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BackgroundVenous thromboembolism (VTE) is a common morbidity in trauma patients. Standard VTE chemoprophylaxis is often inadequate. We hypothesized that weight-based dosing would result in appropriate prophylaxis more reliably than fixed dosing.MethodsAll patients admitted to a Level 1 trauma center over a 6-month period were included unless contra-indications for VTE prophylaxis existed. A prospective adjusted-dosing group was compared to a retrospective uniform-dosing group. The adjusted-dosing approach consisted of initial weight-based dosing of 0.5 mg/kg subcutaneously (subQ) every 12 h (q12h). Peak anti-factor Xa was measured. Patients outside of the prophylactic range had their dose adjusted by ± 10 mg. The uniform-dosing group received 30 mg subQ q12h, without adjustments.ResultsEighty-four patients were included: 44 in the retrospective control cohort and 40 in the prospective experimental cohort. More patients were sub-prophylactically dosed in the uniform-dosing group relative to the adjusted-dosing group (25% vs 5%, p = 0.03). There was no difference in overall prophylactic range targeting, because the supra-prophylactically dosed patients in the adjusted-dosing group eliminated the effect (p = 0.173). However, after a single dose adjustment, zero patients were outside of prophylactic range (25% versus 0%, RR = infinite, p = 0.003). In the uniform-dosing group, anti-Xa level correlated with body surface area (BSA; R2 = 0.33, p < 0.0001) and weight (R2 = 0.26, p = 0.0005). Weight-based dosing both pre- and post-readjustment normalized the correlation of anti-Xa with BSA (R2 = 0.07, p = 0.1) and weight (R2 = 0.07, p = 0.1).ConclusionsWeight-based VTE prophylaxis with anti-Xa-based dose adjustment improves prophylactic range targeting relative to uniform dosing and eliminates variances secondary to BSA and weight in trauma patients.

IntroductionPoor communication about serious injury in older adults can lead to treatment that is inconsistent with patient preferences, create conflict and strain healthcare resources. We developed a communication intervention called Best Case/Worst Case-intensive care unit (ICU) that uses daily scenario planning, that is, a narrative description of plausible futures, to support prognostication and facilitate dialogue among patients, their families and the trauma ICU team. This article describes a protocol for a multisite, randomised, stepped-wedge study to test the effectiveness of the intervention on the quality of communication (QOC) in the ICU.Methods and analysisWe will follow all patients aged 50 and older admitted to the trauma ICU for 3 or more days after a serious injury at eight high-volume level 1 trauma centres. We aim to survey one family or ‘like family’ member per eligible patient 5–7 days following their loved ones’ admission and clinicians providing care in the trauma ICU. Using a stepped-wedge design, we will use permuted block randomisation to assign the timing for each site to begin implementation of the intervention and routine use of the Best Case/Worst Case-ICU tool. We will use a linear mixed-effects model to test the effect of the tool on family-reported QOC (using the QOC scale) as compared with usual care. Secondary outcomes include the effect of the tool on reducing clinician moral distress (using the Measure of Moral Distress for Healthcare Professionals scale) and patients’ length of stay in the ICU.Ethics and disseminationInstitutional review board (IRB) approval was granted at the University of Wisconsin, and all study sites ceded review to the primary IRB. We plan to report results in peer-reviewed publications and national meetings.Trial registration number NCT05780918.

In a randomized trial comparing antibiotic therapy with appendectomy in patients with appendicitis, antibiotics were noninferior on the basis of EQ-5D scores. In the antibiotics group, nearly 3 in 10 participants had undergone appendectomy by 90 days, and complications were more common, especially in those with an appendicolith.

We conducted individual and ecologic analyses of prospectively collected data from 839 injured bicyclists who collided with motorized vehicles and presented to Bellevue Hospital, an urban Level-1 trauma center in New York City, from December 2008 to August 2014. Variables included demographics, scene information, rider behaviors, bicycle route availability, and whether the collision occurred before the road segment was converted to a bicycle route. We used negative binomial modeling to assess the risk of injury occurrence following bicycle path or lane implementation. We dichotomized U.S. National Trauma Data Bank Injury Severity Scores (ISS) into none/mild (0–8) versus moderate, severe, or critical (>8) and used adjusted multivariable logistic regression to model the association of ISS with collision proximity to sharrows (i.e., bicycle lanes designated for sharing with cars), painted bicycle lanes, or physically protected paths. Negative binomial modeling of monthly counts, while adjusting for pedestrian activity, revealed that physically protected paths were associated with 23% fewer injuries. Painted bicycle lanes reduced injury risk by nearly 90% (IDR 0.09, 95% CI 0.02–0.33). Holding all else equal, compared to no bicycle route, a bicycle injury nearby sharrows was nearly twice as likely to be moderate, severe, or critical (adjusted odds ratio 1.94; 95% confidence interval (CI) 0.91–4.15). Painted bicycle lanes and physically protected paths were 1.52 (95% CI 0.85–2.71) and 1.66 (95% CI 0.85–3.22) times as likely to be associated with more than mild injury respectively.

