Collaborative Care for Injured Older Adults: The Trauma Medical Home Randomized Clinical Trial

Importance

Older adults with recent injuries can have impaired long-term biopsychosocial function and may benefit from interventions adapted to their needs.

Objective

To determine if a collaborative care intervention, Trauma Medical Home (TMH), improved the biopsychosocial function of older patients in the year after injury.

Design, Setting, and Participants

This was a single-blinded, randomized clinical trial conducted at 4 level I trauma centers in Indianapolis, Indiana, and Madison, Wisconsin. Between October 2017 and October 2021, patients aged 50 years and older with an Injury Severity Score (ISS) of 9 or greater and without traumatic brain or spinal cord injury were enrolled. Exclusions were significant brain injury or a spinal cord injury with a persistent neurologic deficit at the time of enrollment, extensive burns, pregnancy, incarceration, neurodegenerative disease, visual or auditory impairment that would preclude study participation, a life expectancy of less than 1 year, significant alcohol or drug use history, and acute stroke during admission. Of 10 276 patients screened, 430 were randomized and 299 completed 12-month follow-up. Data were analyzed from March to July 2023.

Intervention

Intervention patients received 6 months of TMH delivered by a nurse care coordinator guided by an interdisciplinary team (trauma surgeon, pulmonary critical care and geriatrician physicians, nurses, and psychologist) in partnership with primary care. The care coordinator used standard protocols to monitor and treat biopsychosocial symptoms.

Main Outcomes and Measures

Primary outcomes were Medical Outcome Study Short Form-36 (SF-36) score and Short Physical Performance Battery (SPPB) score at 12 months. Secondary outcomes were Patient Health Questionnaire-9 (PHQ-9) score, the Generalized Anxiety Disorder scale-7 (GAD-7) score, and health care utilization.

Results

A total of 429 participants (228 [53.1%] female; mean [SD] age, 69.3 [10.8] years; mean [SD] ISS, 12.3 [4.6]) completed baseline assessments and were randomized. Follow-up was 76% (n = 324) at 6 months and 70% (n = 299) at 12 months. There were no differences between the TMH and usual care groups at 12 months in SF-36 Physical Component Summary score (mean [SD], 40.42 [12.82] vs 39.18 [12.43]), SF-36 Mental Component Summary score (mean [SD], 53.92 [10.02] vs 53.21 [10.82]), or SPPB score (mean [SD], 8.00 [3.60] vs 8.28 [3.88]). Secondary outcomes were also no different. Planned subgroup analysis revealed patients with baseline symptoms of anxiety or depression (high GAD-7 and PHQ-9 scores) experienced improvement in the Mental Component Summary score when randomized to the TMH intervention.

Conclusions and Relevance

The TMH intervention did not significantly influence quality of life, depressive and anxiety symptoms, or physical function of older adults with injury at 12 months. Subgroup analysis showed positive impact in patients with a high burden of anxiety and depression symptoms at enrollment. Collaborative care interventions may improve long-term outcomes of select patients, but further research is needed.

Trial Registration

ClinicalTrials.gov Identifier: NCT03108820.

Pain management in trauma: the need for trauma-informed opioid prescribing guidelines

Background/objectives

Surgical populations and particularly injury survivors often present with complex trauma that elevates their risk for prolonged opioid use and misuse. Changes in opioid prescribing guidelines during the past several years have yielded mixed results for pain management after trauma, with a limiting factor being the heterogeneity of clinical populations and treatment needs in individuals receiving opioids. The present analysis illuminates this gap between clinical guidelines and clinical practice through qualitative feedback from hospital trauma providers and unit staff members regarding current opioid prescribing guidelines and practices in the setting of traumatic injury.

Methods

The parent study aimed to implement a pilot screening tool for opioid misuse in four level I and II trauma hospitals throughout Wisconsin. As part of the parent study, focus groups were conducted at each study site to explore the facilitators and barriers of implementing a novel screening tool, as well as to examine the current opioid prescribing guidelines, trainings, and resources available for trauma and acute care providers. Focus group transcripts were independently coded and analyzed using a modified grounded theory approach to identify themes related to the facilitators and barriers of opioid prescribing guidelines in trauma and acute care.

Results

Three major themes were identified as impactful to opioid-related prescribing and care provided in the setting of traumatic injury; these include (1) acute treatment strategies; (2) patient interactions surrounding pain management; and (3) the multifactorial nature of trauma on pain management approaches.

Conclusion

Providers and staff at four Wisconsin trauma centers called for trauma-specific opioid prescribing guidelines in the setting of trauma and acute care. The ubiquitous prescription of opioids and challenges in long-term pain management in these settings necessitate additional community-integrated research to inform development of federal guidelines.

Level of evidence

Therapeutic/care management, level V.

Is nonoperative management of appendicitis safe and effective in multi-morbid patients?

BACKGROUND

The purpose of this study was to (1) compare post-treatment outcomes of operative and nonoperative management of acute appendicitis in multi-morbid patients and (2) evaluate the generalizability of prior clinical trials by determining whether outcomes differ in multi-morbid patients compared to the young and healthy patients who resemble prior clinical trial participants.

METHODS

We conducted a retrospective cohort study using the National Inpatient Sample from 2004 to 2017. We included 368,537 patients with acute, uncomplicated appendicitis who were classified as having 0 or 2+ comorbidities. We compared inpatient morbidity, mortality, length of stay, and costs using propensity scores. Unmeasured confounding was addressed with probabilistic sensitivity analysis.

RESULTS

Overall, 5% of patients without comorbidities were treated nonoperatively versus 20% of multi-morbid patients. Compared to surgery, nonoperative management was associated with a 3.5% decrease in complications (95% confidence interval 3%-4%) for multi-morbid patients, but there was no significant difference for patients without comorbidity. However, nonoperative management was associated with a 1.5% increase in mortality for multimorbid patients (95% confidence interval 1.3%-1.7%). Costs and length of stay were lower for all patients treated with surgery. Probabilistic sensitivity analysis showed that results were robust to the effects of unmeasured confounding.

CONCLUSION

Our results raise concerns about the generalizability of clinical trials that compared nonoperative and operative management of appendicitis because (1) those trials enrolled mostly young and healthy patients, and (2) results in multi-morbid patients differ from outcomes in younger and healthier patients.

Mobile Critical Care Recovery Program for Survivors of Acute Respiratory Failure: A Randomized Clinical Trial

Importance

Over 50% of Acute Respiratory Failure (ARF) survivors experience cognitive, physical, and psychological impairments that negatively impact their quality of life (QOL).

Objective

To evaluate the efficacy of a post-intensive care unit (ICU) program, the Mobile Critical Care Recovery Program (m-CCRP) consisting of a nurse care coordinator supported by an interdisciplinary team, in improving the QOL of ARF survivors.

Design, Setting, and Participants

This randomized clinical trial with concealed outcome assessments among ARF survivors was conducted from March 1, 2017, to April 30, 2022, with a 12-month follow-up. Patients were admitted to the ICU services of 4 Indiana hospitals (1 community, 1 county, 2 academic), affiliated with the Indiana University School of Medicine.

Intervention

A 12-month nurse-led collaborative care intervention (m-CCRP) supported by an interdisciplinary group of clinicians (2 intensivists, 1 geriatrician, 1 ICU nurse, and 1 neuropsychologist) was compared with a telephone-based control. The intervention comprised longitudinal symptom monitoring coupled with nurse-delivered care protocols targeting cognition, physical function, personal care, mobility, sleep disturbances, pain, depression, anxiety, agitation or aggression, delusions or hallucinations, stress and physical health, legal and financial needs, and medication adherence.

Main Outcomes and Measures

The primary outcome was QOL as measured by the 36-item Medical Outcomes Study Short Form Health Survey (SF-36) physical component summary (PCS) and mental component summary (MCS), with scores on each component ranging from 0-100, and higher scores indicating better health status.

Results

In an intention-to-treat analysis among 466 ARF survivors (mean [SD] age, 56.1 [14.4] years; 250 [53.6%] female; 233 assigned to each group), the m-CCRP intervention for 12 months did not significantly improve the QOL compared with the control group (estimated difference in change from baseline between m-CCRP and control group: 1.61 [95% CI, -1.06 to 4.29] for SF-36 PCS; -2.50 [95% CI, -5.29 to 0.30] for SF-36 MCS. Compared with the control group, the rates of hospitalization were higher in the m-CCRP group (117 [50.2%] vs 95 [40.8%]; P = .04), whereas the 12-month mortality rates were not statistically significantly lower (24 [10.3%] vs 38 [16.3%]; P = .05).

Conclusions and Relevance

Findings from this randomized clinical trial indicated that a nurse-led 12-month comprehensive interdisciplinary care intervention did not significantly improve the QOL of ARF survivors after ICU hospitalization. These results suggest that further research is needed to identify specific patient groups who could benefit from tailored post-ICU interventions.

Trial Registration

ClinicalTrials.gov Identifier: NCT03053245.

