Trauma and Injury Prevention Section Newsletter - April 2008, Vol 12, #1
From the Chair
Mark R. Sochor, MD, FACEP
Hope everyone enjoyed the winter months. It was great to see some of you at the Section meeting at Scientific Assembly. We had a great speaker, Holly Wheeling, MD, FACEP, who was the only ED physician at Montgomery Regional Hospital which saw most of the victims from the Virginia Tech shootings. The nimbleness and quick decision making was a sight to behold. I would imagine most of our respective emergency departments would need all the planets aligned to run with such efficiency. Which is a great segue into inviting those of our section who wish to write a council resolution to update ACEP’s stand on gun control.
Our Section continues to thrive and provide valuable insight to the college. As many of you know we are completing our Section Grant "ED directors Alcohol Survey". If your ED directors ask you about this survey, please encourage them to complete it. The results of this survey will lead to articles and positive exposure on our Section as well as providing a valuable resource to our college. The national trauma program continues to struggle without congressional funding. However, there are still trauma champions fighting the uphill battle. One of these projects, which are trying to gain momentum, is the National Trauma Institute (NTI) based in San Antonio, TX.
National Trauma Institute
The College and other medical and surgical organizations are collaborating on an initiative to formally establish and secure funding for a National
Trauma Institute (NTI). As envisioned, the NTI would carry out the following activities:
- Provide a public/private partnership for funding of clinical and experimental studies in injury.
- Integrate laboratory, transitional, and clinical evaluative research to hasten improvements in care to the civilian bedside and to wounded soldiers.
- Ensure that military and civilian data are optimally used to drive research agendas and measure improvements in outcomes.
- Fund the full spectrum of injury research and evaluation, including: laboratory, transitional, and clinical research; point of wounding and pre-hospital care; early resuscitative management; initial and definitive surgical care; and rehabilitation and reintegration into society.
- Coordinate multi-institutional civilian/military collaboration and trauma research.
Reps. Ciro Rodriguez (D-TX) and Charlie Gonzalez (D-TX) have introduced a House bill, H.R. 3673, that would support the NTI, and efforts are underway to identify sponsors of companion legislation in the Senate. In addition to the College, other groups that are involved in these efforts
include: the Coalition for American Trauma Care, the Orthopaedic Trauma Association, the American Association of Neurological Surgeons/Congress of Neurological Surgeons, the American Association of Orthopaedic Surgeons, the American Association for the Surgery of Trauma, and the Eastern Association for the Surgery of Trauma.
Although we did not put in for a section grant this year, I would like to start gathering ideas for a submission for next year. Please email me (email@example.com ) and or Barbara (firstname.lastname@example.org ) with your ideas. Section grants are a great way to become involved with the section and also tap the wide and deep expertise that is contained within our section. Have a great spring and look for our summer newsletter.
Wanted: Now that TIPS has 174 members, it would be great to have braoder participation. We still need a newsletter editor and a bigger turnout at our annual meeting at SA. Those of you who missed Dr. Holly Wheeler’s presentation in Seattle about being in the small, Blacksburg ED after the VA Tech shootings missed a poignant story and great learning opportunity.
If you have articles you’d like to share with your TIPS colleagues, forward them to email@example.com any time and we will use them in the next newsletter.
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A Critical Look at the "Revised" Cochrane Review of Trauma Ultrasound
William T. Hosek, MD, MBA, FACEP
Johns Hopkins University
The Cochrane review of trauma ultrasound was first published in February of 20051. The objective of the analysis was to assess the impact (efficiency & effectiveness) of ultrasound in blunt abdominal trauma algorithms. The analysis combined results from four studies2-5 and concluded that ultrasound had no statistically significant impact on mortality, CT scan use, laparotomy or DPL rates. Additionally, the authors implied that use of ultrasound might be reducing CT use at the expense of patient survival. However, as detailed in a recent letter to the editor in the Annals of Emergency Medicine6, these conclusions were based upon incorrect data and poor study assignment.
