Characterizing proximity and transfers of deceased organ donors to donor care units in the United States.

Some United States organ procurement organizations transfer deceased organ donors to donor care units (DCUs) for recovery procedures. We used Organ Procurement and Transplantation Network data, from April 2017 to June 2021, to describe the proximity of adult deceased donors after brain death to DCUs and understand the impact of donor service area (DSA) boundaries on transfer efficiency. Among 19 109 donors (56.1% of the cohort) in 25 DSAs with DCUs, a majority (14 593 [76.4%]) were in hospitals within a 2-hour drive. In areas with DCUs detectable in the study data set, a minority of donors (3582 of 11 532 [31.1%]) were transferred to a DCU; transfer rates varied between DSAs (median, 27.7%, range, 4.0%-96.5%). Median hospital-to-DCU driving times were not meaningfully shorter among transferred donors (50 vs 51 minutes for not transferred, P < .001). When DSA boundaries were ignored, 3241 cohort donors (9.5%) without current DCU access were managed in hospitals within 2 hours of a DCU and thus potentially eligible for transfer. In summary, approximately half of United States deceased donors after brain death are managed in hospitals in DSAs with a DCU. Transfer of donors between DSAs may increase DCU utilization and improve system efficiency.

Toward Equitable Kidney Function Estimation in Critical Care Practice: Guidance From the Society of Critical Care Medicine's Diversity, Equity, and Inclusion in Renal Clinical Practice Task Force.

OBJECTIVES: Accurate glomerular filtration rate (GFR) assessment is essential in critically ill patients. GFR is often estimated using creatinine-based equations, which require surrogates for muscle mass such as age and sex. Race has also been included in GFR equations, based on the assumption that Black individuals have genetically determined higher muscle mass. However, race-based GFR estimation has been questioned with the recognition that race is a poor surrogate for genetic ancestry, and racial health disparities are driven largely by socioeconomic factors. The American Society of Nephrology and the National Kidney Foundation (ASN/NKF) recommend widespread adoption of new "race-free" creatinine equations, and increased use of cystatin C as a race-agnostic GFR biomarker. DATA SOURCES: Literature review and expert consensus. STUDY SELECTION: English language publications evaluating GFR assessment and racial disparities. DATA EXTRACTION: We provide an overview of the ASN/NKF recommendations. We then apply an Implementation science methodology to identify facilitators and barriers to implementation of the ASN/NKF recommendations into critical care settings and identify evidence-based implementation strategies. Last, we highlight research priorities for advancing GFR estimation in critically ill patients. DATA SYNTHESIS: Implementation of the new creatinine-based GFR equation is facilitated by low cost and relative ease of incorporation into electronic health records. The key barrier to implementation is a lack of direct evidence in critically ill patients. Additional barriers to implementing cystatin C-based GFR estimation include higher cost and lack of test availability in most laboratories. Further, cystatin C concentrations are influenced by inflammation, which complicates interpretation. CONCLUSIONS: The lack of direct evidence in critically ill patients is a key barrier to broad implementation of newly developed "race-free" GFR equations. Additional research evaluating GFR equations in critically ill patients and novel approaches to dynamic kidney function estimation is required to advance equitable GFR assessment in this vulnerable population.

Does Practice Match Training? Consultation Practices in Surgical Critical Care.

