Annual Report Blurb

THE TRAUMA PROGRAM BOSTON MEDICAL CENTER 2007 ANNUAL REPORT The Annual Report for the Trauma Program at Boston Medical Center provides a unique opportunity for us to stop and reflect on the activities and accomplishments of the past year as well as look forward, setting new goals in how we care for those that are injured and brought to us for care, and to assist in furthering the common goals of the Medical Center. One of the highlights of this past year was the American College of Surgeons Committee on Trauma Verification Review Committee site visit in February that re-verified Boston Medical Center as a Level I Adult and Pediatric Trauma Center for a full three years. As we were the first such program in Boston originally verified in 1994, we have maintained the longest continuous verified status which is also a Massachusetts Department of Public Health requirement for state designation as an Adult and Pediatric Trauma Center. Aligning ourselves with the Medical Center’s Goals of Volume, Satisfaction, Safety and Cost we have continually worked to increase our admissions each year. A primary reason for this has been our well known 24 hour No Refusal Trauma Referral Policy. Our admissions have gone up each of the past five years. This past year, we recorded a three percent increase which is part of a 17% overall increase since 2003. This is reflective of a department and institutional commitment.

ADMISSIONS 2200 2100

2088

2000 1900 1800

2104

2162

1988 1843

1700 1600 2003

2004

2005

2006

2007

We have undertaken an attempt to control costs, increase patient satisfaction, decrease length of stay, and provide continuity by the expansion of our use of nurse practitioners in the critical care areas, inpatient teams and ambulatory setting. Definitive data is unavailable at this time but we are confident this will be a value added service.

PERSONNEL The Trauma Program staff continues to grow and mature and this past year we were pleased to have the addition of Dr. Kofi Abbensetts who joined us from Hartford Hospital and Dr. Eric Mahoney from Rhode Island Hospital and Brown University. Both are fully integrated as Trauma/Critical Care Attending Surgeons. Dr. Steve Moulton left to become the Chief of Pediatric Surgery at the University of Colorado in Boulder. Joseph Blansfield, NP, our Trauma Program Manager returned from 16 months of active duty including a year in Iraq with the 399th Combat Support Hospital to resume his position prior to deployment. This was much to the relief of Janet Orf, NP who did a superlative job in covering the position during Joe’s absence (to include the ACS Trauma Center site visit). We are delighted that Janet has stayed on in a more clinical capacity as the Lead Nurse Practitioner in the Surgical Intensive Care Unit working along with Amanda Young, NP providing the continuity piece with the physician and nursing staff necessary to reduce length of stay and complications. Nancy Connors, NP has joined the team and with Patricia Harrison, NP we now have six day a week nurse practitioner coverage for the inpatient surgical services on both the Clowes (trauma) Service and Egdahl (emergency surgery) Service. We owe a special debt of gratitude to several Surgical Faculty to include Dr. Miguel Burch, Dr. Donald Hess, Dr. David McAneny, and Dr. Jonathan Woodson for contributing their time and expertise during a period of decreased staff coverage. We are most appreciative and fortunate to have this type of commitment within our ranks. It is another example of why this program has been so successful for so long. Thank you.

HIGHLIGHTS FROM THE TRAUMA REGISTRY Many departments around the Medical Center continue to access data from the Trauma Registry for research, publication and educational purposes and we are happy to oblige. This year, Heidi Wing, Data Program Manager and Amanda Wing, Data Coordinator incorporated a new report writer capability which increases efficiency and accuracy and keeps our Registry software completely up to date. In the body of this report are many of the traditional data points that we have reported on over the years along with a comparison of last year’s numbers. We have also incorporated benchmarking data from the National Trauma Data Bank (NTDB) which represents a national average of all Level I trauma centers that are comparable in size to BMC. Analysis from the department staff has provided the following highlights and trends:

Mechanisms of Injury

Falls continue to be the most common mechanism of injury in our trauma program and have increased this year to almost one-fourth of all injury mechanisms. This includes simple trip and fall from standing to fall from roof or scaffolding as a work-related occurrence. Motor vehicle related injuries are second while nationally motor vehicle related injuries are first with falls a very close second.