In this randomized trial comparing antibiotic treatment with appendectomy in patients with appendicitis, the percentage of patients in the antibiotics group who later underwent appendectomy was 40% at 1 year and 46% at 2 years and was higher in patients with an appendicolith. Videos present information on treatment options for use in shared decision making between clinicians and patients.

Thromboelastography (TEG) may have a role in managing injured patients on pre-existing anticoagulant/antiplatelet agents. This was a prospective observational study involving elderly trauma patients who were on pre-existing anticoagulant/antiplatelet agents. The correlation between conventional coagulation tests (CCTs), platelet function analysis (PFA) and TEG values was examined. The sensitivity and specificity of these tests in identifying hemorrhage progression were calculated. 109 patients were included. INR and PTT correlated positively with TEG Reaction-time (r = 0.377, p < 0.001, r = 0.552, p < 0.001, respectively). The correlations of both TEG maximum amplitude and α-angle with PFA were equal (r = −0.3, p = 0.05). TEG had a higher specificity (86.1%) in identifying hemorrhage progression compared with CCTs (72.8%) and PFA (59.6%) but this relationship was not statistically significant. TEG correlates positively with INR and PTT and has greater, but non-significant, specificity in identifying hemorrhage progression as compared to CCTs/PFA. •INR and PTT correlate positively with thromboelastography R-time in elderly trauma patients on pre-existing blood thinning medications.•Compared to conventional coagulation tests, thromboelastography has a greater, but non-significant, specificity in identifying hemorrhage progression in elderly trauma patients on pre-existing blood thinning medications.

Objectives. We determined the demographic characteristics, behaviors, injuries, and outcomes of commercial bicyclists who were injured while navigating New York City’s (NYC’s) central business district. Methods. Our study involved a secondary analysis of prospectively collected data from a level 1 regional trauma center in 2008 to 2014 of bicyclists struck by motor vehicles. We performed univariable and multivariable logistic regression analyses. Results. Of 819 injured bicyclists, 284 (34.7%) were working. Commercial bicyclists included 24.4% to 45.1% of injured bicyclists annually. Injured commercial bicyclists were more likely Latino (56.7%; 95% confidence interval [CI] = 50.7, 62.8 vs 22.7%; 95% CI = 19.2, 26.5). Commercial bicyclists were less likely to be distracted by electronic devices (5.0%; 95% CI = 2.7, 8.2 vs 12.7%; 95% CI = 9.9, 15.9) or to have consumed alcohol (0.7%; 95% CI = 0.9, 2.5 vs 9.5%; 95% CI = 7.2, 12.3). Commercial and noncommercial bicyclists did not differ in helmet use (38.4%; 95% CI = 32.7, 44.4 vs 30.8%; 95% CI = 26.9, 34.9). Injury severity scores were less severe in commercial bicyclists (odds ratio = 0.412; 95% CI = 0.235, 0.723). Conclusions. Commercial bicyclists represent a unique cohort of vulnerable roadway users. In NYC, minorities, especially Latinos, should be targeted for safety education programs.

Context. Discharge to skilled nursing facilities (SNF) has been associated with increased long-term mortality. Currently, discharge disposition is not evaluated in trauma center verification but is a performance measure in primary stroke center (PSC) certification. Objectives. To determine trends in trauma and stroke patient discharges and examine the effect of PSC certification requirements on discharge disposition. Design, Setting, and Patients: Retrospective cohort study of adult trauma and stroke patients discharged from January 2003 to December 2009. The National Trauma Data Bank and Healthcare Cost and Utilization Project Nationwide Inpatient Sample were used to study trauma and stroke patients respectively. The Joint Commission PSC program was implemented December 2003. Main outcome measure. Relative risk of discharge to SNFs and inpatient rehabilitation facilities (IRF), over time. Results. Over the period of the study, the proportion of trauma patients age ≥65 years increased from 23% (95% confidence interval [CI], 20.2%–25.8%) to 30% (CI, 25.6%–34.6%). In-hospital mortality decreased from 4.5% [CI, 2.0%–6.9%] in 2003, to 3.2% [CI, 2.8%–3.5%] in 2009. The majority of patients who survived hospitalization were discharged home (64.6% [CI, 61.3%–67.9%]). On average, stroke patients were 71.9 (SD, 0.01) years old and 72.6% (CI, 72.5%–72.6%) were age ≥65 years. In-hospital mortality was 6.1% (CI, 6.0%–6.1%). Less than half (45.7% [CI, 45.7%–45.8%]) of patients who survived hospitalization were discharged home. In 2009, trauma patients were 34% (adjusted RR 1.34 [CI, 1.15–1.57]) more likely to be discharged to SNF, compared to 2003, but 36% (adjusted RR 0.64 [CI, 0.48–0.85]) less likely to be discharged to IRF. However, stroke patients were 78% (adjusted RR 1.78 [CI, 1.74–1.82]) more likely to be discharged to IRF. The largest absolute increase (2.1% [CI, 2.1%–2.1%]) in stroke patient discharges to IRF occurred in the year following PSC implementation. Conclusions. After adjusting for confounding factors, there was a significant increase in trauma center discharges to SNF and a decrease in discharges to IRF. However, during the same period and especially after implementation of the PSC program, stroke patients were more likely to be discharged to IRF. Trauma centers should evaluate discharge disposition as a part of the verification process.