Alcohol and injury prevention.
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Accidents, Traffic↗
Biomedical subjects
Carol R Schermer
Publications and source records attributed to Carol R Schermer.
Trauma center brief interventions for alcohol disorders decrease subsequent driving under the influence arrests.
BACKGROUND: A substantial number of trauma center admissions are related to driving under the influence (DUI); however, there has been no prior report of brief intervention (BI) after injury reducing subsequent DUI arrests. The hypothesis of this study was that injured patients receiving BI would have a lower risk of DUI arrest within 3 years of discharge than those receiving standard care (SC). METHODS: This prospective, randomized clinical trial randomly allocated patients involved in motor vehicle collisions to receive SC or a BI regarding alcohol use. The primary outcome measure was DUI arrest within 3 years of hospital discharge. DUI arrests were documented by matching demographic information to state traffic safety data. RESULTS: After randomization (N = 126), BI and SC groups were similar in age, prior DUI arrests, and alcohol screening score. BI sessions lasted an average of 30 minutes and were performed by either a social worker or a trauma surgeon. Approximately one in six participants (n = 21, 16.7%) had a DUI arrest within 3 years of hospital discharge. Within 3 years of hospital discharge, 14 of 64 patients (21.9%) in the SC group had an arrest for DUI compared with only 7 of 62 patients (11.3%) who received the BI. Multivariate analysis demonstrated that BI was the strongest protective factor against DUI arrest (odds ratio [OR], 0.32; 95% confidence interval < or =CI], 0.11-0.96). Prior number of DUIs (OR, 1.43; 95% CI, 1.03-2.01) and age (OR, 0.94; 95% CI, 0.88-0.99) were also associated with DUI arrest post-hospitalization, but alcohol screening score (OR, 1.06; 95% CI, 0.99-1.13) was not. The absolute risk reduction implies that only nine patients would need to receive a BI to prevent one DUI arrest. CONCLUSION: Patients who receive BI during a trauma center admission are less likely to be arrested for DUI within 3 years of discharge. BI represents a viable intervention to reduce DUI after trauma center admission.
Accidents, Traffic↗
Retrospective evaluation of anemia and transfusion in traumatic brain injury.
BACKGROUND: Despite clear evidence in critical care that blood transfusion has an adverse impact on outcome, neurosurgical textbooks still recommend transfusion of patients with traumatic brain injury (TBI) to a hematocrit (HCT) of 30%. There is little empirical evidence to support this practice. The current study addresses transfusion requirements in TBI in terms of neurologic outcome. METHODS: Retrospective record review of patients with severe TBI. Outcome measures were Glasgow Coma Scale score (GCS), Glasgow Outcome Score (GOS), and Ranchos Los Amigos Score (RLA) at hospital discharge (D/C); and GOS and Functional Independence Measures at follow-up. Association of outcomes with the number of days the HCT <30% and lowest measured HCT were evaluated. RESULTS: In all, 169 patients reviewed; 150 with D/C outcome data and 72 with long-term follow-up data. Univariate analysis showed that lowest measured HCT was associated with lower D/C GCS, D/C GOS, and RLA scores. Linear regression showed that more days with HCT <30% were associated with improved neurologic outcomes measured by GOS (R2 = 0.424, p < 0.001), GCS (R2 = 0.381, p < 0.001) and RLA (R2 = 0.392, p < 0.001) scores on D/C. Both transfusion and lowest measured HCT were significantly associated with all lower outcome scores on D/C. Additional factors with adverse impact on outcome were head Abbreviated Injury Score (AIS), Injury Severity Score, hyperglycemia, and hypotension. Long-term outcomes were only significantly associated with head AIS. CONCLUSIONS: Patients with severe TBI should not have a different transfusion threshold than other critical care patients. Prospective studies are needed to evaluate the effects of anemia in TBI.
Adult↗
Addressing substance abuse in health care settings.