Several changes to the Cochrane review were subsequently made in the fall of 2007. The Navarrete-Navarro study 4 was dropped from and the Melniker study 7 was added to the analysis. In addition, several data points were corrected in the CT and DPL analyses. Despite these changes, the Cochrane review again concluded that there is "insufficient evidence to justify promotion of ultrasound-based clinical pathways in diagnosing patients with suspected blunt abdominal trauma."8 Unfortunately, this "revised" Cochrane analysis is plagued by new problems that are just as significant as the original ones. Laparotomy data from the Boulanger study 3 and mortality data from the Melniker study 7 are incorrectly reported. Valuable endpoint data (time to operative care, hospital length of stay and total charges) from the Melniker study were excluded from the analysis. Finally, data regarding DPL rates are excluded from the conclusions and never discussed.
When these mistakes and omissions are taken into account, the studies actually show that ultrasound does, in fact, have a positive impact in the evaluation of patients with torso trauma. Diagnostic time, time to operative care, CT use, total charges and hospital length of stay are all reduced when ultrasound-based clinical pathways are used. In addition, diagnostic peritoneal lavage has been replaced, in large part, by ultrasound. All of these benefits are observed without any adverse effect on mortality or laparotomy rates. While further studies regarding trauma ultrasound are needed to improve upon clinical pathways as they exist today, the beneficial impact of ultrasound thus far should not be discounted.
- Stengel D, Bauwens K, Sehouli J, et al. Emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma. Cochrane Database of Systematic Reviews. 2005, Issue 2. Art. No.: CD004446. DOI:10.1002/14651858.CD004446.pub2.
- Arrillaga A, Graham R, York JW, et al. Increased efficiency and cost-effectiveness in the evaluation of the blunt abdominal trauma patient with the use of ultrasound. The American Surgeon. 1999;65:31-35.
- Boulanger BR, McLellan BA, Brenneman FD, et al. Prospective evidence of the superiority of a sonography-based algorithm in the assessment of blunt abdominal injury. J Trauma. 1999;47(4):632-637.
- Navarrete-Navarro P, Vazquez G, Bosch JM, et al. Computed tomography vs. clinical and multidisciplinary procedures for early evaluation of severe abdomen and chest trauma-a cost analysis approach. Intensive Care Med. 1996;22:208-212.
- Rose JS, Levitt MA, Porter J, et al. Does the presence of ultrasound really affect computed tomographic scan use? A prospective randomized trial of ultrasound in trauma. J Trauma. 2001;51:545-549.
- Hosek WT, McCarthy ML. Trauma ultrasound and the 2005 Cochrane Review. Ann Emerg Med. 2007;50(5):619-620.
- Melniker LA, Evan L, McKenney, et al. Randomized controlled clinical trial of point-of-care, limited ultrasonography for trauma in the emergency department: The first sonographic outcomes assessment program trial. Ann Emerg Med. 2006;48(3):227-235.
- (Revised 2007) Stengel D, Bauwens K, Sehouli J, et al. Emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma. Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD00446. DOI:10.1002/14651858.CD004446.pub2.
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Agency for Healthcare Research and Quality Sees Increase in Violence-related Trauma
An estimated 308,200 patients were hospitalized in the U.S. for violence-related trauma in 2005, according to a new report from AHRQ. That’s 24,000 more patients that in 2002. Nearly two-thirds of violence-related stays resulted from self-inflicted acts, while 31% resulted from assaults.
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There are several important upcoming dates that everyone should put on their calendar. The Annual Leadership and Advocacy Conference will be held in Washington D.C, at the Omni Shoreham Hotel from May 18th to the 21st. Springtime is gorgeous in the nation’s capitol, and at the same time, you can meet with your Congressional delegation and help put a constituent face on emergency department concerns. This year’s Scientific Assembly will take place from October 27th-30th in the windy city of Chicago. Please join your colleagues in several days of camaraderie, and in celebrating the 40th year of ACEP while sharing the newest ideas and technology in Emergency Medicine.
