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Supported by the Lancaster General Health Research Institute, Emergency Medicine and Trauma research has been presented at regional and national conferences including the American Association for the Surgery of Trauma, the Society of Critical Care Medicine, and the American College of Surgeons.

Read Summaries of Emergency Medicine and Trauma Peer-Reviewed Publications Below

Our active clinical research program includes participation from trauma surgeons, nurses, advanced practitioners, liaisons from other specialties, and a research coordinator.

Summaries of Peer-Reviewed Publications of 2019

American Society of Hematology 2019 Guidelines for Management of Venous Thromboembolism: Prevention of Venous Thromboembolism in Surgical Hospitalized Patients

Venous thromboembolism (VTE) is a common source of perioperative morbidity and mortality. A panel was formed and agreed on 30 recommendations for VTE prevention in surgical hospitalized patients.

An Analysis of Pediatric Trauma Center Undertriage in a Mature Trauma System

We sought to determine the overall undertriage rate (UTR) in the pediatric trauma population within Pennsylvania (PA) using geospatial mapping. We found undertriage was clustered in eastern PA, with most areas of high undertriage located around existing trauma centers in high-density population areas. This pattern may suggest pediatric undertriage is related to a system issue as opposed to inadequate access.

A Preliminary Analysis of Level IV Trauma Centers within an Organized Trauma System

The effect of Level IV trauma center (TC) accreditation within an existing trauma network remains understudied. This study compared preaccreditation to postaccreditation data from Level IV TCs within a mature trauma system in Pennsylvania to determine whether TC designation affected time to and/or rate of transfer to definitive care. This study found Level IV TC accreditation has beneficial effects on increased transfer rates and may improve mortality.

A Multicenter Trial of Vena Cava Filters in Severely Injured Patients

This multicenter, randomized, controlled trial sought to determine whether early placement of an inferior vena cava filter reduces the risk of pulmonary embolism or death in severely injured patients who have a contraindication to prophylactic anticoagulation. This study found that early prophylactic placement of a vena cava filter after major trauma did not result in a lower incidence of symptomatic pulmonary embolism or death at 90 days than no placement of a filter.

A population-based analysis of firearm injuries among young children in the United States 2010-2015

This study compared the survival of children younger than five years to children and adolescents of age 5–19 years who presented to an ED for gunshot wounds (GSWs) in the United States to test the hypothesis of higher GSW mortality in very young children. This study found the mortality from GSW is highest among the youngest children compared with older children.

A Retrospective Study Comparing Volumetric Based Feeding to Rate Controlled Feeding of ICU Patient Conditions and Outcomes

Volumetric based feeding (VBF) protocols have begun to be implemented to feed critical care individuals in order to more effectively deliver the proper daily amount of nutrients and energy. We hypothesized that VBF patients will be younger, with shorter lengths of stay and lower readmission rates. Our results suggest that VBF is recommended for younger patients.

Bad blood: A coagulopathy associated with trauma and massive transfusion review

This review educates trauma and emergency medicine staff on the currently available diagnostic tools to assess coagulopathy, provides an overview of the coagulopathy pathway, as well as provides examples of how to intervene and treat coagulopathy, including the use of crew resource management during mass transfusion protocol activations.

Preliminary Analysis of Non-Stroke Related Should Subluxations in the Critical Care Setting

Shoulder subluxations in the Intensive Care Unit (ICU) are uncommon and when they do occur, they are a frequent complication in patients post cerebral vascular accident (CVA). However, there is little information surrounding shoulder subluxations in patients with other critical conditions. We sought to determine if underlying conditions would increase the risk of shoulder subluxation. We found that, besides CVA, possible risk factors for shoulder subluxations could include respiratory failure, paralytic use and continuous sedation.

Summaries of Peer-Reviewed Publications of 2018

Preliminary Results of a Novel Hay-Hole Fall Prevention Initiative

Hay-hole falls are a prevalent source of trauma among Anabaptists - particularly Anabaptist youth. We sought to decrease hay-hole falls in South Central Pennsylvania through the development and distribution of all-weather hay-hole covers to members of the at-risk Anabaptist community.

