Article 1
Effect of Interfacility Transfer on Outcomes in Pediatric Severe Traumatic Brain Injury Patients. Kumar S, Lee P, Chin B, Nasef H, Yates Z, Ford A, Bundschu I, Plumley D, Elkbuli A. J Trauma Nursing. 2025 Oct 29.
Traumatic brain injuries (TBI) cause approximately 6100 deaths per year in the US, as well as contributing to significant neurological dysfunction in pediatric populations. Approximately 35% of pediatric TBI (pTBI) cases involve interfacility transfer. Pediatric trauma centers (PTCs) are equipped to optimize trauma care in patients under the age of 18; in fact, mortality of pTBI patients is lowest at PTCs. However, due to limited access, approximately 50% of pTBI patients do not receive treatment at a PTC. This retrospective cohort analysis of ACS TQIP data seeks to evaluate the impact of transfer from lower level (III-IV) to higher level (I-II) trauma care on pediatric trauma patients with isolated severe TBI versus those who were treated at a lower-level trauma center. In 4154 alive patients <18 years with ISS greater than or equal to 9, GCS<8, AIS 3 or above TBI with all other regions <3, 1723 were transferred to a higher level of trauma care and 2418 were not. Transfer futility (primary outcome) was defined as patient discharge within 24-48h without neurosurgical intervention and rates of neurosurgical intervention between similarly injured patients (transferred vs un-transferred). Secondary outcomes comprised ED and 24-h mortality, rates of initial and repeat head CT scans, ICU LOS, ventilator-free days, and discharge disposition to home. Patients who were transferred to higher levels of care had lower odds of being discharged within 24-48h, higher odds of neurosurgical intervention, shorter ICU length of stay, reduction in need for head CT, and higher odds of being discharged home than those not transferred. There were no differences found in in-hospital mortality or 24h mortality in those patients transferred, suggesting little to no risk of transfer. Authors conclude that these findings emphasize the need for well-developed screening protocols and transfer policies for pTBI patients to help prioritize care and resource utilization, for strengthening the ability of lower-level TCs to manage pediatric TBI, and to optimize TBI management within trauma systems.
This article highlights some of the critical aspects of pediatric trauma care, including the need for specialized care for pediatric patients versus the limited access to pediatric trauma centers, a disparity more pronounced in rural than urban environments. Though ACS does recommend transfer of pediatric TBI patients to the highest level of care available, this study further refines these recommendations to emphasize transfer to higher level of care and PTC prioritization as strategies which improve discharge disposition and facilitate needed neurosurgical interventions. The comparison of transfer and non-transfer in similarly injured patients suggests that the benefits of transfer outweigh the risk, providing impetus for trauma systems to optimize their transfer protocols. The study does not address functional or long-term outcomes, nor does it address potential differences in care received at lower-level trauma centers. Further, age groups are not separated nor are types/severity of bleeds.
Article 2
Mental Health Screening in a Rural Trauma Center: Feasibility and Impact. Savell TC, Peterson AL, Carroll RP, Orr LC, Palm CE, Englehart MS, Thompson SJ. J Trauma Nursing. 2025 Jul-Aug;32(4):208-216.
Trauma patients are affected not only physically, but also emotionally, with many suffering from depression and post-traumatic stress disorder (PTSD). Recognized trauma associations recommend screening for early detection of mental disorders because it could reduce associated morbidity. However, implementing mental health screenings in rural trauma centers can be challenging due to limited resources. This quasi-experimental study aimed to evaluate the feasibility and impact of a mental health screening initiative at a Level II trauma center in rural northwestern U.S. The initiative included inclusion and exclusion criteria for screening using the Injured Trauma Survivor Screen (ITSS), as well as resources pamphlet and psychiatric consultations offers for those who screened positive. Of the 1,114 patients eligible for screening, 84.2% were screened throughout the study period, surpassing the target compliance rate of 80%. Missed screening opportunities decreased significantly from 20.5% to 13.6% in the post-implementation year. All patients who screened positive received a resource pamphlet and an offer for a psychiatric consultation. However, while 33.5% of patients screened positive, only 10.5% received a consultation.
This study, conducted among a large sample of patients, demonstrated a high screening rate that was maintained over a two-year period, highlighting the feasibility of the target initiative. However, few details were available regarding the professionals involved in screening and responsible for activating the other components of the initiative. Screening for mental disorders in patients admitted to trauma centers is a first step in identifying patients who may need psychological support or specialized mental health interventions. Nevertheless, as acknowledged by the authors, some disorders may appear after discharge from the trauma center, and mechanisms must also be put in place to enable longer-term screening. Similarly, the fact that few patients who screened positive were evaluated by a psychiatrist remains a problem. This study therefore demonstrates the need to explore solutions to address the lack of specialized mental health resources in rural trauma centers to meet patient needs. To this end, it is necessary to consider whether all patients who screen positive should undergo a psychiatric consultation and whether other solutions could be considered for those with mild symptoms.
Article 3
Symptoms and Functional Outcomes Among Traumatic Brain Injury Patients 3- to 12-Months Post-Injury. Gerber KS, Alvarez G, Alamian A, Behar-Zusman V, Downs CA. J Trauma Nursing. 2024 Mar-Apr;31(2):72-81.