To leave or not to leave: American Association for the Surgery of Trauma (AAST) panel discussion on personal, parental, and family leave

Navigating planned and emergent leave during medical practice is very confusing to most physicians. This is especially challenging to the trauma and acute care surgeon, whose practice is unique due to overnight in-hospital call, alternating coverage of different services, and trauma center's staffing challenges. This is further compounded by a surgical culture that promotes the image of a 'tough' surgeon and forgoing one's personal needs on behalf of patients and colleagues. Frequently, surgeons find themselves having to make a choice at the crossroads of personal and family needs with work obligations: to leave or not to leave. Often, surgeons prioritize their professional commitment over personal wellness and family support. Extensive research has been conducted on the topic of maternity leave and inequality towards female surgeons, primarily focused on trainees. The value of paternity leave has been increasingly recognized recently. Consequently, significant policy changes have been implemented to support trainees. Practicing surgeon, however, often lack such policy support, and thus may default to local culture or contractual agreement. A panel session at the American Association for the Surgery of Trauma 2022 annual meeting was held to discuss the current status of planned or unanticipated leave for practicing surgeons. Experiences, perspectives, and propositions for change were discussed, and are presented here.

Angioembolization for Isolated Severe Blunt Splenic Injuries with Hemodynamic Instability: A Propensity Score Matched Analysis

BACKGROUND

This study aimed to compare patient outcomes after splenic angioembolization (SAE) or splenectomy for isolated severe blunt splenic injury (BSI) with hemodynamic instability, and to identify potential candidates for SAE.

METHODS

Adult patients with isolated severe BSI (Abbreviated Injury Scale [AIS] 3-5) and hemodynamic instability between 2013 and 2019 were identified from the American College of Surgeons Trauma Quality Improvement (ACS TQIP) database. Hemodynamic instability was defined as an initial systolic blood pressure (SBP) <90 mmHg, heart rate (HR) >120 bpm, or lowest SBP <90 mmHg within 1 h after admission, with ≥1 unit of blood transfused within 4 h after admission. In-hospital mortality was compared between splenectomy and SAE groups using 2:1 propensity-score matching. The characteristics of unmatched and matched splenectomy patients were also compared.

RESULTS

A total of 478 patients met our inclusion criteria (332 splenectomy, 146 SAE). After propensity-score matching, 166 splenectomy and 83 SAE patients were compared. Approximately 85% of propensity-score matched patients sustained AIS 3/4 injuries, and 50% presented with normal SBP and HR before becoming hemodynamically unstable. The median time to intervention (splenectomy or SAE) was 137 min (interquartile range 94-183). In-hospital mortality between splenectomy and SAE groups was not significantly different (5.4% vs. 4.8%, p = 1.000). More than half of unmatched patients in the splenectomy group sustained AIS 5 injuries and presented with initially unstable hemodynamics. The median time to splenectomy in such patients was significantly shorter than in matched splenectomy patients (67 vs. 132 min, p < 0.001).

CONCLUSION

Splenectomy remains the mainstay of treatment for patients with AIS 5 BSI who present to hospital with hemodynamic instability. However, SAE might be a feasible alternative for patients with AIS 3/4 injuries.

Utility of the Healthy Aging Brain Care Monitor as a Patient-Reported Symptom Monitoring Tool in Older Injury Survivors

INTRODUCTION

The objective of this study was to evaluate the performance of the Healthy Aging Brain Care Monitor (HABC-M) as a patient-reported outcome tool to measure cognitive, functional, and psychological symptoms among older adults who sustained non-neurologic injuries requiring hospital admission.

METHODS

We used data from a multicenter randomized controlled trial to evaluate the utility of the HABC-M Self-Report version in older patients recovering from traumatic injuries. A total of 143 patients without cognitive impairment were included in the analysis. Cronbach's alpha was used to measure the internal consistency, and Spearman's rank correlation test was used to evaluate the relationship of the HABC-M with standard measures of cognitive, functional, and psychological outcomes.

RESULTS

The HABC-M subscales and the total scale showed satisfactory internal consistency (Cronbach's alpha = 0.64 to 0.77). The HABC-M cognitive subscale did not correlate with the Mini-Mental State Examination. The HABC-M functional and psychological subscales correlated with corresponding standard reference measures (|rs| = 0.24-0.59).

CONCLUSIONS

The HABC-M Self-Report version is a practical alternative to administering multiple surveys to monitor functional and psychological sequelae in older patients recovering from recent non-neurologic injuries. Its clinical application may facilitate personalized, multidisciplinary care coordination among older trauma survivors without cognitive impairment.

Catastrophic health expenditure in nonneurological injury due to motor vehicle crash

BACKGROUND

Motor vehicle crashes (MVCs) are a leading cause of nonfatal injury in the United States and impose a high financial cost to the patient and the economy. For many patients, this cost may be financially devastating and contribute to worsening health outcomes after injury. We aimed to describe the population level risk of catastrophic health expenditure (CHE) and determine factors associated with risk of CHE.

METHODS

We performed a retrospective review using the 2014-2017 Nationwide Inpatient Sample. The study population consisted of uninsured and privately insured adults aged 26 to 64 years who were hospitalized for nonneurologic traumatic injury due to MVCs. Our measure of financial hardship was CHE, which was defined as hospital charges ≥40% of postsubsistence income. Income estimates were derived from zip-code level data using Γ distribution modeling.

RESULTS

Our sample included 189,000 patients, of which 149,705 had private insurance and 39,375 were uninsured. The median estimated income for the study cohort was $66,118 (interquartile range, $65,353-$66,884). The median cost of hospitalization was $53,467 (interquartile range, $29,854-$99,914). In addition, 91.5% of uninsured patients suffering from MVC are at risk for CHE, and 10.1% of privately insured patients are at risk for CHE. Among the insured, Black, Hispanic, and low income were associated with CHE.

CONCLUSION

Nine of 10 uninsured patients are at risk for CHE after hospitalization for MVC. Despite having insurance, 10% of patients are still at risk of CHE. Black, Hispanic, and low-income communities are at highest risk of having private insurance and still experiencing CHE. This is the first population level analysis after the implementation of the Affordable Care Act that assesses the financial burden of no insurance and underinsurance. These data are important to understand the effectiveness of insurance coverage and guide hospital and policy level interventions to prevent CHE.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Establishing a core outcome set for blunt cerebrovascular injury: an EAST modified Delphi method consensus study

Objectives

Our understanding of blunt cerebrovascular injury (BCVI) has changed significantly in recent decades, resulting in a heterogeneous description of diagnosis, treatment, and outcomes in the literature which is not suitable for data pooling. Therefore, we endeavored to develop a core outcome set (COS) to help guide future BCVI research and overcome the challenge of heterogeneous outcomes reporting.

Methods

After a review of landmark BCVI publications, content experts were invited to participate in a modified Delphi study. For round 1, participants submitted a list of proposed core outcomes. In subsequent rounds, panelists used a 9-point Likert scale to score the proposed outcomes for importance. Core outcomes consensus was defined as >70% of scores receiving 7 to 9 and <15% of scores receiving 1 to 3. Feedback and aggregate data were shared between rounds, and four rounds of deliberation were performed to re-evaluate the variables not achieving predefined consensus criteria.

Results

From an initial panel of 15 experts, 12 (80%) completed all rounds. A total of 22 items were considered, with 9 items achieving consensus for inclusion as core outcomes: incidence of postadmission symptom onset, overall stroke incidence, stroke incidence stratified by type and by treatment category, stroke incidence prior to treatment initiation, time to stroke, overall mortality, bleeding complications, and injury progression on radiographic follow-up. The panel further identified four non-outcome items of high importance for reporting: time to BCVI diagnosis, use of standardized screening tool, duration of treatment, and type of therapy used.

Conclusion

Through a well-accepted iterative survey consensus process, content experts have defined a COS to guide future research on BCVI. This COS will be a valuable tool for researchers seeking to perform new BCVI research and will allow future projects to generate data suitable for pooled statistical analysis with enhanced statistical power.

Level of evidence

Level IV.

Measuring long-term outcomes after injury: current issues and future directions

Maximizing long-term outcomes for patients following injury is the next challenge in the delivery of patient-centered trauma care. The following review outlines three important components in trauma outcomes: (1) data gathering and monitoring, (2) the impact of traumatic brain injury, and (3) trajectories in recovery and identifies knowledge gaps and areas for needed future research.

Empiric tranexamic acid use provides no benefit in urgent orthopedic surgery following injury

Background

Orthopedic literature has demonstrated a significant decrease in postoperative transfusion requirements when tranexamic acid (TXA) was given during elective joint arthroplasty. The purpose of this study was to evaluate the empiric use of TXA in semi-urgent orthopedic procedures following injury. We hypothesized that TXA would be associated with increased rates of venous thromboembolic events (VTE) and have no effect on transfusion requirements.

Methods

Patients who empirically received TXA during a semi-urgent orthopedic surgery following injury (TXA+) were matched using propensity scoring to historical controls (CONTROL) who did not receive TXA. Outcomes included VTE within 6 months of injury and packed red blood cell utilization. Multivariable logistic regression and generalized linear modeling were used to determine odds of VTE and transfusion.

