Trauma & Injury Prevention Section Newsletter - September 2012
Editor: M. Kit Delgado, MD, MS, Division of Emergency Medicine and the Centers for Health Policy/Primary Care and Outcomes Research, Stanford University School of Medicine
Chair’s Corner - Trauma & Injury Prevention Section Newsletter, September 2012
Megan Ranney, MD, MPH
Welcome to this edition of the ACEP TIPS newsletter. I’m excited to get to see you all – both old and new members - in Denver next month. I’d also like to congratulate the newest CDC-funded Injury Control Research Centers, many of which are led by emergency physicians. (See the newsletter for more details.)
Additionally, in preparation for our meeting, I wanted to share a few important news items with you:
1. Trauma & Injury Prevention Section Membership Survey
We’ve created a VERY brief (5 minute) survey to identify what our members want out of TIPS. I ask you to please take a few minutes to complete it. You are spending YOUR money on section membership – help us make your investment worthwhile! (And if you’ve already completed the survey, thank you.)
The link for the survey is: https://www.acep.org/snapsurveys/2012tips/2012tips.htm
I’ll be presenting the results of the survey as part of our meeting in October.
2. Annual TIPS Meeting
Our meeting will be Tuesday October 9th, from 2p-4p.
The meeting will be held in the Sheraton Hotel, Row H, on the Lobby level. (Please note: the meeting is NOT at the Hyatt! The Sheraton is a few blocks away.)
We have a number of exciting agenda items for our meeting, including:
- "Emergency Medicine & the CDC Injury Center: Opportunities for Collaboration" (Sara Patterson, Policy Director for the CDC's National Center for Injury Prevention & Control);
- A discussion of our survey results (see above);
- Planning for a section grant application;
- Electing a new Chair-Elect.
If you have any other items you’d like added to our agenda, please email me prior to the meeting.
3. Firearm Safety Research: A Council Resolution
As per my email to all of you last month, ACEP TIPS co-sponsored a resolution (along with Cal/ACEP) asking for increased research into existing firearm legislation and its effectiveness.
I very much appreciated all of your feedback and ultimate support on co-sponsoring this resolution. There is a good possibility that we could be asked to gather data on existing legislation and its effectiveness if the resolution is approved. I will hopefully have an update on its status before our 10/9 meeting.
And for those of you who didn’t email me, here are the “resolved” of the resolution. Greg Larkin, our councilor-at-large, and I very much welcome any additional feedback or thoughts you might have.
RESOLVED, That ACEP condemn the recent massacres in Aurora, CO, and Wisconsin, and daily firearm violence throughout our nation; and be it further
RESOLVED, That ACEP recognize that these shootings, and ongoing firearm violence in the United States is a public health crisis; and be it further
RESOLVED, That ACEP gather available data on state and federal firearm and ammunition legislation focused on firearm violence prevention, and research these laws’ efficacy while identifying gaps in related public policies; and be it further
RESOLVED, That ACEP provide the data and research gathered to interested state chapters, and assist them in advocating for firearm and ammunition legislation at the state and federal level; and be it further
RESOLVED, That ACEP encourage increased research and federal funding for firearm safety and violence prevention.
4. Newsletter Editor
Finally, I’d like to thank M. Kit Delgado, MD MS, currently of Stanford Hospital, for being our newsletter editor this year, and to welcome Ali Raja, MD, from Brigham & Women’s as our new newsletter editor.
Please feel free to contact either Ali or myself with any questions, suggestions or comments.
We have a great selection of articles in this Newsletter – I hope you enjoy them. Thanks as always for your support, and I’ll see you on October 9th.
Megan L. Ranney MD MPH FACEP
Injury Prevention Ctr, Department of Emergency Medicine, Brown University/Rhode Island Hospital
Chair, ACEP Trauma & Injury Prevention Section
A Night of Adrenaline and Instinct - Trauma & Injury Prevention Section Newsletter, September 2012
Comilla Sasson, MD, MS
I wasn’t even supposed to work that night. I had finished a long day of meetings, and found out at 6:30 pm that a colleague had influenza. Could I fill in for him? “Just power through until 8 am,” I thought. “Nothing too bad happens on Thursday nights.”
The ED was full, with another 10 patients in the waiting room. We were on “divert,” meaning ambulances would bypass University of Colorado Hospital and head elsewhere.