Improved Outcomes in Elderly Trauma Patients with the Implementation of Two Innovative Geriatric-Specific Protocols - Final Report

Elderly trauma care is challenging due to the unique physiology and comorbidities prevalent in this population. Two practice management guidelines were implemented (HRGP and ACT Alert) to improve the care of these patients. A significant decrease in mortality was observed with combined implementation of both protocols compared to mortality prior to introduction of these guidelines.

Development of a Trauma System and Optimal Placement of Trauma Centers Using Geospatial Mapping

While the care of patients at individual trauma centers has been carefully optimized, the placement of TCs within the trauma systems could use improvement. PTSF and PHC4 databases were queried for adult trauma admissions from 2003-2015. ArcGIS Desktop was used to generate models to determine optimal locations of trauma centers across the state of Pennsylvania.

Undertriage in Trauma: Does an Organized Trauma Network Capture the Major Trauma Victim? A Statewide Analysis

Proper triage of critical trauma patients is essential for survival and patient outcomes. We sought to determine the percentage and distribution of patients meeting trauma criteria who received care at non-trauma centers within the state of Pennsylvania. We determined nearly a third of trauma patients are inappropriately triaged to non-trauma centers and that pockets of undertriage are scattered across the state.

Rapid Release Protocol Optimizes Product Utilization Compared With Massive Transfusion Protocol in Selected Patients

While massive transfusion protocols (MTPs) are effective in expeditiously delivering blood products to patients with exsanguinating hemorrhage, activation can lead to product wastage and overtransfusion. We sought to determine whether the additional implementation of a new protocol (called Rapid Release [RR]), which uses less resources, would result in decrease in blood product wastage. We found the institution of the RR protocol resulted in higher mean wastage of FFP per activation despite the appropriateness of the RR protocol.

The Magic Number: Are Improved Outcomes Observed at Trauma Centers with Undertriage Rates Below 5%?

The American College of Surgeons Committee on Trauma (ACSCOT) advises trauma centers maintain <5% undertriage rate (UTR). We sought to determine whether patients managed at Level I/II trauma centers with a UTR less than 5% had improved outcomes and found a UTR of <5% appears to have limited impact on institutional mortality.

Comparison of Two Prognostic Models in Trauma Outcome

This study compared the anatomical injury components of the Trauma Audit and Research Network (TARN) model with the Trauma Mortality Prediction Model (TMPM) and found the TMPM had greater discrimination, proximity to the true model and goodness-of-fit than the anatomical injury component of TARN.

Early Neurological Deterioration in Older Adults with Traumatic Brain Injury

Neurological deterioration often goes unrecognized at the injury scene. We examined the proportion of older adults experiencing early neurological deterioration and the association of the magnitude of neurological deterioration with TBI severity and found patients with severe and critical head injuries had the highest odds of early neurological deterioration.

Summaries of Peer-Reviewed Publications of 2017

Vena Cava Filter Use in Trauma and Rates of Pulmonary Embolism

Vena cava filter (VCF) placement for pulmonary embolism (PE) prophylaxis in trauma is controversial. Limited research exists detailing trends in VCF use and occurrence of PE over time. We analyzed state and nationwide trends in VCF placement and PE occurrence from 2003 to 2015 and discovered that despite a precipitous decline of VCF use in trauma, PE rates remained unchanged during this period.

A Novel Approach to Optimal Placement of New Trauma Centers within an Existing Trauma System Using Geospatial Mapping

Trauma system expansion is a complex process often governed by financial and health care system imperatives. We sought to propose a new, informed approach to trauma system expansion through the use of geospatial mapping. Our study suggests that geospatial mapping set to specific parameters can effectively identify optimal locations for future TCs within an existing trauma network.

Outcome Differences in Adolescent Blunt Severe Polytrauma Patients Managed at Pediatric versus Adult Trauma Centers

The appropriate managing facility for adolescent trauma patients is debatable. We hypothesized that no differences in adjusted outcomes would be observed between pediatric trauma centers and adult trauma centers for this population. Despite similar rates of mortality and complications, these patients have improved functional status at discharge.

