Initial Hemorrhage Control Procedure for Splenic Injuries May Affect Risk of Venous Thromboembolism.

INTRODUCTION: Venous thromboembolism (VTE) continues to be a major cause of morbidity in trauma. It is unclear whether the type of hemorrhage control procedure (i.e., splenectomy versus angioembolization) is associated with an increased risk of VTE. We hypothesize that hemodynamically stable patients undergoing angioembolization for blunt high-grade splenic injuries have lower rates of VTE compared to those undergoing splenectomy. METHODS: The American College of Surgeons Trauma Quality Program dataset from 2017 to 2019 was queried to identify all patients with American Association for the Surgery of Trauma grade 3-5 blunt splenic injuries. Outcomes including VTE rates were compared between those who were managed with splenectomy versus angioembolization. Propensity score matching (1:1) was performed adjusting for age, sex, initial vital signs, Injury Severity Score, and splenic injury grade. RESULTS: The analysis included 4698 matched patients (splenectomy [n = 2349] and angioembolization [n = 2349]). The median (interquartile range) age was 41 (27-58) years and 69% were male. Patients were well matched between groups. Angioembolization was associated with significantly lower VTE than splenectomy (2.2% versus 3.4%, P = 0.010) despite less use of VTE chemoprophylaxis (70% versus 80%, P < 0.001), as well as a relative delay in initiation of chemoprophylaxis (44 h versus 33 h, P < 0.001). Hospital and intensive care unit length of stay and mortality were also significantly lower in the angioembolization group. CONCLUSIONS: Angioembolization is associated with a significantly lower incidence of VTE than splenectomy. Thus, angioembolization should be considered for initial management of hemodynamically stable patients with high-grade blunt splenic injuries in whom laparotomy is not otherwise indicated.

A comparison of outcomes including bile duct injury of subtotal cholecystectomy versus open total cholecystectomy as bailout procedures for severe cholecystitis: A multicenter real-world study.

BACKGROUND: Dense inflammation obscuring the hepatocystic anatomy can hinder the ability to perform a safe standard laparoscopic cholecystectomy in severe cholecystitis, requiring use of a bailout procedure. We compared clinical outcomes of laparoscopic and open subtotal cholecystectomy against the traditional standard of open total cholecystectomy to identify the optimal bailout strategy for the difficult gallbladder. METHODS: A multicenter, multinational retrospective cohort study of patients who underwent bailout procedures for severe cholecystitis. Procedures were compared using one-way analysis of variance/Kruskal-Wallis tests and χ2 tests with multiple pairwise comparisons, maintaining a family-wise error rate at 0.05. Multiple multivariate linear/logistical regression models were created. RESULTS: In 11 centers, 727 bailout procedures were conducted: 317 laparoscopic subtotal cholecystectomies, 172 open subtotal cholecystectomies, and 238 open cholecystectomies. Baseline characteristics were similar among subgroups. Bile leak was common in laparoscopic and open fenestrating subtotal cholecystectomies, with increased intraoperative drain placements and postoperative endoscopic retrograde cholangiopancreatography(P < .05). In contrast, intraoperative bleeding (odds ratio = 3.71 [1.9, 7.22]), surgical site infection (odds ratio = 2.41 [1.09, 5.3]), intensive care unit admission (odds ratio = 2.65 [1.51, 4.63]), and length of stay (Δ = 2 days, P < .001) were higher in open procedures. Reoperation rates were higher for open reconstituting subtotal cholecystectomies (odds ratio = 3.43 [1.03, 11.44]) than other subtypes. The overall rate of bile duct injury was 1.1% and was not statistically different between groups. Laparoscopic subtotal cholecystectomy had a bile duct injury rate of 0.63%. CONCLUSION: Laparoscopic subtotal cholecystectomy is a feasible surgical bailout procedure in cases of severe cholecystitis where standard laparoscopic cholecystectomy may carry undue risk of bile duct injury. Open cholecystectomy remains a reasonable option.

The impact of post-operative enteral nutrition on duodenal injury outcomes: A post hoc analysis of an EAST multicenter trial.

