Trauma Monthly
Volume:22 Issue: 5, Sep-Oct2017

Neonatal intensive care units are prone to a variety of errors due to their special conditions. Failure mode and effects analysis (FMEA) is a method for risk assessment and management, which assesses the safety of patient care processes through its system approach.

The present study aimed to identify and assess common medical errors at Amirkola Children’s hospital NICU in 2016.

This was a cross-sectional study conducted from September 2015 to February 2016 in the NICU of Amirkola Children’s Hospital in the city of Babol to identify and assess the medical errors and their effects qualitatively and quantitatively using FMEA through direct observations of the NICU processes, brainstorming, and focus group discussions (FGD). The FMEA standard worksheet was used for data collection. The collected data were analyzed using Excel 2010.

In this study, 4 key processes were selected through studying the care methods and brainstorming including drug administration, infection control, medical equipment use, and laboratory tests; 27 activities and 50 potential failure modes, as well as their impacts were detected and recorded in the final worksheet of FMEA. According to the calculated PRNs, 27 potential failure modes with PRN > 65 were determined as high-risk failures. The highest and lowest PRNs were, respectively, related to improper and incomplete washing and disinfecting the hands (PRN = 127) and illegibility of the lab requests for laboratory tests (PRN = 32).

Based on the findings of this study, 57 potential failure modes in 4 key processes of the studied NICU were determined, among which 27 potential errors and failures with high risks were recognized. Therefore, it can be suggested that the senior managers and administrators should create multidisciplinary teams for patient safety at the organizational and unit levels

Traffic events are the second most common cause of mortality and the first cause of years of life lost (YLL) in Iran.

The aim of this study was to determine the survival of patients with traffic injury and evaluate hospital care quality using the trauma and injury severity score (TRISS) method.

This cross-sectional study was conducted on 1000 patients aged 1 to 89 years old who were hospitalized in two university hospitals in East Azerbaijan, Iran. Patients were selected by using stratified sampling. Data were extracted from medical records and analyzed by STATA11 software. Injury severity score (ISS), revised trauma score (RTS), and expected survival were calculated using the TRISS software package. W-scores and Z-scores were calculated to evaluate the performance of hospitals. Finally, results were compared to those of the major trauma outcome study (MTOS).

Among 1000 patients, 246 (24.6%) were female. The mean age was 32.6 years (SD, 18.6). Mean ISS for living patients was 12.4 (SD, 4.3) while it was 36.9 (SD, 8.9) for fatal cases. The average RTS was reported to be 7.1 and 4.35 for alive and fatal cases, respectively (P < 0.001). Based on TRISS, 58 cases were expected to result in death; however, 65 fatalities were observed (65/1000). The W-score was -7 per 1000 and Z-score was + 0.02. The TRISS misclassification rate for survival status of patients with traffic injury was reported as 2.6%.

Our findings indicate that the quality of care at the hospitals under study using the TRISS method was lower than the quality of care in the MTOS study. Further, survival of traffic injury patients was clearly influenced by the quality of hospital services provided

The effectiveness of topical phenytoin on wound healing has been cited in several research papers. However, methodological flaws and inappropriate controls, as well as the absence of randomization and double blinding devalue most of them.

We attempted a more stringent assessment of topical phenytoin powder and its role in the enhancement of wound healing.

76 rats were assigned and divided into two groups: phenytoin-treated and normal saline-treated. Phenytoin and saline were applied on incised open wounds in both groups. The efficacy of phenytoin and normal saline applications was assessed via morphological and histological evaluation over a 4-week period.

The results showed considerable reeducation in epithelization in the phenytoin-treated group vs. the control group over the study period. Neovascularization and tensile strength were significantly higher in phenytoin-treated rats as well. There was an insignificant difference regarding wound contraction time.

Phenytoin application promoted wound healing. The healing properties of topical phenytoin powder were better in wounds.

Central venous catheters (CVCs) are increasingly used for central vein pressure measurement, fluid replacement, blood-product transfusion, hemodialysis, and chemotherapy. Considering the urgent nature of placing CVCs in many patients, local anesthesia is used in order to facilitate recovery and prevent the side effects of general anesthesia. The successful placement of CVCs can reduce injury to adjacent structures.

