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Vella MA, Zone A, Succar B, Cheng M, Maiga AW, Appelbaum RD, Notario L, Pannell D, Holena DN, Dumas RP. Teamwork matters: The association between nontechnical skills and cardiac arrest in trauma patients presenting with hypotension. Surgery 2024; 175:1595-1599. [PMID: 38472080 DOI: 10.1016/j.surg.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 01/20/2024] [Accepted: 02/08/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND The impact of trauma team dynamics on outcomes in injured patients is not completely understood. We sought to evaluate the association between trauma team function, as measured by a modified Trauma Non-Technical Skills assessment, and cardiac arrest in hypotensive trauma patients. We hypothesized that better team function is associated with a decreased probability of developing cardiac arrest. METHODS Trauma video review was used to collect data from resuscitations of adult hypotensive trauma patients at 19 centers. Hypotension at emergency department presentation was defined as an initial systolic blood pressure <90 mm Hg or an initial systolic blood pressure ≥90 mm Hg followed by a systolic blood pressure <90 mm Hg within the first 5 minutes. Team dynamics were scored using a modified Trauma Non-Technical Skills assessment composed of 5 domains with combined scores ranging from 5 (best) to 15 (worst). Scores were compared between cardiac arrest/noncardiac arrest cases in the trauma bay. Logistic regression was used to evaluate the independent association between the Trauma Non-Technical Skills assessment and cardiac arrest. RESULTS A total of 430 patients were included (median age 43 years [interquartile range: 29-61]; 71.8% male; 36% penetrating mechanism; median Injury Severity Score 20 [10-33]; 11% experienced cardiac arrest in trauma bay). The median total Trauma Non-Technical Skills assessment score was 7 (6-9), higher in patients who experienced cardiac arrest in the trauma bay (9 [6-10] vs 7 [6-9]; P = .016). This association persisted after controlling for age, sex, mechanism, injury severity, initial systolic blood pressure, and initial Glasgow Coma Scale score (adjusted odds ratio: 1.28; 95% confidence interval:1.11-1.48; P < .001), indicating a ∼3% higher predicted probability of cardiac arrest per Trauma Non-Technical Skills point. CONCLUSION Better team function is independently associated with a decreased probability of cardiac arrest in trauma patients presenting with hypotension. This suggests that trauma team training may improve outcomes in peri-arrest patients.
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Affiliation(s)
- Michael A Vella
- University of Rochester Medical Center Division of Acute Care Surgery, Rochester, NY. http://www.twitter.com/MichealVella32
| | - Alea Zone
- UT Southwestern Medical Center, Division of Burn Trauma Acute and Critical Care Surgery, Dallas, TX
| | - Bahaa Succar
- UT Southwestern Medical Center, Division of Burn Trauma Acute and Critical Care Surgery, Dallas, TX. http://www.twitter.com/B_Succar
| | - Mingyuan Cheng
- UT Southwestern Medical Center, Division of Burn Trauma Acute and Critical Care Surgery, Dallas, TX
| | - Amelia W Maiga
- Vanderbilt University Medical Center, Division of Acute Care Surgery, Nashville, TN. http://www.twitter.com/AmeliaMaiga
| | - Rachel D Appelbaum
- Vanderbilt University Medical Center, Division of Acute Care Surgery, Nashville, TN. http://www.twitter.com/AppelbaumMD
| | | | | | - Daniel N Holena
- Medical College of Wisconsin Division of Trauma and Acute Care Surgery Milwaukee, WI. http://www.twitter.com/Daniel_Holena
| | - Ryan P Dumas
- UT Southwestern Medical Center, Division of Burn Trauma Acute and Critical Care Surgery, Dallas, TX.
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Al Tannir AH, Golestani S, Tentis M, Maring M, Biesboer EA, Dodgion C, Murphy PB, Holena DN, Trevino CM, Peschman JR, Carver TW, Milia DJ, Schellenberg M, de Moya MA, Morris RS. A Collaborative Multidisciplinary Trauma Program Improvement Team Improves VTE Chemoprophylaxis Guideline Compliance In Non-Operative Stable TBI. J Trauma Acute Care Surg 2024:01586154-990000000-00646. [PMID: 38437527 DOI: 10.1097/ta.0000000000004294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2024]
Abstract
BACKGROUND Delays in initiating venous thromboembolism (VTE) prophylaxis in patients suffering from traumatic brain injury (TBI) persist despite guidelines recommending early initiation. We hypothesized that the expansion of a Trauma Program Performance Improvement (PI) team will improve compliance of early (24-48 hour) initiation of VTE prophylaxis and will decrease VTE events in TBI patients. METHODS We performed a single-center retrospective review of all TBI patients admitted to a Level I trauma center before (2015-2016,) and after (2019-2020,) the expansion of the Trauma Performance Improvement and Patient Safety (PIPS) team and the creation of trauma process and outcome dashboards. Exclusion criteria included discharge or death within 48 hours of admission, expanding intracranial hemorrhage on CT scan, and a neurosurgical intervention (craniotomy, pressure monitor, or drains) prior to chemoprophylaxis initiation. RESULTS A total of 1,112 patients met the inclusion criteria, of which 54% (n = 604) were admitted after Trauma PIPS expansion. Following the addition of a dedicated PIPS nurse in the trauma program and creation of process dashboards, the time from stable CT to VTE prophylaxis initiation decreased (52 hours to 35 hours; p < 0.001) and more patients received chemoprophylaxis at 24-48 hours (59% from 36%, p < 0.001) after stable head CT. There was no significant difference in time from first head CT to stable CT (9 vs 9 hours; p = 0.15). The Contemporary group had a lower rate of VTE events (1% vs 4%; p < 0.001) with no increase in bleeding events (2% vs 2%; p = 0.97). On multivariable analysis, being in the Early cohort was an independent predictor of VTE events (aOR: 3.74; 95%CI: 1.45-6.16). CONCLUSION A collaborative multidisciplinary Trauma PIPS team improves guideline compliance. Initiation of VTE chemoprophylaxis within 24-48 hours of stable head CT is safe and effective. LEVEL OF EVIDENCE Level III, Therapeutic/Care Management.
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Affiliation(s)
- Abdul Hafiz Al Tannir
- Department of Surgery, Division of Trauma & Critical Care Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Simin Golestani
- Department of Surgery, Division of Trauma & Critical Care Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Morgan Tentis
- Department of Surgery, Division of Trauma & Critical Care Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Morgan Maring
- Department of Surgery, Division of Trauma & Critical Care Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Elise A Biesboer
- Department of Surgery, Division of Trauma & Critical Care Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Christopher Dodgion
- Department of Surgery, Division of Trauma & Critical Care Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Patrick B Murphy
- Department of Surgery, Division of Trauma & Critical Care Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Daniel N Holena
- Department of Surgery, Division of Trauma & Critical Care Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Colleen M Trevino
- Department of Surgery, Division of Trauma & Critical Care Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Jacob R Peschman
- Department of Surgery, Division of Trauma & Critical Care Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Thomas W Carver
- Department of Surgery, Division of Trauma & Critical Care Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - David J Milia
- Department of Surgery, Division of Trauma & Critical Care Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Morgan Schellenberg
- Department of Surgery, Division of Trauma & Critical Care Surgery, USC+LAC, Los Angeles, California
| | - Marc A de Moya
- Department of Surgery, Division of Trauma & Critical Care Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Rachel S Morris
- Department of Surgery, Division of Trauma & Critical Care Surgery, Medical College of Wisconsin, Milwaukee, WI
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Succar B, Vella MA, Holena DN, Dumas RP. Navigating the challenges of vascular access in hypotensive injured patients. Surgery 2024; 175:559-560. [PMID: 37980201 DOI: 10.1016/j.surg.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 10/17/2023] [Indexed: 11/20/2023]
Affiliation(s)
- Bahaa Succar
- UT Southwestern Medical Center, Division of Burn Trauma Acute and Critical Care Surgery, Dallas, TX. https://twitter.com/B_Succar
| | - Michael A Vella
- University of Rochester Medical Center, Division of Acute Care Surgery, Rochester, NY. https://twitter.com/MichaelVella32
| | - Daniel N Holena
- Medical College of Wisconsin, Division of Trauma and Acute Care Surgery, Milwaukee, WI
| | - Ryan P Dumas
- UT Southwestern Medical Center, Division of Burn Trauma Acute and Critical Care Surgery, Dallas, TX.
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Succar B, Vella MA, Holena DN, Dumas RP. Response to "Letter To The Editor" on "Moving the needle on time to resuscitation: An EAST prospective multicenter study of vascular access in hypotensive injured patients using trauma video review". J Trauma Acute Care Surg 2024; 96:e17-e18. [PMID: 37936274 DOI: 10.1097/ta.0000000000004178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
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Maiga AW, Vella MA, Appelbaum RD, Irlmeier R, Ye F, Holena DN, Dumas RP. Getting out of the bay faster: Assessing trauma team performance using trauma video review. J Trauma Acute Care Surg 2024; 96:76-84. [PMID: 37880840 DOI: 10.1097/ta.0000000000004168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Abstract
BACKGROUND Minutes matter for trauma patients in hemorrhagic shock. How trauma team function impacts time to the next phase of care has not been rigorously evaluated. We hypothesized better team performance scores to be associated with decreased time to the next phase of trauma care. METHODS This retrospective secondary analysis of a prospective multicenter observational study included hypotensive trauma patients at 19 centers. Using trauma video review, we analyzed team performance with the validated Non-Technical Skills for Trauma scale: leadership, cooperation and resource management, communication, assessment/decision making, and situational awareness. The primary outcome was minutes from patient arrival to next phase of care; deaths in the bay were excluded. Secondary outcomes included time to initiation and completion of first unit of blood and inpatient mortality. Associations between team dynamics and outcomes were assessed with a linear mixed-effects model adjusting for Injury Severity Score, mechanism, initial blood pressure and heart rate, number of team members, and trauma team lead training level and sex. RESULTS A total of 441 patients were included. The median Injury Severity Score was 22 (interquartile range, 10-34), and most (61%) sustained blunt trauma. The median time to next phase of care was 23.5 minutes (interquartile range, 17-35 minutes). Better leadership, communication, assessment/decision making, and situational awareness scores were associated with faster times to next phase of care (all p < 0.05). Each 1-point worsening in the Non-Technical Skills for Trauma scale score (scale, 5-15) was associated with 1.6 minutes more in the bay. The median resuscitation team size was 12 (interquartile range, 10-15), and larger teams were slower ( p < 0.05). Better situational awareness was associated with faster completion of first unit of blood by 4 to 5 minutes ( p < 0.05). CONCLUSION Better team performance is associated with faster transitions to next phase of care in hypotensive trauma patients, and larger teams are slower. Trauma team training should focus on optimizing team performance to facilitate faster hemorrhage control. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
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Affiliation(s)
- Amelia W Maiga
- From the Division of Acute Care Surgery, Department of Surgery (A.W.M., R.D.A.), Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee; Critical Illness, Brain dysfunction, and Survivorship Center (A.W.M.), Vanderbilt University Medical Center, Nashville, Tennessee; Division of Acute Care Surgery and Trauma (M.A.V.), University of Rochester Medical Center, Rochester, New York; Department of Biostatistics (R.I.), Vanderbilt University Medical Center, Nashville, Tennessee; Department of Medicine (F.Y.), Vanderbilt University Medical Center, Nashville, Tennessee; Division of Trauma and Acute Care Surgery (D.N.H.), Medical College of Wisconsin, Milwaukee, Wisconin; and Division of Burn Trauma Acute and Critical Care Surgery (R.P.D.), UT Southwestern Medical Center, Dallas, Texas
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Kheirbek T, Hashmi DL, Bankhead BK, Holena DN, Winfield RD, Zarzaur BL, Hartwell J, Stassen NA, Foster SM. To leave or not to leave: American Association for the Surgery of Trauma (AAST) panel discussion on personal, parental, and family leave. Trauma Surg Acute Care Open 2023; 8:e001104. [PMID: 38020861 PMCID: PMC10649785 DOI: 10.1136/tsaco-2023-001104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 09/04/2023] [Indexed: 12/01/2023] Open
Abstract
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.
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Affiliation(s)
- Tareq Kheirbek
- Department of Surgery, Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
| | - Danielle L Hashmi
- Department of Surgery, Crozer-Chester Medical Center, Upland, Pennsylvania, USA
| | - Brittany K Bankhead
- Division of Trauma, Burns and Critical Care, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Daniel N Holena
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Robert D Winfield
- Department of Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Ben L Zarzaur
- Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Jennifer Hartwell
- Department of Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Nicole A Stassen
- Surgery, University of Rochester Medical Center, Rochester, New York, USA
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7
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Kaufman EJ, Keele LJ, Wirtalla CJ, Rosen CB, Roberts SE, Mavroudis CL, Reilly PM, Holena DN, McHugh MD, Small D, Kelz RR. Operative and Nonoperative Outcomes of Emergency General Surgery Conditions: An Observational Study Using a Novel Instrumental Variable. Ann Surg 2023; 278:72-78. [PMID: 35786573 PMCID: PMC9810765 DOI: 10.1097/sla.0000000000005519] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To determine the effect of operative versus nonoperative management of emergency general surgery conditions on short-term and long-term outcomes. BACKGROUND Many emergency general surgery conditions can be managed either operatively or nonoperatively, but high-quality evidence to guide management decisions is scarce. METHODS We included 507,677 Medicare patients treated for an emergency general surgery condition between July 1, 2015, and June 30, 2018. Operative management was compared with nonoperative management using a preference-based instrumental variable analysis and near-far matching to minimize selection bias and unmeasured confounding. Outcomes were mortality, complications, and readmissions. RESULTS For hepatopancreaticobiliary conditions, operative management was associated with lower risk of mortality at 30 days [-2.6% (95% confidence interval: -4.0, -1.3)], 90 days [-4.7% (-6.50, -2.8)], and 180 days [-6.4% (-8.5, -4.2)]. Among 56,582 intestinal obstruction patients, operative management was associated with a higher risk of inpatient mortality [2.8% (0.7, 4.9)] but no significant difference thereafter. For upper gastrointestinal conditions, operative management was associated with a 9.7% higher risk of in-hospital mortality (6.4, 13.1), which increased over time. There was a 6.9% higher risk of inpatient mortality (3.6, 10.2) with operative management for colorectal conditions, which increased over time. For general abdominal conditions, operative management was associated with 12.2% increased risk of inpatient mortality (8.7, 15.8). This effect was attenuated at 30 days [8.5% (3.8, 13.2)] and nonsignificant thereafter. CONCLUSIONS The effect of operative emergency general surgery management varied across conditions and over time. For colorectal and upper gastrointestinal conditions, outcomes are superior with nonoperative management, whereas surgery is favored for patients with hepatopancreaticobiliary conditions. For obstructions and general abdominal conditions, results were equivalent overall. These findings may support patients, clinicians, and families making these challenging decisions.
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Affiliation(s)
- Elinore J. Kaufman
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Center for Surgery and Health Economics, University of Pennsylvania Perelman School of Medicine, The Leonard Davis Institute of Health Economics, The University of Pennsylvania
| | - Luke J. Keele
- Department of Surgery, Center for Surgery and Health Economics, The University of Pennsylvania Perelman School of Medicine
| | - Christopher J. Wirtalla
- Department of Surgery, Center for Surgery and Health Economics, The University of Pennsylvania Perelman School of Medicine
| | - Claire B. Rosen
- Department of Surgery, Center for Surgery and Health Economics, The University of Pennsylvania Perelman School of Medicine
| | - Sanford E. Roberts
- Department of Surgery, Center for Surgery and Health Economics, The University of Pennsylvania Perelman School of Medicine
| | - Catherine L. Mavroudis
- Department of Surgery, Center for Surgery and Health Economics, The University of Pennsylvania Perelman School of Medicine
| | - Patrick M. Reilly
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Center for Surgery and Health Economics, University of Pennsylvania Perelman School of Medicine, The Leonard Davis Institute of Health Economics, The University of Pennsylvania
| | - Daniel N. Holena
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Center for Surgery and Health Economics, University of Pennsylvania Perelman School of Medicine, The Leonard Davis Institute of Health Economics, The University of Pennsylvania
| | - Matthew D. McHugh
- Department of Biobehavioral Health Sciences and Center for Health Outcomes and Policy Research, The University of Pennsylvania School of Nursing
| | - Dylan Small
- Department of Statistics and Data Science, The Wharton School, The University of Pennsylvania
| | - Rachel R. Kelz
- Department of Surgery, Center for Surgery and Health Economics, The University of Pennsylvania Perelman School of Medicine
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Peden CJ, Aggarwal G, Aitken RJ, Anderson ID, Balfour A, Foss NB, Cooper Z, Dhesi JK, French WB, Grant MC, Hammarqvist F, Hare SP, Havens JM, Holena DN, Hübner M, Johnston C, Kim JS, Lees NP, Ljungqvist O, Lobo DN, Mohseni S, Ordoñez CA, Quiney N, Sharoky C, Urman RD, Wick E, Wu CL, Young-Fadok T, Scott MJ. Enhanced Recovery After Surgery (ERAS®) Society Consensus Guidelines for Emergency Laparotomy Part 3: Organizational Aspects and General Considerations for Management of the Emergency Laparotomy Patient. World J Surg 2023:10.1007/s00268-023-07039-9. [PMID: 37277506 DOI: 10.1007/s00268-023-07039-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND This is Part 3 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy using an enhanced recovery after surgery (ERAS) approach. This paper addresses organizational aspects of care. METHODS Experts in management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and MEDLINE database searches were performed for ERAS elements and relevant specific topics. Studies were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations. RESULTS Components of organizational aspects of care were considered. Consensus was reached after three rounds of a modified Delphi process. CONCLUSIONS These guidelines are based on best current available evidence for organizational aspects of an ERAS® approach to patients undergoing emergency laparotomy and include discussion of less common aspects of care for the surgical patient, including end-of-life issues. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies.