INTRODUCTION: Intensive care unit (ICU) patient and provider attributes may prompt specialty consultation. We sought to determine practice patterns of surgical critical care (SCC) physicians for ICU consultation. METHODS: We surveyed American Association for the Surgery of Trauma members. Various diagnoses were listed under each of nine related specialties. Respondents were asked for which conditions they would consult a specialist. Conditions were cross-referenced with the SCC fellowship curriculum. Other perspectives on practice and consultation were queried. RESULTS: 314 physicians (18.6%) responded (68% male; 79% White; 96.2% surgical intensivist); 284 (16.8%) completed all questions. Percentage of clinical time practicing SCC was 26-50% in 57% and >50% in 14.5%. ICUs were closed (39%), open (25%), or hybrid (36%). Highest average confidence ratings (1 = least, 5 = most) for managing select conditions were ventilator, 4.64; palliative care, 4.51; infections, 4.44; organ donation, hemodynamics (tie), 4.31; lowest rating was myocardial ischemia, 3.85. Consults were more frequent for Cardiology, Hematology, and Neurology; less frequent for nephrology, palliative care, gastroenterology, infectious disease, and pulmonary; and low for curriculum topics (<25%) except for infectious diseases and palliative care. Attending staffing 24 h/day was associated with a lower mean number of topics for consultation (mean 24.03 versus 26.31, P = 0.015). CONCLUSIONS: ICU consultation practices vary based on consultant specialty and patient diagnosis. Consultation is most common for specialty-specific diseases and specialist interventions, but uncommon for topics found in the SCC curriculum, suggesting that respondents' scope of practice closely matched their training.

A Statewide Analysis of Self-Inflicted Injuries During COVID-19 Pandemic: Is There Adequate Access to Mental Health?

INTRODUCTION: Many social and behavioral changes occurred during the COVID-19 pandemic. Our objective was to identify changes in incidence of self-inflicted injuries during COVID-19 compared to prepandemic years. Further, we aimed to identify risk factors associated with self-inflicted injuries before and during the pandemic. METHODS: A retrospective cohort study of patients aged ≥18 y with self-inflicted injuries from 2018 to 2021 was performed using the Pennsylvania Trauma Outcome Study registry. Patients were grouped into pre-COVID Era (pre-CE, 2018-2019) and COVID Era (CE, 2020-2021). Statistical comparisons were accomplished using Wilcoxon rank-sum tests and chi-square or Fisher's exact tests. RESULTS: There were a total of 1075 self-inflicted injuries in the pre-CE cohort and 482 during the CE. There were no differences in age, gender, race or ethnicity between the two cohorts. Among preexisting conditions, those within the pre-CE cohort had a higher incidence of mental/personality disorder (59.2% versus 52.3%, P = 0.01). There were no significant differences in the mechanism of self-inflicted injuries or place of injury between the two periods. Additionally, there were no differences in discharge destinations or mortality between the two cohorts. CONCLUSIONS: During the height of social isolation in Pennsylvania, there were no associated increases in self-inflicted injuries. However, there were increased incidences of self-inflicted injuries among those with a prior diagnosis of mental or personality disorder in the pre-CE group. Further investigations are required to study the access to mental health services in future pandemics or public health disasters.

Adolescent Gun Violence Shows an Age Group to Focus Trauma Prevention.

INTRODUCTION: Gun violence continues to escalate in America's urban areas. Peer groups of gun wound victims are potential targets for violence prevention initiatives; identification of this cohort is pivotal to efficient deployment strategies. We hypothesize a specific age at which the incidence of penetrating trauma increases significantly in adolescence, below which should be the focus on future trauma prevention. METHODS: Adolescent trauma patients with gunshot wounds seen from July 2011 through June 2021 at a well-established, urban, academic level 1 trauma center were reviewed retrospectively and grouped by age. A linear regression and repeated measured analysis of variance evaluated the change in gunshot wound victims over this time, grouped by age. Demographics were extrapolated, and standard statistical analysis was performed. RESULTS: A total of 1304 adolescent trauma patients were included. Those aged 15 y and under had an unchanged incidence of gunshot wounds. However, those aged 16 y and more experienced the majority of increased gun violence; 92% were Black and 90% were male with a mortality of 12%. Adolescents aged 15 y and below were 95% Black and 84% male, with a mortality of 18%. CONCLUSIONS: Primary prevention efforts to mitigate gun violence should be focused on adolescents below 16 y of age. Prevention of gun violence should include community outreach efforts directed toward middle school-aged children and younger, hoping to decrease the incidence of injury due to gun violence in older adolescents in the future.