Then at about 12:30 am a call came in over the dispatch radio. There’d been a shooting at an Aurora theater. Nine minutes later, we received a frantic police call. Multiple shooting victims. Not enough ambulances. Officers would haul patients to hospitals, including ours. So much for divert.
The first police car showed up at 1:06 am. It looked like a crime scene, with blood splattered throughout. As we pulled the first two victims out of the car, another arrived. And another. And another. In total, nine police cars and an ambulance rolled in within 45 minutes.
This was a night of adrenaline and instinct.
As the attending ED physicians, Dr. Barbara Blok and I stationed ourselves in the ambulance bay so that we could assess patients. We were in official disaster mode. Operating rooms were opened, surgeons and nurses raced to the ED, along with residents who’d been paged by one of their quick-thinking colleagues.
We were running a chess game, coordinated chaos as we rotated the nine most critically injured patients in and out of resuscitation so we could place them on ventilators or put tubes in their chests to drain their lungs of blood.
We cared for victims with bullets through the head, chest, abdomen, neck and extremities. Each resident had one or two patients and reported back every five minutes. Bullet wounds are tricky – a slug in to the shoulder can wreak havoc in the abdomen. It was crucial for us to monitor vital signs to make sure nobody was crashing.
In total, 23 patients arrived within two hours of the incident. Our amazing team worked all night and morning with these patients, most of whom were between 16 and 30 years old.
I am proud that every single patient who arrived with a pulse that night, 22 of the 23, is still alive today. People talk about the “Aurora massacre” but to me, considering how many seriously injured people were saved, it was the “Aurora miracle.”
Comilla Sasson, MD, MS is an attending physician at the University of Colorado Hospital and Assistant Professor in the Department of Emergency Medicine at the University of Colorado. Questions or comments? Email: Comilla Sasson, MD, MS . For more coverage of the ED response to the shootings, see the New York Times article, The Night the E.R. Staff Can Never Forget, August 16, 2012. http://www.nytimes.com/2012/08/17/us/colorado-mass-shooting-tested-an-er-staff.html
Evaluating Cost in Trauma Care - Trauma & Injury Prevention Section Newsletter, September 2012
Daniel Nishijima, MD, MAS
In our current landscape of escalating healthcare costs in the US, it is inevitable that we will need to take a hard look at inefficient healthcare practices. It is estimated that healthcare waste accounts for a third of our $2.7 trillion dollar health care tab.1 A significant proportion of this waste is attributed to overtesting and overtreatment.1 If the goal is reducing waste, decreasing costs, and improving the delivery of healthcare resources, perhaps there is no bigger low-hanging fruit than trauma care. Traumatic injuries is the second most expensive disease condition after cardiovascular disease in the U.S.2 However, there seems to be a general paucity of economic related research for traumatic conditions.
The most common method of evaluating the cost effectiveness of interventions or strategies is a cost-effectiveness analysis (CEA). A CEA compares two or more interventions in terms of their relative costs and effectiveness (frequently measured in quality adjusted life years [QALY]). Healthcare related CEAs are often used by clinicians, policy-makers, and industry to identify cost effective interventions and to make resource allocation decisions. The number of CEAs has increased dramatically over the last decade (Figure 1).3
Figure 1. Number of Published Cost-Effectiveness Analyses Since 19763
A search of the CEA Registry, a comprehensive database of 3,067 CEAs on a wide variety of diseases and treatments, demonstrated only 25 trauma related CEAs.3 Compared to other disease conditions it is clear that there is a relative paucity of trauma related CEAs (Figure 2).
Figure 2. Number of Published Cost-Effectiveness Analyses by Disease Condition
Why the lack of trauma related CEAs? In general, the role of CEAs in the US has long been an ongoing debate, despite its use to impact funding decisions in other countries such as the UK and Canada. This may be largely attributed to our suspicion with research that resembles the dreaded “R-word” – rationing of health care.4 For trauma care - which has a disproportionate share of young, healthy patients, this apprehension may be particularly evident.
Due to the difficulties often encountered in conducting research on an emergent, high acuity condition such as trauma, we are often faced with limited information on specific interventions. It is unlikely a randomized controlled trial will ever be conducted on emergent thoracotomy for traumatic arrest, however, an economic analysis may provide useful data on its utility.5
In summary, given rising health care costs, the shift of our national health research agenda towards comparative effectiveness research, and the difficulties of conducting trauma research, the use of economic analyses may be particular pertinent in trauma care research.