This article summarizes the proceedings of a roundtable discussion at the 2005 annual meeting of the Research Society on Alcoholism in Santa Barbara, California. The chair was William R. Miller. The presentations were as follows: (1) Screening and Brief Intervention for Alcohol Problems, by Allen Zweben; (2) Three Intervention Models and Their Impact on Medical Records, by Denise Ernst; (3) Pharmacotherapies for Managing Alcohol Dependence in Health Care Settings, by Roger D. Weiss; (4) The Trauma Center as an Opportunity, by Carol R. Schermer; (5) Motivational Interviewing by Telephone and Telemedicine, by Catherine Baca; (6) Health Care as a Context for Treating Drug Abuse and Dependence, by Wilson M. Compton; and (7) Interventions for Heavy Drinking in Health Care settings: Barriers and Strategies, by Mark L. Willenbring.
Alcohol Deterrents↗
Feasibility of alcohol screening and brief intervention.
BACKGROUND: A variety of policy groups recommend that screening and brief intervention (SBI) programs for alcohol-use disorders be widely implemented in health care settings. This article reports the extent to which trauma surgeons support SBI programs and the feasibility of implementing these programs in trauma centers. METHODS: Trauma surgeons were surveyed to assess their support for implementing alcohol screening and brief intervention in trauma centers. To assess feasibility of implementation, three trauma centers implemented such programs. Each trauma center used one half-time research assistant who screened trauma inpatients for alcohol-use disorders and provided brief interventions for at-risk drinkers. The research assistant also recorded time spent screening and performing interventions, patient satisfaction with the intervention, and whether standard intervention elements were performed. RESULTS: Most surgeons surveyed supported alcohol screening, and 72% supported brief interventions. Research assistants who had no previous training in alcohol screening and brief interventions were successfully trained to screen and interview patients. One half-time research assistant was able to screen the eligible inpatient trauma population, with the exception of patients who were hospitalized on the weekends. Nearly 17% of patients at one trauma center were not screened because of language barriers. On any given day, roughly half the patients could not be screened because of the severity of their injuries. However, most of the patients were eventually screened during their hospital stay. Patient satisfaction was high. CONCLUSION: Most trauma surgeons supported alcohol screening and interventions. Preliminary data showed that one half-time research assistant at each facility could successfully screen most injured patients and implement brief interventions. An alcohol screening and brief intervention program seems feasible in any trauma center committed to implementation.
Alcohol-Related Disorders↗
Who has life-sustaining therapy withdrawn after injury?
BACKGROUND: Trauma scoring systems have been developed to help surgeons predict who will die after injury. However, some patients may not actually die of their injuries but may undergo withdrawal of life-sustaining therapy (WLST). The goal of this study was to determine which factors were associated with WLST among older patients who died. We hypothesized that patients with comorbid illnesses, higher injury severity scores (ISS), complications, and existing advanced directives (AD) would be more likely to have WLST and that patients having WLST would receive more medication for symptom relief in the 24 hours before death. METHODS: Data were collected via a retrospective chart review of patients age 55 years and older admitted to the intensive care unit after injury who subsequently died. In addition to demographic and injury information, documentation of family discussions regarding care wishes and formal ADs were evaluated. Patients dying despite curative attempts were compared with those who died after WLST by Student's t test and chi test where appropriate. RESULTS: In a 3-year period, of 330 patients age 55 and older admitted to the intensive care unit, 66 (20%) died. Complete records were available for 64 patients. More than half of those who died (n = 35, 54.7%) had WLST. ADs were available for 15 patients (23.4%), and 11 (17.2%) patients had expressed to their families desires to not undergo aggressive curative care. Family discussions were documented for 50 (78%) cases. Comorbid illnesses were present in 46 (71.9%) patients and 35 (54.7%) developed at least one complication. Among people with ADs, 73% had WLST versus 49% of people without ADs (p = 0.09). WLST was independent of comorbid illnesses (p = 0.3), complications (p = 0.8), age (p = 0.5), and ISS (p = 0.2). Patients for whom there was documentation of a family discussion were more likely to have WLST than those without (91.4% versus 62.1%, p = 0.005). Morphine and benzodiazepine dosing in the 24 hours preceding death were greater in the WLST group than the curative therapy group (p = 0.02 and p = 0.05, respectively). CONCLUSIONS: Expected associations with WLST such as age, ISS, comorbidities, and complications were not present in this population. Although trends may exist regarding patient wishes and ADs, larger studies are needed to corroborate these findings. Given the percentage of patients having supportive care withdrawn, trauma registries and scoring systems should include WLST.