Stopping Hospital Infections With Environmental Services (SHINE): A Cluster-randomized Trial of Intensive Monitoring Methods for Terminal Room Cleaning on Rates of Multidrug-resistant Organisms in the Intensive Care Unit.

BACKGROUND: Multidrug-resistant organisms (MDROs) frequently contaminate hospital environments. We performed a multicenter, cluster-randomized, crossover trial of 2 methods for monitoring of terminal cleaning effectiveness. METHODS: Six intensive care units (ICUs) at 3 medical centers received both interventions sequentially, in randomized order. Ten surfaces were surveyed each in 5 rooms weekly, after terminal cleaning, with adenosine triphosphate (ATP) monitoring or an ultraviolet fluorescent marker (UV/F). Results were delivered to environmental services staff in real time with failing surfaces recleaned. We measured monthly rates of MDRO infection or colonization, including methicillin-resistant Staphylococcus aureus, Clostridioides difficile, vancomycin-resistant Enterococcus, and MDR gram-negative bacilli (MDR-GNB) during a 12-month baseline period and sequential 6-month intervention periods, separated by a 2-month washout. Primary analysis compared only the randomized intervention periods, whereas secondary analysis included the baseline. RESULTS: The ATP method was associated with a reduction in incidence rate of MDRO infection or colonization compared with the UV/F period (incidence rate ratio [IRR] 0.876; 95% confidence interval [CI], 0.807-0.951; P = .002). Including the baseline period, the ATP method was associated with reduced infection with MDROs (IRR 0.924; 95% CI, 0.855-0.998; P = .04), and MDR-GNB infection or colonization (IRR 0.856; 95% CI, 0.825-0.887; P < .001). The UV/F intervention was not associated with a statistically significant impact on these outcomes. Room turnaround time increased by a median of 1 minute with the ATP intervention and 4.5 minutes with UV/F compared with baseline. CONCLUSIONS: Intensive monitoring of ICU terminal room cleaning with an ATP modality is associated with a reduction of MDRO infection and colonization.

Admission Triage With Pain, Inspiratory Effort, Cough Score can Predict Critical Care Utilization and Length of Stay in Isolated Chest Wall Injury.

INTRODUCTION: Damage to the thoracic cage is common in the injured patient, both when the injuries are confined to this single cavity and as part of the overall injury burden of a polytraumatized patient. In a subset of these patients, the severity of injury to the intrathoracic viscera is either underappreciated at admission or blossom over the following 48-72 h. The ability to promptly identify these patients and abrogate complications therefore requires triage of such at-risk patients to close monitoring in a critical care environment. At our institution, this triage hinges on the Pain, Inspiratory effort, Cough (PIC) score, which generates a composite unitless score from a nomogram which aggregates several variables-patient-reported Pain visual analog scale, Incentive spirometry effort, and the perceived adequacy of Cough. We thus sought to audit PIC's discriminant power in predicting intensive care unit (ICU) need. METHODS: This retrospective cohort study was performed at an urban, academic, level 1 trauma center. All isolated chest wall injuries (excluded any Abbreviated Injury Score >2 in head or abdomen) from January 2020 to June 2021 were identified in the local trauma registry. The electronic medical record was queried for standard demographics, admission PIC score, postadmission destination, ICU and hospital length of stay (LOS), and any unplanned admissions to the ICU. Chi-squared tests were used to determine differences between PIC score outcomes and the recursive partitioning method correlated admission PIC score to ICU LOS. RESULTS: Two hundred and thirty six isolated chest wall injury patients were identified, of whom 194 were included in the final analysis. The median age was 60 (interquartile range [IQR] 50-74) years, 63.1% were male, and the median (IQR) number of rib fractures was 3.0 (2.0-5.0). A cutoff PIC score of 7 or lower was associated with ICU admission (odds ratio [OR] 95% CI: 8.19 [3.39-22.55], P < 0.001 with a PPV = 41.4%, NPV = 91%), and with ICU admission for greater than 48 h [OR (95% CI): 26.86 (5.5-43.96), P < 0.001, with a PPV = 25.9%, NPV = 98.7%] but not anatomic injury severity score, hospital LOS or ICU, or the requirement for mechanical ventilation. The association between PIC score 7 or below and the presence of bilateral fractures, flail chest, or sternal fracture did not meet statistical significance. The accurate cut point of the PIC score to predict ICU admission over 48 h in our retrospective cohort was calculated as PIC ≤ 7 for P = 0.013 and PIC ≤ 6 for P = 0.001. CONCLUSIONS: Patients with isolated chest wall injuries require effective reproducible triage for ICU-level care. The PIC score appears to be a moderate discriminator of critical care need, per se, as judged by our recorded complication rate requiring critical care intervention. This vigilance may pay dividends in early detection and abrogation of respiratory failure emergencies. Furthermore, PIC score delineation for ICU need appears to be appropriate at 7 or less; this threshold can be used during admission triage to guide care.