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Affiliation(s)
- Carol J Peden
- Department of Anesthesiology Keck School of Medicine, University of Southern California, 2020 Zonal Avenue IRD 322, Los Angeles, CA, 90033, USA.
- Department of Anesthesiology, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA, 19104, USA.
| | - Geeta Aggarwal
- Department of Anesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey, GU5 7XX, UK
| | - Robert J Aitken
- Sir Charles Gardiner Hospital, Hospital Avenue, Nedlands, WA, 6009, Australia
| | - Iain D Anderson
- Salford Royal NHS Foundation Trust, Stott La, Salford, M6 8HD, UK
- University of Manchester, Manchester, UK
| | - Angie Balfour
- Western General Hospital, NHS Lothian, Edinburgh, EH4 2XU, Scotland
| | | | - Zara Cooper
- Center for Surgery and Public Health, Harvard Medical School, Brigham and Women's Hospital, 1620 Tremont Street, Boston, MA, 02120, USA
- Division of Trauma, Burns, Surgical Critical Care, and Emergency Surgery, Brigham and Women's Hospital, 1620 Tremont Street, Boston, MA, 02120, USA
| | - Jugdeep K Dhesi
- Perioperative Medicine for Older People Undergoing Surgery (POPS), Guy's and St Thomas' NHS Foundation Trust, London, UK
- Faculty of Life Sciences and Medicine, King's College London, London, UK
- Research Department of Targeted Intervention, Division of Surgery & Interventional Science, University College London, London, UK
| | - W Brenton French
- Department of Surgery, Virginia Commonwealth University Health System, 1200 E. Broad Street, Richmond, VA, 23298, USA
| | - Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, Department of Surgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD, 21287, USA
| | - Folke Hammarqvist
- Department of Emergency and Trauma Surgery, Karolinska University Hospital, CLINTEC, Karolinska Institutet, Stockholm, Sweden
- Karolinska University Hospital Huddinge, Hälsovägen 3. B85, S 141 86, Stockholm, Sweden
| | - Sarah P Hare
- Department of Anaesthesia, Perioperative Medicine and Critical Care, Medway Maritime Hospital, Windmill Road, Gillingham, Kent, ME7 5NY, UK
| | - Joaquim M Havens
- Division of Trauma, Burns and Surgical Critical Care, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Daniel N Holena
- Division of Trauma and Acute Care Surgery, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI, 53226, USA
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Carolyn Johnston
- Department of Anaesthesia, St George's Hospital, Tooting, London, UK
| | - Jeniffer S Kim
- Kaiser Permanente Research, Department of Research & Evaluation, 100 South Los Robles Ave, 2nd Floor, Pasadena, CA, 91101, USA
| | - Nicholas P Lees
- Department of General & Colorectal Surgery, Salford Royal NHS Foundation Trust, Scott La, Salford, M6 8HD, UK
| | - Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Queen's Medical Centre, Nottingham University Hospitals and University of Nottingham, Nottingham, NG7 2UH, UK
- MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, Queen's Medical Centre, School of Life Sciences, University of Nottingham, Nottingham, NG7 2UH, UK
| | - Shahin Mohseni
- Division of Trauma and Emergency Surgery, Department of Surgery, School of Medical Sciences, Orebro University Hospital, Orebro University, 701 85, Orebro, Sweden
| | - Carlos A Ordoñez
- Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Cra 98 No. 18 - 49, 760032, Cali, Colombia
- Sección de Cirugía de Trauma y Emergencias, Universidad del Valle - Hospital Universitario del Valle, Cl 5 No. 36-08, 760032, Cali, Colombia
| | - Nial Quiney
- Department of Anesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey, GU5 7XX, UK
| | - Catherine Sharoky
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Richard D Urman
- Department of Anesthesiology, The Ohio State University and Wexner Medical Center, 410 West 10th Ave, Columbus, OH, 43210, USA
| | - Elizabeth Wick
- Department of Surgery, University of California San Francisco, 513 Parnassus Ave HSW1601, San Francisco, CA, 94143, USA
| | - Christopher L Wu
- Department of Anesthesiology, Critical Care and Pain Medicine, and Department of Anesthesiology, Weill-Cornell Medicine, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Tonia Young-Fadok
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic College of Medicine, Mayo Clinic Arizona, 5777 e. Mayo Blvd., Phoenix, AZ, 85054, USA
| | - Michael J Scott
- Department of Anesthesiology and Critical Care Medicine, and Leonard Davis Institute for Health Economics, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA, 19104, USA
- University College London, London, UK
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9
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Scott MJ, Aggarwal G, Aitken RJ, Anderson ID, Balfour A, Foss NB, Cooper Z, Dhesi JK, French WB, Grant MC, Hammarqvist F, Hare SP, Havens JM, Holena DN, Hübner M, Johnston C, Kim JS, Lees NP, Ljungqvist O, Lobo DN, Mohseni S, Ordoñez CA, Quiney N, Sharoky C, Urman RD, Wick E, Wu CL, Young-Fadok T, Peden CJ. Consensus Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS ®) Society Recommendations Part 2-Emergency Laparotomy: Intra- and Postoperative Care. World J Surg 2023:10.1007/s00268-023-07020-6. [PMID: 37277507 DOI: 10.1007/s00268-023-07020-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND This is Part 2 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy (EL) using an Enhanced Recovery After Surgery (ERAS) approach. This paper addresses intra- and postoperative aspects of care. METHODS Experts in aspects of management of high-risk and emergency general surgical patients were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and Medline database searches were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses, and large cohort studies and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations. Some ERAS® components covered in other guideline papers are outlined only briefly, with the bulk of the text focusing on key areas pertaining specifically to EL. RESULTS Twenty-three components of intraoperative and postoperative care were defined. Consensus was reached after three rounds of a modified Delphi Process. CONCLUSIONS These guidelines are based on best available evidence for an ERAS® approach to patients undergoing EL. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies.
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Affiliation(s)
- Michael J Scott
- Department of Anesthesiology and Critical Care Medicine, Leonard Davis Institute for Health Economics, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA, 19104, USA.
- University College London, London, UK.
| | - Geeta Aggarwal
- Department of Anesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Guildford, Surrey, UK
| | - Robert J Aitken
- Sir Charles Gardiner Hospital, Hospital Avenue, Nedlands, WA, 6009, Australia
| | - Iain D Anderson
- Salford Royal NHS Foundation Trust, Stott La, Salford, M6 8HD, UK
- University of Manchester, Manchester, UK
| | - Angie Balfour
- Western General Hospital, NHS Lothian, Edinburgh, EH4 2XU, Scotland
| | | | - Zara Cooper
- Harvard Medical School, Kessler Director, Center for Surgery and Public Health, Brigham and Women's Hospital and Division of Trauma, Burns, Surgical Critical Care, and Emergency Surgery, Brigham and Women's Hospital, 1620 Tremont Street, Boston, MA, 02120, USA
| | - Jugdeep K Dhesi
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, Guy's and St Thomas' NHS Foundation Trust, King's College London, London, UK
- Division of Surgery and Interventional Science, University College London, London, UK
| | - W Brenton French
- Department of Surgery, Virginia Commonwealth University Health System, 1200 E. Broad Street, Richmond, VA, 23298, USA
| | - Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, Department of Surgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD, 21287, USA
| | - Folke Hammarqvist
- Department of Emergency and Trauma Surgery, Karolinska University Hospital, CLINTEC, Karolinska Institutet, Stockholm, Sweden
- Karolinska University Hospital Huddinge, Hälsovägen 3. B85, 141 86, Stockholm, Sweden
| | - Sarah P Hare
- Department of Anaesthesia, Perioperative Medicine and Critical Care, Medway Maritime Hospital, Windmill Road, Gillingham, Kent, ME7 5NY, UK
| | - Joaquim M Havens
- Division of Trauma, Burns and Surgical Critical Care, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Daniel N Holena
- Division of Trauma and Acute Care Surgery, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI, 53226, USA
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Carolyn Johnston
- Department of Anesthesia, St George's Hospital, Tooting, London, UK
| | - Jeniffer S Kim
- Department of Research and Evaluation, Kaiser Permanente Research, Pasadena, CA, 9110, USA
| | - Nicholas P Lees
- Department of General and Colorectal Surgery, Salford Royal NHS Foundation Trust, Scott La, Salford, M6 8HD, UK
| | - Olle Ljungqvist
- Faculty of Medicine and Health, School of Health and Medical Sciences, Department of Surgery, Örebro University, Örebro, Sweden
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK
- MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - Shahin Mohseni
- Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital and School of Medical Sciences, Orebro University, 701 85, Orebro, Sweden
| | - Carlos A Ordoñez
- Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Cra 98 No. 18 - 49, 760032, Cali, Colombia
- Sección de Cirugía de Trauma y Emergencias, Universidad del Valle - Hospital Universitario del Valle, Cl 5 No. 36-08, 760032, Cali, Colombia
| | - Nial Quiney
- Department of Anesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey, GU5 7XX, UK
| | - Catherine Sharoky
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Richard D Urman
- Department of Anesthesiology, The Ohio State University and Wexner Medical Center, 410 West 10Th Ave, Columbus, OH, 43210, USA
| | - Elizabeth Wick
- Department of Surgery, University of California San Francisco, 513 Parnassus Ave HSW1601, San Francisco, CA, 94143, USA
| | - Christopher L Wu
- Department of Anesthesiology, Critical Care and Pain Medicine-Hospital for Special Surgery, Department of Anesthesiology-Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
| | - Tonia Young-Fadok
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic College of Medicine, Mayo Clinic Arizona, 5777 e. Mayo Blvd., Phoenix, AZ, 85054, USA
| | - Carol J Peden
- Department of Anesthesiology Keck School of Medicine, University of Southern California, 2020 Zonal Avenue IRD 322, Los Angeles, CA, 90033, USA
- Department of Anesthesiology, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St., Philadelphia, PA, 19104, USA
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Scrushy MG, Nagaraj M, Burke K, Kuhlenschmidt K, Jeter S, Johnson D, Brown K, Edwards C, Marinica A, Vella MA, Holena DN, Park C, Dumas RP. Under the Lens: Team Perception of Trauma Video Review. J Trauma Nurs 2023; 30:171-176. [PMID: 37144808 DOI: 10.1097/jtn.0000000000000723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
BACKGROUND Video-based assessment and review are becoming increasingly common, and trauma video review (TVR) has been shown to be an effective educational, quality improvement, and research tool. Yet, trauma team perception of TVR remains incompletely understood. OBJECTIVE We evaluated positive and negative perceptions of TVR across multiple team member groups. We hypothesized that members of the trauma team would find TVR educational and that anxiety would be low across all groups. METHODS An anonymous electronic survey was provided to nurses, trainees, and faculty during weekly multidisciplinary trauma performance improvement conference following each TVR activity. Surveys assessed perception of performance improvement and anxiety or apprehension (Likert scale: 1 "strongly disagree" to 5 "strongly agree"). We report individual and normalized cumulative scores (average of responses for each positive [n = 6] and negative [n = 4] question stem). RESULTS We analyzed 146 surveys over 8 months, with 100% completion rate. Respondents were trainees (58%), faculty (29%), and nurses (13%). Of the trainees, 73% were postgraduate year (PGY) 1-3 and 27% were PGY 4-9. Of all respondents, 84% had participated previously in a TVR conference. Respondents reported an improved perception of resuscitation education quality and personal leadership skills development. Participants found TVR to be more educational than punitive overall. Analysis of team member types showed lower scores for faculty for all positive stemmed questions. Trainees were more likely to agree with negative stemmed questions if they were a lower PGY, and nurses were least likely to agree with negative stemmed questions. CONCLUSIONS TVR improves trauma resuscitation education in a conference setting, with trainees and nurses reporting the greatest benefit. Nurses were noted to be the least apprehensive about TVR.
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Affiliation(s)
- Marinda G Scrushy
- Division of Burn, Trauma Acute and Critical Care Surgery (Drs Park and Dumas), Department of Surgery (Drs Scrushy, Nagaraj, Burke, Kuhlenschmidt, and Marinica), University of Texas at Southwestern, Dallas; Parkland Memorial Hospital, Dallas, Texas (Mss Jeter and Johnson and Drs Brown and Edwards); Department of Acute Care Surgery, University of Rochester Medical Center, New York (Dr Vella); and Division of Trauma and Acute Care Surgery, Medical College of Wisconsin, Milwaukee (Dr Holena)
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11
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Choron RL, Teichman A, Bargoud C, Sciarretta JD, Smith R, Hanos D, Afif IN, Beard JH, Dhillon NK, Zhang A, Ghneim M, Devasahayam RJ, Gunter OL, Smith AA, Sun B, Cao CS, Reynolds JK, Hilt LA, Holena DN, Chang G, Jonikas M, Echeverria-Rosario K, Fung NS, Anderson A, Dumas RP, Fitzgerald CA, Levin JH, Trankiem CT, Yoon J, Blank J, Hazelton JP, McLaughlin CJ, Al-Aref R, Kirsch JM, Howard DS, Scantling DR, Dellonte K, Vella M, Hopkins B, Shell C, Udekwu PO, Wong EG, Joseph B, Lieberman H, Ramsey WA, Stewart CH, Alvarez C, Berne JD, Nahmias J, Puente I, Patton JH, Rakitin I, Perea L, Pulido O, Ahmed H, Keating J, Kodadek LM, Wade J, Henry R, Schreiber MA, Benjamin AJ, Khan A, Mann LK, Mentzer CJ, Mousafeiris V, Mulita F, Reid-Gruner S, Sais E, Foote C, Palacio CH, Argandykov D, Kaafarani H, Coyle S, Macor M, Bover Manderski MT, Narayan M, Seamon MJ. Outcomes Among Trauma Patients with Duodenal Leak Following Primary vs Complex Repair of Duodenal Injuries: An EAST Multicenter Trial. J Trauma Acute Care Surg 2023:01586154-990000000-00340. [PMID: 37072889 DOI: 10.1097/ta.0000000000003972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2023]
Abstract
BACKGROUND Duodenal leak is a feared complication of repair and innovative, complex repairs with adjunctive measures(CRAM) were developed to decrease both leak occurrence and severity when leaks occur. Data on the association of CRAM and duodenal leak is sparse and its impact on duodenal leak outcomes nonexistent. We hypothesized primary repair alone (PRA) would be associated with decreased duodenal leak rates, however CRAM would be associated with improved recovery and outcomes when leaks do occur. METHODS A retrospective, multicenter analysis from 35 Level-1 trauma centers included patients older than 14 with operative, traumatic duodenal injuries(1/2010-12/2020). The study sample compared duodenal operative repair strategy: primary repair alone(PRA) vs CRAM(any repair plus pyloric exclusion, gastrojejunostomy, triple tube drainage, duodenectomy). RESULTS The sample(n = 861) was primarily young(33 years) male(84%) with penetrating injuries(77%); 523 underwent PRA and 338 underwent CRAM. CRAM were more critically injured than PRA and had higher leak rates(CRAM 21% vs PRA 8%, p < 0.001). Adverse outcomes were more common after CRAM with more IR drains, prolonged NPO and LOS, greater mortality, and more readmissions than PRA(all p < 0.05). Importantly, CRAM had no positive impact on leak recovery; there was no difference in number of operations, drain duration, NPO duration, need for IR drainage, HLOS, or mortality between PRA leak vs CRAM leak patients(all p > 0.05). CRAM leaks had longer antibiotic duration, more GI complications, and longer duration until leak resolution(all p < 0.05). PRA was associated with 60% lower odds of leak, whereas injury grade II-IV, damage control, and BMI had higher odds of leak(all p < 0.05). There were no leaks among patients with grade IV-V injuries repaired by PRA. CONCLUSIONS CRAM did not prevent duodenal leaks and moreover, did not reduce adverse sequelae when leaks did occur. Our results suggest CRAM is not a protective operative duodenal repair strategy and PRA should be pursued for all injury grades when feasible. LEVEL OF EVIDENCE IV, Multicenter retrospective comparative study.