1. Berwick DM, Hackbarth AD. Eliminating waste in US health care. JAMA 2012;307:1513-6.
2. Olin GL RJ. The five most costly medical conditions, 1997 and 2002: estimates for the U.S. civilian noninstitutionalized populations.2006; AHRQ, Rockville, MD.
3. CEA registry and Center for the Evaluation of Value and Risk in Health. Tufts Institute for Clinical Research and Health and Policy Studies (2010). Retrieved July 1, 2010 from https://research.tufts-nemc.org/cear.
4. Bloche MG. Beyond the "R word"? Medicine's new frugality. The N Engl J Med 2012;366:1951-3.
5. Brown TB, Kilgore M, Romanello M. Cost-utility analysis of emergency partment thoracotomy for trauma victims. J Trauma 2007;62:1180-5.
Daniel Nishijima, MD, MAS, is an Assistant Professor in the Department of Emergency Medicine, University of California-Davis. Questions or comments? Email: Daniel Nishijima, MD, MAS.
Overview of NCIPC and Collaborations with Emergency Medicine - Trauma & Injury Prevention Section Newsletter, September 2012
Sara Patterson, MA
The National Center for Injury Prevention and Control (Injury Center) within the Centers for Disease Control and Prevention (CDC) is the federal lead for a comprehensive approach to non-occupational injury and violence prevention. The Injury Center addresses both unintentional injuries – including such topics as falls among older adults, prescription drug overdoses, motor vehicle-related crashes, and sports-related injuries – and violence – such as child maltreatment, suicide, dating violence, domestic violence, and sexual violence.
The Injury Center uses the public health approach when addressing injuries and violence, the same approach used to address diseases. This approach includes four steps: define the problem, identify risk and protective factors, develop and test prevention strategies, and assure widespread adoption of effective injury prevention principles and strategies.
Established by Congress in 1992, the Injury Center allocates approximately 75% of its annual budget of $137 million to funding states, research entities, and other partners for critical public health activities that include surveillance, research, program and policy implementation, evaluation, and dissemination of evidence-based approaches.
Partnerships are a critical component of fulfilling the Injury Center’s mission, and the center has a long-standing history of working with emergency medicine in a number of ways. For example, the Injury Center has worked for several years with emergency medicine experts to contribute to the scientific knowledge around emergency response. The Injury Center worked with a variety of national organizations, including ACEP, to develop, disseminate, and promote implementation of Guidelines for the Field Triage of the Injured Patient. These field triage guidelines are designed to ensure that emergency medical services have the decision tools needed to take patients to the appropriate hospital for the type of injuries sustained. These guidelines have been disseminated and implemented widely, and they are revised every several years to ensure the state-of-the art science is incorporated into the decision scheme. The most recent version of the guidelines were finalized in early 2012 and published in CDC’s Morbidity and Mortality Weekly Report (http://www.cdc.gov/mmwr/pdf/rr/rr6101.pdf).
Another partnership with emergency medicine has been on the topic of prescription opioid abuse and overdose. CDC has been a federal leader in identifying the tremendous rise in deaths from prescription opioids, and we are now working with various partners, including ACEP, to address the problem through reducing the use of opioids while ensuring appropriate treatment of pain. One of these strategies includes developing prescribing guidelines for emergency departments to help limit the quantity of opioids prescribed in these settings. The Injury Center supported ACEP to develop emergency department guidelines, which were finalized and disseminated in July 2012 (https://www.acep.org/clinicalpolicies/). CDC is now working to identify mechanisms to incorporate these guidelines into policy.
Beyond these existing partnerships, there are a number of opportunities to enhance the partnership between the Injury Center and emergency medicine on injury and violence topics that include suicide, homicide, falls among older adults, child injuries, and many more.
Sara Patterson is an Associate Director for Policy at the Centers for Disease Control and Prevention. Questions or comments? Email: firstname.lastname@example.org or call 770-488-1429. Please also visit the Injury Center’s website at www.cdc.gov/injury.