Process mining in healthcare - An updated perspective on the state of the art.

Process mining is the research domain focusing on the development of innovative methods to gather insights from event logs. It has been used for various use cases within the healthcare domain with the ambition to instigate evidence-based process improvement. Over the past years, the research interest in process mining in healthcare has been increasing. This paper presents the results of an extensive systematic literature review on process mining in healthcare in which 263 papers have been reviewed. Besides providing the most recent overview of literature and the extensive number of reviewed papers, we complement existing reviews by considering three novel review dimensions: (i) the process mining project stages, (ii) the involvement of domain expertise, and (iii) the Key Performance Indicators (KPI) considered during the process mining analysis. Orthogonal to these three novel dimensions, we also highlight the evolution of the research domain by considering time trends within the review dimensions. The review generates new perspectives on process mining in healthcare as a research domain. For instance, process redesign is rarely part of a process mining project, domain experts are mostly asked for validating insights, and less than half of the published papers considers one or more specific KPIs to direct their analysis.

Supporting capacity management decisions in healthcare using data-driven process simulation.

Healthcare managers are confronted with various Capacity Management decisions to determine appropriate levels of resources such as equipment and staff. Given the significant impact of these decisions, they should be taken with great care. The increasing amount of process execution data - i.e. event logs - stored in Hospital Information Systems (HIS) can be leveraged using Data-Driven Process Simulation (DDPS), an emerging field of Process Mining, to provide decision-support information to healthcare managers. While existing research on DDPS mainly focuses on the fully automated discovery of simulation models from event logs, the interaction between process execution data and domain expertise has received little attention. Nevertheless, data quality issues in real-life process execution data stored in HIS prevent the discovery of accurate and reliable models from this data. Therefore, complementary information from domain experts is necessary. In this paper, we describe the application of DDPS in healthcare by means of an extensive real-life case study at the radiology department of a Belgium hospital. In addition to formulating our recommendations towards the radiology management, we will elaborate on the experienced challenges and formulate recommendations to move research on DDPS within a healthcare context forward. In this respect, explicit attention is attributed to data quality assessment, as well as the interaction between the use of process execution data and domain expertise.

Process mining for healthcare: Characteristics and challenges.

Process mining techniques can be used to analyse business processes using the data logged during their execution. These techniques are leveraged in a wide range of domains, including healthcare, where it focuses mainly on the analysis of diagnostic, treatment, and organisational processes. Despite the huge amount of data generated in hospitals by staff and machinery involved in healthcare processes, there is no evidence of a systematic uptake of process mining beyond targeted case studies in a research context. When developing and using process mining in healthcare, distinguishing characteristics of healthcare processes such as their variability and patient-centred focus require targeted attention. Against this background, the Process-Oriented Data Science in Healthcare Alliance has been established to propagate the research and application of techniques targeting the data-driven improvement of healthcare processes. This paper, an initiative of the alliance, presents the distinguishing characteristics of the healthcare domain that need to be considered to successfully use process mining, as well as open challenges that need to be addressed by the community in the future.

