Journal of Trauma Nursing最新文献

Background: Unidentified patients pose challenges in emergency care due to missing clinical history and identification, impacting patient safety and decision-making. Despite known risks, little is understood about this group in middle-income countries.

Objective: To describe the epidemiological profile and the clinical, structural, and social challenges that influence the care of unidentified patients in a public teaching hospital.

Methods: This retrospective cohort study was conducted from January 2019 to December 2022 in the emergency department (ED) of a public teaching hospital in Belo Horizonte, Brazil. Data from unidentified patients were extracted from electronic medical records, including demographics, admission reasons, risk classification, clinical management, outcomes, and hospital length of stay. Multivariate logistic regression was used to identify factors associated with adverse outcomes, adjusting for clinical and sociodemographic variables.

Results: Among 2,425 unidentified ED admissions, 332 cases were sampled using a finite population correction formula. Of these, 81.6% were male; median age was 32 years (interquartile range 26-43). Main admission causes were physical assault (39.8%), falls (20.5%), and road traffic collisions (10.8%); 69.9% were triaged as very urgent. Only 29.2% were identified before discharge; time as unidentified ranged from 0 to 411 days (median 1 day). Remaining unidentified beyond one day was strongly associated with adverse outcomes (odds ratio 8.56; 95% confidence interval 5.0-14.6; p < .001).

Conclusion: Delayed identification was associated with adverse outcomes, but causality cannot be inferred. Early identification initiatives should be combined with broader strategies to address underlying risks and ensure continuity of care.

Background: Massive transfusion protocol (MTP) activations at rural Level III trauma centers often face blood delivery delays, limited support, and product waste. While MTPs are well described in higher-level centers, their effectiveness and staff perceptions in rural Level III settings are unclear. Process breakdowns at one such center, including staffing gaps, delivery delays, and product waste, prompted implementation of a targeted MTP response system.

Objective: This project aims to evaluate the effectiveness of an MTP activation response system in a rural Level III trauma center setting.

Methods: This quality improvement project, using a descriptive design with qualitative methods, was conducted at two rural Midwestern, US Level III trauma centers within the same health system from August 1, 2023, to February 1, 2024. The population included all interdisciplinary team members participating in MTP activations. The project's revised MTP activation response system featured centralized dispatcher notifications, new modes of communication, multidisciplinary education, and clarification of team roles and processes. After each activation, project participants received a secure, online, anonymous questionnaire assessing perceived system effectiveness, resource delivery, communication, and documentation. Responses were analyzed using descriptive statistics for quantitative data and narrative analysis for open-ended responses to identify thematic outcomes.

Results: A total of N = 35 team members responded across eight MTP activations using the revised response system, including 16 (46%) nurses, 7 (20%) blood bank staff, 5 (14%) pharmacists, 5 (14%) administrative supervisors, and 2 (6%) physicians. Key barriers included inaccurate paging (50%), communication challenges (62.5%), and rapid infuser issues (50%). Appropriate calcium administration occurred in 87.5% of cases; compliance with documentation was high, with 89% noting unit documentation and 83% order confirmation.

Conclusion: Implementing a structured multidisciplinary MTP response system in rural Level III trauma centers improved resource delivery, team coordination, and documentation, although communication and workflow challenges persisted.

Background: Members of a trauma program in both informal and formal leadership roles are embedded in the foundation of a trauma center. The presence of leadership influence is required across the continuum, with voices that are heard and the ability to act as a change agent. Current research has not explored whether members of a trauma program perceive they have actual leadership influence.

Objective: The purpose of this study was to describe self-assessed leadership influence and identify factors associated with higher and lower self-assessed leadership influence among trauma program professionals.

Methods: This quantitative study used a descriptive, cross-sectional design. A study invitation was sent to membership of the Society of Trauma Nurses on November 20, December 4, and December 18, 2024. Participants were invited to complete a survey that included the Shillam-Clipper Leader Minimum Demographic Data Set and the Leadership Influence Self-Assessment instrument. A two-step cluster procedure was used to categorize participants into two groups. Participants included those aged 18 years or older, able to read English, and working in a trauma program in any role (trauma program manager, trauma medical director, outreach, injury prevention, educators, researchers, registrar, clinical staff, or data analyst).

Results: A total of n = 153 participants were included in the analysis. Demographic data were as follows: 86% were female, mean age was 48 years, and 97% reported a practice background as a registered nurse, clinical nurse specialist, or nurse practitioner. The low self-assessed leadership influence group consisted of 93 participants (61%), and the high self-assessed leadership influence group consisted of 60 participants (39%). Ten items were considered important for determining the separation of participants into the two groups. The most important item in the integrity subscale was "Are you making proactive, currently informed decisions?"