BACKGROUND: Leak following surgical repair of traumatic duodenal injuries results in prolonged hospitalization and oftentimes nil per os(NPO) treatment. Parenteral nutrition(PN) has known morbidity; however, duodenal leak(DL) patients often have complex injuries and hospital courses resulting in barriers to enteral nutrition(EN). We hypothesized EN alone would be associated with 1)shorter duration until leak closure and 2)less infectious complications and shorter hospital length of stay(HLOS) compared to PN. METHODS: This was a post-hoc analysis of a retrospective, multicenter study from 35 Level-1 trauma centers, including patients >14 years-old who underwent surgery for duodenal injuries(1/2010-12/2020) and endured post-operative DL. The study compared nutrition strategies: EN vs PN vs EN + PN using Chi-Square and Kruskal-Wallis tests; if significance was found pairwise comparison or Dunn's test were performed. RESULTS: There were 113 patients with DL: 43 EN, 22 PN, and 48 EN + PN. Patients were young(median age 28 years-old) males(83.2%) with penetrating injuries(81.4%). There was no difference in injury severity or critical illness among the groups, however there were more pancreatic injuries among PN groups. EN patients had less days NPO compared to both PN groups(12 days[IQR23] vs 40[54] vs 33[32],p = <0.001). Time until leak closure was less in EN patients when comparing the three groups(7 days[IQR14.5] vs 15[20.5] vs 25.5[55.8],p = 0.008). EN patients had less intra-abdominal abscesses, bacteremia, and days with drains than the PN groups(all p < 0.05). HLOS was shorter among EN patients vs both PN groups(27 days[24] vs 44[62] vs 45[31],p = 0.001). When controlling for predictors of leak, regression analysis demonstrated EN was associated with shorter HLOS(ß -24.9, 95%CI -39.0 to -10.7,p < 0.001). CONCLUSION: EN was associated with a shorter duration until leak closure, less infectious complications, and shorter length of stay. Contrary to some conventional thought, PN was not associated with decreased time until leak closure. We therefore suggest EN should be the preferred choice of nutrition in patients with duodenal leaks whenever feasible. LEVEL OF EVIDENCE: IV.

An Executive Summary of the National Trauma Research Action Plan (NTRAP).

ABSTRACT: The National Trauma Research Action Plan (NTRAP) project successfully engaged multidisciplinary experts to define opportunities to advance trauma research and has fulfilled the recommendations related to trauma research from the National Academies of Sciences, Engineering and Medicine (NASEM) report. These panels identified more than 4,800 gaps in our knowledge regarding injury prevention and the optimal care of injured patients and laid out a priority framework and tools to support researchers to advance this field. Trauma research funding agencies and researchers can use this executive summary and supporting manuscripts to strategically address and close the highest priority research gaps. Given that this is the most significant public health threat facing our children, young adults, and military service personnel, we must do better in prioritizing these research projects for funding and providing grant support to advance this work. Through the Coalition for National Trauma Research (CNTR), the trauma community is committed to a coordinated, collaborative approach to address these critical knowledge gaps and ultimately reduce the burden of morbidity and mortality faced by our patients.

Prehospital Time Following Traumatic Injury Is Independently Associated With the Need for In-Hospital Blood and Early Mortality for Specific Injury Types.

