Research Forum Abstracts

heterogeneity (P � 0.40, I2 � 2.4%) and a significant decrease in mortality(OR � 0.50; 95% CI: 0.37 to 0.69). The late quantitative resuscitation studies(n � 3) demonstrated no significant effect on mortality (OR � 1.16; 95% CI:0.60 to 2.22).

Conclusion: This meta-analysis found that applying an early quantitativeresuscitation strategy to patients with sepsis imparts a significant reduction inmortality.

208 Abstract Withdrawn

209 Implementation of a Team Training Program forTrauma Care: The BETTER (Bringing EnhancedTeam Training to the Emergency Room) Initiative

Gagliano N, Passarello B, Johnson S, Fox N, Resurreccion D, Moore C, WoodsP, Pirrung J, Laskowsi Jones L/Christiana Care Health System, Newark, DE

Study Objective: The purpose of this study was to evaluate the effect of ateam training educational program on emergency department (ED) length of stay(LOS) and disposition times for trauma patients in a Level I trauma center( � 3000 trauma admissions, 144,000 ED visits annually in an 1,100 inpatientbed hospital system).

Methods: A multi-disciplinary team was formed with representatives from thedepartments of surgery, anesthesiology, emergency medicine, nursing, andaccreditation/performance improvement. This group developed an organizationallycustomized curriculum for team training based on the Agency for HealthcareResearch and Quality/Department of Defense Team STEPPS™ program, anevidence-based teamwork system derived from industry, military, and aviation safetyprinciples.

The educational curriculum consisted of interactive, multi-disciplinary sessions topromote safe, effective, and efficient patient-centered care through enhancedteamwork skills and behaviors. Teamwork training concepts were introduced fromMarch 2007 through October 2007. Three-hundred-sixty-three clinicians(physicians, nurses, and ancillary personnel), representing 83% of the targetedpopulation, attended team training sessions.

A retrospective review of Trauma Registry data was conducted to assess mean EDLOS and patient disposition times. Baseline ED LOS data were gathered from thetrauma registry for a twelve month period prior to the trauma team trainingintervention. Post-intervention data were gathered for three months after completionof trauma team training.

Results: Analysis of the data shows a statistically significant reduction in meanED LOS, time to non-telemetry unit, time to telemetry unit, and time to operatingroom (OR) after team training intervention. See Table.

Conclusion: During the post-team training period, there was an overall increasein general ED census and non-trauma patient LOS. Despite these increases, the EDLOS for the trauma population decreased. The implementation of a structured teamtraining educational program in a busy Level I Trauma Center can significantlyreduce trauma patient ED LOS and disposition times to other units.

210 Predicting the Need for Emergent Surgery in AdultTrauma Patients: External Validation of a ClinicalDecision Rule and Implications for Trauma Triage

Paulson S, Byyny R, Erickson C, Gravitz C, Haukoos J/Denver Health MedicalCenter, Denver, CO

Study Objective: Trauma center certification requires a trauma surgeon to bepresent in the emergency department (ED) on arrival of seriously injured patients.However, with improved diagnostic studies and non-surgical therapeutic options, theneed for emergent surgery has decreased, and many centers have used criteria-based“secondary triage” protocols to guide when the immediate involvement of a surgeonis necessary. Recently, a clinical decision rule was developed in an attempt to

accurately predict which patients need emergent operative intervention (EOI),

Volume , . : October

defined as general surgery within one hour of ED arrival. The components of the ruleinclude penetrating mechanism, an initial systolic blood pressure (SBP) less than 100mmHg, and an initial pulse greater than 100 per minute. The objective of this studywas to externally validate this rule.

Methods: This study was performed using data from a prospectively collected andmaintained trauma registry between 1993 and 2006 at an urban Level 1 traumacenter with an approximate annual ED census of 55,000 patients. Patientdemographics, mechanisms of injury, initial vital signs, injury severity scores (ISS),and times of ED arrival and surgical intervention were obtained. EOI was confirmedin all cases using trained physician research assistants blinded to the purpose of thestudy and using standardized medical record abstraction methodology. The clinicaldecision rule was then applied to the study sample and the sensitivity, specificity, and95% confidence intervals (CI) were calculated.