Results

200 patients were included in each group. There was no difference in mortality between groups. TXA+ patients did not have an increase in VTE events (OR 0.680, 95% CI 0.206 to 2.248). TXA+ patients had a significantly higher odds of being transfused during their hospital stay (OR 2.175, 95% CI 1.246 to 3.797) and during the index surgery (increased 0.95 units (SD 0.16), p<0.0001). Overall transfusion was also significantly higher in the TXA+ group (p=0.0021).

Conclusion

Empiric use of TXA in semi-urgent orthopedic surgeries did not increase the odds of VTE. Despite the elective literature, TXA administration did not associate with less transfusion requirements. A properly powered, prospective, randomized trial should be designed to elucidate the risks and benefits associated with TXA use in this setting.

Level of evidence

Level IV.

Which hospital-acquired conditions matter the most in trauma? An evidence-based approach for prioritizing trauma program improvement

BACKGROUND

Prevention of hospital-acquired conditions (HACs) is a focus of trauma center quality improvement. The relative contributions of various HACs to postinjury hospital outcomes are unclear. We sought to quantify and compare the impacts of six HACs on early clinical outcomes and resource utilization in hospitalized trauma patients.

METHODS

Adult patients from the 2013 to 2016 American College of Surgeons Trauma Quality Improvement Program Participant Use Data Files who required 5 days or longer of hospitalization and had an Injury Severity Score of 9 or greater were included. Multiple imputation with chained equations was used for observations with missing data. The frequencies of six HACs and five adverse outcomes were determined. Multivariable Poisson regression with log link and robust error variance was used to produce relative risk estimates, adjusting for patient-, hospital-, and injury-related factors. Risk-adjusted population attributable fractions estimates were derived for each HAC-outcome pair, with the adjusted population attributable fraction estimate for a given HAC-outcome pair representing the estimated percentage decrease in adverse outcome that would be expected if exposure to the HAC had been prevented.

RESULTS

A total of 529,856 patients requiring 5 days or longer of hospitalization were included. The incidences of HACs were as follows: pneumonia, 5.2%; urinary tract infection, 3.4%; venous thromboembolism, 3.3%; surgical site infection, 1.3%; pressure ulcer, 1.3%; and central line-associated blood stream infection, 0.2%. Pneumonia demonstrated the strongest association with in-hospital outcomes and resource utilization. Prevention of pneumonia in our cohort would have resulted in estimated reductions of the following: 22.1% for end organ dysfunction, 7.8% for mortality, 8.7% for prolonged hospitalization, 7.1% for prolonged intensive care unit stay, and 6.8% for need for mechanical ventilation. The impact of other HACs was comparatively small.

CONCLUSION

We describe a method for comparing the contributions of HACs to outcomes of hospitalized trauma patients. Our findings suggest that trauma program improvement efforts should prioritize pneumonia prevention.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Variations in clot phenotype following injury: The MA-R ratio and fragile clots

INTRODUCTION

Trauma-induced coagulopathy is a continuum ranging from hypercoagulable to hypercoagulable phenotypes. In single-center studies, the maximum amplitude (MA) to r-time (R) (MA-R) ratio has identified a phenotype of injured patients with high mortality risk. The purpose of this study was to determine the relationship between MA-R and mortality using multicenter data and to investigate fibrinogen consumption in the development of this specific coagulopathy phenotype.

METHODS

Using the Pragmatic Randomized Optimal Platelet and Plasma Ratios data set, patients were divided into blunt and penetrating injury cohorts. MA was divided by R time from admission thromboelastogram to calculate MA-R. MA-R was used to assess odds of early and late mortality using multivariable models. Multivariable models were used to assess thrombogram values in both cohorts. Refinement of the MA-R cut point was performed with Youden index. Repeat multivariable analysis was performed with a binary CRITICAL and NORMAL MA-R.

RESULTS

In initial analysis, MA-R quartiles were not associated with mortality in the penetrating cohort. In the blunt cohort, there was an association between low MA-R and early and late mortality. A refined cut point of 11 was identified (CRITICAL: MA-R, ≤11; NORMAL: MA-R, >11). CRITICAL MA-R was associated with mortality in both penetrating and blunt subgroups. In further injury subgroup analysis, CRITICAL patients had significantly decreased fibrinogen levels in the blunt subgroup only. In both blunt and penetrating injury, there was no difference in time to initiation of thrombin burst (lagtime). However, both endogenous thrombin potential and peak thrombin levels were significantly lower in CRITICAL patients.

CONCLUSIONS

MA-R identifies a trauma-induced coagulopathy phenotype characterized in blunt injury by impaired thrombin generation that is associated with early and late mortality. The endotheliopathy and tissue factor release likely plays a role in the cascade of impaired thrombin burst, possible early fibrinogen consumption and the weaker clot identified by MA-R.

LEVEL OF EVIDENCE

Therapeutic/care management, level II.

A core outcome set for damage control laparotomy via modified Delphi method

OBJECTIVES

Damage control laparotomy (DCL) remains an important tool in the trauma surgeon's armamentarium. Inconsistency in reporting standards have hindered careful scrutiny of DCL outcomes. We sought to develop a core outcome set (COS) for DCL clinical studies to facilitate future pooling of data via meta-analysis and Bayesian statistics while minimizing reporting bias.

METHODS

A modified Delphi study was performed using DCL content experts identified through Eastern Association for the Surgery of Trauma (EAST) 'landmark' DCL papers and EAST ad hoc COS task force consensus.

RESULTS

Of 28 content experts identified, 20 (71%) participated in round 1, 20/20 (100%) in round 2, and 19/20 (95%) in round 3. Round 1 identified 36 potential COS. Round 2 achieved consensus on 10 core outcomes: mortality, 30-day mortality, fascial closure, days to fascial closure, abdominal complications, major complications requiring reoperation or unplanned re-exploration following closure, gastrointestinal anastomotic leak, secondary intra-abdominal sepsis (including anastomotic leak), enterocutaneous fistula, and 12-month functional outcome. Despite feedback provided between rounds, round 3 achieved no further consensus.

CONCLUSIONS

Through an electronic survey-based consensus method, content experts agreed on a core outcome set for damage control laparotomy, which is recommended for future trials in DCL clinical research. Further work is necessary to delineate specific tools and methods for measuring specific outcomes.

LEVEL OF EVIDENCE

V, criteria.

Treatment of asymptomatic blunt cerebrovascular injury (BCVI): a systematic review

Background

The management of asymptomatic blunt cerebrovascular injury (BCVI) with respect to stroke prevention and vessel healing is challenging.

Objectives

The aim of this systematic review was to determine if a specific treatment results in lower stroke rates and/or improved vessel healing in asymptomatic BCVI.

Data sources

An electronic literature search of MEDLINE, EMBASE, Cochrane Library, CINAHL, SCOPUS, Web of Science, and ClinicalTrials.gov performed from inception to March 2020.

Study eligibility criteria

Studies were included if they reported on a comparison of any treatment for BCVI and stroke and/or vessel healing rates.

Participants and interventions

Adult patients diagnosed with asymptomatic BCVI(s) who were treated with any preventive medication or procedure.

Study appraisal and synthesis methods

All studies were systematically reviewed and bias was evaluated by the Newcastle-Ottawa Scale. No meta-analysis was performed secondary to significant heterogeneity across studies in patient population, screening protocols, and treatment selection. The main outcomes were stroke and healing rate.

Results

Of 8781 studies reviewed, 19 reported on treatment effects for asymptomatic BCVI and were included for review. Any choice of medical management was better than no treatment, but no specific differences between choice of medical management and stroke outcomes were found. Vessel healing was rare and the majority of healed vessels were following low-grade injuries.

Limitations

Majority of the included studies were retrospective and at high risk of bias.

Conclusions or implications of key findings

Asymptomatic BCVI should be treated medically using a consistent, local protocol. High-quality studies on the effect of individual antithrombotic agents on stroke rates and vessel healing for asymptomatic BCVI are required.

The Relative Impact of Specific Postoperative Complications on Older Patients Undergoing Hip Fracture Repair

BACKGROUND

Hip fractures affect a vulnerable population and are associated with high rates of morbidity, mortality, and resource utilization. Although postoperative complications are a known driver of mortality and resource utilization, the comparative impacts of specific complications on outcomes is unknown. This study assessed which complications are associated with the highest effects on mortality and resource utilization for older patients who undergo hip fracture repair.

METHODS

Patients ≥ 65 years of age who underwent hip fracture repair during 2016-2017 included in the Hip Fracture Targeted ACS NSQIP (American College of Surgeons National Surgical Quality Improvement Program) database populated the data set. Prolonged hospitalization (≥ 75th percentile) and 30-day mortality and readmission were the primary outcomes. Population attributable fractions (PAFs) were used to quantify the anticipated reduction in the primary outcomes that would result from complete prevention of 10 postoperative complications.