OBJECTIVE: Treating traumatic hemorrhage is time sensitive. Prehospital care and transport modes (eg, helicopter and ground) may influence in-hospital events. We hypothesized that prehospital time (on-scene time [OST] and total prehospital time [TPT]) and transport mode are associated with same-day transfusion and mortality. Furthermore, we sought to identify regions of anatomic injury that modify the relationship between prehospital time and outcomes in strata corresponding to transport types. METHODS: We obtained prehospital, in-hospital, and trauma registry data from an 8-center cohort of adult nonburn trauma patients from 2017 to 2022 directly transported from the scene to the hospital and having an Injury Severity Score (ISS) > 9 for the Task Order 1 project of the Linking Investigators in Trauma and Emergency Services research network. We excluded patients missing prehospital times, patients < 18 years of age, patients from interfacility transfers, and recipients of prehospital blood. Our same-day outcomes were in-hospital transfusions within 4 hours and 24-hour mortality. Each outcome was adjusted using multivariable logistic regression for covariates of prehospital phases (OST and TPT), mode of transport (helicopter and ground), age, sex, ISS, Glasgow Coma Scale motor subscale score < 6, and field hypotension (systolic blood pressure < 90 mm Hg). We evaluated the association of prehospital time on outcomes for scene missions by transport mode across severe injury patterns defined by Abbreviated Injury Scale > 2 body regions. RESULTS: Of 78,198 subjects, 34,504 were eligible for the study with a mean age of 47.6 ± 20.3 years, ISS of 18 ± 11, OST of 15.9 ± 9.5 minutes, and TPT of 48.7 ± 20.3 minutes. Adjusted for injury severity and demographic factors, transport type significantly modified the relationship between prehospital time and outcomes. The association of OST and TPT with the odds of 4-hour transfusion was absent for the ground emergency medical services (GEMS) cohort and present for the helicopter emergency medical services (HEMS) ambulance cohort, whereas these times were associated with decreased 24-hour mortality for both transport types. When stratifying by injury to most anatomic regions, OST and TPT were associated with a decreased need for 4-hour transfusions in the GEMS cohort. However, OST was associated with increased early transfusion only among patients with severe injuries of the thorax, and this association persisted after adjusting additionally for injury type (odds ratio [OR] = 1.03; 95% confidence interval [CI], 1.00-1.05; P = .02). The presence of polytrauma supported an association between prehospital time and decreased 24-hour mortality for the GEMS cohort (OST: OR = 0.97; 95% CI, 0.95-0.99; P < .01; TPT: OR = 0.99; 95% CI, 0.98-0.99; P = .02), whereas no injuries showed significant association of helicopter prehospital time on mortality after adjustment. CONCLUSION: We determined that transport type affects the relationship between prehospital time and hospital outcomes (4-hour transfusion: positive relationship for HEMS and negative for GEMS, 24-hour mortality: negative for both transport types). Furthermore, we identified regions of anatomic injury that modify the relationship between prehospital time and outcomes in strata corresponding to transport types. Of these regions, most notable were severe isolated injuries to the thorax that supported a positive relationship between HEMS OST and 4-hour transfusions and polytrauma that showed a negative relationship between GEMS OST or TPT and 24-hour mortality after adjustment.

Effects of gender on work-life balance satisfaction among trauma surgeons: A survey study.

BACKGROUND: Physician burnout rates are rising. Because dissatisfaction with work-life balance (WLB) is associated with burnout, improving this balance is a key solution. This cross-sectional survey study aims to evaluate factors associated with WLB in trauma surgeons, stratified by gender. METHODS: This is a secondary analysis, studying gender, of a AAST survey evaluating predictors of WLB in trauma surgeons. Survey topics include demographics, clinical practice, family, lifestyle, and emotional support. Subgroups were analyzed independently; primary outcome was WLB satisfaction. RESULTS: 292 AAST members completed the survey. Responses were stratified by gender (29% females, 71% males). Independent predictors of WLB satisfaction are: Females: more awake hours at home, having a job well-suited for them, better about meeting deadlines. Males: comfortable declining new tasks, fair compensation, healthy diet, workplace emotional support. CONCLUSION: Factors associated with WLB satisfaction in trauma surgeons are different based on gender. This information may help trauma surgeons mitigate burnout.

Outcomes among trauma patients with duodenal leak following primary versus complex repair of duodenal injuries: An Eastern Association for the Surgery of Trauma multicenter trial.

