications. The effectiveness of non-invasive positive pressure ventilation (NPPV) in preventing respiratory complications such as pneumonia in acute CSCIs remains unclear. We evaluated whether intermittent NPPV (iNPPV) could prevent pneumonia in patients with acute CSCIs.

Methods: This single-center, retrospective study evaluated patients diagnosed with CSCIs with American Spinal Injury Association Impairment Scale scores of A-C between January 2012 and December 2022. Patients were categorized based on receipt of iNPPV into the iNPPV and usual care groups. Prophylactic iNPPV was defined as the initiation of iNPPV within 72 hours of admission. The primary outcome was the development of pneumonia. The secondary outcomes were other respiratory complications (tracheal intubation and tracheostomy) and adverse events (delirium and vomiting). The groups were compared with regard to outcomes after adjustment for patient backgrounds using inverse probability of treatment weighting (IPTW) with propensity scores.

Results: Of the 213 patients during the study period, 94 were included. Of these, 61 (64.9%) received prophylactic iNPPV. The incidence of pneumonia was 27.9% in the iNPPV group and 48.5% in the usual care group in the unadjusted cohort. In the propensity score analysis using IPTW, the iNPPV group showed a lower incidence of pneumonia than the usual care group (29.0% vs 56.5%, p<0.001). Tracheal intubation and tracheostomy were less common in the iNPPV group than those in the usual care group (10.6% vs 29%; p=0.001 and 10.6% vs 27.1%; p=0.003, respectively). The incidences of delirium and vomiting did not increase in the iNPPV group.

Conclusions: Prophylactic iNPPV was associated with a lower incidence of pneumonia in patients with acute CSCIs.

Level of evidence: Ⅳ.