Overview of Injury Control Research Centers - Trauma & Injury Prevention Section Newsletter, September 2012
Sara Patterson, MA
In 1987, the Centers for Disease Control and Prevention (CDC) began funding Injury Control Research Centers (ICRCs) throughout the United States to study ways to prevent injuries and disabilities. The ICRCs conduct high quality research and help translate scientific discoveries into practice for the prevention of fatal and nonfatal injuries, violence, and related disabilities. The research is interdisciplinary and incorporates the fields of medicine, engineering, epidemiology, law, and criminal justice, behavioral and social sciences, biostatistics, public health, and biomechanics. In addition, the Centers provide professional training and serve as resource centers for the public.
An Injury Control Research Center is not just a collection of research projects. It is a multidisciplinary/interdisciplinary organization that addresses training and research in a cross-cutting and integrated manner to impact the field of injury and violence prevention. Centers strive to strengthen the injury and/or violence prevention infrastructure by integrating resources at the local, state, and national levels. Center’s activities focus on high CDC priority topics and issues as well as problems of injury and/or violence prevention unique to the Center’s geographic region. Centers’ activities also focus on translating research into practice.
The National Center for Injury Prevention and Control (NCIPC) currently funds 11 centers. Each ICRC is funded for five years. NCIPC recently completed a competitive award process. NCIPC is pleased to announce the award of seven Injury Control Research Centers.
Three are newly supported ICRCs:
• The University of Michigan
• Columbia University
• The University of Rochester
Four are current ICRC grantees that successfully competed again for funding:
• University of Iowa
• Mount Sinai School of Medicine
• West Virginia University
• Research Institute at Nationwide Children’s Hospital
The four centers that are funded through 2014 are:
• Emory University
• Johns Hopkins University
• University of North Carolina
• Washington University in St. Louis
Sara Patterson is an Associate Director for Policy at the Centers for Disease Control and Prevention. Questions or comments? Email: email@example.com or call 770-488-1429. More information about the ICRCs, including individual centers’ areas of focus, can be found at http://www.cdc.gov/injury/erpo/icrc/index.html. Please also visit the Injury Center’s website at www.cdc.gov/injury.
Tranexamic Acid: It’s time for us to become drug reps - Trauma & Injury Prevention Section Newsletter, September 2012
Ali S. Raja, MD, MBA, MPH
This past July, I spoke at a conference in Florida and gave a talk on the management of patients with severe trauma. During the talk I mentioned tranexamic acid (TXA), the synthetic lysine derivative that acts as a fibrinolysis inhibitor and has a number of studies supporting its use in hemorrhagic trauma. Given the few puzzled looks in the room, I asked the audience (which consisted of 100 community and academic emergency physicians from around the country) how many of them had access to TXA in their EDs. Only one other physician and I raised our hands. Looking out at the group, I couldn’t help but think that if I had asked about the latest and greatest antibiotic – the one touted by the drug reps, the one advertised in all the journals, and the one that likely has much less evidence supporting it than TXA – there would have been many more hands in the air.
We’ve all heard of TXA. We read the original CRASH-2 study, published in the Lancet in July 2010, which involved 274 hospitals, 40 countries, and 20,211 adult trauma patients. It’s likely the largest study that will ever be conducted on TXA, and it concluded that there was a reduction in all-cause mortality with the use of the drug. A follow-up analysis, published in the Lancet in March 2011, found that the benefit was greatest if TXA is given within 1 hour but that TXA is still beneficial when given up to 3 hours after the injury. However, as I found out during my talk over a year after this paper was published, TXA still isn’t being used in most hospitals in the U.S. This has remained true even after the MATTERs trial, which provided further support for TXA by demonstrating lower mortality in a military population, was published in February 2012 in Archives of Surgery. In an article about TXA written a month later on March 20, the New York Times noted that hospitals in New York, Chicago, San Francisco, and Atlanta were moving towards adoption of the drug but that they were still months away having it in their EDs.
The problem with TXA is not that it doesn’t work, it’s that nobody is advocating for it. I’m not sure whether that is because emergency physicians believe that aminocaproic acid, a TXA analogue stocked in many hospitals, is just as effective (it isn’t – TXA is 10 times more effective in vitro) or because we believe that the trauma surgeons will get it approved for us (they won’t – why should they when we won’t?). The truth is that, since it needs to be given within 3 hours of injury, TXA is entirely our responsibility as emergency physicians.
