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Publication A Model to Advance Nursing Science in Trauma Practice and Injury Outcomes Research(2011-01-01) Richmond, Therese S; Aitken, Leanne MAims: This discussion paper reports development of a model to advance nursing science and practice in trauma care based on an analysis of the literature and expert opinion. Background: The continuum of clinical care provided to trauma patients extends from the time of injury through to long-term recovery and final outcomes. Nurses bring a unique expertise to meet the complex physical and psychosocial needs of trauma patients and their families to influence outcomes across this entire continuum. Data Sources: Literature was obtained by searching CINAHL, PubMed and OvidMedline databases for 1990 – 2010. Search terms included trauma, nursing, scope of practice and role, with results restricted to those published in English. Manual searches of relevant journals and websites were undertaken. Discussion: Core concepts in this trauma outcomes model include environment, person/family, structured care settings, long term outcomes and nursing interventions. The relationships between each of these concepts extend across all phases of care. Intermediate outcomes are achieved in each phase of care and influence and have congruence with long term outcomes. Implications for Policy and Practice: This model is intended to provide a framework to assist trauma nurses and researchers to consider the injured person in the context of the social, economic, cultural and physical environment from which they come and the long term goals that each person has during recovery. The entire model requires testing in research and assessment of its practical contribution to practice. Conclusion: Planning and integrating care across the trauma continuum, as well as recognition of the role of the injured person’s background, family and resources, will lead to improved long term outcomes.Publication A Delphi Study on Research Priorities for Trauma Nursing(1994-05-01) Bayley, Elizabeth W; Richmond, Therese S; Noroian, Elizabeth L; Allen, Lois RObjectives: To identify and prioritize research questions of importance to trauma patient care and of interest to trauma nurses. Methods: A three-round Delphi technique was used to solicit, identify, and prioritize problems for trauma nursing research. In round 1, experienced trauma nurses (N = 208) generated 513 problems, which were analyzed, categorized, and collapsed into 111 items for subsequent rounds. Round 2 participants rated each research question on a 1 to 7 scale on two criteria: impact on patient welfare and value for practicing nurses. Group median scores provided by 166 round 2 respondents and respondents' individual round 2 scores were indicated on the round 3 questionnaire. Subjects rated the questions again on the same criteria and indicated whether nurses, independently or in collaboration with other health professionals, should assume responsibility for that research. Median and mean scores and rank order were determined for each item. Results: Respondents who completed all three rounds (n = 137) had a mean of 8.3 years of trauma experience. Nine research questions ranked within the top 20 on both criteria. The two research questions that ranked highest on both criteria were: What are the most effective nursing interventions in the prevention of pulmonary and circulatory complications in trauma patients? and What are the most effective methods for preventing aspiration in trauma patients during the postoperative phase? The third-ranked question regarding patient welfare was: What psychological and lifestyle changes result from traumatic injury? Regarding value for practicing nurses, What are the most effective educational methods to prepare and maintain proficiency in trauma care providers? ranked third. Conclusion: These research priorities provide impetus and direction for nursing and collaborative investigation in trauma care.Publication Journey Towards Recovery Following Physical Trauma(2000-01-01) Richmond, Therese S; Thompson, Hilaire Jane; Deatrick, Janet A; Kauder, Donald RConvalescence and recovery following illness are of central importance to nursing. These themes have been explored increasingly in the literature. The focus, however, has been primarily on the process of integrating chronic illness into one’s life. Recovery from physical injury is rarely addressed. A body of work focusing on physical trauma demonstrates that recovery is often not complete after injuries that have not been viewed as disabling. To illuminate understanding of recovery following physical trauma, the purpose of our 1997 study was to describe more thoroughly the nature of recovery. A total of 63 adults, in a convenience sample, who