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12
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Dumas RP, Vella MA, Maiga AW, Erickson CR, Dennis BM, da Luz LT, Pannell D, Quigley E, Velopulos CG, Hendzlik P, Marinica A, Bruce N, Margolick J, Butler DF, Estroff J, Zebley JA, Alexander A, Mitchell S, Grossman Verner HM, Truitt M, Berry S, Middlekauff J, Luce S, Leshikar D, Krowsoski L, Bukur M, Polite NM, McMann AH, Staszak R, Armen SB, Horrigan T, Moore FO, Bjordahl P, Guido J, Mathew S, Diaz BF, Mooney J, Hebeler K, Holena DN. MOVING THE NEEDLE ON TIME TO RESUSCITATION: AN EAST PROSPECTIVE MULTICENTER STUDY OF VASCULAR ACCESS IN HYPOTENSIVE INJURED PATIENTS USING TRAUMA VIDEO REVIEW. J Trauma Acute Care Surg 2023:01586154-990000000-00324. [PMID: 37012624 DOI: 10.1097/ta.0000000000003958] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
INTRODUCTION Vascular access in hypotensive trauma patients is challenging. Little evidence exists on the time required and success rates of vascular access types. We hypothesized that intraosseous (IO) access would be faster and more successful than peripheral IV (PIV) and central venous catheter (CVC) access in hypotensive patients. METHODS An EAST prospective multicenter trial was performed; 19 centers provided data. Trauma video review (TVR) was used to evaluate the resuscitations of hypotensive (systolic blood pressure ≤ 90 mmHg) trauma patients. Highly granular data from video recordings were abstracted. Data collected included vascular access attempt type, location, success rate, and procedural time. Demographic and injury-specific variables were obtained from the medical record. Success rates, procedural durations, and time to resuscitation were compared among access strategies (IO vs PIV vs CVC). RESULTS 1,410 access attempts occurred in 581 patients with a median age of 40[27-59] years and an ISS of 22[10-34]. 932 PIV, 204 IO and 249 CVC were attempted. 70% of access attempts were successful but were significantly less likely to be successful in females (64% vs. 71%, p = 0.01). Median time to any access was 5.0[3.2-8.0] minutes. IO had higher success rates than PIV or CVC (93% vs. 67% vs. 59%, p < 0.001) and remained higher after subsequent failures (second attempt 85% vs. 59% vs. 69%, p = 0.08; third attempt 100% vs 33% vs. 67%, p = 0.002). Duration varied by access type (IO 36[23-60]sec; PIV 44[31-61]sec; CVC 171[105-298]sec) and was significantly different between IO vs. CVC (p < 0.001) and PIV vs. CVC (p < 0.001) but not PIV vs. IO. Time to resuscitation initiation was shorter in patients whose initial access attempt was IO, 5.8 minutes vs. 6.7 minutes (p = 0.015). This was more pronounced in patients arriving to the hospital with no established access (5.7 minutes vs. 7.5 minutes, p = 0.001). CONCLUSIONS IO is as fast as PIV and more likely to be successful compared with other access strategies in hypotensive trauma patients. Patients whose initial access attempt was IO were resuscitated more expeditiously. IO access should be considered a first line therapy in hypotensive trauma patients. LEVEL OF EVIDENCE Level II Therapeutic/Care Management.
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Affiliation(s)
- Ryan P Dumas
- UT Southwestern Medical Center, Division of Burn Trauma Acute and Critical Care Surgery, Dallas TX
| | - Michael A Vella
- University of Rochester Medical Center Division of Acute Care Surgery, Rochester, NY
| | - Amelia W Maiga
- Vanderbilt University Medical Center, Division of Acute Care Surgery, Nashville, TN
| | - Caroline R Erickson
- Vanderbilt University Medical Center, Division of Acute Care Surgery, Nashville, TN
| | - Brad M Dennis
- Vanderbilt University Medical Center, Division of Acute Care Surgery, Nashville, TN
| | | | | | - Emily Quigley
- University of Colorado, Section of Trauma, Acute Care Surgery and Critical Care, Aurora, CO
| | - Catherine G Velopulos
- University of Colorado, Section of Trauma, Acute Care Surgery and Critical Care, Aurora, CO
| | - Peter Hendzlik
- University of Rochester Medical Center Division of Acute Care Surgery, Rochester, NY
| | - Alexander Marinica
- UT Southwestern Medical Center, Division of Burn Trauma Acute and Critical Care Surgery, Dallas TX
| | - Nolan Bruce
- University of Arkansas for Medical Sciences, Trauma and Acute Care Surgery, Little Rock, AR
| | - Joseph Margolick
- University of Arkansas for Medical Sciences, Trauma and Acute Care Surgery, Little Rock, AR
| | - Dale F Butler
- University of Pennsylvania, Traumatology, Surgical Critical Care and Emergency Surgery, Philadelphia, PA
| | - Jordan Estroff
- George Washington University, Center for Trauma and Critical Care, Washington DC
| | - James A Zebley
- George Washington University, Center for Trauma and Critical Care, Washington DC
| | | | | | | | | | - Stepheny Berry
- University of Kansas, Acute Care Surgery, Trauma, and Surgical Critical Care, Kansas City, KS
| | - Jennifer Middlekauff
- University of Kansas, Acute Care Surgery, Trauma, and Surgical Critical Care, Kansas City, KS
| | - Siobhan Luce
- UC Davis Medical Center - Trauma, Acute Care Surgery and Surgical Critical Care, Sacramento, CA
| | - David Leshikar
- UC Davis Medical Center - Trauma, Acute Care Surgery and Surgical Critical Care, Sacramento, CA
| | | | | | | | | | - Ryan Staszak
- Penn State Health Medical Center, Division of Trauma, Acute Care and Critical Care Surgery, Hershey PA
| | - Scott B Armen
- Penn State Health Medical Center, Division of Trauma, Acute Care and Critical Care Surgery, Hershey PA
| | | | | | | | | | | | | | | | | | - Daniel N Holena
- Medical College of Wisconsin Division of Trauma and Acute Care Surgery Milwaukee, WI
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13
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Marinica AL, Nagaraj MB, Elson M, Vella MA, Holena DN, Dumas RP. Evaluating emergency department tube thoracostomy: A single-center use of trauma video review to assess efficiency and technique. Surgery 2023; 173:1086-1092. [PMID: 36740501 DOI: 10.1016/j.surg.2022.12.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 12/01/2022] [Accepted: 12/22/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND Emergency department tube thoracostomy is a common procedure; however, assessing procedural skills is difficult. We sought to describe procedural variability and technical complications of emergency department tube thoracostomy using trauma video review. We hypothesized that factors such as hemodynamic abnormality lead to increased technical difficulty and malpositioning. METHODS Using trauma video review, we reviewed all emergency department tube thoracostomy from 2020 to 2022. Patients were stratified into hemodynamically abnormal (systolic blood pressure <90 or heart rate >120) and hemodynamically normal (systolic blood pressure ≥90 or heart rate ≤120). Emergency department tube thoracostomies outside of video-capable rooms, with incomplete visualization, or in patients undergoing cardiopulmonary resuscitation or resuscitative thoracotomy were excluded. The primary outcome was a procedure score modified from the validated tool ranging from 0 to 11 (higher score indicating better performance). Also measured were procedural times to (1) decision to place, (2) pleural entry, and (3) procedure completion. Postprocedure x-ray and chart review were used to determine accuracy. RESULTS In total, 51 videos met the inclusion criteria. The median age was 34 [interquartile range 24-40] years, body mass index 25.8 [interquartile range 21.8-30.7], predominately male (75%), blunt injury (57%), with Injury Severity Score of 22 [14.5-41]. The median procedure score was 9 [7-10]. Emergency department tube thoracostomies in patients with abnormal hemodynamics had significantly lower procedure scores (8 vs 10, P < .05). Hemodynamically abnormal patients had significantly shorter times from decision to proceed to pleural entry (4.05 vs 8.25 minutes, P < .001), and to completion (6.31 vs 14.23 minutes, P < .001). The most common complication was malpositioning (35.1%), with no significant difference noted when comparing hemodynamically normal and abnormal patients (P = .41). CONCLUSION Using trauma video review we identified significant procedural variability in emergency department tube thoracostomy, mainly that hemodynamic abnormality led to lower proficiency scores and increased malpositioning. Efforts are needed to define procedural benchmarks and evaluation in the context of patient outcomes. Using this technology and methodology can help establish procedural norms.
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Affiliation(s)
| | - Madhuri B Nagaraj
- University of Texas Southwestern Medical Center, Division of Burn, Trauma, Acute, and Critical Care Surgery, Dallas, TX. https://twitter.com/nagaraj_madhuri
| | - Matthew Elson
- University of Texas Southwestern Medical Center, Division of Burn, Trauma, Acute, and Critical Care Surgery, Dallas, TX. https://twitter.com/mElsonMD
| | - Michael A Vella
- University of Rochester Medical Center, Division of Acute Care Surgery and Trauma, NY. https://twitter.com/MichaelVella32
| | - Daniel N Holena
- Medical College of Wisconsin, Division of Acute Care Surgery, Milwaukee, WI. https://twitter.com/Daniel_Holena
| | - Ryan P Dumas
- University of Texas Southwestern Medical Center, Division of Burn, Trauma, Acute, and Critical Care Surgery, Dallas, TX. https://twitter.com/RPDUmasMD
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14
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Hornor MA, Blank JJ, Hatchimonji JS, Bailey JA, Jacovides CL, Reilly PM, Cannon JW, Holena DN, Seamon MJ, Kaufman EJ. Higher center volume is significantly associated with lower mortality in trauma patients with shock. Injury 2023; 54:1400-1405. [PMID: 37005134 DOI: 10.1016/j.injury.2023.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 02/16/2023] [Accepted: 03/06/2023] [Indexed: 04/04/2023]
Abstract
INTRODUCTION Injured patients presenting in shock are at high risk of mortality despite numerous efforts to improve resuscitation. Identifying differences in outcomes among centers for this population could yield insights to improve performance. We hypothesized that trauma centers treating higher volumes of patients in shock would have lower risk-adjusted mortality. METHODS We queried the Pennsylvania Trauma Outcomes Study from 2016 to 2018 for injured patients ≥16 years of age at Level I&II trauma centers who had an initial systolic blood pressure (SBP) of <90 mmHg. We excluded patients with critical head injury (abbreviated injury score [AIS] head ≥5) and patients coming from centers with a shock patient volume of ≤10 for the study period. The primary exposure was tertile of center-level shock patient volume (low, medium, or high volume). We compared risk-adjusted mortality by tertile of volume using multivariable Cox proportional hazards model incorporating age, injury severity, mechanism, and physiology. RESULTS Of 1,805 included patients at 29 centers, 915 (50.7%) died. The median annual shock trauma patient volume was 9 patients for low volume centers, medium 19.5, and high 37. Median ISS was higher at high volume compared to low volume centers (22 vs 18, p <0.001). Raw mortality was 54.9% at high volume centers, 46.7% for medium, and 42.9% for low. Time elapsed from arrival to emergency department (ED) to the operating room (OR) was lower at high volume than low volume centers (median 47 vs 78 min) p = 0.003. In adjusted analysis, hazard ratio for high volume centers (referenced to low volume) was 0.76 (95% CI 0.59-0.97, p = 0.030). CONCLUSION After adjusting for patient physiology and injury characteristics, center-level volume is significantly associated with mortality. Future studies should seek to identify key practices associated with improved outcomes in high-volume centers. Furthermore, shock patient volume should be considered when new trauma centers are opened.
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Affiliation(s)
- Melissa A Hornor
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Jacqueline J Blank
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Justin S Hatchimonji
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Joanelle A Bailey
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Christina L Jacovides
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Patrick M Reilly
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Jeremy W Cannon
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Daniel N Holena
- Division of Trauma and Critical Care, Medical College of Wisconsin, Milwaukee, WI, USA.
| | - Mark J Seamon
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Elinore J Kaufman
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
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Kester L, Holena DN, Hynes AM, Kaufman EJ, Brahmbhatt T, Sanchez S, Byrne JP, Dechert T, Seamon M, Scantling DR. Preventing the most common firearm deaths: Modifiable factors related to firearm suicide. Surgery 2023; 173:544-552. [PMID: 36396492 DOI: 10.1016/j.surg.2022.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 09/21/2022] [Accepted: 10/11/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND More than 20,000 firearm suicides occur every year in America. Firearm restrictive legislation, firearm access, demographics, behavior, access to care, and socioeconomic metrics have been correlated to firearm suicide rates. Research to date has largely evaluated these contributors singularly. We aimed to evaluate them together as they exist in society. We hypothesized that state firearm laws would be associated with reduced firearm suicide rates. METHODS We acquired the 2013 to 2016 data for firearm suicide rates from The Centers for Disease Control Wide-ranging Online Data for Epidemiologic Research. Firearm laws were obtained from the State Firearms Law Database. Depression rates and access to care were obtained from the Behavioral Risk Factor Surveillance System and Occupational Employment and Wage Statistics program. Population demographics, poverty, and access to social support were obtained from the American Community Survey. Firearm access estimates were retrieved from the National Instant Criminal Background Check System. We used a univariate panel linear regression with fixed effect for state and firearm suicide rates as the outcome. We created a final multivariable model to determine the adjusted associations of these factors with firearm suicide rates. RESULTS In univariate analysis, firearm access, heavy drinking behavior, demographics, and access to care correlated to increased firearm suicide rates. The state proportion identifying as white and the proportion of those in poverty receiving food benefits correlated to decreased firearm suicide rates. In multivariable regression, only heavy drinking (β, 0.290; 95% confidence interval, 0.092-0.481; P = .004) correlated to firearm suicides rates increases. CONCLUSIONS During our study, few firearm laws changed. Heavy drinking behavior association with firearm suicide rates suggests an opportunity for interventions exists in the health care setting.
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Affiliation(s)
- Louis Kester
- Division of Trauma and Acute Care Surgery, The Boston University School of Medicine/Boston Medical Center, MA. https://twitter.com/lou_was
| | - Daniel N Holena
- Division of Trauma and Acute Care Surgery, Medical College of Wisconsin Department of Surgery, Milwaukee, WI. https://twitter.com/daniel_holena
| | - Allyson M Hynes
- Department of Emergency Medicine, The University of New Mexico, Albuquerque, NM. https://twitter.com/elinorejkaufman
| | - Elinore J Kaufman
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, The University of Pennsylvania Department of Surgery, Philadelphia, PA
| | - Tejal Brahmbhatt
- Division of Trauma and Acute Care Surgery, The Boston University School of Medicine/Boston Medical Center, MA. https://twitter.com/tejalsb
| | - Sabrina Sanchez
- Division of Trauma and Acute Care Surgery, The Boston University School of Medicine/Boston Medical Center, MA. https://twitter.com/sesanchezmd
| | - James P Byrne
- Division of Traumatology, Johns Hopkins Hospital, Surgical Critical Care and Emergency Surgery, Baltimore, MD. https://twitter.com/dctrjbyrne
| | - Tracey Dechert
- Division of Trauma and Acute Care Surgery, The Boston University School of Medicine/Boston Medical Center, MA. https://twitter.com/traceydechert
| | - Mark Seamon
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, The University of Pennsylvania Department of Surgery, Philadelphia, PA. https://twitter.com/markseamonmd
| | - Dane R Scantling
- Division of Trauma and Acute Care Surgery, The Boston University School of Medicine/Boston Medical Center, MA.