This study aimed to assess the patients’ pain level, satisfaction, and injury to adjacent structures. Patients and

This case series evaluated 213 patients with end-stage renal disease (ESRD) who had been referred for duallumen hemodialysis catheter (large-bore) placement during the year 2011 at Hasheminejad kidney center (Tehran, Iran). Catheters were placed by a single surgeon, and 5 ml of subcutaneous lidocaine 2% was used at the site of catheterization. At the end of the procedure, pain was measured using a visual analog scale, and the patients’ satisfaction was verbally determined with regard to whether they would accept local anesthesia if they required catheter placement again in the future.

Fifteen patients reported that they would prefer general anesthesia for a similar procedure in the future. Five of these patients experienced mild pain with the present procedure, and the remainder had severe pain. The mean pain scores were 1.93 ± 0.799 in patients who preferred general anesthesia and 1.26 ± 0.450 in the remainder. The difference between the two groups was significant. One hundred ninety-eight patients experiencedmild pain during catheter placement, of which 187 (94.4%) would accept local anesthesia for this procedure in the future. Twenty-two (10.3%) patients underwent arterial puncture, 163 had single-attempt venous puncture, and 50 had two or more puncture attempts. In nine patients, the puncture was unsuccessful and the vein could not be found despite three attempts to insert the needle; for these patients, the anatomical area approached for access was changed.

Local anesthesia facilitates quick recovery, is time-saving, and can reduce hospital expenses. It seems to be a suitable method for reducing complications and increasing patient satisfaction.

Low back pain (LBP) is the primary cause of disability for individuals under 45 years of age, the second most common reason for physician visits, and the third most common diagnosis for surgery. Evidence supports the effectiveness of the Alexander technique (AT) for chronic LBP. Health promotion programs must be evaluated to determine their sustainability and validity. The purpose of this study was to evaluate the theory-based AT program for the management of LBP in teachers according to the Kirkpatrick evaluation model.

This was a quasi-experimental study of female teachers with nonspecific LBP in southern Tehran in 2014. Group one AT training based on the integrative model (IM) of behavioral prediction contained 42 subjects and group 2 AT training alone contained 35 subjects. To evaluate the groups based on Kirkpatrick, a previously confirmed questionnaire was used for the reaction stage, and for the learning and behavior stage, a self-designed questionnaire was used that was confirmed for validity and reliability using content validity (CVR 0.94, CVI 0.90) and Cronbach’s α (0.83). Skill was assessed using a checklist objectively. The data from before the intervention, after, and 3 months later were assessed with an independent and one sample t-test, paired t-test, correlation, and univariate (GLM) assessment via SPSS 19.

Significant differences were not recorded between the two groups in terms of teaching methods (P = 0.36), class conditions (P = 0.49), and general assessment (P = 0.11). For teaching methods, the patients’ satisfaction as reported in all items in both groups was higher than 4 (P < 0.001). In both groups, significant differences were recorded in knowledge, skills, and behavior before and after the intervention, but the AT training based on IM group was higher than the AT training only group in behavior and skills (P < 0.001).

Applying an educational framework such as IM to the design of AT lessons has positive effects on behavior and skills that can facilitate LBP management.

Recently, the use of synthetic bone graft substitutes has garnered attention and become more popular than traditional methods for reconstructing osseous defects in the fields of orthopedics and maxillofacial surgery. Commercially available hydroxyapatites (HAs) have been widely reported to be effective bone graft substitutes. Unfortunately, they are expensive to produce. Thus, there is a need to develop methods of producing HA bone graft substitutes from inexpensive sources.

To synthesize nanocrystalline HA using recycled eggshell and trimethyl phosphate. Until date, several phosphate solutions have been utilized for this purpose. However, this is for the first time to the best of our knowledge that trimethyl phosphate is used as a source of phosphate to synthesize eggshell-derived HA.

