How then shall we change?
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Diffusion of Innovation↗
Biomedical subjects
Steven Shackford
Publications and source records attributed to Steven Shackford.
Workload redistribution: a new approach to the 80-hour workweek.
BACKGROUND: The new Accreditation Council for Graduate Medical Education-mandated 80-hour resident work week has resulted in busy trauma services struggling to meet these strict guidelines, or face loss of accreditation. METHODS: Beginning in July 2003, our Level I trauma service began a policy of direct admission of isolated neurosurgical or orthopedic injuries to the specific subspecialty service after complete evaluation by the trauma service in the emergency department for associated injuries. Complications, missed injuries, delayed diagnoses, and admission rates were compared in two 6-month periods: PRE, before the policy change; and POST, after the new policy had been instituted. Resident work hours were likewise compared over the two time periods. RESULTS: Selected single-system injury admission to subspecialty services resulted in a 15% reduction in admissions to the trauma service. There were no significant differences in the overall complication rate, delayed diagnoses, or missed diagnoses between the PRE and POST time periods. Overall, there was a 9.7% reduction in resident work hours (p = 0.45; analysis of variance) between the PRE and POST periods, which allowed them, on average, to meet the Accreditation Council for Graduate Medical Education 80-hour workweek mandate. CONCLUSION: Direct admission of patients with isolated injuries to subspecialty services is safe and decreases the workload of residents on busy trauma services.
Age Distribution↗
Use of vena cava filters in pediatric trauma patients: data from the National Trauma Data Bank.
BACKGROUND: Placement of vena cava filters (VCFs) in high-risk adult trauma patients is a well-described intervention for prophylaxis against pulmonary embolism (PE). Few data exist regarding the use of VCFs in pediatric trauma. METHODS: We performed a cross-sectional study using the National Trauma Data Bank of the American College of Surgeons. Patients 17 years old or younger were included. Data regarding demographics, injuries, hospitalization, survival, and treating institution were analyzed. The prevalence of deep vein thrombosis (DVT), PE, and VCF placement were calculated. Odds ratios (ORs) for predictors of VCF placement were determined using multivariate logistic regression. RESULTS: There were 116,357 pediatric patients in the National Trauma Data Bank. VCFs were placed in 214 (0.18%) patients. VCF patients had longer mean hospital (23.99 vs. 4.12 days) and intensive care unit stays (13.65 vs. 1.12 days) and more severe injuries (mean Injury Severity Score, 30.89 vs. 9.04) than those without VCFs. Sixty-five patients had DVT, and PE was diagnosed in 28 patients, representing 0.06% and 0.02% of the cohort, respectively. University-associated teaching hospitals placed 72.4% (95% confidence interval, 65.9-78.3%) of VCFs and Level I trauma centers placed 46.3% (95% confidence interval, 39.4-53.2%) of VCFs. In multivariate analysis, significant predictors of VCF use were DVT (OR, 33.13), spinal cord injury (OR, 15.28), probability of survival (OR, 10.52), severe femur fracture (OR, 3.39), increasing age (OR, 1.99), ISS (OR, 1.05), intensive care unit stay (OR, 1.04), and length of stay (OR, 1.02). Higher Glasgow Coma Scale score decreased the likelihood of VCF use (OR, 0.87). CONCLUSION: Placement of VCFs in pediatric trauma patients is uncommon and is associated with several characteristics of the patient, the injury, and the treating institution. Long-term VCF efficacy in pediatric trauma is not known, and application of VCFs in these patients requires further investigation.
Adolescent↗
A needs assessment for regionalization of trauma care in a rural state.
Systems of trauma care in urban areas have a demonstrated survival benefit. Little is known of the benefit of trauma system organization in rural areas. We hypothesized that examination of all trauma deaths during a 1-year period would provide opportunities to improve care in our rural state. We used a medical examiner database of trauma deaths occurring during a 1-year period. Five board-certified surgeons analyzed deaths as preventable (P), potentially preventable (PP), and non-preventable (NP) using modified Delphi technique. There were 223 trauma deaths during a 1-year period. Most (63%) died at the scene prior to any medical intervention. Adjudication of the deaths demonstrated 5 P (2%; 95% CI 1-5%), 36 PP (16%; 95% CI 12-27%), and 179 NP (81%; 95% CI 76-86%). Agreement among trauma surgeons was only moderate with a k of 0.46. Suicide accounted for a significant number of the overall trauma deaths at 32 per cent. Rural trauma system design should focus on discovery, as that is where the majority of deaths occur. Suicide is a significant problem in this rural state that should be aggressively targeted with prevention programs.
Female↗