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McLauchlan NR, Igra NM, Fisher LT, Byrne JP, Beyer CA, Geng Z, Schmulevich D, Brinson MM, Dumas RP, Holena DN, Hynes AM, Rosen CB, Shah AN, Vella MA, Cannon JW. Open versus percutaneous tube thoracostomy with and without thoracic lavage for traumatic hemothorax: a novel randomized controlled simulation trial. Trauma Surg Acute Care Open 2023; 8:e001050. [PMID: 36967862 PMCID: PMC10030794 DOI: 10.1136/tsaco-2022-001050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 02/25/2023] [Indexed: 03/29/2023] Open
Abstract
Objective To quantify and assess the relative performance parameters of thoracic lavage and percutaneous thoracostomy (PT) using a novel, basic science 2×2 randomized controlled simulation trial. Summary background data Treatment of traumatic hemothorax (HTX) with open tube thoracostomy (TT) is painful and retained HTX is common. PT is potentially less painful whereas thoracic lavage may reduce retained HTX. Yet, procedural time and the feasibility of combining PT with lavage remain undefined. Methods A simulated partially clotted HTX (2%-gelatin-saline mixture) was loaded into a TT trainer and then evacuated after randomization to one of four protocols: TT+/-lavage or PT+/-lavage. Standardized inserts with fixed 28-Fr TT or 14-Fr PT positioning were used to minimize tube positioning variability. Lavage consisted of two 500 mL aliquots of warm saline after initial HTX evacuation. The primary outcome was HTX volume evacuated. The secondary outcome was additional procedural time required for the addition of the lavage. Results A total of 40 simulated HTX trials were randomized. TT alone evacuated a median of 1236 mL (IQR 1168, 1294) leaving a residual volume of 265 mL (IQR 206, 333). PT alone resulted in a significantly greater median residual volume of 588 mL (IQR 497, 646) (p=0.002). Adding lavage resulted in similar residual volumes for TT compared with TT alone but significantly less for PT compared with PT alone (p=0.002). Lavage increased procedural time for TT by a median of 7.0 min (IQR 6.5, 8.0) vs 11.7 min (IQR 10.2, 12.0) for PT (p<0.001). Conclusion This simulation trial characterized HTX evacuation in a standardized fashion. Adding lavage to thoracostomy placement may improve evacuation, particularly for small-diameter tubes, with little added procedural time. Further prospective clinical study is warranted. Level of evidence NA.
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Affiliation(s)
- Nathaniel R McLauchlan
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Noah M Igra
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Lydia T Fisher
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - James P Byrne
- Johns Hopkins Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Carl A Beyer
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Zhi Geng
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Daniela Schmulevich
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Martha M Brinson
- Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | | | - Allyson M Hynes
- University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Claire B Rosen
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Michael A Vella
- Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Jeremy W Cannon
- Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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17
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Hatchimonji JS, Holena DN, Xiong R, Scantling DR, Hornor MA, Dowzicky PM, Reilly PM, Kaufman EJ. The variable role of damage control laparotomy over 19 years of trauma care in Pennsylvania. Surgery 2022; 173:1289-1295. [PMID: 36517291 DOI: 10.1016/j.surg.2022.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 11/15/2022] [Accepted: 11/15/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Damage control laparotomy emphasizes physiologic stabilization of critically injured patients and allows staged surgical management. However, there is little consensus on the optimal criteria for damage control laparotomy. We examined variability between centers and over time in Pennsylvania. METHODS We analyzed the Pennsylvania Trauma Outcomes Study data between 2000 and 2018, excluding centers performing <10 laparotomies/year. Laparotomy was defined using International Classification of Diseases codes, and damage control laparotomy was defined by a code for "reopening of recent laparotomy" or a return to the operating room >4 hours from index laparotomy that was not unplanned. We examined trends over time and by center. Multivariable logistic regression models were developed to predict both damage control laparotomy and mortality, generate observed:expected ratios, and identify outliers for each. We compared risk-adjusted mortality rates to center-level damage control laparotomy rates. RESULTS In total, 18,896 laparotomies from 22 centers were analyzed; 3,549 damage control laparotomies were performed (18.8% of all laparotomies). The use of damage control laparotomy in Pennsylvania varied from 13.9% to 22.8% over time. There was wide variation in center-level use of damage control laparotomy, from 11.1% to 29.4%, despite adjustment. Factors associated with damage control laparotomy included injury severity and admission vital signs. Center identity improved the model as demonstrated by likelihood ratio test (P < .001), suggesting differences in center-level practices. There was minimal correlation between center-level damage control laparotomy use and mortality. CONCLUSION There is wide center-level variation in the use of damage control laparotomy among centers, despite adjustment for patient factors. Damage control laparotomy is both resource intensive and highly morbid; regional resources should be allocated to address this substantial practice variation to optimize damage control laparotomy use.
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Affiliation(s)
- Justin S Hatchimonji
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
| | - Daniel N Holena
- Division of Trauma and Critical Care, Medical College of Wisconsin, Milwaukee, WI. https://twitter.com/Daniel_Holena
| | - Ruiying Xiong
- Department of General Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA. https://twitter.com/AriaXiong
| | - Dane R Scantling
- Section of Acute Care and Trauma Surgery, Boston University School of Medicine, MA. https://twitter.com/Dane_Scantling
| | - Melissa A Hornor
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA. https://twitter.com/HornorMD
| | - Phillip M Dowzicky
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA. https://twitter.com/PDowzicky
| | - Patrick M Reilly
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA. https://twitter.com/reillyp648
| | - Elinore J Kaufman
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA. https://twitter.com/ElinoreJKaufman
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18
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Dumas RP, Cook C, Holena DN, Qi Y, Tabone N, Studwell SL, Miglani A, Vella MA. Roll the Tape: Implementing and Harnessing the Power of Trauma Video Review. J Surg Educ 2022; 79:e248-e256. [PMID: 36096880 DOI: 10.1016/j.jsurg.2022.08.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 06/07/2022] [Accepted: 08/15/2022] [Indexed: 06/15/2023]
Abstract
Trauma video review (TVR) is a powerful technology with a rapidly expanding role in trauma performance improvement, education, and research. Video review is particularly well suited for evaluating elements not found in the medical record such as rapid changes in patient condition, medical decision making, resuscitation tempo, and team leadership. As such, TVR is an ideal tool for general surgery trainee education and as a means to evaluate multiple ACGME Core Competencies and entrustable professional activities. This article describes the development of a TVR program and the novel way in which we have integrated TVR into our resident trauma curriculum.
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Affiliation(s)
- Ryan P Dumas
- Department of Surgery, University of Texas Southwestern Medical Center/Parkland Memorial Hospital, Dallas, Texas
| | - Caitlin Cook
- Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Daniel N Holena
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Yanjie Qi
- Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Nora Tabone
- Privacy Office, University of Rochester Medical Center, Rochester, New York
| | - Spencer L Studwell
- Office of Counsel, Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York
| | - Aekta Miglani
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, New York
| | - Michael A Vella
- Department of Surgery, University of Rochester Medical Center, Rochester, New York.
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19
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Holland HK, Holena DN. Moving the Needle on Early Mortality After Injury-A Role for Liberalizing Prehospital Needle Decompression? JAMA Surg 2022; 157:941. [PMID: 35976665 DOI: 10.1001/jamasurg.2022.3561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
| | - Daniel N Holena
- Department of Surgery, Medical College of Wisconsin, Wauwatosa
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20
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Rees JR, Maher Z, Dumas RP, Vella MA, Schroeder ME, Milia DJ, Zone AI, Cannon JW, Holena DN. Trauma video review outperforms prospective real-time data collection for study of resuscitative thoracotomy. Surgery 2022; 172:1563-1568. [PMID: 35927077 DOI: 10.1016/j.surg.2022.06.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 06/20/2022] [Accepted: 06/23/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND A major challenge in the study of high-impact, low-frequency procedures in trauma is the lack of accurate data for time-sensitive processes of care. Trauma video review offers a possible solution, allowing investigators to collect extremely granular time-stamped data. Using resuscitative thoracotomy as a model, we compared data collected using review of audiovisual recordings to data prospectively collected in real time with the hypothesis that data collected using video review would be subject to less missingness and bias. METHODS We conducted a prospective cohort study of patients undergoing resuscitative thoracotomy at a single urban academic level 1 trauma center. Key data on the timing and completion of procedural milestones of resuscitative thoracotomy were collected using video review and prospective collection. We used McNemar's test to compare proportions of missing data between the 2 methods and calculated bias in time measurements for prospective collection with respect to video review. Statistical analyses were performed using Stata v. 15.0 (College Station, TX). RESULTS We included 51 subjects (88% Black, 82% male, 90% injured by gunshot wounds) over the study period. Missingness in resuscitative thoracotomy procedural milestone time measurements ranged from 34% to 63% for prospective collection and 0 to 8% for video review and was less missing for video review for all key variables (P < .001). When not missing, bias in data collected by prospective collection was 10% to 43% compared with data collected by video review. CONCLUSIONS The data collected using video review have less missingness and bias than prospective collection data collected by trained research assistants. Audiovisual recording should be the gold standard for data collection for the study of time-sensitive processes of care in resuscitation.
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Affiliation(s)
- John R Rees
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Zoe Maher
- Division of Trauma and Surgical Critical Care, Lewis Katz School of Medicine at Temple University, Philadelphia, PA. https://twitter.com/zoe_maher
| | - Ryan P Dumas
- Division of Burn, Trauma, Acute, and Critical Care Surgery, University of Texas Southwestern, Dallas, TX. https://twitter.com/RPDumasMD
| | - Michael A Vella
- Division of Acute Care Surgery and Trauma, University of Rochester Medical Centre, Rochester, NY. https://twitter.com/MichaelVella32
| | - Mary E Schroeder
- Division of Trauma and Acute Care Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - David J Milia
- Division of Trauma and Acute Care Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Alea I Zone
- Penn Acute Research Collaboration, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Jeremy W Cannon
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Penn Acute Research Collaboration, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Department of Surgery, Uniformed Services University F. Edward Hébert School of Medicine, Bethesda, MD
| | - Daniel N Holena
- Division of Trauma and Acute Care Surgery, Medical College of Wisconsin, Milwaukee, WI.
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21
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Rosen CB, Wirtalla C, Keele LJ, Roberts SE, Kaufman EJ, Holena DN, Halpern SD, Kelz RR. Multimorbidity Confers Greater Risk for Older Patients in Emergency General Surgery Than the Presence of Multiple Comorbidities: A Retrospective Observational Study. Med Care 2022; 60:616-622. [PMID: 35640050 PMCID: PMC9262850 DOI: 10.1097/mlr.0000000000001733] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Little is known about the impact of multimorbidity on outcomes for older emergency general surgery patients. OBJECTIVE The aim was to understand whether having multiple comorbidities confers the same amount of risk as specific combinations of comorbidities (multimorbidity) for a patient undergoing emergency general surgery. RESEARCH DESIGN Retrospective observational study using state discharge data. SUBJECTS Medicare beneficiaries who underwent an operation for an emergency general surgery condition in New York, Florida, or Pennsylvania (2012-2013). MEASURES Patients were classified as multimorbid using Qualifying Comorbidity Sets (QCSs). Outcomes included in-hospital mortality, hospital length of stay and discharge status. RESULTS Of 312,160 patients, a large minority (37.4%) were multimorbid. Non-QCS patients did not have a specific combination of comorbidities to satisfy a QCS, but 64.1% of these patients had 3+ comorbid conditions. Multimorbidity was associated with increased in-hospital mortality (10.5% vs. 3.9%, P <0.001), decreased rates of discharge to home (16.2% vs. 37.1%, P <0.001), and longer length of stay (10.4 d±13.5 vs. 6.7 d±9.3, P <0.001) when compared with non-QCS patients. Risks varied between individual QCSs. CONCLUSIONS Multimorbidity, defined by satisfying a specific QCS, is strongly associated with poor outcomes for older patients requiring emergency general surgery in the United States. Variation in risk of in-hospital mortality, discharge status, and length of stay between individual QCSs suggests that multimorbidity does not carry the same prognostic weight as having multiple comorbidities-the specifics of which are important in setting expectations for individual, complex patients.
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Affiliation(s)
- Claire B. Rosen
- Department of Surgery, Hospital of the University of Pennsylvania; 3400 Spruce Street, Philadelphia, PA 19104
- Perelman School of Medicine; 3400 Civic Center Blvd, Philadelphia, PA 19104
| | - Chris Wirtalla
- Perelman School of Medicine; 3400 Civic Center Blvd, Philadelphia, PA 19104
| | - Luke J. Keele
- Perelman School of Medicine; 3400 Civic Center Blvd, Philadelphia, PA 19104
| | - Sanford E. Roberts
- Department of Surgery, Hospital of the University of Pennsylvania; 3400 Spruce Street, Philadelphia, PA 19104
- Perelman School of Medicine; 3400 Civic Center Blvd, Philadelphia, PA 19104
| | - Elinore J. Kaufman
- Department of Surgery, Hospital of the University of Pennsylvania; 3400 Spruce Street, Philadelphia, PA 19104
- Perelman School of Medicine; 3400 Civic Center Blvd, Philadelphia, PA 19104
| | - Daniel N. Holena
- Department of Surgery, Hospital of the University of Pennsylvania; 3400 Spruce Street, Philadelphia, PA 19104
- Perelman School of Medicine; 3400 Civic Center Blvd, Philadelphia, PA 19104
| | - Scott D. Halpern
- Department of Surgery, Hospital of the University of Pennsylvania; 3400 Spruce Street, Philadelphia, PA 19104
- Department of Medicine, Hospital of the University of Pennsylvania; 3400 Spruce Street, Philadelphia, PA 19104
| | - Rachel R. Kelz
- Department of Surgery, Hospital of the University of Pennsylvania; 3400 Spruce Street, Philadelphia, PA 19104
- Perelman School of Medicine; 3400 Civic Center Blvd, Philadelphia, PA 19104
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22
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Arenas DJ, Hernandez PT, Hwang J, Agarwal D, Warshauer AK, Holena DN. A low appendiceal mucinous neoplasm lesion in an inflamed appendix within an inguinal hernia. J Surg Case Rep 2022; 2022:rjab489. [PMID: 35673540 PMCID: PMC9167813 DOI: 10.1093/jscr/rjab489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 10/08/2021] [Indexed: 11/30/2022] Open
Abstract
Amyand’s hernia, an incarcerated appendix inside an inguinal hernia, accounts for <1% of hernias in children and even less in adults. Similarly, low-grade appendiceal mucinous (LAMN) lesions are only found in <1% of removed appendices. We present the case of a 72-year-old man with a 15-year history of a large right inguinoscrotal hernia that presented with right lower quadrant pain, was found by computed tomography imaging to have an incarcerated appendix with a large fluid collection, and was post-operatively diagnosed with an LAMN lesion. Although our case is rare due to the simultaneity of the Amyand’s hernia and LAMN conditions, each separate condition is prevalent enough for most surgical providers to encounter at least one of these. For our case, we discuss the decisions made in the pre-operative and post-operative management and relevant literature.
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Affiliation(s)
- Daniel J Arenas
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Paul T Hernandez
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jasmine Hwang
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Divyansh Agarwal
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Daniel N Holena
- Division of Trauma and Acute Care Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
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23
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Ross SW, Reinke CE, Ingraham AM, Holena DN, Havens JM, Hemmila MR, Sakran JV, Staudenmayer KL, Napolitano LM, Coimbra R. Emergency General Surgery Quality Improvement: A Review of Recommended Structure and Key Issues. J Am Coll Surg 2022; 234:214-225. [PMID: 35213443 DOI: 10.1097/xcs.0000000000000044] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Emergency general surgery (EGS) accounts for 11% of hospital admissions, with more than 3 million admissions per year and more than 50% of operative mortality in the US. Recent research into EGS has ignited multiple quality improvement initiatives, and the process of developing national standards and verification in EGS has been initiated. Such programs for quality improvement in EGS include registry formation, protocol and standards creation, evidenced-based protocols, disease-specific protocol implementation, regional collaboratives, targeting of high-risk procedures such as exploratory laparotomy, focus on special populations like geriatrics, and targeting improvements in high opportunity outcomes such as failure to rescue. The authors present a collective narrative review of advances in quality improvement structure in EGS in recent years and summarize plans for a national EGS registry and American College of Surgeons verification for this under-resourced area of surgery.