Gunshot Wounds Resulting in Hospitalization in the United States: 2004-2013

The United States (US) leads all high income countries in gunshot wound (GSW) deaths. However, as a result of two decades of reduced federal support, study of GSW has been largely neglected. During the study period, the annual rate of hospitalizations for GSW remained stable at 80 per 100,000 hospital admissions with decreased adjusted odds for mortality over the study duration.

Big Children or Little Adults? A Statewide Analysis of Adolescent Isolated Severe Traumatic Brain Injury Outcomes at Pediatric versus Adult Trauma Centers

The appropriate managing center for adolescent trauma patients is debated. We sought to determine whether outcome differences existed for adolescent severe traumatic brain injury (sTBI) patients treated at pediatric versus adult trauma centers. Results of this study suggest outcomes for adolescent TBI patients are similar at both pediatric and adult centers.

An Overview of Nonoperative Blunt Splenic Injury Management with associated Splenic Artery Pseudoaneurysm

The delayed development of splenic artery pseudoaneurysm (SAP) can complicate the non-operative management of splenic injuries. The study sought to determine the utility of repeat imaging in diagnosing SAP in patients managed non-operatively without angioembolization. Results of this investigation suggest patients with splenic injuries greater than Grade III managed non-operatively without angioembolization may benefit from repeat imaging within 48 hours.

An Epidemiological Overview of 13 Years of Firearm Hospitalizations in Pennsylvania

Gun violence is a controversial public health issue. We sought to provide a 13-y overview of firearm hospitalizations in Pennsylvania, analyzing trends in mode, intent, and outcome. All admissions to the Pennsylvania Trauma Outcome Study database from 2003 to 2015 were queried and GSWs were identified by external cause-of-injury codes. 4.2% of the patients presenting to Pennsylvania trauma centers were GSWs with handguns as the most common weapon of injury. Temporal trends in outcomes suggest rates of firearm hospitalizations are declining in Pennsylvania; however, outcomes remain unchanged.

An Analysis of Compassion Fatigue in a Surgeon Population: Are Female Surgeons at Heightened Risk?

Compassion fatigue (CF) is a prevalent issue for today’s healthcare provider. We sought to characterize levels of CF within a surgeon population, particularly comparing trauma surgery with other surgical specialties. Levels of CS were significantly lower in the trauma surgeon subgroup compared to other surgical specialties. Female surgeons from all specialties exhibited significantly higher levels of burnout and compassion fatigue compared with male surgeons.

The Effect of Time to International Normalized Ratio Reversal on Intracranial Hemorrhage Evolution in Patients with Traumatic Brain Injury

The incidence of geriatric traumatic brain injury (TBI) is increasing throughout the United States, with many of these patients taking anticoagulation medication. This investigation attempted to determine the effect of time to international normalized ratio (INR) reversal on intracranial hemorrhage evolution in TBI patients taking prehospital AC medication. Reversal of INR of less than 5 hr was not associated with intracranial hemorrhage evolution; however, reversal of less than 10 hr was found to be associated with a decreased odds ratio for intracranial hemorrhage evolution.

A Preliminary Analysis of Compassion Satisfaction and Compassion Fatigue with Considerations for Nursing Unit Specialization and Demographic Factors

Compassion fatigue (CF) is a state of physical/emotional distress that results from caring for those experiencing pain. We sought to characterize levels of CF in intensive care unit (ICU) and oncology nursing populations with subanalyses comparing specific personal and/or professional demographic factors. Levels of compassion satisfaction were significantly lower and levels of burnout were significantly higher in ICU nurses than in oncology nurses. Intensive care unit nurses and female nurses from both ICU and oncology specialties may be at increased risk for developing a poorer overall ProQOL and CF.

Omega-3 Fatty Acid Supplementation and Warfarin: A Lethal Combination in Traumatic Brain Injury

Polyunsaturated fatty acids such as omega-3 eicosapentaenoic acid and omega-6 docosahexaenoic acid, found in over-the-counter fish oil supplements, are often consumed for their beneficial, prophylactic, anti-inflammatory effects. Unfortunately, the risks of omega-3 fatty acid supplementation are often underappreciated, particularly its ability to inhibit platelet aggregation and promote bleeding in patients taking anticoagulant medications. This study details the clinical case of an elderly patient taking warfarin and fish oil supplementation whose warfarin-induced coagulopathy could not be reversed after suffering blunt head trauma.