Characteristics, Outcomes, and Trends of Patients With COVID-19-Related Critical Illness at a Learning Health System in the United States.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic continues to surge in the United States and globally. OBJECTIVE: To describe the epidemiology of COVID-19-related critical illness, including trends in outcomes and care delivery. DESIGN: Single-health system, multihospital retrospective cohort study. SETTING: 5 hospitals within the University of Pennsylvania Health System. PATIENTS: Adults with COVID-19-related critical illness who were admitted to an intensive care unit (ICU) with acute respiratory failure or shock during the initial surge of the pandemic. MEASUREMENTS: The primary exposure for outcomes and care delivery trend analyses was longitudinal time during the pandemic. The primary outcome was all-cause 28-day in-hospital mortality. Secondary outcomes were all-cause death at any time, receipt of mechanical ventilation (MV), and readmissions. RESULTS: Among 468 patients with COVID-19-related critical illness, 319 (68.2%) were treated with MV and 121 (25.9%) with vasopressors. Outcomes were notable for an all-cause 28-day in-hospital mortality rate of 29.9%, a median ICU stay of 8 days (interquartile range [IQR], 3 to 17 days), a median hospital stay of 13 days (IQR, 7 to 25 days), and an all-cause 30-day readmission rate (among nonhospice survivors) of 10.8%. Mortality decreased over time, from 43.5% (95% CI, 31.3% to 53.8%) to 19.2% (CI, 11.6% to 26.7%) between the first and last 15-day periods in the core adjusted model, whereas patient acuity and other factors did not change. LIMITATIONS: Single-health system study; use of, or highly dynamic trends in, other clinical interventions were not evaluated, nor were complications. CONCLUSION: Among patients with COVID-19-related critical illness admitted to ICUs of a learning health system in the United States, mortality seemed to decrease over time despite stable patient characteristics. Further studies are necessary to confirm this result and to investigate causal mechanisms. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.

Outcome of Hypotensive Trauma Patients by Time and Day of Arrival.

BACKGROUND: Although most studies of trauma patients have not demonstrated a "weekend" or "night" effect on mortality, outcomes of hypotensive (systolic blood pressure <90 mm Hg) patients have not been studied. We sought to evaluate whether outcomes of hypotensive patients were associated with admission time and day. METHODS: We retrospectively analyzed patients from Pennsylvania Level 1 and Level 2 trauma centers with systolic blood pressure of <90 mm Hg over 5 y. Patients were stratified into four groups by arrival day and time: Group 1, weekday days; Group 2, weekday nights; Group 3, weekend days; and Group 4, weekend nights. Patient characteristics and outcomes were compared for the four groups. Adjusted mortality risks for Groups 2, 3, and 4 with Group 1 as the reference were determined using a generalized linear mixed effects model. RESULTS: After exclusions, 27 trauma centers with a total of 4937 patients were analyzed. Overall mortality was 44%. Compared with patients arriving during the day (Groups 1 and 3), those arriving at night (Groups 2 and 4) were more likely to be younger, to be male, to have lower Glasgow Coma Scale scores and blood pressures, to have penetrating injuries, and to die in the emergency room. Controlled for admission variables, odds ratios (95% confidence intervals) for Groups 2, 3, and 4 were 0.92 (0.72-1.17), 0.89 (0.65-1.23), and 0.76 (0.56-1.02), respectively, for mortality with Group 1 as reference. CONCLUSIONS: Patients arriving in shock to Pennsylvania Level 1 and Level 2 trauma centers at night or weekends had no increased mortality risk compared with weekday daytime arrivals.

A Novel Immune Modulator for Patients With Necrotizing Soft Tissue Infections (NSTI): Results of a Multicenter, Phase 3 Randomized Controlled Trial of Reltecimod (AB 103).