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Affiliation(s)
- Samuel W Ross
- From Atrium Health Carolinas Medical Center, Wake Forest School of Medicine, Charlotte, NC (Ross, Reinke)
| | - Caroline E Reinke
- From Atrium Health Carolinas Medical Center, Wake Forest School of Medicine, Charlotte, NC (Ross, Reinke)
| | - Angela M Ingraham
- University of Wisconsin School of Medicine and Public Health, Madison, WI (Ingraham)
| | - Daniel N Holena
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA (Holena)
| | - Joaquim M Havens
- Brigham and Women's Hospital, Harvard School of Medicine, Boston, MA (Havens)
| | - Mark R Hemmila
- University of Michigan School of Medicine, Ann Arbor, MI (Hemmila, Napolitano)
| | - Joseph V Sakran
- Johns Hopkins University School of Medicine, Baltimore, MD (Sakran)
| | | | - Lena M Napolitano
- University of Michigan School of Medicine, Ann Arbor, MI (Hemmila, Napolitano)
| | - Raul Coimbra
- Riverside University Health System Medical Center, Loma Linda University School of Medicine, Loma Linda, CA (Coimbra)
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24
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Jenkins PC, Timsina L, Murphy P, Tignanelli C, Holena DN, Hemmila MR, Newgard C. Extending Trauma Quality Improvement Beyond Trauma Centers: Hospital Variation in Outcomes Among Nontrauma Hospitals. Ann Surg 2022; 275:406-413. [PMID: 35007228 PMCID: PMC8794234 DOI: 10.1097/sla.0000000000005258] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The American College of Surgeons (ACS) conducts a robust quality improvement program for ACS-verified trauma centers, yet many injured patients receive care at non-accredited facilities. This study tested for variation in outcomes across non-trauma hospitals and characterized hospitals associated with increased mortality. SUMMARY BACKGROUND DATA The study included state trauma registry data of 37,670 patients treated between January 1, 2013, and December 31, 2015. Clinical data were supplemented with data from the American Hospital Association and US Department of Agriculture, allowing comparisons among 100 nontrauma hospitals. METHODS Using Bayesian techniques, risk-adjusted and reliability-adjusted rates of mortality and interfacility transfer, as well as Emergency Departments length-of-stay (ED-LOS) among patients transferred from EDs were calculated for each hospital. Subgroup analyses were performed for patients ages >55 years and those with decreased Glasgow coma scores (GCS). Multiple imputation was used to address missing data. RESULTS Mortality varied 3-fold (0.9%-3.1%); interfacility transfer rates varied 46-fold (2.1%-95.6%); and mean ED-LOS varied 3-fold (81-231 minutes). Hospitals that were high and low statistical outliers were identified for each outcome, and subgroup analyses demonstrated comparable hospital variation. Metropolitan hospitals were associated increased mortality [odds ratio (OR) 1.7, P = 0.004], decreased likelihood of interfacility transfer (OR 0.7, P ≤ 0.001), and increased ED-LOS (coef. 0.1, P ≤ 0.001) when compared with nonmetropolitan hospitals and risk-adjusted. CONCLUSIONS Wide variation in trauma outcomes exists across nontrauma hospitals. Efforts to improve trauma quality should include engagement of nontrauma hospitals to reduce variation in outcomes of injured patients treated at those facilities.
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Affiliation(s)
- Peter C. Jenkins
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Lava Timsina
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Patrick Murphy
- Department of Surgery, Medical College of Wisconsin, Wauwatosa, WI, USA
| | | | - Daniel N. Holena
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Mark R. Hemmila
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Craig Newgard
- Department of Emergency Medicine, Oregon Health & Science University School of Medicine, Portland, OR, USA
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25
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Zebrowski AM, Hsu JY, Holena DN, Wiebe DJ, Carr BG. Developing a measure of overall intensity of injury care: A latent class analysis. J Trauma Acute Care Surg 2022; 92:193-200. [PMID: 34225349 PMCID: PMC8692337 DOI: 10.1097/ta.0000000000003321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND While injury is a leading cause of death and debility in older adults, the relationship between intensity of care and trauma remains unknown. The focus of this analysis is to measure the overall intensity of care delivered to injured older adults during hospitalization. METHODS We used Centers for Medicare and Medicaid Services Medicare fee-for-service claims data (2013-2014), to identify emergency department-based claims for moderate and severe blunt trauma in age-eligible beneficiaries. Medical procedures associated with care intensity were identified using a modified Delphi method. A latent class model was estimated using the identified procedures, intensive care unit length of stay, demographics, and injury characteristics. Clinical phenotypes for each class were explored. RESULTS A total of 683,398 cases were classified as low- (73%), moderate- (23%), and high-intensity care (4%). Greater age and reduced injury severity were indicators of lower intensity, while males, non-Whites, and nonfall mechanisms were more common with high intensity. Intubation/mechanical ventilation was an indicator of high intensity and often occurred with at least one other procedure or an extended intensive care unit stay. CONCLUSION This work demonstrates that, although heterogeneous, care for blunt trauma can be evaluated using a single novel measure. LEVEL OF EVIDENCE For prognostic/epidemiological studies, level III.
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Affiliation(s)
- Alexis M. Zebrowski
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Jesse Y. Hsu
- Department of Epidemiology, Biostatistics, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Daniel N. Holena
- Department of Epidemiology, Biostatistics, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, 19104, USA
- Department of Surgery, Division of Traumatology, Perelman School of Medicine, University of Pennsylvania
| | - Douglas J. Wiebe
- Department of Epidemiology, Biostatistics, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Brendan G. Carr
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, 19104, USA
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Burke K, Nagaraj M, Kuhlenschmidt K, Marinica AL, Lowe J, Park C, Vella MA, Holena DN, Cripps MW, Dumas RP. Under the Lens: Provider Perception of Trauma Video Review. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.08.468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Hynes AM, Geng Z, Schmulevich D, Fox EE, Meador CL, Scantling DR, Holena DN, Abella BS, Young AJ, Holland S, Cacchione PZ, Wade CE, Cannon JW. Staying on target: Maintaining a balanced resuscitation during damage-control resuscitation improves survival. J Trauma Acute Care Surg 2021; 91:841-848. [PMID: 33901052 PMCID: PMC8547746 DOI: 10.1097/ta.0000000000003245] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 03/17/2021] [Accepted: 04/10/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Damage-control resuscitation (DCR) improves survival in severely bleeding patients. However, deviating from balanced transfusion ratios during a resuscitation may limit this benefit. We hypothesized that maintaining a balanced resuscitation during DCR is independently associated with improved survival. METHODS This was a secondary analysis of the Prospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study. Patients receiving >3 U of packed red blood cells (PRBCs) during any 1-hour period over the first 6 hours and surviving beyond 30 minutes were included. Linear regression assessed the effect of percent time in a high-ratio range on 24-hour survival. We identified an optimal ratio and percent of time above the target ratio threshold by Youden's index. We compared patients with a 6-hour ratio above the target and above the percent time threshold (on-target) with all others (off-target). Kaplan-Meier analysis assessed the combined effect of blood product ratio and percent time over the target ratio on 24-hour and 30-day survival. Multivariable logistic regression identified factors independently associated with 24-hour and 30-day survival. RESULTS Of 1,245 PROMMTT patients, 524 met the inclusion criteria. Optimal targets were plasma/PRBC and platelet/PRBC of 0.75 (3:4) and ≥40% time spent over this threshold. For plasma/PRBC, on-target (n = 213) versus off-target (n = 311) patients were younger (median, 31 years; interquartile range, [22-50] vs. 40 [25-54]; p = 0.002) with similar injury burdens and presenting physiology. Similar patterns were observed for platelet/PRBC on-target (n = 116) and off-target (n = 408) patients. After adjusting for differences, on-target plasma/PRBC patients had significantly improved 24-hour (odds ratio, 2.25; 95% confidence interval, 1.20-4.23) and 30-day (odds ratio, 1.97; 95% confidence interval, 1.14-3.41) survival, while on-target platelet/PRBC patients did not. CONCLUSION Maintaining a high ratio of plasma/PRBC during DCR is independently associated with improved survival. Performance improvement efforts and prospective studies should capture time spent in a high-ratio range. LEVEL OF EVIDENCE Epidemiologic/prognostic study, level II; Therapeutic, level IV.
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Affiliation(s)
- Allyson M. Hynes
- From the Division of Traumatology (A.M.H., D.S., D.R.S., D.N.H., S.H., J.W.C.), Surgical Critical Care and Emergency Surgery, Penn Acute Research Collaboration (A.M.H., D.S., D.N.H., B.S.A., P.Z.C., J.W.C.), Perelman School of Medicine, Leonard Davis Institute of Health Economics (Z.G., J.W.C.), University of Pennsylvania, Philadelphia, Pennsylvania; Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery (E.E.F., C.E.W.), Medical School, University of Texas Health Science Center at Houston, Houston; Arcos, Inc. (C.L.M.), Missouri City, Texas; Center for Resuscitation Science, Department of Emergency Medicine (B.S.A.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Trauma, Critical Care, and Burn, Department of Surgery (A.J.Y.), The Ohio State University, Columbus, Ohio; Department of Nursing (P.Z.C.), Penn Presbyterian Medical Center, Philadelphia, Pennsylvania; and Department of Surgery (J.W.C.), Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Zhi Geng
- From the Division of Traumatology (A.M.H., D.S., D.R.S., D.N.H., S.H., J.W.C.), Surgical Critical Care and Emergency Surgery, Penn Acute Research Collaboration (A.M.H., D.S., D.N.H., B.S.A., P.Z.C., J.W.C.), Perelman School of Medicine, Leonard Davis Institute of Health Economics (Z.G., J.W.C.), University of Pennsylvania, Philadelphia, Pennsylvania; Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery (E.E.F., C.E.W.), Medical School, University of Texas Health Science Center at Houston, Houston; Arcos, Inc. (C.L.M.), Missouri City, Texas; Center for Resuscitation Science, Department of Emergency Medicine (B.S.A.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Trauma, Critical Care, and Burn, Department of Surgery (A.J.Y.), The Ohio State University, Columbus, Ohio; Department of Nursing (P.Z.C.), Penn Presbyterian Medical Center, Philadelphia, Pennsylvania; and Department of Surgery (J.W.C.), Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Daniela Schmulevich
- From the Division of Traumatology (A.M.H., D.S., D.R.S., D.N.H., S.H., J.W.C.), Surgical Critical Care and Emergency Surgery, Penn Acute Research Collaboration (A.M.H., D.S., D.N.H., B.S.A., P.Z.C., J.W.C.), Perelman School of Medicine, Leonard Davis Institute of Health Economics (Z.G., J.W.C.), University of Pennsylvania, Philadelphia, Pennsylvania; Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery (E.E.F., C.E.W.), Medical School, University of Texas Health Science Center at Houston, Houston; Arcos, Inc. (C.L.M.), Missouri City, Texas; Center for Resuscitation Science, Department of Emergency Medicine (B.S.A.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Trauma, Critical Care, and Burn, Department of Surgery (A.J.Y.), The Ohio State University, Columbus, Ohio; Department of Nursing (P.Z.C.), Penn Presbyterian Medical Center, Philadelphia, Pennsylvania; and Department of Surgery (J.W.C.), Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Erin E. Fox
- From the Division of Traumatology (A.M.H., D.S., D.R.S., D.N.H., S.H., J.W.C.), Surgical Critical Care and Emergency Surgery, Penn Acute Research Collaboration (A.M.H., D.S., D.N.H., B.S.A., P.Z.C., J.W.C.), Perelman School of Medicine, Leonard Davis Institute of Health Economics (Z.G., J.W.C.), University of Pennsylvania, Philadelphia, Pennsylvania; Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery (E.E.F., C.E.W.), Medical School, University of Texas Health Science Center at Houston, Houston; Arcos, Inc. (C.L.M.), Missouri City, Texas; Center for Resuscitation Science, Department of Emergency Medicine (B.S.A.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Trauma, Critical Care, and Burn, Department of Surgery (A.J.Y.), The Ohio State University, Columbus, Ohio; Department of Nursing (P.Z.C.), Penn Presbyterian Medical Center, Philadelphia, Pennsylvania; and Department of Surgery (J.W.C.), Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Christopher L. Meador
- From the Division of Traumatology (A.M.H., D.S., D.R.S., D.N.H., S.H., J.W.C.), Surgical Critical Care and Emergency Surgery, Penn Acute Research Collaboration (A.M.H., D.S., D.N.H., B.S.A., P.Z.C., J.W.C.), Perelman School of Medicine, Leonard Davis Institute of Health Economics (Z.G., J.W.C.), University of Pennsylvania, Philadelphia, Pennsylvania; Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery (E.E.F., C.E.W.), Medical School, University of Texas Health Science Center at Houston, Houston; Arcos, Inc. (C.L.M.), Missouri City, Texas; Center for Resuscitation Science, Department of Emergency Medicine (B.S.A.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Trauma, Critical Care, and Burn, Department of Surgery (A.J.Y.), The Ohio State University, Columbus, Ohio; Department of Nursing (P.Z.C.), Penn Presbyterian Medical Center, Philadelphia, Pennsylvania; and Department of Surgery (J.W.C.), Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Dane R. Scantling
- From the Division of Traumatology (A.M.H., D.S., D.R.S., D.N.H., S.H., J.W.C.), Surgical Critical Care and Emergency Surgery, Penn Acute Research Collaboration (A.M.H., D.S., D.N.H., B.S.A., P.Z.C., J.W.C.), Perelman School of Medicine, Leonard Davis Institute of Health Economics (Z.G., J.W.C.), University of Pennsylvania, Philadelphia, Pennsylvania; Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery (E.E.F., C.E.W.), Medical School, University of Texas Health Science Center at Houston, Houston; Arcos, Inc. (C.L.M.), Missouri City, Texas; Center for Resuscitation Science, Department of Emergency Medicine (B.S.A.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Trauma, Critical Care, and Burn, Department of Surgery (A.J.Y.), The Ohio State University, Columbus, Ohio; Department of Nursing (P.Z.C.), Penn Presbyterian Medical Center, Philadelphia, Pennsylvania; and Department of Surgery (J.W.C.), Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Daniel N. Holena
- From the Division of Traumatology (A.M.H., D.S., D.R.S., D.N.H., S.H., J.W.C.), Surgical Critical Care and Emergency Surgery, Penn Acute Research Collaboration (A.M.H., D.S., D.N.H., B.S.A., P.Z.C., J.W.C.), Perelman School of Medicine, Leonard Davis Institute of Health Economics (Z.G., J.W.C.), University of Pennsylvania, Philadelphia, Pennsylvania; Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery (E.E.F., C.E.W.), Medical School, University of Texas Health Science Center at Houston, Houston; Arcos, Inc. (C.L.M.), Missouri City, Texas; Center for Resuscitation Science, Department of Emergency Medicine (B.S.A.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Trauma, Critical Care, and Burn, Department of Surgery (A.J.Y.), The Ohio State University, Columbus, Ohio; Department of Nursing (P.Z.C.), Penn Presbyterian Medical Center, Philadelphia, Pennsylvania; and Department of Surgery (J.W.C.), Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Benjamin S. Abella
- From the Division of Traumatology (A.M.H., D.S., D.R.S., D.N.H., S.H., J.W.C.), Surgical Critical Care and Emergency Surgery, Penn Acute Research Collaboration (A.M.H., D.S., D.N.H., B.S.A., P.Z.C., J.W.C.), Perelman School of Medicine, Leonard Davis Institute of Health Economics (Z.G., J.W.C.), University of Pennsylvania, Philadelphia, Pennsylvania; Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery (E.E.F., C.E.W.), Medical School, University of Texas Health Science Center at Houston, Houston; Arcos, Inc. (C.L.M.), Missouri City, Texas; Center for Resuscitation Science, Department of Emergency Medicine (B.S.A.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Trauma, Critical Care, and Burn, Department of Surgery (A.J.Y.), The Ohio State University, Columbus, Ohio; Department of Nursing (P.Z.C.), Penn Presbyterian Medical Center, Philadelphia, Pennsylvania; and Department of Surgery (J.W.C.), Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Andrew J. Young
- From the Division of Traumatology (A.M.H., D.S., D.R.S., D.N.H., S.H., J.W.C.), Surgical Critical Care and Emergency Surgery, Penn Acute Research Collaboration (A.M.H., D.S., D.N.H., B.S.A., P.Z.C., J.W.C.), Perelman School of Medicine, Leonard Davis Institute of Health Economics (Z.G., J.W.C.), University of Pennsylvania, Philadelphia, Pennsylvania; Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery (E.E.F., C.E.W.), Medical School, University of Texas Health Science Center at Houston, Houston; Arcos, Inc. (C.L.M.), Missouri City, Texas; Center for Resuscitation Science, Department of Emergency Medicine (B.S.A.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Trauma, Critical Care, and Burn, Department of Surgery (A.J.Y.), The Ohio State University, Columbus, Ohio; Department of Nursing (P.Z.C.), Penn Presbyterian Medical Center, Philadelphia, Pennsylvania; and Department of Surgery (J.W.C.), Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Sara Holland
- From the Division of Traumatology (A.M.H., D.S., D.R.S., D.N.H., S.H., J.W.C.), Surgical Critical Care and Emergency Surgery, Penn Acute Research Collaboration (A.M.H., D.S., D.N.H., B.S.A., P.Z.C., J.W.C.), Perelman School of Medicine, Leonard Davis Institute of Health Economics (Z.G., J.W.C.), University of Pennsylvania, Philadelphia, Pennsylvania; Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery (E.E.F., C.E.W.), Medical School, University of Texas Health Science Center at Houston, Houston; Arcos, Inc. (C.L.M.), Missouri City, Texas; Center for Resuscitation Science, Department of Emergency Medicine (B.S.A.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Trauma, Critical Care, and Burn, Department of Surgery (A.J.Y.), The Ohio State University, Columbus, Ohio; Department of Nursing (P.Z.C.), Penn Presbyterian Medical Center, Philadelphia, Pennsylvania; and Department of Surgery (J.W.C.), Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Pamela Z. Cacchione
- From the Division of Traumatology (A.M.H., D.S., D.R.S., D.N.H., S.H., J.W.C.), Surgical Critical Care and Emergency Surgery, Penn Acute Research Collaboration (A.M.H., D.S., D.N.H., B.S.A., P.Z.C., J.W.C.), Perelman School of Medicine, Leonard Davis Institute of Health Economics (Z.G., J.W.C.), University of Pennsylvania, Philadelphia, Pennsylvania; Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery (E.E.F., C.E.W.), Medical School, University of Texas Health Science Center at Houston, Houston; Arcos, Inc. (C.L.M.), Missouri City, Texas; Center for Resuscitation Science, Department of Emergency Medicine (B.S.A.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Trauma, Critical Care, and Burn, Department of Surgery (A.J.Y.), The Ohio State University, Columbus, Ohio; Department of Nursing (P.Z.C.), Penn Presbyterian Medical Center, Philadelphia, Pennsylvania; and Department of Surgery (J.W.C.), Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Charles E. Wade
- From the Division of Traumatology (A.M.H., D.S., D.R.S., D.N.H., S.H., J.W.C.), Surgical Critical Care and Emergency Surgery, Penn Acute Research Collaboration (A.M.H., D.S., D.N.H., B.S.A., P.Z.C., J.W.C.), Perelman School of Medicine, Leonard Davis Institute of Health Economics (Z.G., J.W.C.), University of Pennsylvania, Philadelphia, Pennsylvania; Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery (E.E.F., C.E.W.), Medical School, University of Texas Health Science Center at Houston, Houston; Arcos, Inc. (C.L.M.), Missouri City, Texas; Center for Resuscitation Science, Department of Emergency Medicine (B.S.A.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Trauma, Critical Care, and Burn, Department of Surgery (A.J.Y.), The Ohio State University, Columbus, Ohio; Department of Nursing (P.Z.C.), Penn Presbyterian Medical Center, Philadelphia, Pennsylvania; and Department of Surgery (J.W.C.), Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Jeremy W. Cannon
- From the Division of Traumatology (A.M.H., D.S., D.R.S., D.N.H., S.H., J.W.C.), Surgical Critical Care and Emergency Surgery, Penn Acute Research Collaboration (A.M.H., D.S., D.N.H., B.S.A., P.Z.C., J.W.C.), Perelman School of Medicine, Leonard Davis Institute of Health Economics (Z.G., J.W.C.), University of Pennsylvania, Philadelphia, Pennsylvania; Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery (E.E.F., C.E.W.), Medical School, University of Texas Health Science Center at Houston, Houston; Arcos, Inc. (C.L.M.), Missouri City, Texas; Center for Resuscitation Science, Department of Emergency Medicine (B.S.A.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Trauma, Critical Care, and Burn, Department of Surgery (A.J.Y.), The Ohio State University, Columbus, Ohio; Department of Nursing (P.Z.C.), Penn Presbyterian Medical Center, Philadelphia, Pennsylvania; and Department of Surgery (J.W.C.), Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Kaufman EJ, Zebrowski AM, Holena DN, Loher P, Wiebe DJ, Carr BG. The Short and the Long of it: Timing of Mortality for Older Adults in a State Trauma System. J Surg Res 2021; 268:17-24. [PMID: 34280661 DOI: 10.1016/j.jss.2021.06.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 04/14/2021] [Accepted: 06/14/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND The impact of injury extends beyond the hospital stay, but trauma center performance metrics typically focus on in-hospital mortality. We compared risk adjusted rates of in-hospital and long-term mortality among Pennsylvania trauma centers. We hypothesized that centers with low rates of in-hospital mortality would also have low rates of long-term mortality. METHODS We identified injured patients (age ≥ 65) admitted to Pennsylvania trauma centers in 2013 and 2014 using the Pennsylvania Trauma Outcomes Study, a robust, state-wide trauma registry. We matched trauma registry records to Medicare claims from the y 2013 to 2015. Matching variables included admission date and patient demographics including date of birth, zip, sex, and race and/or ethnicity. Outcomes examined were inpatient, 30-day, and 1-y mortality. Multivariable logistic regression models including presenting physiology, comorbidities, injury characteristics, and demographics were developed to calculate expected mortality rates for each trauma center at each time point. Trauma center performance was assessed using observed-to-expected ratios and ranking for in-hospital, 30-day, and 1-y mortality. RESULTS Of the 15,451 patients treated at 28 centers, 8.1% died before discharge or were discharged to hospice. Another 3.4% died within 30 d, and another 14.7% died within 1 y of injury. Of patients who survived hospitalization but died within 30 d, 92.5% were injured due to fall, and 75.0% sustained head injuries. Survival at 1 y was higher in patients discharged home (88.4%), compared to those discharged to a skilled nursing facility or long-term acute care hospital (72.7% and 52.6%, respectively). Three centers were identified as outliers (two low and one high) for in-hospital mortality, none of which were outliers when the horizon was stretched to 30 d from injury. At 30 d, two different low and two different high outliers were found. CONCLUSION Nearly one-in-three injured older adults who die within 30 d of injury dies after hospital discharge. Hospital rankings for in-hospital mortality correlate poorly with long-term outcomes. These findings underscore the importance of looking beyond survival to discharge for quality improvement and benchmarking.