Advance Directives↗
What defines a distracting injury in cervical spine assessment?
BACKGROUND: The National Emergency X-Radiography Utilization Study defined five criteria for obtaining cervical spine radiographic investigations in blunt trauma patients. Distracting injury was given as the indication for more than 30% of all x-ray studies ordered. The hypothesis of this study was that upper and lower torso injuries would have different effects on clinical cervical spine assessment. METHODS: This is a single-center, prospective, observational study of admitted, alert, adult blunt-trauma patients. All patients underwent cervical spine plain-film radiography. Data were collected on all injuries, physical examination findings, narcotic administration, and radiograph results. Patients with upper and lower torso injuries were compared in their ability complain of pain or midline tenderness relative to a cervical spine fracture. RESULTS: In all, 406 patients participated. All patients received narcotic analgesics before examination. Forty patients (9.9%) had cervical spine fractures, of whom seven had a nontender neck examination. All seven patients with a nontender cervical spine and a neck fracture had at least one upper torso injury. None of the 99 patients with injuries isolated to the lower torso and a nontender neck had a cervical spine fracture (p < 0.05). The frequency of cervical spine fracture among patients with cervical spine tenderness was 19.8% (n = 33). CONCLUSIONS: The National Emergency X-Radiography Utilization Study definition of a distracting injury may be narrowed. Upper torso injuries may be sufficiently painful to distract from a reliable cervical spine examination. Patients may detect spine tenderness in the presence of isolated painful lower torso injuries. Patients with spine tenderness warrant imaging.
Adolescent↗
Readiness to change alcohol use after trauma.
BACKGROUND: Alcohol is the leading risk factor for severe injury. This study examined whether patients hospitalized after an alcohol-related injury are motivated to change alcohol use, thus making them potential candidates for brief motivational interventions. METHODS: Fifty patients hospitalized in a Level I trauma center, admitted with a positive blood alcohol concentration, were assessed for motivation to change alcohol-related behavior using validated questionnaires. Information was gathered regarding level of alcohol use, consequences of use, and motivation to change drinking habits. Demographic variables, alcohol use measures, perception of alcohol's contribution to the current injury, and negative consequences of use were evaluated by linear regression to predict readiness to change drinking. RESULTS: Mean blood alcohol concentration was 197 mg/dL at admission. Patients reported a pattern of binge drinking, with 86% reporting at least one binge-drinking episode in the past month, and a mean of 3.4 days of binge drinking per month. Most patients (84%) reported considering making a change (cutting down or quitting) in their drinking. Finally, patients reported experiencing an average of 22.5 negative lifetime consequences to their drinking. Having more negative consequences was found to significantly predict readiness to change drinking (p < 0.001). CONCLUSION: In this study, most patients were motivated to change their drinking. An increased number of negative consequences of alcohol use before admission predicted readiness to change drinking habits. Brief motivational interventions would be a reasonable option in this group of patients.
Adult↗
Trauma patient willingness to participate in alcohol screening and intervention.
BACKGROUND: Screening and brief interventions for alcohol disorders in the trauma setting are not routine. Perceived barriers to screening and treatment include the perception that patients find the topic offensive and the feasibility of screening all patients. The hypothesis of the study was that discussing alcohol use would be acceptable to patients independent of race or screening test score. Additional aims were to describe whether patients had access to alcohol screening via a primary care physician, to see what types of treatment patients thought appropriate, and to evaluate the feasibility of screening all trauma patients for alcohol disorders. METHODS: We surveyed 150 trauma inpatients regarding the offensiveness of discussing alcohol use and the appropriateness of different treatment options. We asked whether they had access to a primary care physician. As part of our routine screening program, we evaluated the proportion of patients we were able to screen with the Alcohol Use Disorders Identification Test, refusal rates, and whether any patients were not screened. Analysis of covariance and logistic regression were used to evaluate responses. RESULTS: A part-time research assistant approached 90% of 163 patients. Seventy percent were successfully screened, of which 45% screened positive for problematic alcohol use. Of the patients we were unable to screen, one third did not speak English and one half had injuries precluding interaction, leaving 16 patients (9.8%) that were "missed." One patient (<1%) refused screening. One hundred fifty consecutive patients participated in the survey. The ethnic distribution was 26% Native American, 40% Hispanic, 30% white, 2% African American, and 2% other. A brief counseling session was acceptable to all ethnic groups. There were ethnic differences in acceptability of other types of treatment. Ninety-four percent of patients thought that somebody from the trauma team should talk with patients about alcohol. Alcohol Use Disorders Identification Test score did not predict whether patients would be offended (p = 0.48). Forty-five percent had a primary care physician and only 10% had ever spoken to their physician about alcohol use. CONCLUSION: The majority of trauma patients are not offended by discussing alcohol use while hospitalized for injury and can feasibly be screened for alcohol disorders. Treatment types may need to be culturally tailored.