RESULTS

Of 17,755 patients across 117 hospitals, 70.9% were female, 26.0% were over age 90, 22.8% had an American Society of Anesthesiologists (ASA) score of 4-5, and 53.9% presented with an intertrochanteric fracture. Postoperative delirium affected 29.8% of patients and was associated with death (PAF 18.0%; 95% confidence interval [CI] = 13.2-22.5), prolonged hospitalization (PAF 14.3%; 95% CI = 12.7-15.8), and readmission (PAF 15.0%; 95% CI = 11.3-18.6). Pneumonia affected 4.1% of patients and was associated with death (PAF 10.9%; 95% CI = 8.9-12.8), prolonged hospitalization (PAF 4.0%; 95% CI = 3.5-4.5), and readmission (PAF 9.1%; 95% CI = 7.5-10.7). The impact of the other eight complications was comparatively small.

CONCLUSION

Postoperative delirium and pneumonia are the highest-impact complications for older hip fracture repair patients. These complications should be prioritized in quality improvement efforts that target this patient population.

Insights into the association between coagulopathy and inflammation: abnormal clot mechanics are a warning of immunologic dysregulation following major injury

Background

Severe injury initiates a complex physiologic response encompassing multiple systems and varies phenotypically between patients. Trauma-induced coagulopathy may be an early warning of a poorly coordinated response at the molecular level, including a deleterious immunologic response and worsening of shock states. The onset of trauma-induced coagulopathy (TIC) may be subtle however. In previous work, we identified an early warning sign of coagulopathy from the admission thromboelastogram, called the MAR ratio. We hypothesized that a low MAR ratio would be associated with specific derangements in the inflammatory response.

Methods

In this prospective, observational study, 88 blunt trauma patients admitted to the intensive care unit (ICU) were identified. Concentrations of inflammatory mediators were recorded serially over the course of a week and the MAR ratio was calculated from the admission thromboelastogram. Correlation analysis was used to assess the relationship between MAR and inflammatory mediators. Dynamic network analysis was used to assess coordination of immunologic response.

Results

Seventy-nine percent of patients were male and mean age was 37 years (SD 12). The mean ISS was 30.2 (SD 12) and mortality was 7.2%. CRITICAL patients (MAR ratio ≤14.2) had statistically higher shock volumes at three time points in the first day compared to NORMAL patients (MAR ratio >14.2). CRITICAL patients had significant differences in IL-6 (P=0.0065), IL-8 (P=0.0115), IL-10 (P=0.0316) and MCP-1 (P=0.0039) concentrations compared to NORMAL. Differences in degree of expression and discoordination of immune response continued in CRITICAL patients throughout the first day.

Conclusions

The admission MAR ratio may be the earliest warning signal of a pathologic inflammatory response associated with hypoperfusion and TIC. A low MAR ratio is an early indication of complicated dysfunction of multiple molecular processes following trauma.

Blueprint for Restructuring a Department of Surgery in Concert With the Health Care System During a Pandemic: The University of Wisconsin Experience

The current health care environment is complex. Systems often cross US state boundaries to provide care to patients with a wide variety of medical needs. The coronavirus disease 2019 pandemic is challenging health care systems across the globe. Systems face varying levels of complexity as they adapt to the new reality. This pandemic continues to escalate in hot spots nationally and internationally, and the worst strain on health care systems may be yet to come. The purpose of this article is to provide a road map developed from lessons learned from the experience in the Department of Surgery at the University of Wisconsin School of Medicine and Public Health and University of Wisconsin Health, based on past experience with incident command structures in military combat operations and Federal Emergency Management Agency responses. We will discuss administrative restructuring leveraging a team-of-teams approach, provide a framework for deploying the workforce needed to deliver all necessary urgent health care and critical care to patients in the system, and consider implications for the future.

The electric scooter: A surging new mode of transportation that comes with risk to riders

Objective: The proliferation of electric scooter sharing companies has inundated many municipalities with electric scooters. The primary objective of this study is to characterize the epidemiology of injuries from this new mode of transportation in order to inform injury prevention efforts.Methods: A multicenter, retrospective study was conducted at two level 1 trauma centers in an urban setting. Patients seen in the emergency department from September 4, 2018 to November 4, 2018 were included if injury coding and chart review identified a scooter-related injury. Demographics, injury patterns, and other injury related factors were obtained via chart review.Results: Ninety-two patients were identified over the study period in 2018 with electric scooter-related injuries. Of the patients utilizing an electric scooter; none used protective gear and 33% used alcohol prior to presentation. More than 60% of patients required medical intervention including laceration repair (26%), fracture reduction (17%), operative fixation of a fracture (7%), or arterial embolization for an associated arterial injury (1%). Approximately 10% of patients required inpatient admission and one required an admission to the intensive care unit.Conclusion: We found a substantial increase in the number of scooter-related injuries during the first two months of electric scooter legalization. There was a lack of safety equipment utilization and concomitant alcohol utilization was common. These may offer areas of focus for injury prevention efforts. Additionally, standardization of injury coding for electric scooter related injury is critical to future studies and will help better understand the impact of this new mode of transportation.

Alternative clinical trial designs

High-quality clinical trials are needed to advance the care of injured patients. Traditional randomized clinical trials in trauma have challenges in generating new knowledge due to many issues, including logistical difficulties performing individual randomization, unclear pretrial estimates of treatment effect leading to often unpowered studies, and difficulty assessing the generalizability of an intervention given the heterogeneity of both patients and trauma centers. In this review, we discuss alternative clinical trial designs that can address some of these difficulties. These include pragmatic trials, cluster randomization, cluster randomized stepped wedge designs, factorial trials, and adaptive designs. Additionally, we discuss how Bayesian methods of inference may provide more knowledge to trauma and acute care surgeons compared with traditional, frequentist methods.

The System for Telementoring with Augmented Reality (STAR): A head-mounted display to improve surgical coaching and confidence in remote areas

BACKGROUND

The surgical workforce particularly in rural regions needs novel approaches to reinforce the skills and confidence of health practitioners. Although conventional telementoring systems have proven beneficial to address this gap, the benefits of platforms of augmented reality-based telementoring in the coaching and confidence of medical personnel are yet to be evaluated.

METHODS

A total of 20 participants were guided by remote expert surgeons to perform leg fasciotomies on cadavers under one of two conditions: (1) telementoring (with our System for Telementoring with Augmented Reality) or (2) independently reviewing the procedure beforehand. Using the Individual Performance Score and the Weighted Individual Performance Score, two on-site, expert surgeons evaluated the participants. Postexperiment metrics included number of errors, procedure completion time, and self-reported confidence scores. A total of six objective measurements were obtained to describe the self-reported confidence scores and the overall quality of the coaching. Additional analyses were performed based on the participants' expertise level.

RESULTS

Participants using the System for Telementoring with Augmented Reality received 10% greater Weighted Individual Performance Score (P = .03) and performed 67% fewer errors (P = .04). Moreover, participants with lower surgical expertise that used the System for Telementoring with Augmented Reality received 17% greater Individual Performance Score (P = .04), 32% greater Weighted Individual Performance Score (P < .01) and performed 92% fewer errors (P < .001). In addition, participants using the System for Telementoring with Augmented Reality reported 25% more confidence in all evaluated aspects (P < .03). On average, participants using the System for Telementoring with Augmented Reality received augmented reality guidance 19 times on average and received guidance for 47% of their total task completion time.

CONCLUSION

Participants using the System for Telementoring with Augmented Reality performed leg fasciotomies with fewer errors and received better performance scores. In addition, participants using the System for Telementoring with Augmented Reality reported being more confident when performing fasciotomies under telementoring. Augmented Reality Head-Mounted Display-based telementoring successfully provided confidence and coaching to medical personnel.

Perceived loss of social support after non-neurologic injury negatively impacts recovery

BACKGROUND

Traumatic injury is not only physically devastating, but also psychologically isolating, potentially leading to poor quality of life, depression and posttraumatic stress disorder (PTSD). Perceived social support (PSS) is associated with better outcomes in some populations. What is not known is if changes in PSS influence long-term outcomes following nonneurologic injury. We hypothesized that a single drop in PSS during recovery would be associated with worse quality of life.

METHODS

This is a post hoc analysis of a prospectively collected database that included patients 18 years or older admitted to a Level I trauma center with Injury Severity Score (ISS) of 10 or higher, and no traumatic brain or spinal cord injury. Demographic and injury data were collected at the initial hospital admission. Screening for depression, PTSD, and Medical Outcomes Study Short Form 36 Mental Composite Score (MCS) were obtained at the initial hospitalization, 1, 2, 4, and 12 months postinjury. The Multidimensional Scale of Perceived Social Support (MSPSS) was obtained at similar time points. Patients with high MSPSS (>5) at baseline were included and grouped by those that ever reported a score ≤5 (DROP), and those that remained high (STABLE). Outcomes were determined at 4 and 12 months.

