Prospective derivation and validation of a NECROtizing Soft tissue InfectionS (NECROSIS) score: An EAST multicenter trial.

BACKGROUND: Although several risk indices have been developed to aid in the diagnosis of NSTIs, these instruments suffer from varying levels of reproducibility and failure to incorporate key clinical variables in model development. The objective of this study was to derive and validate a clinical risk index score - NECROSIS - for identifying NSTIs in emergency general surgery (EGS) patients being evaluated for severe skin and soft tissue infections. METHODS: We performed a prospective study across 16 sites in the US of adult EGS patients with suspected NSTIs over a 30-month period. Variables analyzed included demographics, admission vitals and labs, physical exam, radiographic, and operative findings. The main outcome measure was the presence of NSTI diagnosed clinically at the time of surgery. Multivariate analysis was performed to identify independent predictors for the presence of NSTI using the Hosmer-Lemeshow test and the Akaike information criteria. RESULTS: Of 362 patients, 297 (82%) were diagnosed with a NSTI. Overall mortality was 12.3%. Multivariate analysis identified 3 independent predictors for NSTI: systolic blood pressure ≤ 120 mmHg, violaceous skin, and WBC ≥15 (x103/uL). Multivariate modelling demonstrated Hosmer-Lemeshow goodness of fit (p = 0.9) with a c-statistic for the prediction curve of 0.75. Test characteristics of the NECROSIS score were similar between the derivation and validation cohorts. CONCLUSION: NECROSIS is a simple and potentially useful clinical index score for identifying at-risk EGS patients with NSTIs. Future validation studies are warranted. LEVEL OF EVIDENCE: Diagnostic Tests or Criteria, Level III.

Prehospital and emergency department pediatric readiness for injured children: A statement from the American College of Surgeons Committee on Trauma Emergency Medical Services Committee.

ABSTRACT: Injury is the leading cause of death in children older than 1 year, and children make up 22% of the population. Pediatric readiness (PR) of the nation's emergency departments and state trauma and emergency medical services (EMS) systems is conceptually important and vital to mitigate mortality and morbidity in this population. The extension of PR to the trauma community has become a focused area for training, staffing, education, and equipment at all levels of trauma center designation, and there is evidence that a higher level of emergency department PR is independently associated with long-term survival among injured children. Although less well studied, there is an associated need for EMS PR, which is relevant to the injured child who needs assessment, treatment, triage, and transport to a trauma center. We outline a blueprint along with recommendations for incorporating PR into trauma system development in this opinion from the EMS Committee of the American College of Surgeons Committee on Trauma. These recommendations are particularly pertinent in the rural and underserved areas of the United States but are directed toward all levels of professionals who care for an injured child along the trauma continuum of care.

Value in acute care surgery, part 2: Defining and measuring quality outcomes.

ABSTRACT: The prior article in this series delved into measuring cost in acute care surgery, and this subsequent work explains in detail how quality is measured. Specifically, objective quality is based on outcome measures, both from administrative and clinical registry databases from a multitude of sources. Risk stratification is key in comparing similar populations across diseases and procedures. Importantly, a move toward focusing on subjective outcomes like patient-reported outcomes measures and financial well-being are vital to evolving surgical quality measures for the 21st century.

Data resources for evaluating the economic and financial consequences of surgical care in the United States.

ABSTRACT: Evaluating the relationship between health care costs and quality is paramount in the current health care economic climate, as an understanding of value is needed to drive policy decisions. While many policy analyses are focused on the larger health care system, there is a pressing need for surgically focused economic analyses. Surgical care is costly, and innovative technology is constantly introduced into the operating room, and surgical care impacts patients' short- and long-term physical and economic well-being. Unfortunately, significant knowledge gaps exist regarding the relationship between cost, value, and economic impact of surgical interventions. Despite the plethora of health care data available in the forms of claims databases, discharge databases, and national surveys, no single source of data contains all the information needed for every policy-relevant analysis of surgical care. For this reason, it is important to understand which data are available and what can be accomplished with each of the data sets. In this article, we provide an overview of databases commonly used in surgical health services research. We focus our review on the following five categories of data: governmental claims databases, commercial claims databases, hospital-based clinical databases, state and national discharge databases, and national surveys. For each, we present a summary of the database sampling frame, clinically relevant variables, variables relevant to economic analyses, strengths, weaknesses, and examples of surgically relevant analyses. This review is intended to improve understanding of the current landscape of data available, as well as stimulate novel analyses among surgical populations. Ongoing debates over national health policy reforms may shape the delivery of surgical care for decades to come. Appropriate use of available data resources can improve our understanding of the economic impact of surgical care on our health care system and our patients. LEVEL OF EVIDENCE: Regular Review, Level V.