Adult↗
National survey of trauma surgeons' use of alcohol screening and brief intervention.
BACKGROUND: A variety of policy groups have recommended that screening and brief interventions (BIs) for alcohol disorders be widely implemented in health care settings. This study was conducted to determine the current status of screening and intervention programs in trauma centers and to evaluate specific barriers to implementation of screening and BIs. The hypotheses tested were that surgeons who support screening and brief interventions would be less likely to endorse the purported barriers to screening and intervention and would have a better understanding of the concept of brief interventions. METHODS: A postal survey of 711 members of the American Association for the Surgery of Trauma and the Western Trauma Association was performed to assess current screening and treatment practices, along with barriers to screening and intervention. Two logistic regression models were constructed to determine which factors result in support for screening and which factors predict support of BIs to help determine potentially modifiable issues to facilitate implementation. RESULTS: Three hundred eighty-three surgeons responded, 315 of whom are currently practicing trauma. The majority of surgeons (267 [83%]) agreed that a trauma center is an appropriate setting for addressing harmful alcohol consumption. Over two thirds frequently check a blood alcohol concentration, with one third of the group reporting that they always do. The use of formal screening questionnaires was much less frequent (25%). Nearly one half (49%) understood the concept of BIs. However, the majority report that less than one half of patients with a suspected alcohol problem at their center have their alcohol problem addressed while they are hospitalized. Several barriers to screening and BIs were identified. Although only 2% thought screening and counseling would significantly increase health care costs, 7% thought screening was too time consuming and 13.6% thought it would compromise patient confidentiality. Screening was perceived to threaten reimbursement by 27%. Over half (55%) stated their facility is currently performing screening. One third (36%) stated their facility is currently performing BIs. Logistic regression revealed that surgeons who support screening were those who thought patients with alcohol problems should be referred for professional alcohol treatment (odds ratio [OR], 6.5; 95% confidence interval [CI], 2.3-18.2) and that a trauma center is an appropriate setting for addressing alcohol disorders (OR, 6.2; 95% CI, 2.7-14.2). In the model of support for BIs, understanding the concept of BIs (OR, 5.7; 95% CI, 3.1-10.5) and lack of the belief that screening and intervention would increase cost too much (OR, 0.14; 95% CI, 0.02-0.96) were the most potent predictors of support for BIs. CONCLUSION: Trauma surgeons are screening for alcohol disorders more frequently than they were 5 years ago. Barriers to screening are not as prevalent as previously reported. Support for implementing screening and intervention programs depends on whether surgeons believe trauma centers are appropriate sites for addressing alcohol disorders, whether surgeons believe patients with alcohol problems should be referred for professional treatment, whether surgeons understand the concept of brief interventions, and whether they believe the cost constraints are not prohibitive. Widespread education in the effectiveness and methods of BIs would facilitate implementation of alcohol screening and intervention programs to help reduce recurrent alcohol-related injury.
Alcoholism↗
Blood culturing practices in a trauma intensive care unit: does concurrent antibiotic use make a difference?