RESULTS

Four hundred eleven patients were included with 96 meeting DROP criteria at 4 months, and 97 at 1 years. There were no differences in sex, race, or injury mechanism. The DROP patients were more likely to be single (p = 0.012 at 4 months, p = 0.0006 at 1 year) and unemployed (p = 0.016 at 4 months, and p = 0.026 at 1 year) compared with STABLE patients. At 4 months and 1 year, DROP patients were more likely to have PTSD, depression, and a lower MCS (p = 0.0006, p < 0.0001).

CONCLUSION

Patients who have a drop in PSS during the first year of recovery have significantly higher odds of poor psychological outcomes. Identifying these socially frail patients provides an opportunity for intervention to positively influence an otherwise poor quality of life.

LEVEL OF EVIDENCE

Therapeutic, Prognostic and Epidemiological, Level III.

Financial toxicity is associated with worse physical and emotional long-term outcomes after traumatic injury

BACKGROUND

Increasing health care costs and high deductible insurance plans have shifted more responsibility for medical costs to patients. After serious illnesses, financial responsibilities may result in lost wages, forced unemployment, and other financial burdens, collectively described as financial toxicity. Following cancer treatments, financial toxicity is associated with worse long-term health-related quality of life (HRQoL) outcomes. The purpose of this study was to determine the incidence of financial toxicity following injury, factors associated with financial toxicity, and the impact of financial toxicity on long-term HRQoL.

METHODS

Adult patients with an Injury Severity Score of 10 or greater and without head or spinal cord injury were prospectively followed for 1 year. The Short-Form-36 was used to determine overall quality of life at 1 month, 2 months, 4 months, and 12 months. Screens for depression and posttraumatic stress syndrome were administered. The primary outcome was any financial toxicity. A multivariable generalized estimating equation was used to account for variability over time.

RESULTS

Five hundred patients were enrolled, and 88% suffered financial toxicity during the year following injury (64% reduced income, 58% unemployment, 85% experienced stress due to financial burden). Financial toxicity remained stable over follow-up (80-85%). Factors independently associated with financial toxicity were lower age (odds ratio [OR], 0.96 [0.94-0.98]), lack of health insurance (OR, 0.28 [0.14-0.56]), and larger household size (OR, 1.37 [1.06-1.77]). After risk adjustment, patients with financial toxicity had worse HRQoL, and more depression and posttraumatic stress syndrome in a stepwise fashion based on severity of financial toxicity.

CONCLUSION

Financial toxicity following injury is extremely common and is associated with worse psychological and physical outcomes. Age, lack of insurance, and large household size are associated with financial toxicity. Patients at risk for financial toxicity can be identified, and interventions to counteract the negative effects should be developed to improve long-term outcomes.

LEVEL OF EVIDENCE

Prognostic/epidemiologic study, level III.

Physiologic stress among surgeons who take in-house call

INTRODUCTION

Burnout and depression is higher in trauma surgeons as compared to surgeons in other specialties. Clinical practice for many acute care surgeons (ACS) includes in-house call (IHC). The goal of this study was to quantitate physiologic stress among ACS who take IHC.

METHODS

ACS with IHC responsibilities from two Level I trauma centers were studied. Participants wore a fitness and heart rate variability (HRV) device over 3 months. HRV was categorized as normal if 85% of baseline, moderate stress when HRV <85% but >50%, and high stress when HRV< 50%.

RESULTS

1421 nights were recorded among 17 surgeons (35.3% female; mean age 45.5 years). Excluding IHC, mean HRV = 32.23, and 95.63% of days were consistent with moderate or high stress. Post-call day 2 had significantly highest percentage of high stress (65.82%, p = 0.0495). High and moderate stress levels returned to baseline on post-call day 3.

CONCLUSIONS

High and moderate stress beyond IHC is common among ACS. Future study is needed to determine consequences of persistent stress and identify factors which impact recovery after IHC.

Timing of Cholecystectomy after Emergent Endoscopic Retrograde Cholangiopancreatography for Cholangitis

Debate remains regarding the timing of laparoscopic cholecystectomy after emergent endoscopic retrograde cholangiopancreatography (ERCP) for acute cholangitis. We hypothesized that patients undergoing early laparoscopic cholecystectomy would have fewer operative complications and a lower conversion rate. This study is a retrospective review of an ERCP database from 2012 to 2016 of adults with a diagnosis of cholangitis secondary to choledocholithiasis who underwent ERCP followed by a laparoscopic cholecystectomy. Patient demographics, ERCP details, timing of operation (<72 hours vs >72 hours after ERCP), complications, and mortality were recorded. Analysis included chi-square, Fisher's exact, and Wilcoxon rank-sum tests, where appropriate. In the 127 patients (65 per cent male; median age, 67 years; 48 (38%) early surgery), there were no differences in demographics, BMI, vital signs, or laboratory values. Patients in the late surgery group were more likely to have a Charlson Comorbidity Index > 3 ( P = 0.002), require pre-operative endoscopic sphincterotomy ( P < 0.002), need pre-operative insertion of a ductal stent ( P < 0.03), and had more postoperative complications ( P = 0.04). Patients in the late laparoscopic cholecystectomy group had more comorbidities and suffered more complications.

Timing of Cholecystectomy after Emergent Endoscopic Retrograde Cholangiopancreatography for Cholangitis

Debate remains regarding the timing of laparoscopic cholecystectomy after emergent endoscopic retrograde cholangiopancreatography (ERCP) for acute cholangitis. We hypothesized that patients undergoing early laparoscopic cholecystectomy would have fewer operative complications and a lower conversion rate. This study is a retrospective review of an ERCP database from 2012 to 2016 of adults with a diagnosis of cholangitis secondary to choledocholithiasis who underwent ERCP followed by a laparoscopic cholecystectomy. Patient demographics, ERCP details, timing of operation (<72 hours vs >72 hours after ERCP), complications, and mortality were recorded. Analysis included chi-square, Fisher's exact, and Wilcoxon rank-sum tests, where appropriate. In the 127 patients (65 per cent male; median age, 67 years; 48 (38%) early surgery), there were no differences in demographics, BMI, vital signs, or laboratory values. Patients in the late surgery group were more likely to have a Charlson Comorbidity Index > 3 (P = 0.002), require pre-operative endoscopic sphincterotomy (P < 0.002), need pre-operative insertion of a ductal stent (P < 0.03), and had more postoperative complications (P = 0.04). Patients in the late laparoscopic cholecystectomy group had more comorbidities and suffered more complications.

Pharmacological Management of Delirium in the Intensive Care Unit: A Randomized Pragmatic Clinical Trial

BACKGROUND/OBJECTIVE

Delirium in the intensive care units (ICUs) is prevalent, with both delirium duration and delirium severity associated with adverse outcomes. We designed a pragmatic trial to test the efficacy of a pharmacological management of delirium (PMD) bundle in improving delirium/coma-free days and reducing delirium severity among ICU patients.

DESIGN

A randomized pragmatic clinical trial.

SETTING

Medical, surgical, and progressive ICUs of three tertiary care hospitals.

PARTICIPANTS

A total of 351 critically ill patients.

INTERVENTION

A multicomponent PMD bundle consisting of reducing the exposure to 20 definite anticholinergic medications and benzodiazepines and prescribing low-dose haloperidol.

MEASUREMENTS

The primary outcomes were delirium/coma-free days, measured through the Richmond Agitation-Sedation Scale and the Confusion Assessment Method for the ICU (CAM-ICU), and delirium severity, measured through Delirium Rating Scale-Revised-98 and the CAM-ICU-7. Secondary outcomes were in-hospital and posthospital discharge 30-day mortality, ICU and hospital lengths of stay, and delirium-related hospital complications.

RESULTS

We randomized 351 critically ill delirious patients (mean age = 59.3 years [SD = 16.9 years]; 52% female, 42% African Americans) to receive the PMD bundle or usual care. There were no significant differences in median delirium/coma-free days at day 8 (PMD vs usual care = 4 [interquartile range {IQR} = 2-7] days vs 5 [IQR = 1-7] days; P = .888) or at day 30 (PMD vs usual care = 26 [IQR 19-29] days vs 26 [IQR, 14-29] days; P = .991). There were no significant differences for decrease in delirium severity at day 8, but at hospital discharge, the intervention group showed a greater reduction in delirium severity (mean decrease in CAM-ICU-7 score for PMD vs usual care = 3.2 [SD = 3.3] vs 2.5 [SD = 3.2]; P = .046). No differences were observed between groups for ICU and hospital lengths of stay, mortality, and delirium-related hospital complications. Similar results were observed when analyses were limited to patients 65 years or older and 75 years or older.

CONCLUSION AND RELEVANCE

Implementing the PMD bundle in the ICU did not reduce delirium duration or severity among critically ill patients.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00842608. J Am Geriatr Soc 67:1057-1065, 2019.

To Sleep, Perchance to Dream: Acute and Chronic Sleep Deprivation in Acute Care Surgeons

BACKGROUND

Acute and chronic sleep deprivation are significantly associated with depressive symptoms and are thought to be contributors to the development of burnout. In-house call inherently includes frequent periods of disrupted sleep and is common among acute care surgeons. The relationship between in-house call and sleep deprivation among acute care surgeons has not been previously studied. The goal of this study was to determine prevalence and patterns of sleep deprivation in acute care surgeons.