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Affiliation(s)
- Elinore J Kaufman
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania Perelman School of Medicine, Penn Presbyterian Medical Center, Philadelphia, PA.
| | - Alexis M Zebrowski
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Daniel N Holena
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania Perelman School of Medicine, Penn Presbyterian Medical Center, Philadelphia, PA
| | - Phillipe Loher
- Computational Medicine Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Douglas J Wiebe
- Department of Biostatistics, Epidemiology, and Informatics, and Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelhia, Pennsylvania, USA
| | - Brendan G Carr
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Scantling DR, Hynes AM, Kaufman EJ, Byrne J, Holena DN, Seamon MJ. Bang for the buck: The impact of political financial contributions on firearm law. J Trauma Acute Care Surg 2021; 91:54-63. [PMID: 33605700 DOI: 10.1097/ta.0000000000003117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND One hundred thousand Americans are shot annually, and 39,000 die. State laws restricting firearm sales and use have been shown to decrease firearm deaths, yet little is known about what impacts their passage or repeal. We hypothesized that spending by groups that favor firearm restrictive legislation would increase new state firearm restrictive laws (FRLs) and that states increasing these laws would endure fewer firearm deaths. METHODS We acquired 2013 to 2018 state data on spending by groups against firearm restrictive legislation and for firearm restrictive legislation regarding lobbying, campaign, and independent and total expenditures from the National Institute on Money in State Politics. State-level political party representation data were acquired from the National Conference of State Legislatures. Mass shooting data were obtained from the Mass Shooter Database of the Violence Project, and firearm death rates were obtained from Centers for Disease Control Wide-ranging Online Data for Epidemiologic Research and Federal Bureau of Investigation Uniform Crime Reporting databases. Firearm restrictive laws were obtained from the State Firearms Law Database. A univariate panel linear regression with fixed effect for state was performed with change in FRLs from baseline as the outcome. A final multivariable panel regression with fixed effect for state was then used. Firearm death rates were compared by whether states increased, decreased, or had no change in FRLs. RESULTS Twenty-two states gained and 13 lost FRLs, while 15 states had no net change (44%, 26%, and 30%; p = 0.484). In multivariable regression accounting for partisan control of state government, for-firearm restrictive legislation groups outspending against-firearm restrictive legislation groups had the largest association with increased FRLs (β = 1.420; 95% confidence interval, 0.63-2.21; p < 0.001). States that gained FRLs had significantly lower firearm death rates (p < 0.001). Relative to states with no change in FRLs, states that lost FRLs had an increase in overall firearm death of 1 per 100,000 individuals. States that gained FRLs had a net decrease in median overall firearm death of 0.5 per 100,000 individuals. CONCLUSION Higher political spending by groups in favor of restrictive firearm legislation has a powerful association with increasing and maintaining FRLs. States that increased their FRLs, in turn, showed lower firearm death rates. LEVEL OF EVIDENCE Epidemiological, level I.
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Affiliation(s)
- Dane R Scantling
- From the Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
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Byrne JP, Nance ML, Scantling DR, Holena DN, Kaufman EJ, Nathens AB, Reilly PM, Seamon MJ. Association between access to pediatric trauma care and motor vehicle crash death in children: An ecologic analysis of United States counties. J Trauma Acute Care Surg 2021; 91:84-92. [PMID: 33605706 DOI: 10.1097/ta.0000000000003110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Access to pediatric trauma care is highly variable across the United States. The purpose of this study was to measure the association between pediatric trauma center care and motor vehicle crash (MVC) mortality in children (<15 years) at the US county level for 5 years (2014-2018). METHODS The exposure was defined as the highest level of pediatric trauma care present within each county: (1) pediatric trauma center, (2) adult level 1/2, (3) adult level 3, or (4) no trauma center. Pediatric deaths due to passenger vehicle crashes on public roads were identified from the NHTSA Fatality Analysis Reporting System. Hierarchical negative binomial modeling measured the relationship between highest level of pediatric trauma care and pediatric MVC mortality within counties. Adjusted analyses accounted for population age and sex, emergency medical service response times, helicopter ambulance availability, state traffic safety laws, and measures of rurality. RESULTS During the study period 3,067 children died in fatal crashes. We identified 188 pediatric trauma centers in 141 counties. Significant disparities in access to pediatric trauma care were observed. Specifically, 99% of pediatric trauma centers were situated in population-dense urban counties, while 28% of children lived in counties no trauma center. After risk adjustment, counties with pediatric trauma centers had significantly lower rates of pediatric MVC death than those with no trauma center: 0.7 versus 3.2 deaths/100,000 child-years; mortality rate ratio, 0.58; and 95% confidence interval, 0.39 to 0.86. In counties where pediatric trauma centers were absent, adult level 1/2 trauma centers were associated with comparable risk reduction. CONCLUSION The presence of pediatric trauma centers was associated with lower rates of MVC death in children. Adult level 1/2 trauma centers appear to offer comparable risk reduction. Where population differences in pediatric trauma mortality are observed, addressing disparities in county-level access to pediatric trauma care may serve as a viable target for system-level improvement. LEVEL OF EVIDENCE Epidemiological, level III; Care management, level III.
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Affiliation(s)
- James P Byrne
- From the Division of Traumatology, Surgical Critical Care and Emergency Surgery (JPB, DRS, DNH, EJK, PMR, MJS), Department of Surgery of the Children's Hospital of Philadelphia (MLN), and the Penn Injury Science Center (JPB, MLN, DNH, EJK, PMR), University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada (ABN)
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Vasquez CR, Gupta S, Miano TA, Roche M, Hsu J, Yang W, Holena DN, Reilly JP, Schrauben SJ, Leaf DE, Shashaty MGS. Identification of Distinct Clinical Subphenotypes in Critically Ill Patients With COVID-19. Chest 2021; 160:929-943. [PMID: 33964301 PMCID: PMC8099539 DOI: 10.1016/j.chest.2021.04.062] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 04/09/2021] [Accepted: 04/25/2021] [Indexed: 02/08/2023] Open
Abstract
Background Subphenotypes have been identified in patients with sepsis and ARDS and are associated with different outcomes and responses to therapies. Research Question Can unique subphenotypes be identified among critically ill patients with COVID-19? Study Design and Methods Using data from a multicenter cohort study that enrolled critically ill patients with COVID-19 from 67 hospitals across the United States, we randomly divided centers into discovery and replication cohorts. We used latent class analysis independently in each cohort to identify subphenotypes based on clinical and laboratory variables. We then analyzed the associations of subphenotypes with 28-day mortality. Results Latent class analysis identified four subphenotypes (SP) with consistent characteristics across the discovery (45 centers; n = 2,188) and replication (22 centers; n = 1,112) cohorts. SP1 was characterized by shock, acidemia, and multiorgan dysfunction, including acute kidney injury treated with renal replacement therapy. SP2 was characterized by high C-reactive protein, early need for mechanical ventilation, and the highest rate of ARDS. SP3 showed the highest burden of chronic diseases, whereas SP4 demonstrated limited chronic disease burden and mild physiologic abnormalities. Twenty-eight-day mortality in the discovery cohort ranged from 20.6% (SP4) to 52.9% (SP1). Mortality across subphenotypes remained different after adjustment for demographics, comorbidities, organ dysfunction and illness severity, regional and hospital factors. Compared with SP4, the relative risks were as follows: SP1, 1.67 (95% CI, 1.36-2.03); SP2, 1.39 (95% CI, 1.17-1.65); and SP3, 1.39 (95% CI, 1.15-1.67). Findings were similar in the replication cohort. Interpretation We identified four subphenotypes of COVID-19 critical illness with distinct patterns of clinical and laboratory characteristics, comorbidity burden, and mortality.
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Affiliation(s)
- Charles R Vasquez
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| | - Shruti Gupta
- Harvard Medical School, Brigham and Women's Hospital, Boston, MA; Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA
| | - Todd A Miano
- Center for Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Meaghan Roche
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jesse Hsu
- Center for Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Wei Yang
- Center for Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Daniel N Holena
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Center for Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - John P Reilly
- Pulmonary, Allergy and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sarah J Schrauben
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - David E Leaf
- Harvard Medical School, Brigham and Women's Hospital, Boston, MA; Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA
| | - Michael G S Shashaty
- Center for Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Pulmonary, Allergy and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Peden CJ, Aggarwal G, Aitken RJ, Anderson ID, Bang Foss N, Cooper Z, Dhesi JK, French WB, Grant MC, Hammarqvist F, Hare SP, Havens JM, Holena DN, Hübner M, Kim JS, Lees NP, Ljungqvist O, Lobo DN, Mohseni S, Ordoñez CA, Quiney N, Urman RD, Wick E, Wu CL, Young-Fadok T, Scott M. Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS) Society Recommendations: Part 1-Preoperative: Diagnosis, Rapid Assessment and Optimization. World J Surg 2021; 45:1272-1290. [PMID: 33677649 PMCID: PMC8026421 DOI: 10.1007/s00268-021-05994-9] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) protocols reduce length of stay, complications and costs for a large number of elective surgical procedures. A similar, structured approach appears to improve outcomes, including mortality, for patients undergoing high-risk emergency general surgery, and specifically emergency laparotomy. These are the first consensus guidelines for optimal care of these patients using an ERAS approach. METHODS Experts in aspects of management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. Pubmed, Cochrane, Embase, and MEDLINE database searches on English language publications were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized controlled trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on non-emergency patients when appropriate. The Delphi method was used to validate final recommendations. The guideline has been divided into two parts: Part 1-Preoperative Care and Part 2-Intraoperative and Postoperative management. This paper provides guidelines for Part 1. RESULTS Twelve components of preoperative care were considered. Consensus was reached after three rounds. CONCLUSIONS These guidelines are based on the best available evidence for an ERAS approach to patients undergoing emergency laparotomy. Initial management is particularly important for patients with sepsis and physiological derangement. These guidelines should be used to improve outcomes for these high-risk patients.