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 are sparse, and its impact on duodenal leak outcomes is nonexistent. We hypothesized that 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 years with operative, traumatic duodenal injuries (January 2010 to December 2020). The study sample compared duodenal operative repair strategy: PRA versus CRAM (any repair plus pyloric exclusion, gastrojejunostomy, triple tube drainage, duodenectomy). RESULTS: The sample (N = 861) was primarily young (33 years) men (84%) with penetrating injuries (77%); 523 underwent PRA and 338 underwent CRAM. Complex repairs with adjunctive measures 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 interventional radiology drains, prolonged nothing by mouth and length of stay, 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, nothing by mouth duration, need for interventional radiology drainage, hospital length of stay, or mortality between PRA leak versus CRAM leak patients (all p > 0.05). Furthermore, CRAM leaks had longer antibiotic duration, more gastrointestinal complications, and longer duration until leak resolution (all p < 0.05). Primary repair alone was associated with 60% lower odds of leak, whereas injury grades II to IV, damage control, and body mass index had higher odds of leak (all p < 0.05). There were no leaks among patients with grades IV and V injuries repaired by PRA. CONCLUSION: Complex repairs with adjunctive measures did not prevent duodenal leaks and, moreover, did not reduce adverse sequelae when leaks did occur. Our results suggest that CRAM is not a protective operative duodenal repair strategy, and PRA should be pursued for all injury grades when feasible. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

History of Equity, Diversity, and Inclusion in Trauma Surgery: for Our Patients, for Our Profession, and for Ourselves.

Purpose of Review: Disparities exist in outcome after injury, particularly related to race, ethnicity, socioeconomics, geography, and age. The mechanisms for this outcome disparity continue to be investigated. As trauma care providers, we are challenged to be mindful of and mitigate the impact of these disparities so that all patients realize the same opportunities for recovery. As surgeons, we also have varied professional experiences and opportunities for achievement and advancement depending upon our gender, ethnicity, race, religion, and sexual orientation. Even within a profession associated with relative affluence, socioeconomic status conveys different professional opportunities for surgeons. Recent Findings: Fortunately, the profession of trauma surgery has undergone significant progress in raising awareness of patient and professional inequity among trauma patients and surgeons and has implemented systematic changes to diminish these inequities. Herein we will discuss the history of equity and inclusion in trauma surgery as it has affected our patients, our profession, and our individual selves. Summary: Our goal is to provide a historical context, a status report, and a list of key initiatives or objectives on which all of us must focus. In doing so, the best possible clinical outcomes can be achieved for patients and the best professional and personal "outcomes" can be achieved for practicing and future trauma surgeons.

Turning value into action: Healthcare workers using digital media advocacy to drive change.

BACKGROUND: The standard method of sharing information in academia is the scientific journal. Yet health advocacy requires alternative methods to reach key stakeholders to drive change. The purpose of this study was to analyze the impact of social media and public narrative for advocacy in matters of firearm-related injury and death. STUDY DESIGN: The movement This Is Our Lane was evaluated through the #ThisIsOurLane and #ThisIsMyLane hashtags. Sources were assessed from November 2018 through March 2019. Analyses specifically examined message volume, time course, global engagement, and content across Twitter, scientific literature, and mass media. Twitter data were analyzed via Symplur Signals. Scientific literature reviews were performed using PubMed, EMBASE, Web of Science, and Google Scholar. Mass media was compiled using Access World News/Newsbank, Newspaper Source, and Google. RESULTS: A total of 507,813 tweets were shared using #ThisIsOurLane, #ThisIsMyLane, or both (co-occurrence 21-39%). Fifteen scientific items and n = 358 mass media publications were published during the study period; the latter included articles, blogs, television interviews, petitions, press releases, and audio interviews/podcasts. Peak messaging appeared first on Twitter on November 10th, followed by mass media on November 12th and 20th, and scientific publications during December. CONCLUSIONS: Social media enables clinicians to quickly disseminate information about a complex public health issue like firearms to the mainstream media, scientific community, and general public alike. Humanized data resonates with people and has the ability to transcend the barriers of language, culture, and geography. Showing society the reality of caring for firearm-related injuries through healthcare worker stories via digital media appears to be effective in shaping the public agenda and influencing real-world events.

Modifiable factors to improve work-life balance for trauma surgeons.