STUDY DESIGN

A prospective study of acute care surgeons with in-house call responsibilities from 2 level I trauma centers was performed. Participants wore a sleep-tracking device continuously over a 3-month period. Data collected included age, sex, schedule of in-house call, hours and pattern of each sleep stage (light, slow wave, and rapid eye movement [REM]), and total hours of sleep. Sleep patterns were analyzed for each night, excluding in-house call, and categorized as normal, acute sleep deprivation, or chronic sleep deprivation.

RESULTS

There were 1,421 nights recorded among 17 acute care surgeons (35.3% female; ages 37 to 65 years, mean 45.5 years). Excluding in-house call, the average amount of sleep was 6.54 hours, with 64.8% of sleep patterns categorized as acute sleep deprivation or chronic sleep deprivation. Average amount of sleep was significantly higher on post-call day 1 (6.96 hours, p = 0.0016), but decreased significantly on post-call day 2 (6.33 hours, p = 0.0006). Sleep patterns with acute and chronic sleep deprivation peaked on post-call day 2, and returned to baseline on post-call day 3 (p = 0.046).

CONCLUSIONS

Sleep patterns consistent with acute and chronic sleep deprivation are common among acute care surgeons and worsen on post-call day 2. Baseline sleep patterns were not recovered until post-call day 3. Future study is needed to identify factors that affect physiologic recovery after in-house call and further elucidate the relationship between sleep deprivation and burnout.

The conference effect: National surgery meetings are associated with increased mortality at trauma centers without American College of Surgeons verification

Background

Thousands of physicians attend scientific conferences each year. While recent data indicate that variation in staffing during such meetings impacts survival of non-surgical patients, the association between treatment during conferences and outcomes of a surgical population remain unknown. The purpose of this study was to examine mortality resulting from traumatic injuries and the influence of hospital admission during national surgery meetings.

Study design

Retrospective analysis of in-hospital mortality using data from the Trauma Quality Improvement Program (2010–2011). Identified patients admitted during four annual meetings and compared their mortality with that of patients admitted during non-conference periods. Analysis included 155 hospitals with 12,256 patients admitted on 42 conference days and 82,399 patients admitted on 270 non-conference days. Multivariate analysis performed separately for hospitals with different levels of trauma center verification by state and American College of Surgeons (ACS) criteria.

Results

Patient characteristics were similar between meeting and non-meeting dates. At ACS level I and level II trauma centers during conference versus non-conference dates, adjusted mortality was not significantly different. However, adjusted mortality increased significantly for patients admitted to trauma centers that lacked ACS trauma verification during conferences versus non-conference days (OR 1.2, p = 0.008), particularly for patients with penetrating injuries, whose mortality rose from 11.6% to 15.9% (p = 0.006).

Conclusions

Trauma mortality increased during surgery conferences compared to non-conference dates for patients admitted to hospitals that lacked ACS trauma level verification. The mortality difference at those hospitals was greatest for patients who presented with penetrating injuries.

What's in a Name? Provider Perception of Injured John Doe Patients

BACKGROUND

We previously demonstrated that unidentified aliased patients, John Doe's (DOEs), are one of the highest risk and most medically fragile populations of injured patients. Aliasing can result in misplaced information and confusion that must be overcome by health care professionals. DOE alias use is institutionally dependent and not uniform, which may lead to significant variation in perception of confusion and error. We sought to determine if health care practitioners experience confusion that may result in compromised care when caring for injured DOE patients.

METHODS

After obtaining institutional review board approval, we surveyed critical care nurses, nurse practitioners, resident physicians, and surgeons who care for DOE patients at two academic level I trauma centers with separate DOE alias practices. Surveys asked whether caring for DOE patients created possible or actual confusion and possible or actual patient care errors. In one institution (Selective DOE), only unidentified patients were given an alias that was reconciled when information became available. At the other institution (All DOE), all trauma patients were admitted with an alias that was reconciled within 24 h. Respondents were invited to complete an anonymous questionnaire regarding the care for DOE patients. Results were analyzed with Wilcoxon rank-sum tests, and significance was assessed at a level of 0.05.

RESULTS

Of 176 total respondents, 120 (68.2%) reported from Selective DOE and 56 (31.8%) from All DOE. Overall 53.1% reported that DOE use can cause serious confusion. Specifically, 31.3% reported experiencing actual confusion, although only 4% reported actual errors. Nurses had significantly higher perceived risk of confusion in the system of All DOE versus Selective DOE assignment (17.9% versus 4.2%, P < 0.01). Resident physicians reported significantly more frequent actual mistakes within the All DOE versus Selective DOE (24.1% versus 6.6%, P < 0.01), despite finding no significant difference in resident perception of confusion (21.4% versus 12.5%, respectively, P = 0.18).

CONCLUSIONS

Our study sheds light on clinical consequences of EMR use and aliases for end users. We show that nurses perceive that there are greater potential complications associated with DOE aliases use, and this varies depending on the system used for managing unidentified patients. Minimizing DOE alias use may help to minimize provider confusion, risk for error, and patient safety.

Preventing Postoperative Delirium After Major Noncardiac Thoracic Surgery-A Randomized Clinical Trial

OBJECTIVES

To assess the efficacy of haloperidol in reducing postoperative delirium in individuals undergoing thoracic surgery.

DESIGN

Randomized double-blind placebo-controlled trial.

SETTING

Surgical intensive care unit (ICU) of tertiary care center.

PARTICIPANTS

Individuals undergoing thoracic surgery (N=135).

INTERVENTION

Low-dose intravenous haloperidol (0.5 mg three times daily for a total of 11 doses) administered postoperatively.

MEASUREMENTS

The primary outcome was delirium incidence during hospitalization. Secondary outcomes were time to delirium, delirium duration, delirium severity, and ICU and hospital length of stay. Delirium was assessed using the Confusion Assessment Method for the ICU and delirium severity using the Delirium Rating Scale-Revised.

RESULTS

Sixty-eight participants were randomized to receive haloperidol and 67 placebo. No significant differences were observed between those receiving haloperidol and those receiving placebo in incident delirium (n=15 (22.1%) vs n=19 (28.4%); p = .43), time to delirium (p = .43), delirium duration (median 1 day, interquartile range (IQR) 1-2 days vs median 1 day, IQR 1-2 days; p = .71), delirium severity, ICU length of stay (median 2.2 days, IQR 1-3.3 days vs median 2.3 days, IQR 1-4 days; p = .29), or hospital length of stay (median 10 days, IQR 8-11.5 days vs median 10 days, IQR 8-12 days; p = .41). In the esophagectomy subgroup (n = 84), the haloperidol group was less likely to experience incident delirium (n=10 (23.8%) vs n=17 (40.5%); p = .16). There were no differences in time to delirium (p = .14), delirium duration (median 1 day, IQR 1-2 days vs median 1 day, IQR 1-2 days; p = .71), delirium severity, or hospital length of stay (median 11 days, IQR 10-12 days vs median days 11, IQR 10-15 days; p = .26). ICU length of stay was significantly shorter in the haloperidol group (median 2.8 days, IQR 1.1-3.8 days vs median 3.1 days, IQR 2.1-5.1 days; p = .03). Safety events were comparable between the groups.

CONCLUSION

Low-dose postoperative haloperidol did not reduce delirium in individuals undergoing thoracic surgery but may be efficacious in those undergoing esophagectomy. J Am Geriatr Soc 66:2289-2297, 2018.

Clinical indicators of hemorrhagic shock in pregnancy

Background

Several hemodynamic parameters have been promoted to help establish a rapid diagnosis of hemorrhagic shock, but they have not been well validated in the pregnant population. In this study, we examined the association between three measures of shock and early blood transfusion requirements among pregnant trauma patients.

Methods

This study included 81 pregnant trauma patients admitted to a level 1 trauma center (2010-2015). In separate logistic regression models, we tested the relationship between exposure variables-initial systolic blood pressure (SBP), shock index (SI), and rate over pressure evaluation (ROPE)-and the outcome of transfusion of blood products within 24 hours of admission. To test the predictive ability of each measure, we used receiver operating characteristic (ROC) curves.

Results

A total of 10% of patients received blood products in the patient cohort. No patients had an initial SBP≤90, so the SBP measure was excluded from analysis. We found that patients with SI>1 were significantly more likely to receive blood transfusions compared with patients with SI<1 (OR 10.35; 95% CI 1.80 to 59.62), whereas ROPE>3 was not associated with blood transfusion compared with ROPE≤3 (OR 2.92; 95% CI 0.28 to 30.42). Furthermore, comparison of area under the ROC curve for SI (0.68) and ROPE (0.54) suggested that SI was more predictive than ROPE of blood transfusion.

Conclusion

We found that an elevated SI was more closely associated with early blood product transfusion than SBP and ROPE in injured pregnant patients.

Level of evidence

Prognostic, level III.