Conclusion: Our findings suggest that the scope of trauma program nurses is vast and arguably of critical importance. Overall, nurses did not perceive a sense of accountability, responsibility for outcomes, autonomous decision-making, and/or financial resource access. More training is needed to support nurses in leading according to their own interests, capacities, and opportunities.

Background: Social determinants of health (SDOH) can impact recovery after traumatic injury, but specific social needs of firearm injury survivors have not been well documented.

Objective: The objective of this study was to document the resources provided to urban firearm injury survivors immediately after hospital discharge, highlighting their outpatient SDOH needs during recovery.

Methods: This was a retrospective cohort review of all firearm injury survivors seen at an outpatient clinic in a Midwestern, U.S. urban Level I trauma center, from November 2020 through October 2022. Patients were evaluated by the clinic's master's-level social worker, who conducted comprehensive biopsychosocial assessments and documented resources provided in routine care notes. The resources provided were abstracted from social work notes and grouped by SDOH domains.

Results: Of the 255 patients evaluated, most were young (32.1 years), Black (80.4%), and male (81.6%); 43.1% sustained severe injuries (Injury Severity Score ≥ 16). Most patients received at least one resource (74.5%). Over half of patients received a financial resource (53.7%), with the most common being Crime Victim Compensation assistance (40.0%). Housing or rent support was also common (22.4%).

Conclusion: Financial and housing assistance are the most frequently needed resources among urban firearm injury survivors. The SDOH assessments by social workers, combined with strong partnerships to provide resources, can help trauma centers promote comprehensive recovery after firearm injury.

Background/rationale: Existing literature on pediatric traumatic brain injury (TBI) transfers to higher-level trauma centers is limited. Most studies focus on inhospital mortality and neurosurgical intervention rates, often overlooking outcomes such as early discharge without neurosurgical intervention, intensive care unit length of stay, and discharge disposition.

Objectives: To assess the impact of transfer to a higher-level trauma center on clinical outcomes of pediatric severe TBI patients.

Methods: This retrospective cohort study used the American College of Surgeons Trauma Quality Improvement Program database between 2017 and 2023 to evaluate pediatric trauma patients with isolated severe TBI transferred from lower-level to higher-level trauma centers. The primary outcome was the odds of discharge within 24 or 48 h without requiring neurosurgical intervention and rates of neurosurgical intervention. Secondary outcomes included emergency department and 24-h mortality, initial and repeat computerized tomography scan rates, intensive care unit length of stay, ventilator-free days, and discharge home.

Results: Of the 4,154 pediatric patients with isolated severe TBI, 1,723 (41.5%) were transferred, and 2,418 (58.2%) were not. Transferred patients had a 42% lower odds of discharge within 24 h without neurosurgical intervention (OR: 0.58, 95% CI [0.41, 0.80], p < .001), were more likely to undergo neurosurgical intervention (OR: 1.26, 95% CI [1.04, 1.53], p = .016), and were more likely to be discharged home (OR: 1.58, 95% CI [1.30, 1.92], p < .001). Mortality rates did not differ significantly between groups.

Conclusion: Transfer to higher-level trauma centers is associated with increased neurosurgical intervention and higher rates of discharge home in pediatric patients with severe TBI, without differences in mortality.

Background: Traumatic brain injury (TBI) is a significant cause of morbidity and mortality in older adults, often necessitating tracheostomy for prolonged ventilation. The optimal timing of tracheostomy in severe TBI remains debated.

Objective: To compare clinical outcomes of early (≤7 days) versus late (>7 days) tracheostomy in older patients with isolated severe TBI.

Methods: This retrospective cohort study utilized the American College of Surgeons Trauma Quality Improvement Participant Use File database from 2017 to 2023 to evaluate clinical outcomes of older trauma patients with isolated severe TBI treated with early (≤7 days) versus late (>7 days) tracheostomy placement.

Results: Of 1,565 older patients with severe TBI, 21.7% received an early tracheostomy and 72.5% a late tracheostomy. Early tracheostomy was associated with significantly shorter intensive care unit length of stay (ICU-LOS) (β= -7.26, 95% CI [-8.95, -5.58], p < .001), more ventilator-free days (β= 4.02, 95% CI [2.75, 5.29], p < .001), fewer ventilator days (β= -6.23, 95% CI [-8.05, -4.41, p < .001), and lower risk of ventilator-associated pneumonia (adjusted odds ratio, aOR = 0.37, 95% CI [0.18, 0.77], p = .008). No significant associations existed between tracheostomy timing and inhospital mortality (aOR = 1.13, 95% CI [0.64, 1.99], p = .670) or remaining complication rates.

Conclusion: Early tracheostomy within 7 days for older patients with severe TBI is a safe management option, with significantly decreased ICU-LOS and ventilation time, improved or comparable complication rates, and no significant increase in mortality rates compared to late tracheostomy.