survived serious physical trauma, were interviewed 2·5 years after injury using an open-ended semistructured interview guide. Three themes were identified: event, fallout, and moving-on. These themes provided the organizing structure for exploring the journey to recovery. This journey, as disclosed by the seriously injured, does not necessarily correspond with the views of most trauma clinicians. Traumatic events create a line of demarcation, separating lives into before and after. The event becomes the starting point of a journey to resume one’s life. The event itself is more than the trauma; it is the perceptual and contextual experience that needs to be incorporated into a person’s essence. Fallout from the injury is multifaceted and includes physical, psychological, social, and spiritual dimensions. Moving-on in this journey is nonlinear as survivors recognize their lives are forever different. The survivors’ accounts suggest that nurses should carefully consider the question, ‘What is successful recovery?’Publication Characteristics and Outcomes of Serious Traumatic Injury in Older Adults(2002-02-01) Richmond, Therese S; Kauder, Donald R; Strumpf, Neville; Meredith, TammyObjectives: The aims were to: 1) describe the seriously injured older adult; 2) characterize and compare the differences in injury characteristics and outcomes in three subgroups of seriously injured older adults: 65-74 years, 75-84 years, and >85 years of age; 3) identify risk factors for death, complications, and discharge placement at hospital discharge. Design: A retrospective secondary analysis of a statewide trauma data set from 1988-1997. Setting: Data submitted from all designated trauma centers in Pennsylvania. Participants: The data set yielded 38,707 patients with a mean age of 77.5 years with serious injury (mean number of injuries = 3.6, mean number of body systems involved = 2). Measurements: Key outcomes were mortality, complications, and discharge placement. Abbreviated Injury Score categorized injuries and Injury Severity Score (ISS) quantified anatomic severity of injury. Results: Mortality was 10%. Mean length of stay 11.5 days. 52.2% of survivors were discharged home and 25.4% to a skilled nursing facility. Injury severity, total number of injuries, complications and increasing age were predictors of mortality (p<.01). The presence of pre-existing co-morbid medical conditions increased the odds of experiencing a complication over three-fold. Increasing age, total number of injuries, injury to extremities or abdominal contents, injuries due to falls, and lower functional level predicted discharge to a skilled nursing facility (p<.01). Conclusions: Traumatic injury in older adults are typically multisystem, life-threatening, and affects older adults of all ages. The standard ISS does not fully capture the potential for mortality in older adults and does not predict discharge placement. The majority of older adults survive multisystem injury. Our findings indicate the need to examine outcomes beyond mortality and to make the identification and management of co-morbid conditions a priority. A geriatric consultation service could be an important additional to the interdisciplinary trauma team.Publication Early Predictors of Long-Term Disability After Injury(2003-01-01) Richmond, Therese S; Kauder, Donald R; Hinkle, Janice Louise; Shults, JustineBackground: Improving outcomes after serious injury is important to patients, patients’ families, and healthcare providers. Identifying early risk factors for long-term disability after injury will help critical care providers recognize patients at risk. Objectives: To identify early predictors of long-term disability after injury and to ascertain if age, level of disability before injury, posttraumatic psychological distress, and social network factors during hospitalization and recovery significantly contribute to long-term disability after injury. Methods: A prospective, correlational design was used. Injury-specific information on 63 patients with serious, non–central nervous system injury was obtained from medical records; all other data were obtained from interviews (3 per patient) during a 2½-year period. A model was developed to test the theoretical propositions of the disabling process. Predictors of long-term disability were evaluated using path analysis in the context of structural equation modeling. Results: Injuries were predominately due to motor vehicle crashes (37%) or violent assaults (21%). Mean Injury Severity Score was 13.46, and mean length of stay was 12 days. With structural equation modeling, 36% of the variance in long-term disability was explained by predictors present at the time of injury (age, disability before injury), during hospitalization (psychological distress), or soon