To produce HA, calcined hen’s eggshell was used as a source of calcium, and trimethyl phosphate was used as a source of phosphate in a sol-gel method at a controlled temperature. The results were estimated using scanning electron microscopy (SEM) observantion to evaluate surface morphology, X-ray diffraction (XRD) to analyze phase composition, and transmission electron microscopy (TEM) to evaluate the shape and size of prepared HA. Micro-chemical analysis was conducted using energy-dispersive X-ray spectroscopy (EDX). Fourier transform infrared spectroscopy (FTIR) was employed to identify the functional groups of the prepared HA.

XRD evaluation showed that high-purity synthetic HA powder was obtained. The results of the SEM, XRD, TEM, EDX, and FTIR analyses demonstrated that the synthesis yielded nanostructured HA.

A complete synthesis of nanocrystalline HA was obtained by using trimethyl phosphate and eggshells in a sol-gel method at a controlled temperature. A spherical particle morphology and particle size ranged 19 - 41 nm were achieved. Eggshell waste material is inexpensive and can be considered a viable choice for high-volume HA powder production, based on the present results.

The most efficient treatment of posterior cruciate ligament (PCL) tears and the consequences of untreated PCL injuries is still debatable.

The aim of this study was to assess the outcomes of a modified technique for the fixation of tibial posterior cruciate ligament (PCL) avulsion fractures.

From January 2009 to March 2012, 45 cases of PCL tibial avulsion fractures were managed through a modified technique. We used a lag screw and washer in the open posterior approach for our patients. Assessment of the range of motion of the knee was initiated on the day after the surgery. Clinical stability, range of motion of the knee, strength of the gastrocnemius muscle, radiographic investigation, and the quality of life of each of our patients was analyzed upon the last follow-up evaluation.

The mean of the overall musculoskeletal functional assessment (MFA) scores was 15 (range 3 - 35). At the last follow-up evaluation, all of the fractures in our patients were unified, and all of their knees were stable upon physical examination. Preoperative assessments showed that the mean Lysholm score for 15 knees was 62 ± 8 with a range of 50 - 75, which changed to 92 ± 7 with a range of 75 - 101 after the operation; our analysis showed that this difference was significant (P < 0.05). At the first-year follow-up evaluation, differences of less than 10 mm in thigh circumference were observed in 42 (93%) patients when comparing their injured to healthy knee.

The management of tibial PCL avulsion fractures with the use of a cancellous lag screw and a washer by means of a modified open posterior approach leads to satisfactory clinical, radiographic, and functional results, and reduces operation time and blood loss.

Traumatic brain injury (TBI) is a leading cause of mortality and morbidity; despite the use of neuroprotective agents for TBI management, no evidence-based recommendation for any particular neuroprotective agent with favorable outcomes and less adverse effects has been made in TBI management.

We aimed to assess the efficacy of erythropoietin (EPO) use for TBI management. Data Sources: This study is part of a review on neuroprotective agents used for traumatic brain injury: A systematic review and meta-analyses was done, based on a wide search strategy incorporating information from Cochrane CENTRAL, MedLine/PubMed, SCOPUS, Thomson Reuters Web of Science, SID.ir, Barekat Foundation, and clinicaltrials.gov databases up to September 06, 2015. Study Selection: The present study limited the retrieved search results only to those using EPO for TBI management. Data Extraction: The retrieved randomized clinical trials (RCTs) were assessed for their quality of reporting according to the consolidated standards of reporting trials (CONSORT) checklist prior to extracting the data for meta-analysis. The meta-analyses in this review was conducted using the extended Glasgow outcome scale (GOS-E) for acute TBI patients, mortalities, and adverse-effects.

Four RCTs were retrieved on EPO use for acute TBI, and two of them were kept for the final analysis. The analysis of the enrolled 645 participants in these studies showed insignificant but slightly better outcomes in the placebo group, while a significant reduction in mortality rates among EPO users was observed. Slightly better outcomes in vascular and non-vascular side-effects were also observed in the intervention group.

EPO may be considered as effective in reducing TBI mortality and vascular side-effects, while there is no evidence to support any benefits in other outcomes or for the elimination of non-vascular side-effects. Further studies, especially well-designed phase-III dose-controlled trials, are needed for building a stronger body of evidence for recommending the use of EPO for acute TBI.