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Affiliation(s)
- Carol J. Peden
- Department of Anesthesiology and Gehr Family Center for Health Systems Science & Innovation, Keck School of Medicine, University of Southern California, 2020 Zonal Avenue IRD 322, Los Angeles, CA 90033 USA
- Department of Anesthesiology, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 USA
| | - Geeta Aggarwal
- Department of Anesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Guildford, Surrey, UK
| | - Robert J. Aitken
- Sir Charles Gardiner Hospital, Hospital Avenue, Nedlands, WA 6009 Australia
| | - Iain D. Anderson
- Salford Royal NHS Foundation Trust, Stott La, Salford, M6 8HD UK
- University of Manchester, Manchester, UK
| | | | - Zara Cooper
- Harvard Medical School, Kessler Director, Center for Surgery and Public Health, Brigham and Women’s Hospital and Division of Trauma, Burns, Surgical Critical Care, and Emergency Surgery, Brigham and Women’s Hospital, 1620, Tremont Street, Boston, MA 02120 USA
| | - Jugdeep K. Dhesi
- Faculty of Life Sciences and Medicine, School of Population Health & Environmental Sciences, Guy’s and St Thomas’ NHS Foundation Trust, King’s College London, Division of Surgery & Interventional Science, University College London, London, UK
| | - W. Brenton French
- Department of Surgery, Virginia Commonwealth University Health System, 1200 E. Broad Street, Richmond, VA 23298 USA
| | - Michael C. Grant
- Department of Anesthesiology and Critical Care Medicine, Department of Surgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287 USA
| | - Folke Hammarqvist
- Department of Emergency and Trauma Surgery, Karolinska University Hospital, CLINTEC, Karolinska Institutet, Stockholm, Sweden
- Karolinska University Hospital, Huddinge Hälsovägen 3. B85, S 141 86, Stockholm, Sweden
| | - Sarah P. Hare
- Department of Anaesthesia, Perioperative Medicine and Critical Care, Medway Maritime Hospital, Windmill Road, Gillingham, Kent, ME7 5NY UK
| | - Joaquim M. Havens
- Division of Trauma, Burns and Surgical Critical Care, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115 USA
| | - Daniel N. Holena
- Department of Surgery and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA 19104 USA
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Jeniffer S. Kim
- Gehr Family Center for Health Systems Science & Innovation, Keck School of Medicine, University of Southern California, 2020 Zonal Avenue IRD 322, Los Angeles, CA 90033 USA
| | - Nicholas P. Lees
- Department of General & Colorectal Surgery, Salford Royal NHS Foundation Trust, Scott La, Salford, M6 8HD UK
| | - Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Dileep N. Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen’s Medical Centre, Nottingham, NG7 2UH UK
- MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen’s Medical Centre, Nottingham, NG7 2UH UK
| | - Shahin Mohseni
- Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital & School of Medical Sciences, Örebro University, 701 85 Örebro, Sweden
| | - Carlos A. Ordoñez
- Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Cra 98 No. 18 – 49, 760032 Cali, Colombia
- Sección de Cirugía de Trauma Y Emergencias, Universidad del Valle – Hospital Universitario del Valle, Cl 5 No. 36-08, 760032 Cali, Colombia
| | - Nial Quiney
- Department of Anesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey, GU5 7XX UK
| | - Richard D. Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital / Harvard Medical School, 75 Francis Street, Boston, MA 02115 USA
| | - Elizabeth Wick
- Department of Surgery, University of California San Francisco, 513 Parnassus Ave HSW1601, San Francisco, CA 94143 USA
| | - Christopher L. Wu
- Department of Anesthesiology, Critical Care and Pain Medicine-Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
- Department of Anesthesiology, Weill Cornell Medicine, 535 East 70th Street, New York, NY 10021 USA
| | - Tonia Young-Fadok
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic College of Medicine, Mayo Clinic Arizona, 5777 E. Mayo Blvd, Phoenix, AZ 85054 USA
| | - Michael Scott
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 USA
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Hatchimonji JS, Bader AL, Ma LW, Chreiman K, Byrne JP, Reilly PM, Braslow BM, Seamon MJ, Holena DN. Pain Interference and Decreased Physical Function After Emergency General Surgery: Measuring Patient-Reported Outcomes. World J Surg 2021; 45:1725-1733. [PMID: 33683414 PMCID: PMC7938883 DOI: 10.1007/s00268-021-06011-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2021] [Indexed: 10/27/2022]
Abstract
INTRODUCTION There is increasing emphasis on patient-reported outcomes (PROs) measures in healthcare, but this area remains largely unexplored in emergency general surgery (EGS) conditions. We hypothesized that postoperative patients in our EGS clinic would report detrimental changes in several domains of health-related quality of life (HRQoL). METHODS We administered the PROMIS-29, a HRQoL measurement tool, to postoperative patients in our EGS clinic (11/2019-4/2020). Patients responded to measures of 7 domains. Domain scores were converted to t-scores, allowing comparison to average values within the general US population (set to 50 by definition). We report the mean scores within each domain. Higher scores in negatively worded domains (e.g., "Depression") are worse; vice versa for positively worded domains (e.g., "Physical Function"). Changes in scores at subsequent clinic visits were analyzed using the paired t-test. RESULTS There were 97 patients who completed the PROMIS-29 at the first postoperative visit. Mean (SD) age was 54.1 (16.2) years; 51% were male. There was no difference in our patients from the average US population in the domains of Ability to Participate in Social Roles and Activities, Anxiety, Fatigue, and Sleep Disturbance. However, EGS patients experienced significantly greater Pain Interference (56.1 [54.1, 58.1]) and worse Physical Function (40.6 [38.4, 42.7]) than average. For patients seen in follow-up twice (13 patients, median interval between clinic visits 21 days), there were improvements in the domains of Physical Function (42.9 vs 37.3; p = 0.04) and Fatigue. CONCLUSION We demonstrate room for improvement in the domains of pain interference and physical function. While positive changes over a relatively short period of time are encouraging, consideration should be given to patient perceptions of illness and lifestyle impact when managing EGS patients.
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Affiliation(s)
- Justin S Hatchimonji
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce St, 4 Maloney, Philadelphia, PA, USA.
| | - Amanda L Bader
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce St, 4 Maloney, Philadelphia, PA, USA
| | - Lucy W Ma
- School of Arts and Sciences, University of Pennsylvania, Philadelphia, PA, USA
| | - Kristen Chreiman
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - James P Byrne
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Patrick M Reilly
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Benjamin M Braslow
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Mark J Seamon
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Daniel N Holena
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Hatchimonji JS, Kaufman EJ, Chreiman K, Stoecker JB, Reilly PM, Smith BP, Holena DN, Seamon MJ. Beyond morbidity and mortality: The practicality of measuring patient-reported outcomes in trauma. Injury 2021; 52:127-133. [PMID: 33223252 DOI: 10.1016/j.injury.2020.11.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 11/03/2020] [Accepted: 11/12/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND The 2016 Zero Preventable Deaths report highlighted the need for comprehensive injury data to include long term outcomes such as societal and workforce re-entry. Currently, postinjury quality of life is poorly understood. We hypothesized that routine measurement of patient-reported outcomes is feasible as a part of post-discharge follow-up, and that trauma patients would report that their injury had a detrimental impact on health-related quality of life (HRQoL) after discharge. METHODS After instruction, patients self-administered the PROMIS-29 instrument in our outpatient office (11/2019-4/2020). We surveyed 7 domains: Participation in Social Roles/Activities, Anxiety, Depression, Fatigue, Pain Interference, Physical Function, and Sleep Disturbance. Results are reported as means (SD) and compared to the U.S population by t-score (mean score=50). Higher scores in negatively-worded domains (e.g. "Depression") are worse; vice versa for positively-worded domains (e.g. "Physical Function"). Repeated scores among patients returning for a second visit were analyzed using paired t-tests. RESULTS 103 patients completed the PROMIS-29. Mean (SD) age was 42.3 (17.3) years, 75% were male, and 42% suffered a penetrating injury. Median length of stay was 3 days and median time from injury to clinic visit was 18 days. Mean scores were worse than population means in every domain. Pain Interference (mean 63.5, 95%CI [61.8-65.3]) and Physical Function (38.0 [36.2-39.8]) were particularly affected. Among patients returning for a second visit (n=10; median time between clinic visits: 17.5 days), there were no significant differences in domain scores over time. CONCLUSION Trauma patients are at high risk for poor quality of life outcomes in the short term following injury. Our results highlight the need for early recognition and multidisciplinary treatment following injury.
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Affiliation(s)
- Justin S Hatchimonji
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
| | - Elinore J Kaufman
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
| | - Kristen Chreiman
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
| | - Jordan B Stoecker
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
| | - Patrick M Reilly
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
| | - Brian P Smith
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
| | - Daniel N Holena
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
| | - Mark J Seamon
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
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Hatchimonji JS, Kaufman EJ, Dowzicky PM, Scantling DR, Holena DN. Efficient evaluation of center-level emergency surgery performance using a high-yield procedure set: A step towards an EGS registry. Am J Surg 2021; 222:625-630. [PMID: 33509544 DOI: 10.1016/j.amjsurg.2021.01.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 01/10/2021] [Accepted: 01/13/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Emergency general surgery (EGS) lacks mechanisms to compare performance between institutions. Focusing on higher-risk procedures may efficiently identify outliers. METHODS EGS patients were identified from the 2016 State Inpatient Databases of Florida, New York, and Kentucky. Risk-adjusted mortality was calculated as an O:E ratio, generating expected mortality from a model including demographic and procedural factors. Outliers were centers whose 90% confidence intervals excluded 1. This was repeated in several subsets, to determine if these yielded outliers similar to the overall dataset. RESULTS We identified 45,430 EGS patients. Overall, 3 high performing centers and 5 low performing centers were identified. Exclusion of appendectomies and cholecystectomies resulted in a remaining data set of 13,569 patients (29.9% of the overall data set), with 2 high performers and 5 low performers. One low performer in the limited data set was not identified in the overall set. CONCLUSION Evaluation of 5 procedures, making up less than a third of EGS, identifies most outliers. A streamlined monitoring procedure may facilitate maintenance of an EGS registry.
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Affiliation(s)
- Justin S Hatchimonji
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Elinore J Kaufman
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Phillip M Dowzicky
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Dane R Scantling
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Daniel N Holena
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
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Winter E, Hynes AM, Shultz K, Holena DN, Malhotra NR, Cannon JW. Association of Police Transport With Survival Among Patients With Penetrating Trauma in Philadelphia, Pennsylvania. JAMA Netw Open 2021; 4:e2034868. [PMID: 33492375 PMCID: PMC7835719 DOI: 10.1001/jamanetworkopen.2020.34868] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Police in Philadelphia, Pennsylvania, routinely transport patients with penetrating trauma to nearby trauma centers. During the past decade, this practice has gained increased acceptance, but outcomes resulting from police transport of these patients have not been recently evaluated. OBJECTIVE To assess mortality among patients with penetrating trauma who are transported to trauma centers by police vs by emergency medical services (EMS). DESIGN, SETTING, AND PARTICIPANTS This cohort study used the Pennsylvania Trauma Outcomes Study registry and included 3313 adult patients with penetrating trauma from January 1, 2014, to December 31, 2018. Outcomes were compared between patients transported by police (n = 1970) and patients transported by EMS (n = 1343) to adult level I and II trauma centers in Philadelphia. EXPOSURES Police vs EMS transport. MAIN OUTCOMES AND MEASURES The primary end point was 24-hour mortality. Secondary end points included death at multiple other time points. After whole-cohort regression analysis, coarsened exact matching was used to control for confounding differences between groups. Matching criteria included patient age, injury mechanism and location, Injury Severity Score (ISS), presenting systolic blood pressure, and Glasgow Coma Scale score. Subgroup analysis was performed among patients with low, moderate, or high ISS. RESULTS Of the 3313 patients (median age, 29 years [interquartile range, 23-40 years]) in the study, 3013 (90.9%) were men. During the course of the study, the number of police transports increased significantly (from 328 patients in 2014 to 489 patients in 2018; P = .04), while EMS transport remained unchanged (from 246 patients in 2014 to 281 patients in 2018; P = .44). On unadjusted analysis, compared with patients transported by EMS, patients transported by police were younger (median age, 27 years [interquartile range, 22-36 years] vs 32 years [interquartile range, 24-46 years]), more often injured by a firearm (1741 of 1970 [88.4%] vs 681 of 1343 [50.7%]), and had a higher median ISS (14 [interquartile range, 9-26] vs 10 [interquartile range, 5-17]). Patients transported by police had higher mortality at 24 hours than those transported by EMS (560 of 1970 [28.4%] vs 246 of 1343 [18.3%]; odds ratio, 1.86; 95% CI, 1.57-2.21; P < .001) and at all other time points. After coarsened exact matching (870 patients in each transport cohort), there was no difference in mortality at 24 hours (210 [24.1%] vs 212 [24.4%]; odds ratio, 0.95; 95% CI, 0.59-1.52; P = .91) or at any other time point. On subgroup analysis, patients with severe injuries transported by police were less likely to be dead on arrival compared with matched patients transported by EMS (64 of 194 [33.0%] vs 79 of 194 [40.7%]; odds ratio, 0.48; 95% CI, 0.24-0.94; P = .03). CONCLUSIONS AND RELEVANCE For patients with penetrating trauma in an urban setting, 24-hour mortality was not different for those transported by police vs EMS to a trauma center. Timely transport to definitive trauma care should be emphasized over medical capability in the prehospital management of patients with penetrating trauma.
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Affiliation(s)
- Eric Winter
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Allyson M. Hynes
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Kaitlyn Shultz
- The West Chester Statistical Institute, Department of Mathematics, West Chester University, West Chester, Pennsylvania
- McKenna EpiLog Fellowship in Population Health, University of Pennsylvania, Philadelphia
| | - Daniel N. Holena
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Neil R. Malhotra
- McKenna EpiLog Fellowship in Population Health, University of Pennsylvania, Philadelphia
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Jeremy W. Cannon
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
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Hatchimonji JS, Ma LW, Kaufman EJ, Dowzicky PM, Scantling DR, Yang W, Holena DN. Differences Between Center-level Outcomes in Emergency and Elective General Surgery. J Surg Res 2020; 261:1-9. [PMID: 33387728 DOI: 10.1016/j.jss.2020.11.086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 10/22/2020] [Accepted: 11/17/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Center-level outcome metrics have long been tracked in elective surgery (ELS). Despite recent interest in measuring emergency general surgery (EGS) quality, centers are often compared based on elective or combined outcomes. Therefore, quality of care for emergency surgery specifically is unknown. METHODS We extracted data on EGS and ELS patients from the 2016 State Inpatient Databases of Florida, New York, and Kentucky. Centers that performed >100 ELS and EGS operations were included. Risk-adjusted mortality, complication, and failure to rescue (FTR, death after complication) rates were calculated and observed-to-expected ratios were calculated by center for ELS and EGS patients. Centers were determined to be high or low outliers if the 90% CI for the observed: expected ratio excluded 1. We calculated the frequency with which centers demonstrated a different performance status between EGS and ELS. Kendall's tau values were calculated to assess for correlation between EGS and ELS status. RESULTS A total of 204 centers with 45,500 EGS cases and 49,380 ELS cases met inclusion criteria. Overall mortality, complication, and FTR rates were 1.7%, 8.0%, and 14.5% respectively. There was no significant correlation between mortality performance in EGS and ELS, with 36 centers in a different performance category (high outlier, low outlier, as expected) in EGS than in ELS. The correlation for complication rates was 0.20, with 60 centers in different categories for EGS and ELS. For FTR rates, there was no correlation, with 16 centers changing category. CONCLUSIONS There was minimal correlation between outcomes for ELS and EGS. High performers in one category were rarely high performers in the other. There may be important differences between the processes of care that are important for EGS and ELS outcomes that may yield meaningful opportunities for quality improvement.
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Affiliation(s)
- Justin S Hatchimonji
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Lucy W Ma
- College of Arts and Sciences, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Elinore J Kaufman
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Phillip M Dowzicky
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Dane R Scantling
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Wei Yang
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Daniel N Holena
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Kaufman EJ, Passman JE, Jacoby SF, Holena DN, Seamon MJ, MacMillan J, Beard JH. Making the news: Victim characteristics associated with media reporting on firearm injury. Prev Med 2020; 141:106275. [PMID: 33027614 PMCID: PMC7533055 DOI: 10.1016/j.ypmed.2020.106275] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 09/24/2020] [Accepted: 09/27/2020] [Indexed: 11/25/2022]
Abstract
Firearm injury is a public health crisis in the United States. Selective media coverage may contribute to incomplete public understanding of firearm injury. To better understand how firearm injury is communicated to the public, we analyzed media coverage of intentional, interpersonal shootings in 3 U.S. cities. We hypothesized that multiple shootings and fatal shootings would be more likely to make the news, as would shootings affecting children, women, and white individuals. We compared police department data on shootings to media reports drawn from the Gun Violence Archive (GVA) for 2017 in Philadelphia, PA, Rochester, NY, and Cincinnati, OH. GVA reports were matched to police data by shooting date, location, victim age, and gender. Matched victims were compared to unmatched using chi2 tests for categorical variables and Kruskal Wallis tests for continuous variables. Philadelphia police reported 1216 firearm assault victims; Cincinnati police reported 407; and Rochester police reported 178. News reports covered 562 (46.2%), 222 (54.6%), and 116 (65.2%) victims, respectively. Fatal shootings were more often reported as were shootings involving multiple victims or women. Half of shooting victims did not make the news. Selective reporting likely limits awareness of the public health impact of firearm injury. Researchers and policy makers should work with journalists and editors to improve the quantity and content of reporting on firearm injury.
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Affiliation(s)
- Elinore J Kaufman
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania Perelman School of Medicine, United States of America.
| | - Jesse E Passman
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, United States of America.
| | - Sara F Jacoby
- University of Pennsylvania School of Nursing, United States of America.
| | - Daniel N Holena
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania Perelman School of Medicine, United States of America.
| | - Mark J Seamon
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania Perelman School of Medicine, United States of America.
| | - Jim MacMillan
- Initiative for Better Gun Violence Reporting, United States of America.
| | - Jessica H Beard
- Division of Trauma and Surgical Critical Care, Temple University School of Medicine, United States of America.