BACKGROUND AND OBJECTIVE: Reltecimod, a CD 28 T-lymphocyte receptor mimetic, inhibits T-cell stimulation by an array of bacterial pathogens. A previous phase 2 trial demonstrated improved resolution of organ dysfunction after NSTI. We hypothesized that early administration of reltecimod would improve outcome in severe NSTI. METHODS: Randomized, double-blind, placebo-controlled trial of single dose reltecimod (0.5 mg/kg) administered within 6 hours of NSTI diagnosis at 65 of 93 study sites. Inclusion: surgical confirmation of NSTI and organ dysfunction [modified Sequential Organ Failure Assessment Score (mSOFA) score ≥3]. Primary analysis was modified Intent-to-Treat (mITT), responder analysis using a previously validated composite endpoint, necrotizing infection clinical composite endpoint, defined as: alive at day 28, ≤3 debridements, no amputation beyond first operation, and day 14 mSOFA ≤1 with ≥3 point reduction (organ dysfunction resolution). A prespecified, per protocol (PP) analysis excluded 17 patients with major protocol violations before unblinding. RESULTS: Two hundred ninety patients were enrolled, mITT (Reltecimod 142, Placebo 148): mean age 55 ±â€Š15 years, 60% male, 42.4% diabetic, 28.6% perineal infection, screening mSOFA mean 5.5 ±â€Š2.4. Twenty-eight-day mortality was 15% in both groups. mITT necrotizing infection clinical composite endpoint success was 48.6% reltecimod versus 39.9% placebo, P = 0.135 and PP was 54.3% reltecimod versus 40.3% placebo, P = 0.021. Resolution of organ dysfunction was 65.1% reltecimod versus 52.6% placebo, P = 0.041, mITT and 70.9% versus 53.4%, P = 0.005, PP. CONCLUSION: Early administration of reltecimod in severe NSTI resulted in a significant improvement in the primary composite endpoint in the PP population but not in the mITT population. Reltecimod was associated with improved resolution of organ dysfunction and hospital discharge status.

Outcomes After Tracheostomy in COVID-19 Patients.

OBJECTIVE: To determine the outcomes of patients undergoing tracheostomy for COVID-19 and of healthcare workers performing these procedures. BACKGROUND: Tracheostomy is often performed for prolonged endotracheal intubation in critically ill patients. However, in the context of COVID-19, tracheostomy placement pathways have been altered due to the poor prognosis of intubated patients and the risk of transmission to providers through this highly aerosolizing procedure. METHODS: A prospective single-system multi-center observational cohort study was performed on patients who underwent tracheostomy after acute respiratory failure secondary to COVID-19. RESULTS: Of the 53 patients who underwent tracheostomy, the average time from endotracheal intubation to tracheostomy was 19.7 days ±â€Š6.9 days. The most common indication for tracheostomy was acute respiratory distress syndrome, followed by failure to wean ventilation and post-extracorporeal membrane oxygenation decannulation. Thirty patients (56.6%) were liberated from the ventilator, 16 (30.2%) have been discharged alive, 7 (13.2%) have been decannulated, and 6 (11.3%) died. The average time from tracheostomy to ventilator liberation was 11.8 days ±â€Š6.9 days (range 2-32 days). Both open surgical and percutaneous dilational tracheostomy techniques were performed utilizing methods to mitigate aerosols. No healthcare worker transmissions resulted from performing the procedure. CONCLUSIONS: Alterations to tracheostomy practices and processes were successfully instituted. Following these steps, tracheostomy in COVID-19 intubated patients seems safe for both patients and healthcare workers performing the procedure.

Obesity is Associated With Mortality and Complications After Trauma: A State-Wide Cohort Study.