BACKGROUND: Febrile trauma patients have repeated blood cultures drawn during a prolonged hospitalization. We examined the diagnostic yield of blood cultures in severely injured patients to determine whether concurrent antimicrobial therapy or prophylactic administration of antibiotics affects blood culture growth. We also determined how rapidly growth changed to determine whether total numbers of blood cultures could be decreased. The hypotheses of the study were that concurrent antimicrobial administration affects blood culture yield, prophylactic administration alters the culture result, and repetitive culturing is unnecessary. METHODS: A retrospective chart review of trauma patients with minimum Injury Severity Score of 15 and minimum 5-day intensive care unit length of stay was performed. The dates and results of blood cultures and antibiotic type and administration dates were recorded. "Prophylactic" antibiotics were defined as antibiotics administered on admission to the unit. Computer software was used to match the blood culture date to the period of antimicrobial administration. Categorical data were compared using Fisher's exact test. RESULTS: Two hundred fifty-eight patients met entry criteria, and 208 charts were complete for review. One hundred twenty-nine patients had 347 sets of blood cultures drawn. The positive blood culture rate was 10.8% in patients off antibiotics, and 13.9% in patients on antibiotics (p = 0.68). All prophylactic antibiotics included a beta-lactam. Only 18% of positive blood cultures in patients receiving prophylactic antibiotics were sensitive to beta-lactams as opposed to 59% sensitivity in those who did not receive prophylaxis (p = 0.03). One hundred seventy-six sets of blood cultures were performed after an initial positive culture. Only three patients with an initial positive culture had a second positive culture with a different organism. The mean time to culturing a new organism after initial growth was 19 days. CONCLUSION: Concurrent antimicrobial administration does not alter blood culture yield. Prophylactic administration alters the type of organism cultured. Little new information is gained from repetitive culturing.
Adult↗
Nonoperative management of blunt splenic injuries: factors influencing success in age >55 years.
Historically poor success rates of nonoperative management of splenic injuries in elderly patients have led to recommendations for operative intervention in patients more than 55 years of age. Recent studies are in opposition to earlier recommendations revealing equal success rates of nonoperative management of splenic injuries in all age groups. A retrospective chart review was performed to assess factors related to the successful management of splenic injuries in patients over 55 years of age at a Level I trauma center. Thirty-seven patients over 55 presented with blunt splenic injuries during the 5-year study period. Thirteen patients were taken immediately to the operating room on the basis of clinical findings and/or abdomen/pelvis CT results. Nonoperative management was attempted in 24 patients on the basis of CT findings. Nonoperative management was successful in 15 patients (62.5%) and failed in eight patients (33.3%). Patients who failed nonoperative management had significantly higher American Association for the Surgery of Trauma splenic injury grade and associated pelvic free fluid. There were no deaths related to complications from failed nonoperative management. We conclude that nonoperative management of blunt splenic injuries in patients over 55 may be attempted. Patients with higher-grade injuries and pelvic free fluid are at greater risk for failure. Patients with these two findings must be monitored closely. The physicians caring for elderly patients with high-grade splenic injuries and free fluid in the pelvis must use clinical judgment regarding the need and timing of operative management.
Age Factors↗
Institutional variations in the management of patients with acute appendicitis.
The purpose of this study was to evaluate institutional differences in preoperative workup, operative approach, complications, and cost in patients with acute appendicitis. A retrospective chart review was performed of all adults operated on for acute appendicitis from June 1999 to November 2000 at the University of New Mexico Hospital (UNMH) and Stanford University Medical Center (SUMC). Variables compared included age, race, sex, duration of symptoms, type of symptoms, results of radiographic evaluation, time from emergency room to operating room, operative approach (open vs. laparoscopic), operative time, length of hospital stay, pathologic findings, and complications. Statistical analysis was performed by means of Fisher's exact test. A total of 154 appendectomies were performed for acute appendicitis at UNMH and 165 at SUMC. Statistically significant differences were found at UNMH vs. SUMC in time from emergency room to operating room (9.1 hours vs. 13.7 hours; P<0.001), operative approach (48% laparoscopic vs. 29% open; P<0.001), and negative appendectomy rate (13% vs. 4.8%; P<0.001). There were no differences in the perforation rate or other complications. Cost analysis showed that $56,744 more was spent at UNMH for the additional negative appendectomy operations, whereas $99,842 more was spent at SUMC for the additional CT scans. Institutional differences in the management of patients with acute appendicitis can result in significant differences in cost without clinically significant differences in outcome. The use of clinical examination and laparoscopy as diagnostic modalities instead of CT scanning resulted in a more cost-effective approach.
Acute Disease↗