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Jacoby SF, Branas CC, Holena DN, Kaufman EJ. Beyond survival: the broader consequences of prehospital transport by police for penetrating trauma. Trauma Surg Acute Care Open 2020; 5:e000541. [PMID: 33305004 PMCID: PMC7692989 DOI: 10.1136/tsaco-2020-000541] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 09/28/2020] [Accepted: 10/25/2020] [Indexed: 11/15/2022] Open
Abstract
Background Time to definitive hemorrhage control is a primary driver of survival after penetrating injury. For these injuries, mortality outcomes after prehospital transport by police and emergency medical service (EMS) providers are comparable. In this study we identify patient and geographic predictors of police transport relative to EMS transport and describe perceptions of police transport elicited from key stakeholders. Methods This mixed methods study was conducted in Philadelphia, Pennsylvania, which has the highest rate of police transport nationally. Patient data were drawn from Pennsylvania’s trauma registry and geographic data from the US Census and American Community Survey. For all 7500 adults who presented to Philadelphia trauma centers with penetrating injuries, 2006–2015, we compared how individual and geospatial characteristics predicted the odds of police versus EMS transport. Concurrently, we conducted qualitative interviews with patients, police officers and trauma clinicians to describe their perceptions of police transport in practice. Results Patients who were Black (OR 1.50; 1.20–1.88) and Hispanic (OR 1.38; 1.05–1.82), injured by a firearm (OR 1.58; 1.19–2.10) and at night (OR 1.48; 1.30–1.69) and who presented with decreased levels of consciousness (OR 1.18; 1.02–1.37) had higher odds of police transport. Neighborhood characteristics predicting police transport included: percent of Black population (OR 1.18; 1.05–1.32), vacant housing (OR 1.40; 1.20–1.64) and fire stations (OR 1.32; 1.20–1.44). All stakeholders perceived speed as police transport’s primary advantage. For patients, disadvantages included pain and insecurity while in transport. Police identified occupational health risks. Clinicians identified occupational safety risks and the potential for police transport to complicate the workflow. Conclusions Police transport may improve prompt access to trauma care but should be implemented with consideration of the equity of access and broad stakeholder perspectives in efforts to improve outcomes, safety, and efficiency. Level of evidence Epidemiological study, level III.
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Affiliation(s)
- Sara F Jacoby
- Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Charles C Branas
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Daniel N Holena
- Division of Trauma, Surgical Critical Care and Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Elinore J Kaufman
- Division of Trauma, Surgical Critical Care and Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Guzman JF, Hatchimonji J, Bormann B, Scantling D, Xiong R, Kaufman E, Holena DN. Serum Albumin and Mortality after Enterocutaneous Fistula Takedown. J Am Coll Surg 2020. [DOI: 10.1016/j.jamcollsurg.2020.08.361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Hatchimonji J, Chreiman K, Stoecker J, Reilly PM, Smith BP, Holena DN, John Seamon M. Beyond Morbidity and Mortality: Patient-Reported Outcomes in Trauma. J Am Coll Surg 2020. [DOI: 10.1016/j.jamcollsurg.2020.07.632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Winter E, Hynes A, Shultz K, Keating J, Holena DN, Malhotra NR, Cannon JW. Police Transport for Penetrating Trauma. J Am Coll Surg 2020. [DOI: 10.1016/j.jamcollsurg.2020.07.674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Raza SS, Kaufman EJ, Hatchimonji JS, Garcia Whitlock AE, Seamon MJ, Holena DN, Gallagher JJ, Reilly PM, Cannon JW. Show Me Where It Hurts: Outcomes from Targeted Delivery of Stop the Bleed (STB) Training in Geomapped Urban Hot Spots for Penetrating Injury. J Am Coll Surg 2020. [DOI: 10.1016/j.jamcollsurg.2020.08.674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Hatchimonji J, Rosen C, Braslow BM, Holena DN, Douglas Martin N. Quantifying Procedure-Specific Risk in Emergency Surgery to Better Inform Perioperative Risk Discussions. J Am Coll Surg 2020. [DOI: 10.1016/j.jamcollsurg.2020.08.357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Hatchimonji JS, Sharoky CE, Kaufman EJ, Ma LW, Garcia Whitlock AE, Smith BP, Holena DN. A Contemporary Analysis of Delayed Diagnoses After Traumatic Injury : The Role of Operative Therapy. Am Surg 2020; 87:384-389. [PMID: 32993352 DOI: 10.1177/0003134820951458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Factors associated with delayed injury diagnosis (DID) have been examined, but incompletely researched. METHODS We evaluated demographics, mechanism, and measures of mental status and injury severity among 10 years' worth of adult trauma patients at our center for association with DID in a multivariable regression model. Descriptions of DID injuries were reviewed to highlight characteristics of these injuries. RESULTS We included 13 509 patients, 89 (0.7%) of whom had a recognized DID. In regression analysis, ISS (OR 1.04 per point, 95% CI 1.02-1.06) and number of injuries (OR 1.08 per injury, 95% CI 1.04-1.11) were associated with DID. Operative patients had twice the odds of DID (OR 2.02, 95% CI 1.18-3.44). The most common category of DID was orthopedic extremity injury (22/89). CONCLUSION DID is associated with injury severity and operative intervention. This suggests that the presence of an injury requiring operation may distract the trauma team from additional injuries.
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Affiliation(s)
- Justin S Hatchimonji
- 6572 Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Catherine E Sharoky
- 6572 Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Elinore J Kaufman
- 14640 Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Lucy W Ma
- 6572 College of Arts and Sciences, University of Pennsylvania, Philadelphia, PA, USA
| | - Anna E Garcia Whitlock
- 6572 Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Brian P Smith
- 14640 Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Daniel N Holena
- 14640 Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Scantling D, Hatchimonji J, Kaufman E, Xiong R, Yang W, Holena DN. Pulmonary complications in trauma: Another bellwether for failure to rescue? Surgery 2020; 169:460-469. [PMID: 32962834 DOI: 10.1016/j.surg.2020.08.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 08/18/2020] [Accepted: 08/19/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Pulmonary complications are the most common adverse event after injury and second greatest cause of failure to rescue (death after pulmonary complications). It is not known whether readily accessible trauma center data can be used to stratify center-level performance for various complications. Performance variation between trauma centers would allow sharing of best practices among otherwise similar hospitals. We hypothesized that high-, average-, and low-performing centers for pulmonary complication and failure to rescue could be identified and that hospital factors associated with success and failure could be discovered. METHODS Pennsylvania state trauma registry data (2007-2015) were abstracted for pulmonary complications. Burns and age <17 were excluded. Multivariable logistic regression models were developed for pulmonary complication and failure to rescue, using demographics, comorbidities, and injuries/physiology. Expected event rates were compared with observed rates to identify outliers. Center-level variables associated with outcomes of interest were taken from the American Hospital Association Annual Survey Database and assessed for inclusion. RESULTS Included in the study were 283,121 patients (male [60%] blunt trauma [92%]). Of these patients, 3% (8,381 of 283,121) developed pulmonary complications (center-level range 0.18%-5.8%). The percentage of failure-to-rescue patients was 13.4% (1,120/8,381, center-level range 0.0%-22.6%). For pulmonary complications, 13 out of 27 centers were high performers (95% CI for O:E ratio <1) and 7 out of 27 were low (95% CI for an O:E ratio >1). For failure-to-rescue patients, 2 out of 27 centers were low performers and the remainder average. There was little concordance between performance for pulmonary complications and failure to rescue. Research programs, large non-teaching hospitals, those with advanced practice providers, and those with health maintenance organizations had reduced failure-to-rescue patients. CONCLUSION Factors associated with complications were distinct from those affecting failure to rescue and center-level success in reducing complications often did not translate into success in preventing death once they occurred. Our data demonstrate that high- and low-performing centers and the factors driving success or failure are identifiable. This work serves as a guide for comparing practices and improving outcomes with readily available data.
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Affiliation(s)
- Dane Scantling
- Division of Traumatology, Critical Care and Emergency Surgery, The University of Pennsylvania, Philadelphia, PA.
| | - Justin Hatchimonji
- Division of Traumatology, Critical Care and Emergency Surgery, The University of Pennsylvania, Philadelphia, PA
| | - Elinore Kaufman
- Division of Traumatology, Critical Care and Emergency Surgery, The University of Pennsylvania, Philadelphia, PA
| | - Ruiying Xiong
- Department of Biostatistics, Epidemiology and Informatics, The University of Pennsylvania, Philadelphia, PA
| | - Wei Yang
- Department of Biostatistics, Epidemiology and Informatics, The University of Pennsylvania, Philadelphia, PA
| | - Daniel N Holena
- Division of Traumatology, Critical Care and Emergency Surgery, The University of Pennsylvania, Philadelphia, PA
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Ma LW, Kaufman EJ, Hatchimonji JS, Xiong R, Scantling DR, Stoecker JB, Holena DN. The Impact of Socially Stigmatized Preexisting Conditions on Outcomes After Injury. J Surg Res 2020; 257:511-518. [PMID: 32916504 DOI: 10.1016/j.jss.2020.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 07/16/2020] [Accepted: 08/02/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Socially stigmatized preexisting conditions (SSPECs), including alcohol use disorder (AUD), drug use disorder (DUD), and major psychiatric illness, may lead to provider minimization of patient symptoms and have been associated with negative outcomes. However, the impact of SSPECs on failure to rescue (FTR) has not been evaluated. We hypothesized that SSPEC patients would have increased probability of complications, mortality, and FTR. MATERIALS AND METHODS We performed a retrospective analysis of the 2015 National Trauma Data Bank, including patients aged ≥18 y and excluding burn victims, patients with Injury Severity Score <9, and non-SSPEC patients with drug or alcohol withdrawal. We defined SSPECs using the National Trauma Data Bank's comorbidity recording codes for AUD, DUD, and major psychiatric illnesses. We built multivariable logistic regression models to determine the relationships between SSPECs and complications, mortality, and FTR. RESULTS We included 365,801 patients (62% male, 76% White, median age 56 y [interquartile range 35-74], median Injury Severity Score 10 [interquartile range 9-17]). After adjusting for patient and injury characteristics, SSPEC patients were more likely to have complications (odds ratio [OR] 1.75, 95% confidence interval [CI] 1.70-1.79), less likely to die (OR 0.43, CI 0.38-0.48), and less likely to have FTR (OR 0.34, CI 0.26-0.43). SSPEC patients had a significantly higher complication rate (12.4% versus 7.2%; P < 0.001). After excluding drug or alcohol withdrawal, the complication rate remained significantly higher for SSPEC patients (9.3% versus 7.2%; P < 0.001). CONCLUSIONS Although SSPEC patients have lower odds of mortality and FTR, they are at higher probability of complications after injury. Further investigation into the causality behind the higher complications despite lower mortality and FTR is warranted.
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Affiliation(s)
- Lucy W Ma
- College of Arts and Sciences, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Elinore J Kaufman
- The Penn Injury Science Center at the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Justin S Hatchimonji
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ruiying Xiong
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Dane R Scantling
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jordan B Stoecker
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Daniel N Holena
- The Penn Injury Science Center at the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Riley JS, Luks VL, de Pina LF, Al Adas Z, Stoecker JB, Jackson BM, Braslow BM, Holena DN. COVID-19 Pandemic Significantly Decreases Acute Surgical Complaints. Am Surg 2020; 86:1492-1500. [PMID: 32862669 DOI: 10.1177/0003134820949506] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND The coronavirus disease 2019 (COVID-19) pandemic significantly reduced elective surgery in the United States, but the impact of COVID-19 on acute surgical complaints and acute care surgery is unknown. STUDY DESIGN A retrospective review was performed of all surgical consults at the Hospital of the University of Pennsylvania in the 30 days prior to and 30 days following confirmation of the first COVID-19 patient at the institution. Consults to all divisions within general surgery were included. RESULTS Total surgical consult volume decreased by 43% in the post-COVID-19 period, with a significant reduction in the median daily consult volume from 14 to 8 (P < .0001). Changes in consult volume by patient location, chief complaint, and surgical division were variable, in aggregate reflecting a disproportionate decrease among less acute surgical complaints. The percentage of consults resulting in surgical intervention remained equal in the 2 periods (31% vs 28%, odds ratio 0.85, 95% CI 0.61-1.21, P = .38) with most but not all operation types decreasing in frequency. The rise in the COVID-19 inpatient census led to increased consultation for vascular access, accommodated at our center by the creation of a new surgical procedures team. CONCLUSION The COVID-19 pandemic significantly altered the landscape of acute surgical complaints at our large academic hospital. An appreciation of these trends may be helpful to other Departments of Surgery around the country as they deploy staff and allocate resources in the COVID-19 era.
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Affiliation(s)
- John S Riley
- 21798 Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Valerie L Luks
- 21798 Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Luis Filipe de Pina
- 21798 Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Ziad Al Adas
- 21798 Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Jordan B Stoecker
- 21798 Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Benjamin M Jackson
- 21798 Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Benjamin M Braslow
- 21798 Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Daniel N Holena
- 21798 Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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Martin ND, Pascual JL, Hirsch J, Holena DN, Kaplan LJ. Excluded but not forgotten: Veterinary emergency care during emergencies and disasters. Am J Disaster Med 2020; 15:25-31. [PMID: 32804383 DOI: 10.5055/ajdm.2020.0352] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Disasters or crises impact humans, pets, and service animals alike. Current preparation at the federal, state, and local level focuses on preserving human life. Hospitals, shelters, and other human care facilities generally make few to no provisions for companion care nor service animal care as part of their disaster management plan. Aban-doned animals have infectious disease, safety and psychologic impact on owners, rescue workers, and those involved in reclamation efforts. Animals working as first responder partners may be injured or exposed to biohazards and require care. DATA SOURCES English language literature available via PubMed as well as lay press publications on emergency care, veterinary care, disaster management, disasters, biohazards, infection, zoonosis, bond-centered care, prepared-ness, bioethics, and public health. No year restrictions were set. CONCLUSIONS Human clinician skills share important overlaps with veterinary clinician skills; similar overlaps occur in medical and surgical emergency care. These commonalities offer the potential to craft-specific and disaster or crisis-deployable skills to care for humans, pets (dogs and cats), service animals (dogs and miniature horses) and first-responder partners (dogs) as part of national disaster healthcare preparedness. Such a platform could leverage the skills and resources of the existing US trauma system to underpin such a program.
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Affiliation(s)
- Niels D Martin
- Program Director, Trauma & Surgical Critical Care Fellowship; Section Chief, Surgical Critical Care; Associate Professor, Surgery, Hospital of the University of Pennsylvania and Presbyterian Medical Center of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jose L Pascual
- Associate Professor, Surgery, Hospital of the University of Pennsylvania and the Presbyterian Medical Center of Philadelphia, Division of Trauma & Surgical Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Julie Hirsch
- Education Coordinator/Medical Liaison, North Penn Animal Hospital, Lansdale, Pennsylvania
| | - Daniel N Holena
- Associate Professor, Surgery, Hospital of the University of Pennsylvania and Presbyterian Medical Center of Philadelphia, Division of Trauma & Surgical Critical Care, Perelman School of Medicine, University of Pennsylvania, Phila-delphia, Pennsylvania
| | - Lewis J Kaplan
- Professor of Surgery, Division of Trauma, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Hatchimonji JS, Kaufman EJ, Young AJ, Smith BP, Xiong R, Reilly PM, Holena DN. High-Performance Trauma Centers in a Single-State Trauma System : Big Saves or Marginal Gains? Am Surg 2020; 86:766-772. [PMID: 32723186 DOI: 10.1177/0003134820934415] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Trauma centers with low observed:expected (O:E) mortality ratios are considered high performers; however, it is unknown whether improvements in this ratio are due to a small number of unexpected survivors with high mortality risk (big saves) or a larger number of unexpected survivors with moderate mortality risk (marginal gains). We hypothesized that the highest-performing centers achieve that status via larger numbers of unexpected survivors with moderate mortality risk. METHODS We calculated O:E ratios for trauma centers in Pennsylvania for 2016 using a risk-adjusted mortality model. We identified high and low performers as centers whose 95% CIs did not cross 1. We visualized differences between these centers by plotting patient-level observed and expected mortality; we then examined differences in a subset of patients with a predicted mortality of ≥10% using the chi-squared test. RESULTS One high performer and 1 low performer were identified. The high performer managed a population with more blunt injuries (97.2% vs 93.6%, P < .001) and a higher median Injury Severity Score (14 vs 11, P < .001). There was no difference in survival between these centers in patients with an expected mortality of <10% (98.0% vs 96.7%, P = .11) or ≥70% (23.5% vs 10.8%, P = .22), but there was a difference in the subset with an expected mortality of ≥10% (77.5% vs 43.1%, P < .001). CONCLUSIONS Though patients with very low predicted mortality do equally well in high-performing and low-performing centers, the fact that performance seems determined by outcomes of patients with moderate predicted mortality favors a "marginal gains" theory.
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Affiliation(s)
- Justin S Hatchimonji
- 6572 Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, PA, USA
| | - Elinore J Kaufman
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, PA, USA
| | - Andrew J Young
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, PA, USA
| | - Brian P Smith
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, PA, USA
| | - Ruiying Xiong
- Department of General Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, PA, USA
| | - Patrick M Reilly
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, PA, USA
| | - Daniel N Holena
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, PA, USA.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, PA, USA
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