BACKGROUND: With rising obesity rates in the United States, knowledge of obesity's impact on trauma outcomes is essential to providing high-quality care. The interaction between body mass and outcomes is unclear, with existing literature demonstrating conflicting results. We hypothesized that in a broad cohort of trauma patients, obesity would be associated with in-hospital mortality. MATERIALS AND METHODS: We conducted a retrospective cohort study using the 2014-2015 Pennsylvania Trauma Outcomes Study (PTOS) registry, a state-wide registry to which all accredited Pennsylvania trauma centers are required to report. We included nonburn adult trauma patients admitted to level I and II centers. Because PTOS lacks height data, weight thresholds of 111.75 kg for men and 95.05 kg for women were used, which correspond to BMI = 30 kg/m2 at the 99th height percentile in the United States. We tested the association of obesity with in-hospital mortality using logistic regression to adjust for confounders. RESULTS: We included 46,329 patients in a complete case analysis. In univariate logistic regression analysis, injury mechanism, presence of a complication, age, sex, need for blood transfusion, Revised Trauma Score, and Injury Severity Score were associated with mortality. On multivariate analysis, including these factors, obesity was significantly associated with mortality (odds ratio 1.36, 95% confidence interval 1.10-1.69). Respiratory, thromboembolic, and infectious complications, as defined by PTOS, were more common in obese patients. CONCLUSIONS: After adjusting for patient and injury characteristics, obesity is associated with increased mortality following trauma. This information may help resolve previous conflicting evidence and guide providers in caring for the obese patient.

The Location and Timing of Failure-to-Rescue Events Across a Statewide Trauma System.

BACKGROUND: Failure to rescue (FTR) refers to death after a major complication. Defining the optimal context in which to reduce FTR after injury requires knowledge of where and when FTR events occur. MATERIALS AND METHODS: Retrospective observational study of patients >16 y with a minimum Abbreviated Injury Score ≥2 at all 30 level I and II Pennsylvania trauma centers (2007-2015). Location and timing of the first major complication were collected. Complication, mortality, and FTR rates were calculated by location (prehospital, emergency department, operating room, stepdown unit, interventional radiology, intensive care unit (ICU), radiology, and the surgical ward) and by postadmission day. Kruskal-Wallis and chi-squared tests were used to compare variables. RESULTS: Major complications occurred in 15,388 of 178,602 (8.6%) patients. The median age was 58 y (interquartile range [IQR] 37-77 y), 78% were Caucasian, 68% were male, 89% were bluntly injured, and the median Injury Severity Score was 19 (IQR 10-29). Death occurred in 2512 of 15,388 patients with a major complication, for an FTR rate of 16.3%. Compared with non-FTR, FTR had earlier major complications (median day 2 [IQR 0-5 d] versus day 4 [IQR 2-8 d], P < 0.001). FTR rates were highest in the prehospital setting (42%), the operating room (33%), and the emergency department (32%), but the greatest number (1608 of 2512 total FTR events, 64%) occurred in the ICU. Pulmonary (32%) and cardiac (26%) complications most frequently contributed to FTR deaths. CONCLUSIONS: Interventions designed to reduce FTR after injury should focus on pulmonary and cardiac complications in the ICU.

A Statewide Assessment of Rib Fixation Patterns Reveals Missed Opportunities.

BACKGROUND: Rib fractures are a common consequence of traumatic injury and can result in significant debilitation. Rib fixation offers fracture stabilization, resulting in improved outcomes and decreased pulmonary complications, especially in high-risk groups such as those with flail segments. However, commercial rib fixation has only recently become clinically prevalent, and we hypothesize that significant variability exists in its utilization based on injury pattern and trauma center. METHODS: The Pennsylvania Trauma System Foundation database was queried for all multiple rib fracture patients occurring statewide in 2016 and 2017. Demographics including the presence of flail and the occurrence of rib fixation was abstracted. Outcomes were compared between the fixation group and all other rib fracture patients. Deidentified treating trauma center was used to elicit center-level disparities. RESULTS: During the study period, there were 12,910 patients with multiple rib fractures, of which 135 had flail segments. 57 patients underwent rib fixation, and 10 of which had a flail segment. Compared with the nonoperative cohort, those who underwent rib fixation were younger (52.5 versus 61.5, P = 0.0009), similar in gender (68% versus 62% male, P = 0.373), and race (80% versus 86% White, P = 0.239). The rib fixation group had higher Injury Severity Scores (19.4 versus 15.4 P = 0.0011). The timing of rib fixation was most frequent within 1 wk of injury but extended out through 3 wk; the occurrence of pulmonary complications had a similar distribution. The frequency of rib fixation rates within trauma centers was not associated with rib fracture patient volume, and 37.1% of multiple rib fracture patients were cared for at centers that did not perform rib fixation. CONCLUSIONS: Rib fixation is infrequently used at trauma centers in Pennsylvania. It is used more frequently in nonflail injuries, and its use may be associated with the occurrence of pulmonary complications. Significant center-level variation exists in rib fixation rates among multiple fractured patients. A significant number of patients are cared for at centers that do not perform rib fixation. Further research is needed to illicit better-defined indications for operative fixation, and opportunities exist to further the penetrance of this practice to all trauma centers.