INTRODUCTION: A balance between work and life outside of work can be difficult for practicing physicians to achieve, especially for trauma surgeons. Work-life balance (WLB) has been associated with burnout and career changes. The specific aim of this study was to investigate factors associated with WLB for trauma surgeons. We hypothesized that trauma surgeons are dissatisfied with their WLB, and there are modifiable factors that can be adjusted to improve and maintain WLB. METHODS: Survey study of AAST members including detailed questions regarding demographics, clinical practice, family, lifestyle, and emotional support. Primary outcome was WLB, while the secondary outcome was surgeon burnout. RESULTS: A total of 1,383 American Association for the Surgery of Trauma members received an email with the survey, and 291 (21%) completed the survey. There was a total of 125 members (43%) satisfied with their WLB, and 166 (57%) were not. Factors independently associated with satisfying WLB included hobbies (2.3 [1.1-4.7], p = 0.03), healthy diet (2.6 [1.2-4.4], p = 0.02), exercise (2.6 [1.3-5.1], p = 0.006), vacation weeks off (1.3 [1.0-1.6], p = 0.02), and fair compensation (2.6 [1.3-5.3], p = 0.008). Conversely, factors independently associated with a poor WLB included being midcareer (0.3 [0.2-0.7], p = 0.002), more work hours (0.4 [0.2-0.7], p = 0.006), fewer awake hours at home (0.2 [0.1-0.6], p = 0.002), and feeling that there is a better job (0.4 [0.2-0.9], p = 0.02]. Risk factors for burnout were the same as those for poor WLB. CONCLUSION: Only 43% of trauma surgeons surveyed were satisfied with their WLB, and 61% reported burnout. Modifiable factors independently associated with a satisfying WLB were related to lifestyle and fair compensation. Factors independently associated with poor WLB and suffering burnout were being midcareer, increased hours at work, decreased awake hours at home, and feeling that there was a better job for yourself. Many factors associated with trauma surgeon WLB are modifiable. Trauma surgeons, as well as trauma leaders, should focus on these modifiable factors to optimize WLB and minimize burnout. LEVEL OF EVIDENCE: Care management, Level III.

A statistically rigorous deep neural network approach to predict mortality in trauma patients admitted to the intensive care unit.

BACKGROUND: Trauma patients admitted to critical care are at high risk of mortality because of their injuries. Our aim was to develop a machine learning-based model to predict mortality using Fahad-Liaqat-Ahmad Intensive Machine (FLAIM) framework. We hypothesized machine learning could be applied to critically ill patients and would outperform currently used mortality scores. METHODS: The current Deep-FLAIM model evaluates the statistically significant risk factors and then supply these risk factors to deep neural network to predict mortality in trauma patients admitted to the intensive care unit (ICU). We analyzed adult patients (≥18 years) admitted to the trauma ICU in the publicly available database Medical Information Mart for Intensive Care III version 1.4. The first phase selection of risk factor was done using Cox-regression univariate and multivariate analyses. In the second phase, we applied deep neural network and other traditional machine learning models like Linear Discriminant Analysis, Gaussian Naïve Bayes, Decision Tree Model, and k-nearest neighbor models. RESULTS: We identified a total of 3,041 trauma patients admitted to the trauma surgery ICU. We observed that several clinical and laboratory-based variables were statistically significant for both univariate and multivariate analyses while others were not. With most significant being serum anion gap (hazard ratio [HR], 2.46; 95% confidence interval [CI], 1.94-3.11), sodium (HR, 2.11; 95% CI, 1.61-2.77), and chloride (HR, 2.11; 95% CI, 1.69-2.64) abnormalities on laboratories, while clinical variables included the diagnosis of sepsis (HR, 2.03; 95% CI, 1.23-3.37), Quick Sequential Organ Failure Assessment score (HR, 1.52; 95% CI, 1.32-3.76). And Systemic Inflammatory Response Syndrome criteria (HR. 1.41; 95% CI, 1.24-1.26). After we used these clinically significant variables and applied various machine learning models to the data, we found out that our proposed DNN outperformed all the other methods with test set accuracy of 92.25%, sensitivity of 79.13%, and specificity of 94.16%; positive predictive value, 66.42%; negative predictive value, 96.87%; and area under the curve of the receiver-operator curve of 0.91 (1.45-1.29). CONCLUSION: Our novel Deep-FLAIM model outperformed all other machine learning models. The model is easy to implement, user friendly and with high accuracy. LEVEL OF EVIDENCE: Prognostic study, level II.