Results: During the study period, 17,080 consecutive adult (age 18 years orgreater) trauma patients presented to our institution, were included in the traumaregistry, and represent our study sample. The median age was 36 (IQR: 25 - 49)years, 72% were male, and the median ISS was 9 (IQR: 4 - 16). Of all patients,15% had penetrating injuries, 11% had a SBP less than 100 mmHg, and 31%had a pulse greater than 100 per minute. EOI was required in 655 (4%) patients.The sensitivity and specificity of the clinical decision rule for predicting EOI was94.7% (95% CI: 92.7% - 96.3%) and 56.8% (95% CI: 56.1% - 57.6%),respectively. When applied to all patients, this rule would have reduced surgeonpresence by 54.9% (95% CI: 54.1% - 55.6%) while failing to identify EOI inonly 0.2% (95% CI: 0.1% - 0.3%).

Conclusions: The American College of Surgeons’ “major resuscitation” criteriaare commonly used to decide which patients require a trauma surgeon at the bedsideon ED arrival. This College suggests that up to a 10% false negative triage rate is“unavoidable” and up to a 50% false positive triage rate is “acceptable.” In this largeexternal validation, this simple clinical decision rule exceeded these thresholds andwas highly sensitive for predicting the need for EOI. Use of this rule may improve theeffectiveness and efficiency of trauma triage. A multi-center study is underway toassess the generalizability of this rule.

211 Base Deficit and Lactate Data Comparable Withthe Infusion of DCLHb in Two Clinical Trials ofTraumatic Hemorrhagic Shock, Suggesting NoAdverse Pressor Effects on Vital Organ Perfusion

Sloan EP, Philbin NB, Koenigsberg MD, DCLHb Traumatic Hemorrhagic ShockStudy Group & the European HOST Investigators/Department of EmergencyMedicine University of Illinois College of Medicine, Chicago, IL; Naval MedicalResearch Center, Silver Spring, MD

Background: Multiple hemoglobin solutions have demonstrated a pressor effectmanifested by increased blood pressure (BP) during and after the time of infusion.This pressor effect could have a deleterious effect on hemorrhagic shock patientsthrough diminished perfusion to vital organs, causing base deficit (BD) and lactateabnormalities that reflect poor perfusion.

Study Objective: BD and lactate abnormalities will demonstrate inadequateperfusion to vital organs in patients treated with DCLHb as compared to thosetreated with normal saline (NS), and in patients who expire as a result of thetraumatic hemorrhagic shock when compared with survivors.

Methods: BD data from two parallel, multi-center traumatic hemorrhagic shockclinical trials conducted in 17 US and 27 EU trauma centers using DCLHb, ahemoglobin-based resuscitation fluid, one conducted in the EU out-of-hospitalsetting, and the other in the US ED setting. Lactate data was available from the USstudy only.

Comparisons at single time points using Student’s T-tests, with significance atp � .05.

Results: In the 219 patients studied from the US and EU studies, BD data didnot differ by treatment group at any time point. Baseline BD data was higher inpatient who ultimately expired as compared to survivors in both studies (US: �14.7vs. �9.3, and EU: �11.1 vs. �4.1 mEq/L, p � .003). Although BD values weresignificantly higher in patients who died as compared to those who lived at the first 3time points following resuscitation, BD values were not different between DCLHband NS survivors or the DCLHb and NS expired patients. Lactate data from the USstudy demonstrated a similar pattern, with baseline lactate data higher in patients whoultimately expired as compared to survivors (82.4 vs. 56.1mmol/L, p � .003). Lactatelevels were also significantly higher in patients who died as compared to those who

lived at the first 5 post-resuscitation time points, but no consistent lactate differences

Annals of Emergency Medicine S107