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Barbara Tomar, ACEP Federal Affairs Director
While the Trauma Care Systems program (P.L. 110-23) was reauthorized in May 2007, no funding has been appropriated yet. ACEP is working with over 25 other organizations this year, including the American College of Surgeons, the American Association of Orthopedic Surgeons and Advocates for EMS to secure $10 million in funding for the Trauma/EMS program for FY 2009. Our coalition successfully inserted over $3m for the program for FY 08 which was passed by Congress, but was removed when a threatened Presidential veto resulted a need to reduce overall discretionary spending by $10b.
Medicare Physician Fee Schedule Will be Cut July 1, 2008 without Further Legislation
In what has been an annual last minute anemic effort, Congress staved off the 10% cut in the fee schedule, and provided a 6-month .05% update. The Senate Finance and House Ways and Means Committees know they have to fix the program’s formula, but each year they watch as the price tag grows exponentially. Estimates to fix the sustainable growth rate formula are now more than $250b over a 10-year budget window. Couple that with a faltering economy, the costs of the war, and a lame-duck President, it’s going to be a challenge.
Traumatic Brain Injury
In March, a House review panel voted to extend the traumatic brain injury rehabilitation grants that were initially set into law in 1996. The program was set to expire in 2005 but the result of this new vote is to continue house appropriations to sustain the program. In addition to providing state grants for brain injury rehabilitation programs, the renewed bill mandates the CDC to monitor brain injuries and create a system-wide reporting system. Furthermore, a joint CDC/NIH collaboration would be conducted to further research in the area.
The slightly altered current house bill (H.R.1418) would contain language to match the Senate’s companion (S.793) bill, and would also authorize improved access to care for the countries veterans. With over 1 million Americans affected by traumatic brain injury (TBI) each year, and the number of veterans returning with the injuries ever-increasing, this bill has the potential for a sizable positive impact on the population.
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TIPS Section Grant Update
"Injury Prevention Efforts at U.S. Trauma Centers: Alcohol Screening and Intervention Practices."
The purpose of our study is to assess the types (if any) of alcohol screening and intervention currently in use in Level I and II trauma center EDs. Recent ACS trauma center certification requires Level Is to have a trauma prevention program with a separately identifiable coordinator and demonstrated evidence of prevention activities. While much of the intervention activity takes place with inpatients, ACEP believes opportunities exist in the ED as well. We plan to publish results and use them to tailor educational sessions for emergency physicians as well as to track behavioral changes in target communities and justify payment for alcohol screening and brief intervention services.
Approximately 440 surveys were mailed or emailed to ED directors on February 28, 2008. They can be completed on-line or via hard copy. We plan to send a second mailing to non-respondents will go out in mid April.
Note: New codes approved for brief screening and intervention for substance abuse AMA’s CPT. Medicare developed its own "G" codes (G 0396 and G0397) because the program does not pay for screenings, but will pay for screening and brief intervention "in the context of a diagnosis or treatment of illness or injury."
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Self-Reported Falls and Fall-Related Injuries Among Persons Aged >65 Years - United States, 2006
Each year, an estimated one third of older adults fall, and the likelihood of falling increases substantially with advancing age. In 2005, a total of 15,802 persons aged =65 years died as a result of injuries from falls1. However, the number of older adults who fall and are not injured or who sustain minor or moderate injuries and seek treatment in clinics or physician offices is unknown. To estimate the percentage of older adults who fell during the preceding 3 months, CDC analyzed data from the 2006 Behavioral Risk Factor Surveillance System (BRFSS) survey. This report summarizes the results of that analysis, which indicated that approximately 5.8 million persons aged =65 years, or 15.9% of all U.S. adults in that age group, fell at least once during the preceding 3 months, and 1.8 million (31.3%) of those who fell sustained an injury that resulted in a doctor visit or restricted activity for at least 1 day. The percentages of women and men who fell during the preceding 3 months were similar (16.4% versus 15.2%, respectively), but women reported significantly more fall-related injuries than men (35.7% versus 24.6%, respectively). The effect these injuries have on the quality of life of older adults and on the U.S. health-care system reinforces the need for broader use of scientifically proven fall-prevention interventions.