Perioperative complications of complex abdominal wall reconstruction with biologic mesh: A pooled retrospective cohort analysis of 220 patients from two academic centers.

BACKGROUND: Perioperative outcomes in patients who undergo complex abdominal wall reconstruction (CAWR) may be associated with severe complications, mainly when these procedures are done urgently or emergently. This study aims to identify perioperative predictors of outcomes after CAWR with biologic mesh (BM). MATERIALS AND METHODS: In a retrospective study, perioperative complications (length of hospital stay, ventilator support, surgical site infection, need for wound VAC, reoperation, total complications, and mortality), were analyzed in all patients who underwent open CAWR with BM over six years in two academic centers. Furthermore, we examined the effect of cardiac disease, BMI, diabetes, COPD, case mixed index, hernia size, wound classification, mesh technique, the setting of surgery, on perioperative complications. Multivariable linear and logistic regression analyses were performed. RESULTS: There were 220 patients: 134 patients from center A and 86 patients from center W Mean age was 54.9 ± 14.8 years, 47.7% were females, 33.8% of the patients had BMI ≥30 kg/m2 and median hospital length of stay was 7 days. Center W patients had increased need for mechanical ventilation (10.5% vs. 3%, p = 0.02) and higher need for wound VAC (19.8% vs. 6.7%, p = 0.003). On multivariable linear regression, independent patient predictors of increased hospital length of stay (HLO) were: urgent/emergent surgery (ß 6.93, 95% CI 1.65-12.22, p = 0.01), cardiac disease (ß 7.84, 95% CI 1.23-14.46, p = 0.02) and epigastric defect (ß 13.68, 95% CI 0.29-27.06, p = 0.045). Addition-ally, urgent/emergent setting (OR 3.06, 95% CI 1.69-5.55, p < 0.001) and cardiac disease (OR 2.15, 95% CI 1.03-4.50, p = 0.042) were independently associated with increased odds for perioperative complications. CONCLUSIONS: Perioperative complications of patients undergoing CAWR are considerable and depend on defect complexities, the setting of surgery, comorbidities, wound classification, procedural factors, and case-mix index. Prospective studies on perioperative complications are needed.

Prolonged operating room time in emergency general surgery is associated with venous thromboembolic complications.

BACKGROUND: We evaluated the association between operating room time and developing a deep vein thrombosis (DVT) or pulmonary embolus (PE) after emergency general surgery (EGS). METHODS: We reviewed six common EGS procedures in the 2013-2015 NSQIP dataset. After tabulating their incidence of postoperative VTE events, we calculated predictors of developing a VTE using adjusted multivariate logistic regressions. RESULTS: Of 108,954 EGS patients, 1,366 patients (1.3%) developed a VTE postoperatively. The median time to diagnosis was 9 days [5-16] for DVTs and 8 days [5-16] for PEs. Operating room time of 100 min or more was associated with increased risk of developing a DVT (OR 1.30 [1.12-2.21]) and PE (OR:1.25 [1.11-2.43]) with a 7% and 5% respective increase for every 10 min increase after the 100 min. Other independent predictors of VTE complications were older age, and history of cancer, and emergent colectomies on procedure-level analysis. CONCLUSION: Prolonged operating room time is independently associated with increased risk of developing VTE complications after an EGS procedure. Most of the VTE complications were delayed in presentation.

Unplanned readmission after traumatic injury: A long-term nationwide analysis.

