"Keeping You Up-to-Date with Current Literature" Brought to you by the EAST Manuscript and Literature Review Committee
This issue was prepared by EAST Injury Control and Violence Prevention Committee Members Anna Goldenberg, DO, Leah Tatebe, MD, FACS, Patrick Maluso, MD and Dane Scantling, DO, MPH.
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Alcohol use and its physical and mental impact specifically above the legal limit of 0.08 g/dL has been well documented as a risk factor for motor vehicle collisions and fatalities. Various studies have demonstrated that higher blood alcohol levels (BAL) in drivers was associated with high speed of travel which subsequently can lead to increase in injury severity scores (ISS) which in turn leads to higher mortality.
In a study by Ahmed and Greenberg, patients’ demographics were surveyed from the US National Trauma Bank (2007-2010) and any blood alcohol level greater than 0.08 g/dL was considered alcohol positive vs. patients who had no alcohol present on testing were identified as alcohol negative. The primary outcome of interest was in- hospital mortality, including death in the emergency department. Secondary outcomes included total length of stay, time of patient expiration, and discharge disposition following the traumatic injury.
A total of 88,794 patients met the inclusion criteria for the study. Of those 27,464 were positive for alcohol with a BAL above legal limit, while remaining patients tested negative. Demographic characteristics were different in respect to positive vs negative patients when it came to age gender, and race but after propensity matching using a 1:1 ration the differences were reduced. While SBP, ISS, and GCS were difference they did not reach true statistical significance. When analyzing in hospital mortality rates observed were 2.7% (95% CI:2,5%,2.9%) vs. 2.5 (95% CI: 2.3%,2.7%) between the alcohol positive and negative (p=0.22). The absolute risk difference with in-hospital mortality between the two groups was 0.2%. There was a difference but not clinically in the total hospital length of stay 3 days vs. 4 days between the positive and negative group. There was no difference in the time of patient expiration as well as disposition of the patients who survived to discharge. A statistically higher proportion of patients who were alcohol positive had a head AIS >3 (12.8% vs. 9.9% p<0.001). Furthermore, when exact matching both patient populations where each group contained 26,304 patients, the demographics, SBP, ISS, and GCS did not reach true statistical significance. In the same manner, the in-hospital mortality was not statistically significant (p=0.23) as well as the post hospital discharge disposition. The only clinically statistically significant difference was in the rate of extremity injuries which was higher in the alcohol negative patients (p<0.001).
This large survey of the US National Trauma Bank on differences in outcomes between alcohol positive and negative patients showed that while 30% of patients who suffer traumatic injuries who arrived at a Level 1 or 2 trauma center had an above legal blood alcohol level, there was no evidence of significant differences in mortality, patients’ expiration time, and length of stay. Although this was a large retrospective study, a lot of patients had missing values of data as well as unreported number of patients who died at the scene. Also, BAL is collected in a categorical format and not all patients had a level tested upon arrival.
In conclusion, although randomized prospective studies on blood alcohol level are unethical further investigation is needed exact patient matching is possible. Currently this study did not show any clinically significant difference in outcomes between alcohol positive and negative patients.
Alcohol-relating driving fatalities represent about one-third of all driving-related deaths. Further, just in time interventions are thought to be effective in promoting behavior change. Counseling during an index medical evaluation following alcohol-related injury may decrease risk of reinjury. Alcohol use disorder (AUD) screening and interventions are a requirement for trauma center verification systems. The Screening, Brief Intervention, Referral, and Treatment (SBIRT) model of such interventions is a commonly used methodology. The authors present a systematic review of SBIRT effectiveness for AUD.
After an extensive search of multiple high-quality databases, 35 articles from 1966-2016 for patients aged 12-70 years were included in the review. Two authors scored the articles for content and quality of evidence. Given substantial differences in methodology, the data was descriptively analyzed. A variety of screening questionnaires were used: Alcohol Use Disorder Identification Test (AUDIT), an abbreviated version called AUDIT-C, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) Guide, the CAGE questionnaire, and positive test for alcohol, and self-report of ingesting alcohol within six hours prior to the injury. Other adolescent-specific screening tools were used as well. In addition, several studies included instruments to evaluate the negative consequences of drinking alcohol and the patient’s readiness to change.
Brief interventions were typically a condensed version of cognitive behavioral therapy, motivational interviewing, or a combination of both. Who was performing the intervention and the depth of the intervention varied by study and the bandwidth of the staff depending on the day. The primary outcome for all studies was reduction in alcohol consumption. About a third of the studies demonstrated significant reduction in the intervention groups over the control group as defined by the number of drink days and number of units per drink day while about one half of the studies demonstrated reduced alcohol consumption in both the intervention and control groups.
The authors emphasize that screening tools can be completed in relatively rapidly and do not add undo time burden on providers. Despite this, only 20% of people report that they have been asked about their alcohol use. The authors posit that the simple act of a provide expressing concern about a patient’s potential for harmful drinking is enough to potentially spark internal questioning of the need for behavioral change. Given the correlation between emergency department (ED) visits and AUD, the ED is a good place for SBIRT to occur. The study conclusions are not particularly strong given that only 37% of studies showed a benefit while 46% showed no difference. The studies reviewed were highly heterogenous such that only descriptive analysis could be performed. Given trauma center verification requirements for AUD screening and intervention, SBIRT remains a resource-efficient method to meet the standards set forth.