BRFSS surveys are conducted in all 50 states, the District of Columbia (DC), and selected U.S. territories (Puerto Rico, the U.S. Virgin Islands, and Guam)2. BRFSS uses a multistage sampling design based on random-digit--dialing methods to select a representative sample of the noninstitutionalized, civilian population aged =18 years in each state or territory. Details on the design, random sampling procedures, and reliability and validity of measures used in BRFSS have been described previously3,4. In 2006, the median response rate among states, based on Council of American Survey Research Organizations (CASRO) guidelines, was 51.4% (range: 35.1%--66.0%). Data were weighted to account for probability of selection and to match the age-, race/ethnicity-, and sex-specific populations from annually adjusted intercensal estimates. Statistical significance was determined by nonoverlap of 95% confidence intervals. Estimates were considered unstable if the unweighted sample size for the subgroup was less than 50. In 2006, interviews with 92,808 persons aged =65 years were completed. Data from all 50 states, DC, Puerto Rico, and the U.S. Virgin Islands are included in this report.
Two questions about falls were included in the 2006 survey. The first was, "The next question asks about a recent fall. By a fall, we mean when a person unintentionally comes to rest on the ground or another lower level. In the past 3 months, how many times have you fallen?" Those who reported a fall were asked a second question, "How many of these falls caused an injury? By an injury, we mean the fall caused you to limit your regular activities for at least a day or to go see a doctor." In response to the first question, the number of reported falls ranged from 0 to 76; the mean number of falls among those who fell was 1.9; median = 1.0. Of respondents who said they had fallen, 23.1% reported falling three times or more. Overall, 15.9% of respondents reported one or more falls (Table 1). The number of reported falls that resulted in injury ranged from 0 to 50. Among those who fell and were injured, the mean number of injurious falls was 1.4; median = 1.0. Overall, 31.3% of respondents who reported falling also reported a fall-related injury.
The percentages of men and women who reported falling during the preceding 3 months were similar (15.2% and 16.4%, respectively) (Table 2), but women reported more fall-related injuries than men (35.7% versus 24.6%). By race/ethnicity, American Indians/Alaska Natives reported the greatest percentage of falls (27.8%); Hispanics reported the greatest percentage of falls with injuries (41.0%). The percentages of persons aged 65-69 years and 70-74 years who reported falling during the preceding 3 months were similar (13.4% versus 14.0%) but increased significantly for persons aged 75-79 years (15.7%) and =80 years (20.8%). Although the percentage of persons reporting falls increased with age, the percentage of persons reporting fall-related injuries was nearly identical for each age group (range: 29.9%-32.1%).
Reports of falls ranged from 12.8% among respondents in Hawaii to 20.1% among those in Vermont, but no geographic patterns were apparent. The 50 states and DC were ranked according to their age-adjusted fall mortality rates for 2003--2004. Of the seven states at or above the 90th percentile nationally (Arizona, Minnesota, New Mexico, Rhode Island, South Dakota, Vermont, and Wisconsin)1, only Vermont (first) and New Mexico (seventh) also were among the 10 states with the greatest proportion of reported falls; only Rhode Island (first) and Arizona (seventh) appeared among the 10 states with the greatest proportion of fall-related injuries. The percentage of respondents who fell and were injured ranged from 23.7% (Nebraska) to 48.0% (Rhode Island).
Reported by: JA Stevens, PhD, KA Mack, PhD, LJ Paulozzi, MD, MF Ballesteros, PhD, Div of Unintentional Injury Prevention, National Center for Injury Prevention and Control, CDC.
Falls are the leading cause of fatal and nonfatal injuries for persons aged =65 years1. National estimates for rates of fatal falls and fall-related injuries treated in emergency departments have been published previously1; however, this report presents the first national estimates of the number and proportion of persons experiencing fall-related injuries associated with either restricted activity or doctor visits. The results in this study suggest that in 2006, approximately 1.8 million persons aged =65 years (nearly 5% of all persons in that age group) sustained some type of recent fall-related injury. Even when those injuries are minor, they can seriously affect older adults' quality of life by inducing a fear of falling, which can lead to self-imposed activity restrictions, social isolation, and depression5. In addition, fall-related medical treatment places a burden on U.S. health-care services. In 2000, direct medical costs for fall-related injuries totaled approximately $19 billion6. A recent study determined that 31.8% of older adults who sustained a fall-related injury required help with activities of daily living as a result, and among them, 58.5% were expected to require help for at least 6 months7.