after discharge (psychological distress, short-term disability after injury). Conclusions: Disability after injury is due partly to an interplay between physical and psychological factors that can be identified soon after injury. By identifying these early predictors, patients at risk for suboptimal outcomes can be detected.Publication Characteristics and Outcomes of Injured Older Adults After Hospital Admission(2010-02-16) Aitken, Leanne M; Burmeister, Elizabeth; Lang, Jacelle; Chaboyer, Wendy; Richmond, Therese SOBJECTIVES: To describe the seriously injured adult population aged 65 and older; compare the differences in injury characteristics and outcomes in three subgroups aged 65 to 74, 75 to 84, and 85 and older; and identify predictors of death, complications, and hospital discharge destination. DESIGN: Retrospective secondary analysis of data from the Queensland Trauma Registry (QTR) using all patients aged 65 and older admitted from 2003 through 2006. SETTING: Data from 15 regional and tertiary hospitals throughout Queensland, Australia. PARTICIPANTS: Six thousand sixty-nine patients: 2,291 (37.7%) aged 65 to 74, 2,265 (37.3%) aged 75 to 84, and 1,513 (24.9%) aged 85 and older. MEASUREMENTS: Outcome variables included mortality, complications, and discharge destination (usual residence, rehabilitation, nursing home, convalescence). Predictive factors incorporated demographic details, injury characteristics, and acute care factors. RESULTS: Hospital survival was 95.0%, with a median length of hospital stay of 8 days (interquartile range 5–15), and 33.8% of cases with a major injury developed a complication. Predictors of death included older age, male sex, admission to the intensive care unit (ICU), greater Injury Severity Score (ISS), injury caused by a fall, and two or more injuries; those who had surgery were less likely to die. Predictors of complications included ICU admission, older age, longer hospital stay, and two or more injuries. Predictors of discharge to a nursing home included older age, greater ISS, longer hospital stay, and injury caused by a fall, among others. CONCLUSION: Older adults with severe injuries are at risk of poor outcomes. These findings suggest opportunities for improving geriatric trauma care that could lead to better outcomes.Publication The Case for Enhanced Data Collection of Gun Type(2004-01-01) Richmond, Therese S; Branas, Charles; Cheney, Rose Ann; Schwab, C WilliamBackground: National surveillance systems have differentiated long guns into rifles and shotguns but fail to do so for handgun type. We sought to determine whether specific gun type data could be collected and whether knowledge of specific gun types (rifle, shotgun, pistol, revolver) could be used to distinguish gun homicide victims with respect to important injury parameters such as number of wounds. Methods: Data on gun fatalities over a 5-year period in three communities were abstracted from medical examiner/coroner, police, and crime laboratory records. Results: Gun type was obtained for 92% of 490 guns linked to 405 gun homicides. Handguns were associated with more wounds per gun than long guns (p = 0.001) and more entry wounds per gun than long guns (p = 0.002). Among handguns, pistols were associated with more wounds per gun (p < 0.001) and entry wounds per gun (p = 0.001) than revolvers. These same associations were not found among specific long gun types (i.e., rifles and shotguns). Conclusion: Our findings demonstrate that information about gun type can be obtained and that significant differences exist in wounds per gun between long guns and handguns and between pistols and revolvers. Classification of long guns into rifles and shotguns and handguns into pistols and revolvers should be included in local, regional, and national data collection systems.Publication Effective Trauma Center Partnerships to Address Firearm Injury: A New Paradigm(2004-01-01) Richmond, Therese S; Schwab, C William; Branas, Charles; Riely, Jeaneen; Cheney, Rose Ann; Dunfey, MauraBackground: Firearm violence is the second leading cause of injury-related death. This study examined the use of local trauma centers as lead organizations in their communities to address firearm injury. Methods: Three trauma centers in cities with populations less than 100,000 were linked with a university-based firearm injury research center. A trauma surgeon director and coordinator partnered with communities, recruited and directed advisory boards, established a local firearm injury surveillance system, and informed communities using community-specific profiles. Primary process and outcome measures included completeness of data, development of community-specific profiles, number of data-driven consumer media pieces, number of meetings to inform policy makers, and