The Obesity Paradox in Emergency General Surgery Patients.

BACKGROUND: Operative management of emergency general surgery (EGS) diagnoses involves a range of procedures which can carry high morbidity and mortality. Little is known about the impact of obesity on patient outcomes. The aim of this study was to examine the association between body mass index (BMI) >30 kg/m2 and mortality for EGS patients. We hypothesized that obese patients would have increased mortality rates. METHODS: A regional integrated health system EGS registry derived from The American Association for the Surgery of Trauma EGS ICD-9 codes was analyzed from January 2013 to October 2015. Patients were stratified into BMI categories based on WHO classifications. The primary outcome was 30-day mortality. Longer-term mortality with linkage to the Social Security Death Index was also examined. Univariate and multivariable analyses were performed. RESULTS: A total of 60 604 encounters were identified and 7183 (11.9%) underwent operative intervention. Patient characteristics include 53% women, mean age 58.2 ± 18.7 years, 64.2% >BMI 30 kg/m2, 30.2% with chronic obstructive pulmonary disease, 19% with congestive heart failure, and 31.1% with diabetes. The most common procedure was laparoscopic cholecystectomy (36.4%). Overall, 90-day mortality was 10.9%. In multivariable analysis, all classes of obesity were protective against mortality compared to normal BMI. Underweight patients had increased risk of inpatient (OR = 1.9, CI = 1.7-2.3), 30-day (OR = 1.9, CI = 1.7-2.1), 90-day (OR = 1.8, CI 1.6-2.0), 1-year (OR = 1.8, CI = 1.7-2.0), and 3-year mortality (OR = 1.7, CI = 1.6-1.9). CONCLUSIONS: When stratified by BMI, underweight EGS patients have the highest odds of death. Paradoxically, obesity appears protective against death, even when controlling for potentially confounding factors. Increased rates of nonoperative management in the obese population may impact these findings.

Maximizing the Calm before the Storm: Tiered Surgical Response Plan for Novel Coronavirus (COVID-19).

The novel coronavirus (COVID-19) was first diagnosed in Wuhan, China in December 2019 and has now spread throughout the world, being verified by the World Health Organization as a pandemic on March 11. This had led to the calling of a national emergency on March 13 in the US. Many hospitals, healthcare networks, and specifically, departments of surgery, are asking the same questions about how to cope and plan for surge capacity, personnel attrition, novel infrastructure utilization, and resource exhaustion. Herein, we present a tiered plan for surgical department planning based on incident command levels. This includes acute care surgeon deployment (given their critical care training and vertically integrated position in the hospital), recommended infrastructure and transfer utilization, triage principles, and faculty, resident, and advanced care practitioner deployment.

"Death Knell" for Prophylactic Vena Cava Filters? A 20-Year Experience with a Venous Thromboembolism Guideline.

The role of prophylactic vena cava filters (pVCFs) in trauma patients remains controversial. After 20 years of data collection and experience, we reviewed our venous thromboembolism guideline for the efficacy of pVCFs in preventing pulmonary embolism (PE). A retrospective cohort study was performed using our Level I trauma center registry from January 1997 thru December 2016. This population was then divided by the presence of pVCFs. Univariate analysis was performed comparing the incidence of PEs, deep vein thrombosis, and mortality between those with and without a pVCF. There were 35,658 patients identified, of whom 2 per cent (n = 847) received pVCFs. The PE rate was 0.4 per cent in both groups. The deep vein thrombosis rate for pVCFs was 3.9 per cent compared with 0.6 per cent in the no-VCF group (P < 0.0001). Given that there was no difference in the rates of PEs between the cohorts, the subset of patients with a PE were analyzed by their risk factors. Only ventilator days > 3 were associated with a higher risk in the no-pVCF group (0.2 vs 1.5%, P = 0.033). pVCFs did not confer benefit reducing PE rate. In addition, despite their intended purpose, pVCFs cannot eliminate PEs in high-risk trauma patients, suggesting a lack of utility for prophylaxis in this population.