Motor vehicle collisions (MVCs) are a major source of morbidity and mortality worldwide and bear a significant financial burden. Distracted driving is a frequent contributor to fatal and major injury MVCs. A major factor in distracted driving is cell phone use while driving (CPWD). Public health based road safety initiatives such as Vision Zero have been adopted in cities around the world. This study both addresses the design of and assesses the effectiveness of a public health campaign to combat distracted driving in London, Ontario. The campaign, entitled Buckle Up, Phone Down, was coordinated with the enactment of provincial legislation targeting CPWD. It was developed in accordance with the “Es” of injury prevention (epidemiology, education, environment, enforcement, and evaluation).
The public health initiative involved a 2-year (2014-2016) multimedia campaign targeted to 16- to 44-year-olds which consisted of educational messages distributed via social media, billboards, movie theater trailers, and educational materials distributed by police. Advertisement locations were geospatially targeted using a geographic information system which accounted for factors such as proximity to a high school or shopping mall, frequency of MVCs, traffic volume, and local population density of the targeted demographics. The same method was used to target local police blitzes and areas for heightened enforcement of CPWD laws.
The initiative’s effectiveness was measured in multiple ways. The effect of the multimedia campaign on awareness was evaluated through telephone surveys, surveys in the movie theaters where the ads were aired, focus groups, and through social media analytics. In total, the multimedia campaign cost $58,357.68 CAD. The movie trailer accounted for almost half of the cost, but was one of the most effective interventions for generating awareness in the public surveys. The social media campaigns were the second most costly prongs of the multimedia blitz, but were found to be cost ineffective, accounting for less than 3% of campaign awareness reported in the surveys. The authors posit that their choice of social media outlets were ill-suited to the target audience, which had moved away from Facebook to other outlets such as Instagram and Snapchat.
To further assess the campaign’s effect, the authors performed an interrupted time series analysis of distracted driving citations from 2011-2019 which demonstrated a statistically significant reduction in the number of distracted driving citations issued after the campaign despite increased enforcement. While the crash data has not been fully collected to assess the effectiveness of the campaign on reducing distracted driving crashes, an initial review demonstrated a mean annual reduction of more than 200 crashes after the campaign. The next phase of the authors’ evaluation aims to assess the impact of the campaign on not only distracted driving crashes, but also on resultant injuries and fatalities.
Motor vehicle crashes (MVCs) kill nearly 40,000 Americans every year. A number of factors may contribute to MVCs, including fatigue, a particular concern amongst residents. Unsurprisingly, MVCs are one of the main sources of mortality in residents of all specialties and the rates of MVC occurrence are known to increase after extended shifts. Prior to this study, no study had specifically evaluated the rates of MVCs or other hazardous driving events in general surgery residents.
The authors surveyed general surgery residents in all 260 United States ACGME-accredited training programs in 2017. All residents taking the American Board of Surgery In-Training Examination (ABSITE) were eligible for inclusion and the survey optionally appeared at the end of the examination. Residents who were not clinically active (such as residents taking dedicated research time) were not offered the survey. Those who did not answer all survey questions about hazard events were not included. In addition to looking at self-reported MVCs, the authors queried residents about near-miss MVCs and nodding off while driving. Residents were specifically asked how many times such events occurred after calls over the past six months. Additional survey data was collected pertaining to the frequency of duty hour violations and psychiatric well-being using the general health questionnaire-12 (GHQ12).
A total of 7,391 clinically active residents participated in the survey and answered all of the questions; a 99.3% response rate. Of respondents, 5% were involved in an MVC, 26.6% had a near miss MVC and nearly 35% reported nodding off while driving after a call over the last six months. Female residents were more likely to report a near miss MVC after a call and PGY-2, PGY-3 and PGY-4 residents were more likely than PGY-1 residents to report nodding off while driving, near miss MVCs and MVCs after taking call. This difference was not maintained when comparing PGY-5 residents to PGY-1 residents. A number of call specific factors were also assessed. Residents reporting working past 28 hours during a single shift three times or more in their most recent general surgery month of service were more likely to nod off while driving or have a near miss MVC. Those with eight hours of less off between calls at least three times during the same interval also were more likely to nod off or endure an MVC. Aside from call length, residents more frequently violating the 80-hour work week restrictions had more frequent episodes of nodding off, near miss MVCs and MVCs. Poor psychiatric well-being was also associated with increased rates of all three hazard events. None of these events had an association with program size, geographic region or type (academic or community). However, urban residents were less likely to report nodding off or near miss MVCs.
While deaths among residents are not frequent, MVCs are a leading – and preventable – cause. This study, which provided the first insight into hazardous driving events amongst general surgery residents, discovered concerning rates of residents nodding off, having near miss crashes of enduring motor vehicle crashes after calls. Poor psychiatric well-being and frequent duty hour violations, including of the 80-hour work week and of the 28-hour call limit were associated with such events and may be a target for improving surgical resident well-being and safety.
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This Literature Review is being brought to you by the EAST Manuscript and Literature Review Committee. Have a suggestion for a review or an additional comment on articles reviewed? Please email litreview@east.org. Previous issues available on the EAST website.