Few studies of falls have used a 3-month time frame, so comparison with other studies is challenging. A recent analysis of data from the National Health Interview Survey (NHIS) presented the number and rate of medically attended falls reported during the preceding 3 months. However, the NHIS design did not permit calculation of the number of persons injured7.
Among persons aged =65 years, other studies have reported that women fall more frequently and are treated for fall-related injuries, especially fractures, more often than men8. Similarly, the analysis of BRFSS data indicated that a greater proportion of women than men reported fall-related injuries, but it did not find a significant difference between the proportion of women and men that experienced falls. The reasons for the differences in results between these studies are uncertain. Women might be less likely than men to report a noninjurious fall, or more likely than men to restrict their activities or seek medical attention after a fall.
The BRFSS definition of a fall-related injury does not specify severity; an injury could be as minor as a small bruise or as severe as a broken hip. This broad definition could have obscured age-related differences if, for example, persons aged 65-69 years sustained less severe injuries and persons aged =80 years experienced more severe injuries.
The findings in this report are subject to at least five limitations. First, BRFSS is a telephone-based survey and excludes households without landline telephones, so the results might be subject to selection bias. Second, data are self-reported and subject to recall bias; therefore, prevalence estimates of falls might be underestimated. Third, BRFSS does not include institutionalized persons, thereby excluding persons in long-term--care facilities, who are most at risk for falls. Fourth, the broad definition of injury might have led participants to report minor falls as injurious, resulting in an estimate of fall-related injuries that is higher than in other similar studies. Finally, the low response rate and possible response bias might have affected the representativeness of these data.
Falls and fall-related injuries seriously affect older adults' quality of life and present a substantial burden to the U.S. health-care system. Modifiable fall risk factors include muscle weakness, gait and balance problems, poor vision, use of psychoactive medications, and home hazards8. Falls among older adults can be reduced through evidence-based fall-prevention programs that address these modifiable risk factors. Most effective interventions focus on exercise, alone or as part of a multifaceted approach that includes medication management, vision correction, and home modifications8. One example of an effective fall-prevention program is "Moving for Better Balance," a Tai Chi program based on a randomized controlled trial conducted at the Oregon Research Institute, which reduced the frequency of falls by 55%9 Preventing Falls: What Works. A Compendium of Effective Community-Based Interventions from Around the World. The companion publication, Preventing Falls: How to Develop Community-Based Fall Prevention Programs for Older Adults, offers guidelines to help organizations develop fall-prevention programs. These publications and other fall-related educational materials are available at http://www.cdc.gov/ncipc/duip/fallsmaterial.htm.
- CDC. Fatalities and injuries from falls among older adults---United States, 1993--2003 and 2001--2005. MMWR 2006;55:1222--4.
- CDC. Public health surveillance for behavioral risk factors in a changing environment: recommendations from the Behavioral Risk Factor Surveillance team. MMWR 2003;52(No. RR-9).
- Nelson D, Holtzman D, Bolen J, Stanwyck CA, Mack K. Reliability and validity of measures from the Behavioral Risk Factor Surveillance System (BRFSS). Int J Pub Health 2001;46:S3--35.
- CDC. Behavioral Risk Factor Surveillance System operational and user's guide, version 3.0. Atlanta, GA: US Department of Health and Human Services, CDC; 2004.
- Vellas BJ, Wayne SJ, Romer LJ, Baumgarner RN, Garry PJ. Fear of falling and restriction of mobility in elderly fallers. Age Ageing 1997;26:189--93.
- Stevens JA, Corso PS, Finkelstein EA, Miller TR. The costs of fatal and non-fatal falls among older adults. Inj Prev 2006;12:290--5.
- Schiller JS, Kramarow EA, Dey AN. Fall injury episodes among noninstitutionalized older adults: United States, 2001--2003. Adv Data 2007;392:1--16.