We are delighted to note that the more violent mechanisms of Gunshot Wounds, Stabbings, and Assaults have decreased this year for the first time in five years for both total number of patients and percentage. While it may be premature to attribute this to our Violence Prevention initiatives, we are encouraged by our re-dedicated and increased efforts in this area. Injury Prevention will be presented as a separate section of this report. However, we are still twice the national average for intentional injuries.

INTERPERSONAL VIOLENCE 700

616

600 500

620

596

527

75

464

400

50

300 200 100

100

25.17

26.5

2003

2004

29.5

29.47

27.57

2005

2006

2007

0

# OF PATIENTS % OF PATIENTS

25 0

Our Blunt vs. Penetrating ratio has been and continues to be approximately 80 to 20 percent which makes the case for more imaging and non-operative management which will also be discussed later.

Safety Devices

When reviewing our documentation of safety device usage for motor vehicles, motorcycles and bicycles, the news is mixed. Motorcyclist use of helmets continues to be very respectable coming in at over 80% last year which is due to the mandatory helmet law in Massachusetts. We are clearly above the national average of 57%. The non-helmeted trauma patients we have received have largely been from New Hampshire where no such law exists. Safety belt use for drivers and passengers is not as satisfying. It is estimated by the National Highway Traffic Safety Administration (NHTSA) that the national average is 82% and 78% respectively. Our data of injured patients presenting while using safety devices in a motor vehicle crash is just over 40% or half of the national average. Massachusetts has no primary enforcement law and states with one have an 85% compliance rate according to NHTSA data.

vehicle related injuries. Clearly we have room for improvement in these areas.

Safety Devices and Vehicles 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% 2003

2004

2005

2006

SEATBELT USE PASSENGER SEATBELT USE DRIVER HELMET USE MOTORCYCLIST HELMET USE BICYCLIST

2007

Patient Arrivals and Patient Acuity

There doesn’t seem to be much difference in how patients are brought to us and from where. Ground and air ambulance numbers are roughly the same as last year for those brought from the scene of an injury or transfer from another facility. Of note, approximately half of all the patients Boston MedFlight has brought to Boston Medical Center have been injured and have involved the Trauma Program. Also, about seven out of every 10 patients are brought to us directly from point of injury with only pre-hospital intervention. Upon evaluation and initial resuscitation, one-third of all trauma patients require admission to a monitored setting, i.e. the Surgical Intensive Care Unit, the Operating Room or a telemetry bed which has also been consistent over the years. We are very comparable to the national data overall except our Direct to the OR rate is higher by 6%.

Diagnostic, Special and Operative Procedures

This past year has seen an overall increase in every diagnostic imaging study that has been tracked with a marked increase in the use of the MRI. Special Procedures showed no appreciable difference while operative procedures were slightly decreased. This may reflect the overall trend of better utilization of resources and the trend toward nonoperative management.

Length of Stay The most notable piece of data in Hospital, Intensive Care Unit Length of Stay and Ventilator Days in the ICU is that we have reduced in half the chronically (> 21 days) ill patients that previously were disproportionately utilizing resources that are now available to others. This has been a collaborative success of early and efficient discharge planning by Care Management, Social Work, Nursing, our NPs and surgical team. Our overall Hospital and Intensive Care Unit length of stay is the same as that reported to the NTDB.

Toxicology

The data from our toxicology screens is encouraging. After years of seeing Blood Alcohol Levels consistently above 180, this year we can report an average Blood Alcohol Level for intoxicated patients of 140.9 which represents a 24% decrease from the previous year. As previously stated, we are reluctant to draw conclusions at this time, but we feel our SBIRT (Screening, Brief Intervention and Referral for Treatment) Alcohol Intervention/Injury Prevention Program may be beginning to bear fruit. AVG ALCOHOL LEVEL 250 200

184.2

196.3

183.2

186.2 140.9

150 100 50 0 2003

2004

2005

2006

2007

Also of note and equally satisfying, is that the toxicology levels across the board of all substances of abuse have decreased this year compared to the previous one. The only exception is opiates and that must be qualified as it cannot be differentiated if opiates were part of an injury event or part of the pre-hospital or hospital treatment. Interestingly, the NTDB has us higher for alcohol and lower for other drugs that are present in the trauma patients than comparable facilities.