Treatment in an intensive care unit (ICU) is both stressful and psychologically traumatic for patients. Many mental disorders can arise following traumatic and stressful events, including anxiety, depression, and post-traumatic stress disorder. Studies have investigated nurses’ and patients’ views on the stressors in a typical intensive care unit. However, there have been inconsistencies in the results of these studies. Moreover, only a limited number of studies have been conducted on this issue in Iran.

This study aimed to compare patients’ and nurses’ views of the traumatic stressors inherent in intensive care units.

This cross-sectional study was conducted on 120 patients who were hospitalized in intensive care units, as well as 60 nurses in the intensive care units, in 2014. The study instrument consisted of two parts, namely a demographic questionnaire (age, sex, level of education for nurses, and length of hospitalization for patients) and Cochran and Ganong’s modified intensive care unit environmental stressor scale. All the nurses and literate patients answered the questionnaire through self-report. However, illiterate patients were interviewed and their answers were recorded in the questionnaires. The data were analyzed using descriptive statistics and the independent samples t-test.

Themean scores of the stressors were 123.23±17.81 and 125.16±17.35 from the nurses’ and patients’ viewpoints, respectively (P > 0.05). A lack of control over urine and stool, fear of death, pain, and having a tube in themouth or nose were themost important stressors from both the patients’ and nurses’ viewpoints. Moreover, the mean stressor scores were approximately the same in both groups for the first eight stressors.

Nurses and patients had approximately similar views as to the top eight stressors in the average intensive care unit. However, it seems that nurses not only need more training in appraising intensive care unit patients’ stressors, but also in how to reduce or eliminate those stressors. Such an approach could be of importance in the provision of high quality care due to reducing stressors and meeting patients’ care-related needs in intensive care units. Hence, early intra-ICU clinical psychological intervention may help critically ill trauma patients recover from this stressful experience.

Adaptive support ventilation (ASV) is one of the advanced modes of ventilation. The available evidence regarding the process of tracheal extubation indicates that staff working in intensive care unit usually performs the weaning process according to their own experiences and conventional methods.

This study aimed to assess the effect of weaning with adaptive support ventilation in two conventional or standard methods on respiratory and hemodynamic performance indices in patients undergoing coronary artery bypass graft (CABG) surgery.

In this clinical trial, 100 patients candidate for coronary artery bypass graft (CABG) surgery at Jamaran hospital were allocated to experimental and control groups in 2015. Each group had patients. The conventional method of ASV was used in the control group without any intervention, while the standard method of ASV was applied in the experimental group. The groups were compared in terms of arterial blood gases, vital signs, atelectasis, and duration of weaning process.

There was no statistically significant difference between the experimental and control groups in terms of demographic variables and disease history. Also, duration of mechanical ventilation and weaning process, duration of the patient’s trigger to the tracheal extubation as well as other respiratory performance indicators and vital signs were similar between the groups (P > 0.05).

The results of this study indicate that in stable patients who have no history of lung problems, there is no need to apply the difficult weaning protocol. These patients can be weaned without any complication.

Nowadays, surgical treatment is the gold standard to manage traumatic intraperitoneal urinary bladder rupture; there is an increasing trend of conservative management in cases of urinary tract trauma.

A 72-year-old male with high energy trauma due to car accident had blunt traumatic intraperitoneal urinary bladder rupture with pelvic fracture. He was successfullymanaged non-operatively by catheter drainage of the bladder and external fixation of the pelvic fracture while he was hemodynamically stable and there was no other organ injury.

Non-operative management for a blunt traumatic intraperitoneal bladder rupture with pelvic fracture is an important treatment modality if a laparotomy is not needed for any other abdominal organ injuries, and urine can be constantly drained through a catheter; and a close surveillance can be performed for generalized peritoneal signs and uroascites.

Pain control is essential for ideal care of surgery patients. Noninvasive or minimally invasive procedures outside the operation room have had an increasing trend in the recent years. Sedation, analgesia or both may be necessary for the majority of these diagnostic or interventional procedures.