- Stevens JA, Sogolow ED. Gender differences for non-fatal unintentional fall related injuries among older adults. Inj Prev 2005;11:115--9.
- Fuzhong L, Harmer P, Fisher KJ, McAuley E, Chaumeton N, Eckstrom E. Tai Chi and fall reductions in older adults: a randomized controlled trial. J Gerontol 2005;60A:187--94.
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Meeting Summary and Annual Report
American College of Emergency Physicians
Trauma and Injury Prevention and Control Section
Meeting Summary and Annual Report
October 2006 – October 2007
||Officers for 2006-2007
Officers for 2007-2008
||Mark R. Sochor, MD, MS
||Mark R. Sochor, MD, MS
||Ernie E. Sullivent, III, MD
||Ernie E. Sullivent, III, MD
|Immediate Past Chair
||Mary P. McKay, MD, MPH, FACEP
||Mary P. McKay, MD, MPH, FACEP
||Michelle McMahon-Downer, MD
||Peggy E. Goodman, MD, FACEP
||Peggy E. Goodman, MD, FACEP
||Fred Vaca, MD, MPH, FACEP
||Gregory Luke Larkin, MD, FACEP
||Robert Solomon, MD, FACEP
||Robert Solomon, MD, FACEP
Dr. Sochor, TIP Section Chair, welcomed the attendees to the October 9, 2007 annual meeting in Seattle and introduced the guest speaker, Holly Wheeling, MD, FACEP. In a moving visual and oral presentation, Dr. Wheeling, the lone emergency physician at Montgomery Regional Hospital in Blacksburg, VA the morning of April 16, 2007, described her shock when the first two Virginia Tech shooting victims were brought in. Two hours later, multiple gun shot victims began to arrive, and while high winds prevented air transport of the severely wounded, patients were strabilized and transferred by gound. Dr. Wheeling cited the crucial importance of having conducted disaster drills and the fact that local surgeons, RNs, and other hospital personnel came quickly to the hospital to fill in wherever they were needed. Communication with EMS, the police, and hundreds of family and friends of the students also went as smoothly as possible, given the chaotic circumstances.
Dr. Solomon, TIPS Board Liaison, introduced himself to the group and described his own interest regarding injury prevention and research and stated that he would like to see the Section get more engaged in gun control issues, particularly access to guns by the mentally ill. Dr. Solomon suggested review of current ACEP policy and need for stronger statements and support of legislation that may be introduced in Congress. Dr. Solomon presented Dr. Sochor, Chair with a plaque of appreciation for his two-years of chairing the Section.
Dr. Linda Lawrence, ACEP President, explained her rationale for disbanding the Trauma Committee and distributing its objectives and current committee members to the newly expanded Public Health and Injury Control Committee. Other issues (and members) have been incorporated into the EMS and Disaster Committees.
Dr. Peggy Goodman, Section Councilor, reported from the Council meeting and urged members to propose resolutions on injury policy issues.
2006-2007 Activities to date:
- Drs. Rebecca Cunningham and Mark Sochor were the primary authors of the winning Section grant application. In June 2007. The title of the grant is "Injury Prevention Efforts at U.S. Trauma Centers: ED Director Survey in Level I and II Trauma Centers." The survey will assess ED physician awareness and activities to comply with the new ACS requirement to provide alcohol screening and brief interventions in Level I and II trauma centers.
- Two Section newsletters were produced last year and we need an editor 2007-2008.
Section membership currently stands at 174.
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This publication is designed to promote communication among emergency physicians of a basic informational nature only. While ACEP provides the support necessary for these newsletters to be produced, the content is provided by volunteers and is in no way an official ACEP communication. ACEP makes no representations as to the content of this newsletter and does not necessarily endorse the specific content or positions contained therein. ACEP does not purport to provide medical, legal, business, or any other professional guidance in this publication. If expert assistance is needed, the services of a competent professional should be sought. ACEP expressly disclaims all liability in respect to the content, positions, or actions taken or not taken based on any or all the contents of this newsletter.