Gender and Age

Even though our volume has continued to increase the male/female percentage has remained relatively constant with about seventy five percent of admissions being male. The national average is about two-thirds male and one-third female. With respect to age, the breakdowns have not differed much in the last few years and we are happy to maintain our share of the pediatric category. We are also exploring ways to increase and re-classify some pediatric patients which would enhance our pediatric trauma capacity. Compared with national data, our trauma population is younger with a higher percentage of patients aged 15-50 than the rest of the country.

Disposition The disposition data for 2007 relates outcomes at the completion of the acute inpatient phase of care. This includes primarily discharge to home, transfers to rehabilitation facilities and deaths, among others. These data have not substantially changed since last year with about 77% of patients going home and an inpatient mortality rate of 3%. The national average for these two categories is 67% and 4% respectively. We recently added APACHE II (Acute Physiology and Chronic Health Evaluation) scoring to patients upon admission to the Surgical ICU. Our data indicates an average APACHE II score of 13 with a 13% mortality rate for this very ill cohort of severely injured patients. The computer model for this group reports a predicted mortality rate of 16.5% which represents over 3 lives saved per 100 patients better than predicted. Our relationship with the Office of the Chief Medical Examiner has continued to be an asset as we now get 100% autopsy results on all trauma deaths referred to that office. This information is incorporated into our Morbidity and Mortality discussions, Peer Review and Program Improvement loop closure process.

Research Program Research has been a cornerstone of the trauma program since Dr. George Clowes lead the Surgical Research Laboratory at the Boston City Hospital. The dedication of the section to the investigation of trauma and acute care surgical problems continues to this day, under the direction of Dr. Peter Burke. The division of trauma surgery participates in numerous projects – many of which originate at Boston Medical Center while others have corporate sponsorship. The ongoing projects are reviewed and dissected, and the new projects discussed, on a bimonthly basis by all of the investigators in the section. In addition to the six trauma surgeons, there are three research fellows, five advanced practice registered nurses, a trauma pharmacist, and two dedicated nurse researchers who participate in the research program. Multiple grants, publications, and presentations have been the end result of this collaboration. Over the past year, articles have been accepted and published by the Journal of Trauma, American Journal of Surgery, Injury, and Hematology. Research has been presented at the American College of Surgeons, the American Association for the Surgery of Trauma, and many local and regional meetings. Each year, the research activities of the department are highlighted at an annual Research Symposium where resident research studies are challenged, critiqued and disseminated. Laboratory Research Dr. Burke is supported by a NIH RO1 Grant which examines the effects of injury on transcriptional regulatory mechanisms. Various animal and cell culture models of injury are being utilized. Laboratory support this past year was three clinical research fellows during their two year surgical research fellowship. Dr. Suresh Agarwal supported by an AAST grant is studying the effects of mechanical force on wound healing and is developing an animal model for vacuum assisted wound closure. Clinical Research The clinical research program involves multiple sponsored and investigator initiated clinical studies and is supported by two full time research assistants with extensive clinical and administrative experience. Studies include ventilator associated pneumonias, new treatments for sepsis and inter-abdominal infections. Dr. Hirsch recently published multiple articles in the Journal of Trauma and a commentary for the J.Trauma regarding the history of wound healing. Dr. Agarwal is the principal investigator of a study examining the effects of a novel antioxidant formula on the inflammatory response of severely injured patients. A new treatment of severe head injury with increased intra cranial pressures utilizing DMSO will begin shortly. Other research projects include assessment of bone proteomics and fracture repair, insulin-like receptors in skeletal muscle, cervical spine evaluation in trauma patients, biliary complications after blunt and penetrating liver injury, the incidence of delirium in the critically ill, and a screening tool for the identification of trauma patients at risk for PTSD.