Comparison of Automated Posttonsillectomy Bleed Capture With Self-report

Importance

Tonsillectomy is one of the most common procedures performed by otolaryngologists and is associated with postoperative bleeding. Bleed rates are usually monitored by self-report.

Objective

To evaluate whether using automated capture and reporting of pediatric posttonsillectomy bleeding is feasible and accurate compared with traditional self-reporting by the surgical team.

Design, Setting, and Participants

An automated complication-reporting algorithm was designed to query the local health information exchange and then tested against self-reported tonsillectomy complication data collected from January 1, 2014, through December 31, 2015, at a tertiary pediatric hospital. The algorithm identified patients undergoing tonsillectomy and searched their postoperative encounters for a hand-selected set of diagnosis codes from the International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision and free-text words to identify complication events. Five months of the 2014-2015 data set were used to help design the algorithm. Data from the remaining 19 months were compared with self-reported complications.

Main Outcomes and Measures

Automated system findings compared with self-reported bleeding events.

Results

During the 19-month period, 1017 tonsillectomies were performed. We compared the algorithm's effectiveness in finding tonsillectomy and adenotonsillectomy procedures for the evaluated surgeons with the hand-reviewed master tonsillectomy list. The algorithm reported 51 false-positive (5.01% missed) and 74 false-negative (7.28% misidentified) procedures. The algorithm agreed with self-report for 986 tonsillectomies and disagreed on 31 cases (3.05%) (κ = 0.69; 95% CI, 0.66-0.73). The algorithm was found to be sensitive to correctly identifying 60.53% (95% CI, 48.63%-71.34%) of tonsillectomies as having bleeding complications, with a specificity of 98.30% (95% CI, 97.19%-98.99%).

Conclusions and Relevance

Capture of posttonsillectomy bleeding is possible through an automatic search of the medical record, although the algorithm will require continued refinement. Leveraging health information exchange data increases the possibilities of capturing complications at hospitals outside the local health system. Use of these algorithms will allow repeatable automated feedback to be provided to surgeons on a cyclical basis.

Resiliency and quality of life trajectories after injury

BACKGROUND

Injury can greatly impact patients' long-term quality of life. Resilience refers to an individual's ability to positively adapt after facing stress or trauma. The objective of this study was to examine the relationship between preinjury resiliency scores and quality of life after injury.

METHODS

Two hundred twenty-five adults admitted with an Injury Severity Score greater than 10 but without neurologic injury were included. The 36-item Short Form was administered at the time of admission and repeated at 1 month, 2 months, 4 months, and 12 months after injury. The Connor-Davidson Resilience Scale was completed at admission and scores were categorized into high resiliency or not high resiliency. Group-based trajectory modeling was used to identify distinct recovery trajectories for physical component scores (PCS) and mental component scores (MCS) of the 36-item Short Form. Multinomial logistic regression was used to determine whether baseline resiliency scores were predictive of PCS and MCS recovery trajectories.

RESULTS

Age, race, sex, mechanism of injury, Charlson Comorbidity Index, Injury Severity Score, presence of hypotension on admission, and insurance status were not associated with high resiliency. Compared with those who made less than US $10,000 per year, those who made more than US $50,000 per year had higher odds of being in the high resilience group (odds ratio, 10.92; 95% confidence interval, 2.58-46.32). Three PCS and 5 MCS trajectories were identified. There was no relationship between resilience and PCS trajectory. However, patients with high resiliency scores were 85% less likely to belong to trajectory 1, the trajectory that had the lowest mental health scores over the course of the study. Follow-up for the study was 93.8% for month 1, 82.7% for month 2, 69.4% for month 4, and 63.6% for month 12.

CONCLUSION

Patient resiliency predicts quality of life after injury in regards to mental health with over 25% of patients suffering poor mental health outcome trajectories. Efforts to teach resiliency skills to injured patients could improve long-term mental health for injured patients. Trauma centers are well positioned to carry out such interventions.

LEVEL OF EVIDENCE

Prognostic/epidemiologic study, level III.

Medication Errors in Injured Patients

Trauma patients are vulnerable to medication error given multiple handoffs throughout the hospital. The purpose of this study was to assess trends in medication errors in trauma patients and the role these errors play in patient outcomes. Injured adults admitted from 2009 to 2015 to a Level I trauma center were included. Medication errors were determined based on a nurse-driven, validated, and prospectively maintained database. Multivariable logistic regression modeling was used to control for differences between groups. Among 15,635 injured adults admitted during the study period, 132 patients experienced 243 errors. Patients who experienced errors had significantly worse injury severity, lower Glasgow Coma Scale scores and higher rates of hypotension on admission, and longer lengths of stay. Before adjustment, mortality was similar between groups but morbidity was higher in the medication error group. After risk adjustment, there were no significant differences in morbidity or mortality between the groups. Medication errors in trauma patients tend to occur in significantly injured patients with long hospital stays. Appropriate adjustment when studying the impact of medical errors on patient outcomes is important.

Medication Errors in Injured Patients

Trauma patients are vulnerable to medication error given multiple handoffs throughout the hospital. The purpose of this study was to assess trends in medication errors in trauma patients and the role these errors play in patient outcomes. Injured adults admitted from 2009 to 2015 to a Level I trauma center were included. Medication errors were determined based on a nurse-driven, validated, and prospectively maintained database. Multivariable logistic regression modeling was used to control for differences between groups. Among 15,635 injured adults admitted during the study period, 132 patients experienced 243 errors. Patients who experienced errors had significantly worse injury severity, lower Glasgow Coma Scale scores and higher rates of hypotension on admission, and longer lengths of stay. Before adjustment, mortality was similar between groups but morbidity was higher in the medication error group. After risk adjustment, there were no significant differences in morbidity or mortality between the groups. Medication errors in trauma patients tend to occur in significantly injured patients with long hospital stays. Appropriate adjustment when studying the impact of medical errors on patient outcomes is important.

An update on nonoperative management of the spleen in adults

Many patients with blunt splenic injury are considered for nonoperative management and, with proper selection, the success rate is high. This paper aims to provide an update on the treatments and dilemmas of nonoperative management of splenic injuries in adults and to offer suggestions that may improve both consensus and patient outcomes.

Does Hyperbilirubinemia Contribute to Adverse Patient Outcomes Following Pancreatoduodenectomy?

BACKGROUND

Jaundice due to biliary obstruction leads to multiple physiologic derangements and a decline in performance status that may result in unfavorable intra- and postoperative outcomes following a Whipple procedure. While preoperative biliary decompression may improve synthetic function, this strategy has been reported to increase the incidence of infectious complications following surgery. We hypothesized that hyperbilirubinemia at the time of pancreatoduodenectomy (PD) would be a risk factor for increased morbidity and mortality postoperatively.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Pancreatectomy Demonstration Project and the 2014 Procedure Targeted Pancreatectomy databases were queried for patients with a bilirubin level obtained within 7 days of PD. Results were compared among patients with bilirubin level percentiles <80th (0-2.9 mg/dL), 80-90th (3-7.3 mg/dL), and >90th (>7.3 mg/dL). Data were further evaluated between those with a bilirubin ≥10 mg/dL and those with a normal level and by utilizing bilirubin as a continuous variable. Outcomes included 30-day mortality and overall and serious morbidity as previously defined by ACS-NSQIP. Categorical variables were compared using chi-squared, Fisher's exact, Kruskal-Wallis, or Wilcoxon rank sum tests with a p = 0.05 considered significant.

RESULTS

The combined databases yielded 2556 patients who had PD and a preoperative bilirubin level for analysis. When comparing patients with bilirubin levels at the 80th (n = 2055), 80-90th (n = 273), and >90th percentiles (n = 228), no difference was observed among groups with respect to overall and serious morbidity or mortality. Similarly, no difference in postoperative outcomes was observed between the 147 patients who had a bilirubin ≥10 mg/dL and those with normal levels or when bilirubin increased when levels were analyzed as a continuous variable.

CONCLUSION

Modest degrees of hyperbilirubinemia were not shown to affect morbidity and mortality following pancreatoduodenectomy. The indication and need for preoperative biliary decompression should be reserved, and utilized selectively, only for those with symptomatic, elevated bilirubin levels.

Reduced morbidity with minimally invasive distal pancreatectomy for pancreatic adenocarcinoma

BACKGROUND

Minimally invasive distal pancreatectomy (MISDP) has been shown to be safe relative to open distal pancreatectomy (ODP). However, MISDP has been slow to adopt for pancreatic adenocarcinoma (PDAC). This study sought to compare outcomes following MISDP vs. ODP for PDAC.

METHODS

Data were prospectively collected from 2011 to 2014 for DP by the American College of Surgeons-National Surgical Quality Improvement Program. Patients without PDAC on surgical pathology were excluded. Impact of minimally invasive approach on morbidity and mortality was analyzed using two-way statistical analyses.

