Research

The Use of Tissue Oxygen Monitoring in Critically Injured Patients

Our assessment of resuscitation status in trauma patients is limited by a lack of precise markers that reflect perfusion of critical organ beds. The purpose of this prospective observational study of severely injured polytrauma patients is to investigate tissue oxygen tension and microcirculatory flow as markers for resuscitation status.

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Investigation of Glucose Control in the Intensive Care Unit (ICU) via Strict Versus Moderate Insulin Infusion Protocol

Unfortunately, little data exists on the glucose control parameters and outcome in trauma patients. We are currently in the middle of a trial to examine the level and effectiveness of glucose control protocols currently applied to our severely injured and ill ICU population at SFGH. We have collected data from 2405 patients regarding the effect of differing insulin protocols on glycemic control and outcome after trauma.

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Continuous Hemoglobin Monitoring in Severly Injured Patients

We are testing the use of continuous hemoglobin (SpHb) monitoring to measure hemoglobin (Hb) concentration and whether this technology will provide a clinically useful measure of bleeding and anemia after trauma that is superior to current invasive, discontinuous techniques.

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Ventilation and Weaning in Spinal Cord Injury Patients after Injury

Spinal cord injury (SCI) is unfortunately common after injury and carries potentially devastating respiratory implications depending on injury level. Guidance for the ventilatory weaning and strategies for mechanical ventilation in the acute post trauma setting are non-existent. This study aims to review our experience to identify predictors of successful extubation after SCI.

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Hemostatic Resuscitation and Traumatic Coagulopathy

Coagulopathy is present in 25-38% of trauma patients on arrival to the hospital and these patients are four times more likely to die. Recently, a high Fresh Frozen Plasma (FFP):Packed Red Blood Cell (PRBC) ratio has been shown to decrease mortality in massively transfused trauma patients. Drawing on our work in acute traumatic coagulopathy we have through the SFIC continued work on the ideal hemostatic resuscitation protocols.

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The Use of rFVIIa in Trauma Patients: A Multi-Center Case Registry Study

Recombinant activated factor VII (rFVIIa) is being utilized as an adjunctive measure to control coagulopathic bleeding associated with major trauma without clear evidence of its efficacy. The present study was undertaken to gather data from U.S. trauma centers on the use of rFVIIa for hemorrhage. We hypothesized that we could identify the patients and describe the setting in which rFVIIa would be successful in reducing mortality from post-traumatic hemorrhage.

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Applied Bioinformatics for Injury and Resuscitation

New applications of techniques in bioinformatics and data mining have been developed in the disparate fields of high throughput genomics, physics, and business data management that are aimed at dealing with increasingly large and complex data sets. We are continuing our work with ICU bioinformatics and continue to test the overall hypothesis that applied bioinformatic techniques can identify previously unrecognized physiologic patterns, which can predict outcome and guide care in severely injured patients.

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Pulmonary Embolism After Trauma

Investigators at the Injury Center have had a long-standing interest in preventing post-traumatic thromboembolic complications (venous thromboembolic events (VTE); deep venous thrombosis (DVT) and pulmonary embolism (PE). Recently, despite vigorous application of prophylactic measure for VTE prevention, we have noted an increase in the number of PE discovered, likely the result of increased imaging with chest CT scans which are capable of detecting event small peripheral clots.

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Prevention of DVT after Injury: Comparing Standard LMWH Prophylaxis with Adjust Dose LMWH

As mentioned above, DVT and PE prevention have been a major focus of the San Francisco Injury Center since its inception in 1989. We have recently received a grant from the National Trauma Institute to join a multi-center study investigating standard dose administration of the LMWH enoxaparin with adjusted-dose enoxaparin based on thromboelastography (TEG) measurements.

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Ace's Adventure Game is a high quality, market-ready interactive computer-based video game which focuses on elementary school-aged pedestrian safety. The game, which was designed by members of the San Francisco Injury Center, was developed by REALTIME ASSOCIATES in Los Angeles. In order to test the "translation" of game-based lessons into performance, a life-size simulated Safety Street was designed by a Hollywood company to resemble the game and to test the child's behavior as he/she walks through the street. The "testing" stations on the street replicate the same safety lessons that are contained in the game. Once we have demonstrated the feasibility of teaching prevention lessons using game-play, we will expand our efforts to additional schools as well as adding additional games that focus on other prevention messages for elementary school children.

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We are actively engaged in preparing the next generation of injury control/prevention professionals through:

• Supporting the NIH Shock Trauma Postdoctoral Research Fellow

• Training 17 premedical and medical student research assistants in the past 18 months

• Disseminating injury research and control messages nationally and internationally through leadership in national trauma organizations and participating in education venues

• Training personnel in low income countries in the basics of first aid for trauma victims and in the use of low-cost diagnostic methods to detect serious injuries

We also collaborated with 3 other universities (University of Vermont, University of Pittsburgh, and the University of Colorado) in a study aimed at investigating the attitudes of premedical students toward careers in trauma and emergency surgery. We found that among students interested in pursuing careers in surgery; orthopedics, pediatric surgery, and trauma/emergency surgery were their top 3 choices at all four institutions. Life-style choices and personal/family time became more significant influences as students progressed from their pre-clinical years to the time on surgical wards. However, the influence of role models in emergency/trauma surgery became significant in influencing their choice of careers. The study was presented at the 2011 Annual Meeting of the Western Trauma Association and the manuscript is currently under review at the Journal of Trauma (co-authors Knudson and Kornblith, UCSF surgical resident).