Defining Dogma: Quantifying Crystalloid Hemodilution in a Prospective Randomized Control Trial with Blood Donation as a Model for Hemorrhage.

BACKGROUND: The concept of hemodilution after blood loss and crystalloid infusion is a surgical maxim that remains unproven in humans. We sought to quantify the effect of hemodilution after crystalloid administration in voluntary blood donors as a model for acute hemorrhage. STUDY DESIGN: A prospective, randomized control trial was conducted in conjunction with community blood drives. Donors were randomized to receive no IV fluid (noIVF), 2 liters of normal saline (NS), or 2 liters lactated Ringer's (LR) after blood donation. Blood samples were taken before donation of 500 mL of blood, immediately after donation, and after IV fluid administration. Hemoglobin (Hgb) was measured at each time point. Hemoglobin measurements between time points were compared between groups using standard statistical tests and the Bonferroni correction for multiple comparisons. Statistical significance was set at p ≤ 0.0167. RESULTS: Of 165 patients consented, 157 patients completed the study. Average pre-donation Hgb was 14.3 g/dL. There was no difference in the mean Hgb levels after blood donation between the 3 groups (p > 0.05). Compared with the control group, there was a significant drop in Hgb in the crystalloid infused groups from the post-donation level to post-resuscitation (13.2 vs 12.1 vs 12.2 g/dL, p < 0.0001). A formula was created to predict hemoglobin levels from a given estimated blood loss (EBL) and volume replacement (VR): Hemodilution Hgb = (mean pre-donation Hgb - hemorrhage Hgb drop - equilibration hemoglobin drop - resuscitation Hgb drop) = Mean pre-donation Hgb - [(EBL/TBV)*l] - [(EBL/TBV)*h] - [(VR/TBV)*r], l = 5.111g/dL = blood loss coefficient, h = 6.722 g/dL = equilibration coefficient, r = 2.617g/dL = resuscitation coefficient. CONCLUSIONS: This study proves the concept of hemodilution and derived a mathematical relationship between blood loss and resuscitation. These data may help to estimate response of hemoglobin levels to blood loss and fluid resuscitation in clinical practice.

Evaluation of 8.0-cm needle at the fourth anterior axillary line for needle chest decompression of tension pneumothorax.

BACKGROUND: Five-centimeter needles at the second intercostal space midclavicular line (2MCL) have high failure rates for decompression of tension pneumothorax. This study evaluates 8-cm needles directed at the fourth intercostal space anterior axillary line (4AAL). METHODS: Retrospective radiographic analysis of 100 consecutive trauma patients 18 years or older from January to September 2011. Measurements of chest wall thickness (CWT) and depth to vital structure (DVS) were obtained at 2MCL and 4AAL. 4AAL measurements were taken based on two angles: closest vital structure and perpendicular to the chest wall. Primary outcome measures were radiographic decompression (RD) (defined as CWT < 80 mm) and radiographic noninjury (RNI) (DVS > 80 mm) of 8-cm needles at 4AAL. Secondary outcome measures are effect of angle of entry on RNI at 4AAL, RD and RNI of 8-cm needles at 2MCL, and comparison of 5-cm needles with 8-cm needles at both locations. RESULTS: Eighty-four percent of the patients were male, with mean Injury Severity Score (ISS) of 17.7 (range, 1.0-66.0) and body mass index of 26.8 (16.5-48.4). Mean CWT at 4AAL ranged from 37.6 mm to 39.9 mm, significantly thinner than mean CWT at 2MCL (43.3-46.7 mm). Eight-centimeter needle RD was more than 96% at both 4AAL and 2MCL. Five-centimeter RD ranged from 66% to 81% at all sites. Mean DVS at 4AAL ranged from 91.8 mm to 128.0 mm. RNI at all sites was more than 91% except at left 4AAL, when taken to the closest vital structure (mean DVS, 91.8 mm), with 68% RNI. Perpendicular entry increased DVS to 109.4 mm and subsequent RNI to 91%. Five-centimeter RNI at all sites was more than 99%. CONCLUSION: CWT at 4AAL is significantly thinner than 2MCL. Based on radiographic measurements, 8-cm catheters have a higher chance of pleural decompression when compared with 5-cm catheters. Steeper angle of entry at 4AAL improves 8-cm noninjury rates to more than 91%. LEVEL OF EVIDENCE: Therapeutic/care management study, level IV.