BACKGROUND: Long-term outcomes after trauma admissions remain understudied. We analyzed the characteristics of inpatient readmissions within 6 months of an index hospitalization for traumatic injury. METHODS: Using the 2010 to 2015 Nationwide Readmissions Database, which captures data from up to 27 US states, we identified patients at least 15 years old admitted to a hospital through an emergency department for blunt trauma, penetrating trauma, or burns. Exclusion criteria included hospital transfers, patients who died during their index hospitalizations, and hospitals with fewer than 100 trauma patients annually. After calculating the incidences of all-cause, unplanned inpatient readmissions within 1 month, 3 months, and 6 months, we used multivariable logistic regression models to identify predictors of readmissions. Analyses adjusted for patient, clinical, and hospital factors. RESULTS: Among 2,763,890 trauma patients, the majority had blunt injuries (92.5%), followed by penetrating injuries (6.2%) and burns (1.5%). Overall, rates of inpatient readmissions were 11.1% within 1 month, 21.6% within 6 months, and 29.8% within 6 months, with limited variability by year. After adjustment, the following were associated with all-cause 6 months inpatient readmissions: male sex (adjusted odds ratio [aOR], 1.10; 95% confidence interval [95% CI], 1.09-1.10), comorbidities (aOR, 1.21; 95% CI, 1.21-1.22), low-income quartiles (first and second) (aOR, 1.08; 95% CI, 1.07-1.10 and aOR, 1.04; 95% CI, 1.03-1.06, respectively), Medicare (aOR, 1.65; 95% CI, 1.62-1.69), Medicaid (aOR, 1.51; 95% CI, 1.48-1.53), being treated at private, investor-owned hospitals (aOR, 1.15; 95% CI, 1.12-1.18), longer hospital length of stay (aOR, 1.01; 95% CI, 1.01-1.01) and patient disposition to short-term hospital (aOR, 1.55; 95% CI, 1.49-1.62), skilled nursing facility (aOR, 1.43; 95% CI, 1.42-1.45), home health care (aOR, 1.27; 95% CI, 1.25-1.28), or leaving against medical advice (aOR, 1.85; 95% CI, 1.78-1.92). CONCLUSION: Unplanned readmission after trauma is high and remains this way 6 months after discharge. Understanding the factors that increase the odds of readmissions within 1 month, 3 months, and 6 months offer a focus for quality improvement and have important implications for hospital benchmarking. LEVEL OF EVIDENCE: Epidemiological study, level III.

Recurring emergency general surgery: Characterizing a vulnerable population.

BACKGROUND: Limited data exist for long-term outcomes after emergency general surgeries (EGSs) in the United States. This study aimed to characterize the incidence of inpatient readmissions and additional operations within 6 months of an EGS procedure. METHODS: In this retrospective observational study, we identified adults (≥18 years old) undergoing one of seven common EGS procedures (appendectomies, cholecystectomies, small bowel resections, large bowel resections, control of gastrointestinal [GI] ulcers and bleeding, peritoneal adhesiolysis, and exploratory laparotomies) who were discharged alive in the 2010-2015 National Readmissions Database. Outcomes included the rates of all-cause inpatient readmissions and of undergoing a second EGS procedure, both within 6 months. Multivariable logistic regression models identified risk factors of reoperation, adjusting for patient, clinical, and hospital factors. RESULTS: Of 706,678 patients undergoing an EGS procedure 131,291 (18.6%) had an inpatient readmission within 6 months. Among those readmitted, 15,178 (11.6%) underwent a second EGS procedure, occurring at a median of 45 days (interquartile range, 15-95). After adjustment, notable predictors of reoperation included male sex (adjusted odds ratio [aOR], 1.06 [95% confidence interval, 1.01-1.10]); private, nonprofit hospitals (aOR, 1.09 [1.02-1.17]); private, investor-owned hospitals (aOR, 1.09 [1.00-1.85]); discharge to short-term hospital (aOR, 1.35 [1.04-1.74]); discharge with home health care (aOR, 1.19 [1.13-1.25]); and index procedure of control of GI ulcer and bleeding (aOR, 9.38 [8.75-10.05]), laparotomy (aOR, 7.62 [6.92-8.40]), or large bowel resection (aOR, 6.94 [6.44-7.47]). CONCLUSION: One fifth of patients undergoing an EGS procedure had an inpatient readmission within 6 months, where one in nine of those underwent a second EGS procedure. As half of all second EGS procedures occurred within 6 weeks of the index procedure, identifying patients with the highest health care needs (index procedure type and discharge needs) may identify patients at risk for subsequent reoperation in nonemergency settings. LEVEL OF EVIDENCE: Epidemiological, level III.