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We have contining efforts in Mulago Hospital and the greater Kampala, Uganda region. We have been involved in three areas of activity there:

• Teaching and implementation of ultrasound as a modality for use in acute trauma care
• Detailing the burden of injury in Kampala
• Developing a prehospital training program for lay first responders (taxi drivers and police)

Our epidemiology work includes a comparative analysis of mortality and an outlining of morbidity. One key finding is that deaths from trauma (25% of the total deaths) were disproportionately higher in Kampala compared to only 6% in San Francisco. Much of this work was performed by medical students and one of our UCSF surgical residents who is planning a career in trauma, Dr. Sudha Jayaraman. The manuscript has been published in the World Journal of Surgery. Finally, we have assisted the faculty at Mulago Hospital to obtain a grant which supports the education and training of lay-person first responders to road traffic crashes (basic first aid and life support measures) in a city where there is no 9-1-1- system.

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Our hospital-based violence prevention program targets individuals who are at particularly high risk for injury recidivism, traditionally running at a rate of 35% in our hospital. The three basic tenants are 1) provide long-term culturally competent case management to victims of violent injury, 2) seize the "teachable moment" during acute hospitalization when individuals are perhaps most amenable to change and are most motivated, 3) shepherd clients to risk reduction resources in our community. We partner with a host of community based organizations and lead a city-wide crisis response team for violent injury. Our program has obtained funding as a line item in the Mayor's budget for the past three years and is dually supported by our Board of Supervisors. In an interim evaluation, we demonstrated success at risk reduction over 50% of the time with our clients within 6 months of program enrollment. Most recently, a Master's student from UC Berkeley presented a poster for the American Association for the Surgery of Trauma on our longer-term outcomes: We have screened over 600 patients and enrolled 186 "intense" clients. Our recidivism rate over 4 years fell to 11%. In this study, we also demonstrated that if we prevented just 3 reinjuries, our violence prevention program would be cost-neutral. In addition to our findings, we have created an encrypted web-accessible database, with the assistance of our case managers, that will allow uniformity across sites as we expand. We expanded to UC Davis in Sacramento in 2010 and are starting to design a fidelity study. Our program is also the model of a violence prevention program at Wishard Trauma Center in Indianapolis. Finally, we are part of the leadership of a national consortium of violence prevention programs and are in the process of developing a white paper as a group. The program has received praise from US Representative Jackie Speier and State Congressman Mark Leno.

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Evaluation of Pedestrian Injury and its Associated Hospital Costs in San Francisco

This study aims to describe the injured pedestrian population in San Francisco, the associated hospital costs for treatment at San Francisco General Hospital (SFGH), and the nature of cost by collision location. One of the unique features of the study is the reporting of cost rather than charge data. The few medical expenditure studies published in the literature have generally reported charge data, which refers to the amount billed for medical care. Our study reports actual cost, which refers to the amount actually paid for care, by insurance companies or patients themselves. Data from patient medical records, the trauma registry, hospital billing information system, and police reports for all patients involved in an auto-versus-pedestrian collision (AVP) from 2004-2008 and treated at SFGH, the city's only Level I Trauma Center, were included in this study. The analysis included total cost of pedestrian injury per year and by Supervisory District. An abstract was submitted and the work was presented at the March 2010 Western Trauma Association Conference. The corresponding manuscript is in review at the Journal of Trauma.

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Evaluation of Bicycle Injury and its Associated Hospital Costs in San Francisco

Police reports are the industry standard for assessing transportation-related collisions and informing policies and interventions that address the issue. Previous studies have suggested that police reports miss a substantial portion of bicycle crashes not involving motor vehicles. Trauma centers may be the only source for surveillance and cost data on "cyclist only" injuries. No study to date has explored the health and economic impact of cyclist-only injuries. Our objective was to report medical cost of injuries from our trauma center databases to make an economic case for prevention. We aimed to compare the incidence, injury severity, admission rate, and cost for cyclist-only and bicycle-versus-auto (BVA) injuries. We hypothesized that cyclist-only injuries carry an equal or greater burden of injury and cost when compared to BVA injuries. We conducted a retrospective cohort analysis of hospital records for 3,049 patients treated for bicycle-related injuries at our city's only level I trauma center. We compared injury type by injury severity, admission status, and cost. We calculated cost using cost-to-charge ratios, ambulance, and professional fees, inflated to 2009 dollars. We analyzed data using parametric and non-parametric statistical tests.

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In a retrospective study, our group found that mental illness is an independent risk factor for unintentional injury and re-injury. Our findings were published in the Journal of Trauma. We are collaborating with the Department of Psychiatry for the prospective phase of our study. The purpose of this most recent study was to administer a standard validated screening instrument and psychosocial needs assessment to admitted patients who suffer unintentional injury. We aimed to prospectively measure the prevalence of mental illness. A bedside structured interview, including the mini international neuropsychiatric interview(MINI), and a needs assessment was performed by lay research personnel trained by faculty from the Department of Psychiatry. The validated needs assessment questions were from the Camberwell Assessment of Need Short Appraisal Schedule (CANSAS) instrument. A total of 1829 people were screened during the study period. Of the 854 eligible people, 348 were able to be approached by researchers prior to discharge with a positive response rate of 63% (N=219 enrolled). This inpatient pilot screening program prospectively identified preexisting MI as a risk factor for unintentional injury. Implementation of validated psychosocial and mental health screening instruments is feasible and efficient in the acute trauma setting. Administration of a validated mental health screening instrument can be achieved by training college level research assistants. This system of screening can lead to identification and treatment of mental illness as a strategy for unintentional injury prevention. We are currently following our population long term and screening for post traumatic stress disorder.

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