We would like thank everyone for the ongoing support and commitment of the Trauma Program. Should there be any questions, please contact us at the numbers below: Erwin F. Hirsch, MD, FACS Trauma Medical Director 617/414-5689 Joseph S. Blansfield, RN, MS, NP Trauma Program Manager 617/414-4088 Heidi A. Wing, Trauma Data Manager, 617/414-5206

Injury Prevention 2007 Highlights 1. INJURY PREVENTION COLLABORATIVE Beginning in October 2007 a collaborative endeavor was begun with the injury prevention coordinators at several statewide trauma centers which included Massachusetts General Hospital, University of Massachusetts Medical Center, Childrens’ Hospital Medical Center, Lahey Clinic Medical Center and Baystate Medical Center. This allowed us the opportunity to share information and explore new ideas with our colleagues. These collaborative efforts will collectively increase our initiatives to best serve our trauma populations. 2. CAR SEAT PROGRAM The Car Seat Program continues with ensuring every newborn has a safe car seat for discharge if parents/guardians are unable to purchase one themselves due to financial constraints . 3. HELMET RX PROGRAM We continue to offer discounted helmets at $5 each for adults and children and provide helmet education to all pediatric trauma patients. 4. MENTAL/BEHAVIORAL HEALTH SCREENING POST TRAUMA Departments of Surgery and Social Work continue to work on a quality improvement project by screening for depression and acute stress prior to discharge of all admitted trauma patients. This allows us to assess their risk for developing depression/PTSD and connect them with resources/referrals in the community. To date 74 inpatients have been screened and data analysis is ongoing. The RNs/NPs in surgical clinic continue these screenings at follow up clinic appointments as well. We are hoping to further develop this as a research proposal with the help of a masterslevel student volunteer to investigate how inpatient surgical care – pain control, etc. has an impact on the scores from these screenings. This, in turn, will eventually help us shift our surgical management to aid with reducing the risk of developing PTSD/Depression post-trauma. 5. VIOLENCE INTERVENTION ADVOCATE PROGRAM (VIAP) We began a Violence Intervention Advocate Program (VIAP) at BMC in October 2006. The VIAP program was born from funding from the Boston Public Health Commission. Massachusetts Governor Patrick and the state Department of Public Health were strong proponents of the violence intervention initiative. DPH funded Dr. Judith Bernstein and Dr. Edward Bernstein, founders and directors of The BNI (Brief Negotiated Interview) Institute at Boston University School of Public Health to supplement their substance abuse initiative with violence intervention. Drs. Bernstein were asked to disseminate the VIAP to six additional emergency departments throughout Massachusetts.

They are Massachusetts General Hospital, University of Massachusetts Medical Center, Baystate Medical Center, Lowell General Hospital, St. Lukes Hospital and Brockton Hospital. Training has been completed for the Violence Intervention Advocates (VIA) who have now expanded their role from Alcohol and Substance Abuse Prevention advocates. We now have weekly conference calls to continue to support the VIA personnel from these facilities in their own programs. In 2007, there have been approx. 74 encounters with almost 50 of them at BMC. Over one fourth of patients who received this intervention had determined retaliation was not the desirable response. 6. PARTNER NETWORKING/COMMUNITY OUTREACH We have networking meetings with several outside agencies who work with high risk victims of violence including, Boston Public Health Commission, Father Friendly Program, Suffolk County Corrections Re-entry Program, Louis D. Brown Peace Institute, Career Collaborative, Pyramid Builders, Wheelchair Sports, Bowden St. Health Clinic and Massachusetts Trial Court. Our objective is to enhance our referral base and collaboration with outside agencies to provide better services for our patients and families. 7. VIOLENCE IS PREVENTABLE (VIP) PROGRAM Several Adult, Pediatric and Psychiatric Emergency Nurses work with selected Boston Public Schools to bring high risk youth into the Emergency Department to tour the trauma rooms and watch a video about a resuscitation. This is followed by a debriefing and discussion about conflict resolution and alternatives to interpersonal violence. 8. INJURY PREVENTION THROUGH ALCOHOL INTERVENTION SBIRT (Screening, Brief Intervention and Referral for Treatment) in the Adult Emergency Department and Inpatient Units continues. There have been 174 Brief Negotiated Interviews conducted during the year on an inpatient setting. On July 12th 2007 BMC hosted training for the American College of Surgeons on Alcohol Intervention. Our SBIRT experience was presented at the New England Regional Trauma Conference on September 27, 2007 and was entitled “Negotiating Behavior Change with the Trauma Patient - Alcohol SBIRT”. 9. MASSACHUSETTS PREVENT INJURIES NOW! NETWORK The Injury Prevention Coordinator has joined a statewide multidisciplinary committee on Injury Prevention that meets quarterly and represents Boston Medical Center in the public, private and professional sectors. Lisa C. Allee, LICSW, MSW Injury Prevention Coordinator