The good news is that getting TXA through your hospital’s Pharmacy and Therapeutics Committee will probably be easier than you think. There is a preponderance of evidence supporting its use in patients with trauma and it’s not an expensive drug. When I got it approved at my hospital, I simply asked one of our trauma surgeons to co-author a short protocol describing when we would use it (in trauma patients receiving massive transfusion as well as others at the attending emergency physicians’ or trauma surgeons’ discretion) and we jointly presented it at the P&T meeting. It took longer to get on the Committee’s schedule than it took to get TXA approved and voila! We were using it in our ED. All it took was an advocate.
ACEP members have a strong history of advocating for change that we think will benefit our patients. I believe that the widespread use of TXA is one of those changes, and it is worth our advocacy. With your help I hope that, by spreading the word and making this inexpensive and effective drug available to more of our patients, I’ll see a lot more hands raised when I bring TXA up again next summer down in Florida.
Ali S. Raja, MD, MBA, MPH is an Assistant Professor in the Department of Emergency Medicine, Brigham and Women’s Hospital, Harvard Medical School. Questions or comments? Email: Ali S. Raja, MD, MBA, MPH.
A Model for Success – the Violence Intervention and Prevention Program at BWHreps - Trauma & Injury Prevention Section Newsletter, September 2012
Ali S. Raja, MD, MBA, MPH
As emergency physicians, we’re used to seeing victims of intentional violence come into our EDs but do not often have the chance to help them avoid similar injuries in the future. However, for those patients fortunate enough to survive to hospital admission, these episodes of violence can be some of the most life-altering events of their lives. A year-old program here at Brigham and Women’s Hospital (BWH) in Boston seeks to capitalize on these highly influential periods in patients’ lives by using a team of community advocates, case managers, nurses, and physicians to address the root causes of the violence that has affected them.
David Crump, a victim advocate, meets with patients injured through intentional violence within 72 hours of their admission to BWH in order to support and advocate for them while connecting them with support systems designed to address the social issues, such as unemployment, that may have contributed to their situations. In a recent article in the Boston Herald, he noted, “You’ve got to be able to give them insight to see the power they do have, the options that they have … you’re trying to put support around them … and empower them to move forward.”
The program has already worked with over 60 patients who were victimized by violence and has managed to develop ongoing relationships with over half of them. Mardi Chadwick, JD, the Director of Violence Intervention and Prevention Programs, has noted that the immediate period surrounding violent injury is like a “second golden hour” and that reaching them quickly maximizes the opportunities for real change.
While the program is still relatively new, it has already begun to receive regional and national attention. For more information regarding the work being done by the Violence Intervention and Prevention Program, please contact Mardi Chadwick, JD.
Ali S. Raja, MD, MBA, MPH is an Assistant Professor in the Department of Emergency Medicine, Brigham and Women’s Hospital, Harvard Medical School.
Literature Updates in Trauma - Trauma & Injury Prevention Section Newsletter, September 2012
S.V. Mahadevan, MD and M. Kit Delgado, MD, MS
1. Trends in CT use
National Trends in Use of Computed Tomography in the Emergency Department
Kocher KE, Meurer WJ, Fazel R, et al. Ann Emerg Med. Nov 2011; 58:452:462.
Research question: Is the use of computed tomography (CT) in the ED increasing?
Design: Retrospective analysis of the National Hospital Ambulatory Medical Survey 1996-2007 (weighted to 1.29 billion ED encounters).
Findings: In 1996, 3.2% of encounters had a CT. In 2007, 13.9% had a CT (330% increase). Overall ED visits only increased 30%. Numbers for trauma are similar: in 1996, 3.5% of trauma encounters had a CT. In 2007, 14% had a CT.
Implications: CT use in trauma has increased significantly even though trauma acuity, census and mortality rates have remained the same. While CTs provide more clinical information and may reduce need for hospitalization, there is concern about cost, contrast-induced nephropathy, and increased cancer risk from ionizing radiation.
2. Trauma Mortality vs Radiation-Induced Cancer Mortality
Comparison of Trauma Mortality and Estimated Cancer Mortality from Computed Tomography During Initial Evaluation of Immediate-Risk Trauma Patients
Laack TA, Thompson KM, Kofler JM, et al. J Trauma. June 2011; 70:1362-1365.