Summaries of Peer-Reviewed Publications of 2016

An Analysis of Neurosurgical Practice Patterns and Outcomes for Serious to Critical Traumatic Brain Injuries in a Mature Trauma State

Limited research exists detailing trends in neurosurgical practice patterns over time. This study sought to analyze trends in rates of craniotomy, craniectomy, and intracranial pressure monitor placement in the Commonwealth of Pennsylvania. While fluctuation in practice patterns was observed over time, no change in outcomes were found for individuals afflicted by traumatic brain injury.

An Analysis of Beta Blocker Administration Pre- and Post-Traumatic Brain Injury with Subanalyses for Head Injury Severity and Myocardial Injury

A growing body of literature indicates that beta blocker administration following traumatic brain injury is cerebroprotective, limiting secondary injury. The effects of preinjury beta blocker status, however, remain poorly understood. This study sought to characterize the effects of pre- and post-injury beta blocker administration on mortality. Results of this study suggest preinjury beta blocker administration does not reduce odds of mortality.

A Bitter Pill to Swallow: Dysphagia in Cervical Spine Injury

Dysphagia is a common complication after cervical spine trauma with spinal cord injury. The purpose of this investigation was to determine whether geriatric patients with spinous injury not involving the spinal cord were also at increased risk. The results of this study suggest even those impacted by non-spinal cord involved injuries are at increased risk for developing dysphagia.

Improved Functional Discharge Status Despite Higher Complication Rates at Level I Trauma Centers

We sought to compare outcome measures besides mortality between level I and level II trauma centers, including complication rates and functional status at discharge (FSD). We hypothesized level I trauma centers would have lower complication rates and higher FSD compared to level II counterparts. Unadjusted total complication rate was significantly higher at level I centers with the three most prevalent significantly higher complications: pneumonia, UTI and DVT. Despite a higher complication rate, severe trauma patients managed at level I centers had increased functional status at discharge.

Repetition, Repetition! Radiographic Re-Read Protocol Identifies Clinically Relevant Errors

Radiographic reading errors, however, can lead to missed diagnoses and adverse outcomes, compromising patient care. In 2015, our level II trauma center implemented a protocol mandating re-reads of all radiographic studies completed on our highest level trauma activations (Code T) within 24 hours. We sought to determine the efficacy of this radiographic re-read protocol in identifying missed diagnoses in Code T patients. Clinically relevant errors, although a marginal amount, were discovered during radiographic re-reads for Code T trauma patients.

Ventilator Autotriggering in a Patient Following Massive Intracerebral Hemorrhage and Brain Death

Ventilator autotriggering may potentially occur following terminal brain stem herniation due to interaction between a hyperdynamic cardiovascular state consequent to massive catecholamine release and high stroke volume interacting with compliant lung tissue causing cyclic gas movement within the patient-ventilator system. Case report of a patient admitted with intracerebral hemorrhage and declining neurologic status is detailed in this study.

Early Hormonal Resuscitation After Nonsurvivable Brain Injury: Impact on Organ Recovery

Cardiopulmonary instability following catastrophic brain injury is consequent to multisystem effects of brain herniation. Delaying hormonal resuscitation (HRT) pending brain death testing and consent for organ procurement causes significant delay between brainstem herniation and optimal mechanism-based care for organ function. This results in poor organ viability, less favorable transplant outcomes and puts at risk the option of organ donation for families. Our team demonstrates dramatically improved cardiopulmonary stability and effectiveness of early hormonal resuscitation in two patients following non-survivable brain injury.

Internship Opportunities

The Lancaster General Research Institute offers summer internship opportunities to students interested in gaining research experience. The number of internships available varies from year to year.

Student interns perform a variety of tasks including data collection, data entry, and statistical analysis. We also encourage interns to shadow physicians in specialties of their choice.

Submit your application today!

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