We sought to compare sedative and analgesic effects of Ketamine-Propofol (Ketofol) and Fentanyl-Midazolam (Fentazolam) Combinations in emergent outpatient orthopedic operations.

Sixty male candidates for closed reduction of Colle’s fracture were divided into two groups of ketamine-propofol (Ketofol, KF) and fentanyl-midazolam (Fentazolam, FZ). Pain, sedation score, hemodynamic variables, recovery times, patients’ and the operator’s satisfaction and complications were evaluated.

Pain score decreased 4.57 units in the KF group and 3 units in the FZ group (P < 0.001); this decrease was more significant in the KF group in comparison with the FZ group (P < 0.001). The patients’ sedation score during the procedure was 3.43±0.73 and 2.4 ± 0.49 in KF and FZ groups, respectively (P < 0.001). The 5th minute systolic blood pressure was significantly higher in the KF group in comparison with the FZ group (P < 0.001). The 5th minute diastolic blood pressure was significantly more in the KF group in comparison with the FZ group (P < 0.001). The 5th minute pulse rate was significantly greater in the KF group in comparison with the FZ group (P < 0.001). The mean recovery time was significantly more in the FZ group (25.6 versus 18.67 minutes, P < 0.001). The mean patient’s satisfaction was 4.37 ± 0.85 in the KF group and 3.73 ± 0.87 in the FZ group (P = 0.006), and the mean doctor’s satisfaction was 4.35 ± 0.89 in the KF group and 3.27 ± 1.08 in the FZ group (P < 0.001).

Ketamine-Propofol, with lower dose of each drug, had a better sedation and analgesic effect as well as lower complications and shorter recovery time when compared to fentanyl-midazolam.

Peritoneal lavage is a need after laparatomies performed for secondary peritonitis. Some previous studies mentioned the benefit of abdominal lavage with antibiotics, in secondary peritonitis operations. The current study aimed to compare normal saline alone (NS) with normal saline plus gentamicin (NS + G) for abdominal lavage in secondary peritonitis.

In this randomized clinical trial (RCT), patients who were referred to the emergency department, and were candidates for urgent laparotomy were enrolled. After giving informed consent, 80 patients were randomized into 2 groups of peritoneal lavage with (NS) and (NS + G). Descriptive statistics were calculated for the presented data. Chi-square test and Fisher’s exact test was used for determining the association between qualitative variables. Comparison between the groups was made using the nonparametric Mann-Whitney test. The Kolmogorov–Smirnov test was used for normality of the data.

Themean age of the patients was 41.39 years, and 67.5% weremale. There were no significant differences in the demographic data, history of abdominal surgery, diabetes, and the cause of peritonitis. Twenty-one patients needed another surgical intervention. The need for surgical interventions was significantly more in the NS group compared to the NS + G group (17.5% vs. 35%, P = 0.039). There was no significant difference in fever, wound infection, admission time, intravenous antibiotic duration, return to work time, and mortality between the 2 groups.

It seems that peritoneal lavage with gentamicin in secondary peritonitis may decrease the need for surgical interventions.

The basic step in planning and policy-making for hospital surge capacity in disasters is the awareness of the current situation and problems. This issue is of greater importance in hospitals of developing countries that usually face many problems in ordinary situations; this paper aimed at identifying the status of hospitals in a developing country for surge capacity and the associated challenges at the time of disasters, and strategies to solve them.

In this qualitative study, semi-structured interviews were conducted with 27 participants, who were mostly officials of hospitals and the authorities of the ministry of health in Iran. Thematic analysis was used for analyzing the data.

In this study, 40 subthemes and 12 themes under 4 main categories, including space, medication/supplies, manpower, and functional structures/plans, were identified. Some of these themes included shortage of space inside the structures, weakness in providing medication/emergency medical supplies, general shortage of manpower, weakness in maintaining and recalling staff at the time of hospital surge capacity in disasters, content defect in hospitals disaster preparedness plan, and weakness in training for disasters

Generally, there are various challenges hospital surge capacity at the time of disasters, and hospitals are disadvantaged in this regard. However, implementing strategies recognized in this study may help resolve these challenges.