Characterizing the underlying diagnoses for exploratory laparotomies to improve risk-adjustment models of postoperative mortality.

BACKGROUND: Surgeons perform emergent exploratory laparotomies (ex-laps) for a myriad of surgical diagnoses. We characterized common diagnoses for which emergent ex-laps were performed and leveraged these groups to improve risk-adjustment models for postoperative mortality. METHODS: Using American Association for the Surgery of Trauma criteria, we identified hospitalizations where the primary procedure was an emergent ex-lap in the 2012 to 2014 (derivation cohort) and 2015 (validation cohort) Nationwide Inpatient Sample. After tabulating all International Classification of Diseases-9th Rev.-Clinical Modification diagnosis codes within these hospitalizations, we divided them into clinically relevant groups. Using two stepwise regression paradigms-forward selection and backward elimination-we identified diagnostic groups significantly associated with postoperative mortality in multivariable logistic regressions. We evaluated the addition of these groups as individual covariates in risk-adjustment models for postoperative mortality using the area under the receiver operator characteristic curve. All regressions additionally adjusted for clinical factors and hospital clustering. RESULTS: We identified 4127 patients in the derivation cohort (median age, 50 years; 46.0% female; 62.1% white), with an overall mortality rate of 13.4%. Among all patients, we tabulated a total of 164 diagnosis codes, of which 27 (16.5%) may have led to an emergent ex-lap. These 27 codes clinically represented seven diagnostic categories, which captured a majority of the patients (70.4%). Backward elimination and forward selection led to four common diagnosis categories associated with mortality: bleeding, obstruction, shock, and ischemia. Adjusting for these four diagnostic groups in a multivariable logistic regression assessing postoperative mortality increased the area under the receiver operator characteristic curve from 74.5% to 88.2% in the derivation cohort and from 73.8% to 88.2% in the validation cohort. CONCLUSION: Seven diagnostic groups account for the majority of the emergent ex-laps. Adjusting for four groups may improve the accuracy of risk-adjustment models for mortality and validating such analytic standardization may optimize best research practices for EGS procedures. LEVEL OF EVIDENCE: Prognostic and epidemiologic, Level III.

Trauma Surgeon and Palliative Care Physician Attitudes Regarding Goals-of-Care Delineation for Injured Geriatric Patients.

BACKGROUND: The value of defining goals of care (GoC) for geriatric patients is well known to the palliative care community but is a newer concept for many trauma surgeons. Palliative care specialists and trauma surgeons were surveyed to elicit the specialties' attitudes regarding (1) importance of GoC conversations for injured seniors; (2) confidence in their own specialty's ability to conduct these conversations; and (3) confidence in the ability of the other specialty to do so. METHODS: A 13-item survey was developed by the steering committee of a multicenter, palliative care-focused consortium and beta-tested by trauma surgeons and palliative care specialists unaffiliated with the consortium. The finalized instrument was electronically circulated to active physician members of the American Association for the Surgery of Trauma and American Academy for Hospice and Palliative Medicine. RESULTS: Respondents included 118 trauma surgeons (8.8%) and 244 palliative care specialists (5.7%). Palliative physicians rated being more familiar with GoC, were more likely to report high-quality training in performing conversations, believed more palliative specialists were needed in intensive care units, and had more interest in conducting conversations relative to trauma surgeons. Both groups believed themselves to perform GoC discussions better than the other specialty perceived them to do so and favored their own specialty leading team discussions. CONCLUSIONS: Both groups believe themselves to conduct GoC discussions for injured seniors better than the other specialty perceived them to do so, which led to disparate views on the optimal leadership of these discussions.