This article by Gerber and colleagues examines symptom burden and functional outcomes among adults recovering from traumatic brain injury (TBI) during the subacute convalescence period of 3 to 12 months post-injury, an interval that is less frequently studied than the acute or chronic phases. Using a cross-sectional design, the authors recruited 39 adults from a South Florida outpatient TBI clinic and assessed cognitive, affective, and physical symptoms using validated patient-reported outcome measures, including Neuro-QOL instruments and the Brain Injury Association of Virginia Symptom Checklist. Functional outcomes were evaluated using the Disability Rating Scale (DRS) and Satisfaction with Life Scale (SWLS). Cognitive symptoms—particularly difficulties with memory and concentration—were the most prevalent, followed by affective symptoms such as depression and anxiety, and then physical complaints. Regression analyses demonstrated that greater cognitive and physical symptom burden, as well as longer hospital and ICU length of stay, were associated with worse physical functioning, while cognitive, depressive, anxiety, and select physical symptoms were associated with lower life satisfaction. The authors conclude that symptom burden remains substantial well into recovery and that multidimensional symptom assessment is essential to guide rehabilitation strategies and improve both functional status and quality of life in individuals with TBI.
The study addresses an important and underexplored phase of TBI recovery and benefits from the use of validated symptom and outcome measures; however, several methodological and statistical limitations restrict the strength and generalizability of the findings. The cross-sectional design limits interpretation to associations and precludes conclusions regarding causality or symptom progression over time, which is a notable limitation given the dynamic nature of TBI recovery. The small convenience sample (N = 39) raises concerns regarding statistical power, particularly in the context of multiple linear regression models examining numerous symptom predictors across two outcomes. The absence of correction for multiple comparisons increases the risk of Type I error, and the inclusion of multiple predictors relative to sample size heightens the possibility of overfitting. Although the authors adjusted for age and sex, other potentially important confounders—such as pre-injury mental health status, rehabilitation intensity, socioeconomic factors, and more granular measures of injury severity—were not consistently incorporated into the models. Additionally, reliance on self-reported symptom measures introduces the possibility of reporting bias. While appropriate for exploratory analysis, the analytic approach and sample size suggest that the results should be viewed as hypothesis-generating rather than definitive. Future studies would benefit from larger, longitudinal cohorts and more robust multivariable modeling to better characterize symptom trajectories and their impact on functional recovery after TBI.
Article 4
Seeking a Relevant Description of Major Trauma Bleeding: Comparison of Four Major Bleeding Definitions. Day DL, Ng K, Severino R, Ng-Kamstra J. J Trauma Nursing. 2024 Jan-Feb;31(1):7-14.
Hemorrhagic shock continues to be the most prevalent cause of preventable death following traumatic injury within the first 24 hours. The first-line treatment for hemorrhagic shock continues to be transfusion, but the definition of massive transfusion (MT) has been defined in multiple ways. The article, "Seeking a Relevant Description of Major Trauma Bleeding: Comparison of Four Major Bleeding Definitions," by Day et al.(2024), is a retrospective cohort study that analyzed four definitions of major bleeding in an adult, American College of Surgeons verified, Level I trauma center. The objective was to determine the most clinically relevant indicators for trauma resuscitation, with a primary outcome of mortality at three, six, and 24-hour intervals following arrival at the trauma bay.
The traditional definition of (MT)-10 red blood cell (RBC) units over 24 hours, is often critiqued for excluding patients who die early from exsanguination, as well as those who still experience meaningful bleeding with significant mortality but don’t require a full 10 units of RBCs. The study reviewed the traditional MT definition, the time-based Resuscitation Intensity (4 units of any combination of crystalloid, colloid, or blood products within 30-minutes of arrival), the event-based Sharpe (10 RBC units during the "interval of hemorrhage control" defined as time from trauma bay to admission), and the authors' proposed Modified Sharpe definition (10 units of any combination of blood products transfused from trauma bay presentation to admission). The study analyzed data from 187 subjects between 2014 and 2019. The results showed that of the 39 deaths in the cohort, 28 (72%) occurred within 6 hours of arrival. The Modified Sharpe captured the highest number of these early deaths (96%, or 27 subjects). In contrast, Resuscitation Intensity captured 71% of these deaths, while Sharpe and the traditional definition each captured 79% each. The authors concluded that the Modified Sharpe may optimally indicate major bleeding during trauma resuscitation because it successfully captured nearly all mortalities within the 3-, 6-, and 24-hour timeframe, making it the most clinically relevant definition examined in this study.
A critique of this research must acknowledge its strengths while highlighting the methodological limitations inherent to its design. A major strength is the study's focus on the definition of massive bleeding during the "interval of hemorrhage control," which reflects the period of highest mortality from hemorrhage and when definitive bleeding control occurs. Furthermore, the Modified Sharpe definition is clinically relevant because it incorporates all blood components (RBCs, plasma, and platelets), aligning with more current trauma practice of balanced resuscitation. Despite these merits, the study explicitly lists several limitations that affect the generalizability and robustness of its findings. First, the research is a small, single-center retrospective study conducted over a 6-year period. Since it was conducted at the only Level I trauma center serving this state and its region, the results may not be applicable to other trauma centers where mechanisms or patient demographics differ. Second, exclusion criteria eliminated patients who died less than one hour after presentation to the trauma bay to control for survivorship bias, but this cutoff may have led to the exclusion of subjects who met early transfusion thresholds, like the Resuscitation Intensity definition. Finally, the study was limited by missing data regarding specific markers of injury severity and documentation errors, such as crystalloids being recorded as "liters hung" without the infused volume, which could potentially impact the accuracy of the Resuscitation Intensity score for some study participants. The study also only considered the initial period of hemorrhage control and did not account for patients who might experience a subsequent major bleeding event later in their 24-hour admission, which would be covered by the traditional MT definition.
