Trauma Surgery & Acute Care Open最新文献

Background: Optimal provider-to-patient (PtP) ratios in acute care surgery (ACS) remain undefined despite their importance for care quality and provider sustainability. This study aimed to understand surgeon perspectives on maximum ideal ratios across trauma, emergency general surgery (EGS) and surgical intensive care unit (SICU) services.

Methods: This multicenter mixed-methods study combined quantitative surveys and semistructured interviews with ACS surgeons at level I/II trauma centers across the USA (1 August 2023-19 April 2024). Service line census data were also collected. Interviews were recorded, transcribed and qualitative analysis performed; surveys were analyzed with descriptive statistics.

Results: Fifty-two interviews were completed. Survey response rate was 50.3% (212/421 eligible division leadership and faculty) from 40 centers across 24 states. The perceived maximum safe patient load for trauma and EGS was <20 patients when working independently, and up to 40 patients with full team support. SICU ratios were lower with most reporting ≤10 patients for independent coverage and ≤20 with team support. Regarding appropriate patient loads for junior residents and advanced practice providers, most respondents recommended ≤10 patients for trauma/EGS and ≤7 for SICU. For senior residents, most recommended ≤13 patients for trauma/EGS and ≤7 for SICU. Notably, 72% of centers exceeded their own leadership-recommended maximums for at least one service line. Qualitative analysis revealed patient acuity, team experience and competing demands as key workload modulators, with concerns about care quality degradation and burnout at higher ratios.

Conclusions: This study establishes potential upper threshold benchmarks for ACS PtP ratios with strong agreement across institutions. Division leadership should consider developing staffing models that account for patient acuity and service complexity while implementing escalation protocols for sustained high workloads. Current practices frequently exceed maximum ideal ratios, highlighting the need for evidence-based staffing guidelines that balance financial constraints with mounting evidence linking workload intensity and density to adverse outcomes.

Level of evidence: IV.

Introduction: The role of resuscitative endovascular balloon occlusion of the aorta (REBOA) in trauma is debated. We hypothesized that the use of REBOA for patients presenting in shock after penetrating abdominal trauma is associated with delay to laparotomy and increased mortality.

Study design: We used 2017-2021 Trauma Quality Improvement Project data to identify adult (≥16 years) penetrating abdominal trauma patients with systolic blood pressure (SBP) ≤90 mm Hg undergoing laparotomy. REBOA was defined by International Classification of Diseases-10 code, with a procedure timestamp preceding or simultaneous to laparotomy incision. We propensity score matched REBOA to non-REBOA patients on demographics, mechanism, injury characteristics and severity, solid organ injury, abdominal vascular injury, SBP, heart rate, and Glasgow Coma Scale motor score. Outcomes were time to incision, transfusion requirements, complications, and in-hospital mortality. We additionally performed a survival analysis stratified by presenting SBP.

Results: There were 148 REBOA patients with complete data for matching to 280 non-REBOA patients. Among patients with REBOA timestamps preceding laparotomy incision, there was a delay to laparotomy (time to incision 40 (31-50) vs 31 (24-43) min, p=0.001). Overall, REBOA was associated with increased transfusion volume (median (IQR) packed red blood cells 5,125 (2,100-9,100) vs 2,925 (1,250-5,500) ccs in the first 4 hours, p<0.001), leg amputations (3.4% vs 0.4%, p=0.010), and mortality (53.4% vs 42.5%, p=0.032). The mortality relationship persisted on 30-day survival analysis.

Conclusion: REBOA for patients in shock after penetrating abdominal trauma is associated with delay to operation, greater transfusion requirement, leg amputation, and mortality. Our data support the need for expeditious definitive hemorrhage control in these patients.

Level of evidence: III, retrospective cohort.

Objective: To analyze whether outpatient opioid and non-opioid analgesic prescribing after traumatic brain injury (TBI) admission has varied over time among commercially insured patients in the USA.

Setting: 2016-2022 Merative MarketScan commercial claims.

Participants: Commercially insured, opioid-naïve adults aged 18-64 hospitalized for TBI and/or long bone fracture (LBF).

Design: Retrospective observational study.

Main measures: We identified patients filling an opioid, benzodiazepine, muscle relaxant, gabapentinoid or non-steroidal anti-inflammatory drug within 30 days of discharge by injury type (TBI, LBF, both). We calculated the difference in prescription prevalence from 2016 to 2022 among patients with TBI compared with the difference among patients with LBF to estimate the change in prescribing practices over time and then used modified Poisson regression to adjust for confounders.

Results: We identified 15,928 patients with TBI only (39.4%), 22,912 patients with LBF (56.6%) and 1,615 patients with both TBI and LBF (4.0%). The proportion of patients filling an opioid was 45.4% after TBI, 75.4% after LBF only and 72.3% after both TBI/LBF. Among all patients, opioid fulfillments were lower in 2022 compared with 2016 (54.6% vs 69.9%; adjusted relative risk (aRR) 0.79 (95% CI 0.77 to 0.82)). Patients with all injury types observed a decrease in opioid prescribing (TBI/LBF: -19.0% (95% CI -27.5% to -10.6%); TBI only: -17.2% (95% CI -20.2% to -14.2%); LBF only: -13.7% (95% CI -15.8% to -11.5%)). Gabapentin use increased from 2016 to 2022 (6.8% vs 19.3%; aRR 2.80 (95% CI 2.52 to 3.11)) whereas muscle relaxant use did not change (14.5% vs 13.5%; aRR 0.93 (95% CI 0.85 to 1.02)).

Conclusion: Opioids remain a significant component of postdischarge pain management for hospitalized patients with TBI, with and without LBF, although the prevalence of opioid prescription has declined.

Level of evidence: Level III.