an analysis of problems encountered. Results: Local trauma centers in smaller communities implemented a firearm injury surveillance system, produced community-specific injury profiles, and engaged community leaders and policy makers to address firearm injury. Community-specific profiles demonstrated consistent firearm suicide rates (6.58–6.82 per 100,000) but variation in firearm homicide rates (1.08–12.5 per 100,000) across sites. There were 63 data-driven media pieces and 18 forums to inform community leaders and policy makers. Completeness of data elements ranged from 57.1% to 100%. Problems experienced were disconnected data sources, multiple data owners, potential for political fallout, limited trauma center data, skills sets of medical professionals, and sustainability. Conclusion: Trauma centers, when provided resources and support, with the model described, can function as lead organizations in partnering with the community to acquire and use community-specific data for local firearm injury prevention.Publication A Feasibility Study of Methodological Issues and Short-Term Outcomes in Seriously Injured Older Adults(2006-03-01) Richmond, Therese S; Thompson, Hilaire Jane; Kauder, Donald R; Robinson, Keith M; Strumpf, NevilleBackground: For any given traumatic injury, older adults experience a longer hospitalization, more complications, and higher mortality than do younger patients. Objectives: To prospectively identify problems in designing follow-up studies in seriously injured older adults without head injury and to examine outcomes after serious trauma in older adults who were sent to a level I trauma center. Methods: A short-term descriptive follow-up design was used in which each patient served as his or her baseline. Eligible patients had injuries that required admission to an intensive care unit, a hospital length of stay longer than 72 hours, or surgery. Patients with isolated hip fractures, central nervous system injuries, and burn injuries were excluded. Data were collected by using standardized instruments during the acute hospital stay and 3 months after discharge from the hospital. Results: During a representative 2-month period, 21% of a potential 77 subjects died in the hospital, 44% had cognitive impairment that precluded participation, and 17% declined to participate. Twenty older adults (mean age 73.5 years) who were injured in motor vehicle crashes (45%), falls (35%), or pedestrian accidents (15%) or who had gunshot wounds (5%) were enrolled. Ten percent died after discharge. Levels of physical disability at 3 months after discharge were higher than those before the injury (score on Sickness Impact Profile physical subscale 24.5 vs 10.9, P = .02), and psychological distress (Impact of Event Scale score 20.9) remained elevated. Conclusion: Mortality, disability, and posttraumatic psychological distress after discharge are problems in seriously injured older adults.Publication The Global Burden of Non-Conflict Related Firearm Mortality(2005-01-01) Richmond, Therese S; Cheney, Rose Ann; Schwab, C WilliamObjective: Understanding global firearm mortality is hindered by data availability, quality, and comparability. This study assesses the adequacy of publicly available data, examines populations for whom firearm mortality data are not publicly available, and estimates the global burden of non-conflict related firearm mortality. Design: The design is a secondary analysis of existing data. A dataset of countries, populations, economic development, and geographic regions was created, using United Nations 2000 world population data and World Bank classifications of economic development and global regions. Firearm mortality data were obtained from governmental vital statistics reported by the World Health Organization and published survey data. A qualitative review of literature informed estimates for the 15 most populous countries without firearm death data. For countries without data, estimates of firearm deaths were made using quartiles of observed rates and peer reviewed literature. Main outcome measures: Non-conflict related firearm deaths. Results: Global non-conflict related firearm deaths were estimated to fall between 196 000 and 229 000, adjusted to the year 2000. 162 800 firearm deaths adjusted for the year 2000 came from countries reporting data and represent 35% of the world’s 186 countries. Public data are not available for 122 of these 186 countries, representing more than three billion (54%) of the world’s population, predominately in lower and lower middle income countries. Estimates of firearm death for those countries without data range from 33 200 to 66 200. Conclusions: This study provides evidence that the burden of firearm related mortality poses a substantial threat to local and global health.