RESULTS

Of 6198 patients undergoing DP, 501 (7.5%) had a pathologic diagnosis of PDAC. MISDP was undertaken in 166 (33.1%) patients, ODP was performed in 335 (66.9%). MISDP and ODP were not different in preoperative comorbidities or pathologic stage. Overall morbidity (MISDP 31%, ODP 42%; p = 0.024), transfusion (MISDP 6%, ODP 23%; p = 0.0001), pneumonia (MISDP 1%, ODP 7%; p = 0.004), surgical site infections (MISDP 8%, OPD 17%; p = 0.013), sepsis (MISDP 2%, ODP 8%; p = 0.007), and length of stay (MISDP 5.0 days, ODP 7.0 days; p = 0.009) were lower in the MIS group. Mortality (MISDP 0%, ODP 1%; p = 0.307), pancreatic fistula (MISDP 12%, ODP 19%; p = 0.073), and delayed gastric emptying (MISDP 3%, ODP 7%; p = 0.140) were similar.

CONCLUSIONS

This analysis of a large multi-institution North American experience of DP for treatment of pancreatic adenocarcinoma suggests that short-term postoperative outcomes are improved with MISDP.

Laparoscopic versus robotic colectomy: a national surgical quality improvement project analysis

INTRODUCTION

Robotic colorectal surgery is being increasingly adopted. Our objective was to compare early postoperative outcomes between robotic and laparoscopic colectomy in a nationally representative sample.

METHODS

The American College of Surgeons National Surgical Quality Improvement Project Colectomy Targeted Dataset from 2012 to 2014 was used for this study. Adult patients undergoing elective colectomy with an anastomosis were included. Patients were stratified based on location of colorectal resection (low anterior resection (LAR), left-sided resection, or right-sided resection). Bivariate data analysis was performed, and logistic regression modeling was conducted to calculate risk-adjusted 30-day outcomes.

RESULTS

There were a total of 25,998 laparoscopic colectomies (30 % LAR's, 45 % left-sided, and 25 % right-sided) and 1484 robotic colectomies (54 % LAR's, 28 % left-sided, and 18 % right-sided). The risk-adjusted overall morbidity, serious morbidity, and mortality were similar between laparoscopic and robotic approaches in all anastomotic groups. Patients undergoing robotic LAR had a lower conversion rate (OR 0.47, 95 % CI 1.20-1.76) and postoperative sepsis rate (OR 0.49, 95 % CI 0.29-0.85) but a higher rate of diverting ostomies (OR 1.45, 95 % CI 1.20-1.76). Robotic right-sided colectomies had significantly lower conversion rates (OR 0.58, 95 % CI 0.34-0.96). Robotic colectomy in all groups was associated with a longer operative time (by 40 min) and a decreased length of stay (by 0.5 days).

CONCLUSIONS

In a nationally representative sample comparing laparoscopic and robotic colectomies, the overall morbidity, serious morbidity, and mortality between groups are similar while length of stay was shorter by 0.5 days in the robotic colectomy group. Robotic LAR was associated with lower conversion rates and lower septic complications. However, robotic LAR is also associated with a significantly higher rate of diverting ostomy. The reason for this relationship is unclear. Surgeon factors, patient factors, and technical factors should be considered in future studies.

Arterial Injuries Associated with Blunt Fractures in the Lower Extremity

Problems related to the combination of an arterial injury and a blunt fracture in the lower extremity are well known—delayed diagnosis, damaged soft tissue, and high amputation rate. The actual incidence of this injury pattern is, however, unknown. The purposes of this study were to determine the current incidence of named arterial injuries in patients with blunt fractures in the lower extremities and assess potential associated risk factors. This was a 7-year (2007–2013) retrospective review of patients ≥18 years with blunt lower extremity fractures at a Level I trauma center. Fracture location and concomitant arterial injury were determined and patients stratified by age, gender, and injury velocity. Low injury velocity was defined as falls or assaults, whereas an injury secondary to a motorized vehicle was defined as high velocity. A total of 4413 patients (mean age 52.2 years, 54.3% male, mean Injury Severity Score 13.1) were identified. Forty-six patients (1.04%) had arterial injuries (20.4% common femoral, 8.2% superficial femoral, 44.9% popliteal, and 26.5% shank). After stratifying by age and injury velocity, younger age was associated with a significantly higher rate of vascular injury. For high-velocity injuries, there was no difference based on age. In conclusion, the prevalence of arterial injury after blunt lower extremity fractures is 1.04 per cent in our study. A significant paradoxical relationship exists between age and associated arterial injuries in patients with low-velocity injuries. If these data are confirmed in future studies, a low index of suspicion in patients >55 years after falls is appropriate.

Arterial Injuries Associated with Blunt Fractures in the Lower Extremity

Problems related to the combination of an arterial injury and a blunt fracture in the lower extremity are well known-delayed diagnosis, damaged soft tissue, and high amputation rate. The actual incidence of this injury pattern is, however, unknown. The purposes of this study were to determine the current incidence of named arterial injuries in patients with blunt fractures in the lower extremities and assess potential associated risk factors. This was a 7-year (2007-2013) retrospective review of patients ≥18 years with blunt lower extremity fractures at a Level I trauma center. Fracture location and concomitant arterial injury were determined and patients stratified by age, gender, and injury velocity. Low injury velocity was defined as falls or assaults, whereas an injury secondary to a motorized vehicle was defined as high velocity. A total of 4413 patients (mean age 52.2 years, 54.3% male, mean Injury Severity Score 13.1) were identified. Forty-six patients (1.04%) had arterial injuries (20.4% common femoral, 8.2% superficial femoral, 44.9% popliteal, and 26.5% shank). After stratifying by age and injury velocity, younger age was associated with a significantly higher rate of vascular injury. For high-velocity injuries, there was no difference based on age. In conclusion, the prevalence of arterial injury after blunt lower extremity fractures is 1.04 per cent in our study. A significant paradoxical relationship exists between age and associated arterial injuries in patients with low-velocity injuries. If these data are confirmed in future studies, a low index of suspicion in patients >55 years after falls is appropriate.

C-spine injury and mandibular fractures: lifesaver broken in two spots

BACKGROUND

Trauma is a leading cause of injury and mortality and may involve mandibular fractures and cervical spine injuries. Manipulation of the spine during trauma protocols and operative treatment has the potential to cause serious spinal cord injuries. The purpose of this study was to identify risk factors associated with cervical spine injury (CSI) in patients with mandibular fractures.

METHODS

The National Trauma Databank (2007-2010) was used to identify patients with mandibular fractures.

RESULTS

A total of 59,028 patients were identified and separated into adult and pediatric cohorts. There were 50,711 adults (86%) and 8317 children (14%). There were statistically significant lower rates of associated CSI in pediatric patients than adults (3.5% versus 7.3%, P < 0.01). Predictors of associated CSI in mandible fractures for both adults and children were older age, lower Glasgow Coma Scale, thoracic injuries, firearm or motor vehicle accident mechanisms, and symphyseal fractures. In the pediatric cohort, body, ramus, and subcondylar fractures were significantly associated with CSI. In adults, female gender, and upper extremity, abdominopelvic, and head injuries were also significantly associated with CSI.

CONCLUSIONS

Multiple mandibular fractures were inversely correlated with CSI. One possibility is that energy dissipation in the mandible with multiple fractures is protective of the C-spine leading to fewer fractures. Children and adults had different associations in the pattern of mandible fractures concomitant with CSI. This has implications in management, imaging, and workup of trauma patients.

Thinking outside the box: re-evaluating the approach to penetrating cardiac injuries

INTRODUCTION

Penetrating cardiac injuries are infrequent but highly lethal. To address these injuries, cardiopulmonary bypass and cardiothoracic surgery availability are required for Level I trauma center verification. However, acute care surgeons are more readily available for this time-sensitive injury. The purpose of this study was to review an acute care surgery-based experience with penetrating cardiac trauma at an urban Level 1 trauma center. Our hypothesis was that care provided solely by acute care surgeons was both safe and effective for this patient population.

METHODS

All patients with injuries to the 'cardiac box' following penetrating thoracic trauma were identified from 2005-2010. Demographic and injury related data were obtained. The types and location of cardiac injury, as well as patient outcomes, were determined from operative reports.

RESULTS

1701 patients with penetrating chest trauma were admitted during the study period. 260 patients were identified as having high-risk injuries and were included in the review. 37 patients underwent resuscitative thoracotomy, with a survival rate of 8 %. 76 patients (29 %) suffered a cardiac injury. 72 % of these patients had a preoperative FAST exam, which had a sensitivity and specificity of 56.5 and 82.5 % respectively. 82 % underwent a pericardial window, which had a positive predictive value of 81.4 %. 61 % (n = 46) of the patients with a cardiac injury survived, while the overall death rate in this cohort was 21 %. No patients in the cohort required cardiopulmonary bypass for emergent repair of cardiac injury and acute care surgeons performed all cases.

CONCLUSION

Penetrating injury to the heart is highly lethal and time-sensitive. Increasingly, FAST and subxyphoid pericardial window are relied upon to make the diagnosis in patients arriving in varying stages of shock to the resuscitation room. Acute care surgeons are the most appropriate surgeons to care for these injuries and provide safe and effective care.