Research question: In high-risk mechanism of injury trauma patients, risk of death from trauma outweighs the risk of cancer from CT (ionizing radiation). Does this also hold true for patients with less severe (low or moderate) mechanisms of injury?
Design: Prospective observational cohort study of 642 patients at intermediate risk for mortality (GCS 13-14, or 2 or more long bone fractures, or known spine fractures, or near drowning, or mild to moderate abdominal pain) or evidence of a high energy injury (e.g., motor vehicle collision > 40 mph) in a high risk patient (e.g., age >65). Median Injury Severity Score (ISS) was 8 in the study group.
Findings: Median radiation dose was 24.7 mSV (annual background radiation to humans is 2.4 mSv). Trauma mortality rate = 0.6%. Estimated cancer mortality rate = 0.1% (1 in 1000 chance).
Implications: Risk of trauma death vs. cancer death was 6 times higher in this intermediate-risk cohort (versus 55 times higher for the high-risk cohort). However, risk of trauma death vs. cancer death was only 3 times higher in younger patients (age <20) due to their radiosensitivity and longer life expectancy.
3. Selective CT vs. Pan Scan
Selective Use of Computed Tomography Compared with Routine Whole Body Imaging in Patients with Blunt Trauma
Gupta M, Schriger DL, Hiatt JR, et al. Ann Emerg Med. Nov 2011; 58:407-416.
Research question: Can selective imaging decrease CTs without missing any clinically important injuries?
Design: Prospective, observational study of 701 patients at a Level I trauma center. 86% of patients underwent pan scan CT. Prior to CT, EM and Trauma MDs were asked if each CT scan was desired. Study population median age 35, ISS 5.
Findings: 600 pan CTs ordered. EM MDs would have ordered 56% fewer, but would have missed 3 abnormal results requiring critical actions, and 99 other abnormal results with varying significance.
Implications: 86% pan scan rate is too high but reducing number of CTs would have delayed 3 critical actions. Need to use more evidence-based approaches such as clinical decision rules to reduce CT scanning.
4. Decision Rule for Chest Radiography
Derivation of a Decision Instrument for Selective Chest Radiography in Blunt Trauma
Rodriguez RM, Hendey GW, Mower W, et al. J Trauma. Sep 2011; 71:549-543.
Research question: Can a decision rule be developed for reducing the number of trauma chest x-rays (CXRs) without missing a significant intrathoracic injury (SITI)? SITI = pnuemo- or hemo-thorax, great vessel injury, more than 2 rib fractures, ruptured diaphragm, sternal fractures, pulmonary contusion.
Design: Prospective observational study of 2,628 patients (age > 14) with blunt trauma at three Level I trauma centers that got both CXR and chest CT.
Findings: “ADAPTED” clinical decision rule. Sensitivity = 99.3%, Specificity = 14%, NPV= 99.4%. Adapted rule would have reduced CXR by 14% and only missed 2 cases of multiple rib fractures.
• Altered mental status
• Alcohol intoxication
• Tenderness (lateral chest wall tenderness)
• Elderly (age > 60)
• Distracting injury
Implications: Potentially promising rule, but requires external validation (which is ongoing).
5. Missed injuries in the Pan Scan Era
Missed Injuries in the Era of the Trauma Scan
Lawson CM, Daley BJ, Ormsby CB, Enderson B. J Trauma. Feb 2011; 70:452-458.
Research question: What are the most common missed injuries (delayed diagnoses) in patients who get pan CT scanning?
Design: Retrospective analysis of 23,900 blunt trauma patients in Level I trauma center registry from 2001-08 (after pan CT protocol implementation).
Findings: Of 11,030 pan scanned patients, 204 had delayed diagnoses. Most common were bowel/mesentery, thoracic/lumbar spine, pelvic, spleen, and diaphragm injuries.
Implications: Missed injuries are rare. Bowel/mesentery injuries are most commonly missed and may not have overt clinical signs at presentation.
SV. Mahadevan, MD is an Associate Professor in the Division of Emergency Medicine, Stanford University School of Medicine. M. Kit Delgado, MD, MS is an Instructor in the Division of Emergency Medicine, Stanford University School of Medicine. Questions, comments? Email: M. Kit Delgado, MD, MS.
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