Training Disparities of Our Future Workforce: A Survey of Trauma Fellowship Candidates.

BACKGROUND: Training in Acute Care Surgery (ACS) is an integral component of general surgery residency and serves as a critical base experience for the added educational qualifications of fellowship. How this training varies between programs is not well characterized. We sought to describe the variation in clinical exposure between residencies in a sample of residents applying to an ACS fellowship. We hypothesized that applicants have significant variations in clinical exposure as well as unique and specific expectations for educational experiences. MATERIALS AND METHODS: We offered an anonymous 82-question survey focused on residency clinical exposure and self-perceived confidence in key areas of ACS training, as well as fellowship training and career expectations to all applicants interviewed at a single trauma, critical care, and emergency surgery fellowship program. Responses were assessed via absolute numbers and confidence via a 5-point Likert scale; data are reported using descriptive statistics and linear regression models. RESULTS: Forty-two interviewing applicants completed the survey, for a 96% response rate. Applicants reported heterogeneous levels of comfort across most ACS domains. There was good correlation between experience and comfort in most procedural areas. During fellowship training, respondents placed highest priority on operative experience, with 43% rating this as their highest priority, followed by penetrating trauma experience (33%). CONCLUSIONS: We found significant variations in both experience and comfort within key ACS domains among fellowship applicants. Despite training variability, there was good correlation between experience and self-reported comfort. Collaboration between residency and fellowship governing bodies may help address areas of limited exposure before entry into clinical practice.

Leaving Contaminated Trauma Laparotomy Wounds Open Reduces Wound Infections But Does Not Add Value.

BACKGROUND: The incidence of surgical site infection (SSI) has become a key quality indicator following clean and clean/contaminated surgical procedures. In contrast, contaminated and dirty wounds have garnered little attention with this quality metric because of the expected higher complication incidence. We hypothesized that wound management strategies in this high-risk population vary significantly and might not add value to the overall care. MATERIALS AND METHODS: This is a retrospective, observational study of trauma patients who underwent an exploratory laparotomy at an urban, academic, level 1 trauma center from 2014 to 2016. Deaths before hospital discharge were excluded. Wounds were classified using the Centers for Disease Control and Prevention definition on review of the operative reports. SSI was determined by review of the medical record, also per Centers for Disease Control and Prevention definition. Wound management strategies were categorized as either primary skin closure or closure by secondary intention. Outcomes were compared using Chi square or Kruskal-Wallis test. RESULTS: There were 128 patients who met study criteria. Fifty-five (42.9%) wounds were left open to close by secondary intention. In the wounds that were closed primarily (n = 73), eight (10.9%) developed an SSI. There were significant differences in the average length of stay (25.0 versus 11.6 d, P = 0.032), number of office visits (3.0 versus 1.8, P = 0.008), and time from last laparotomy to the last wound care office visit (112.8 versus 57.4, P = 0.012) between patients who were treated with secondary intention closure compared to those closed primarily who did not suffer from SSI. CONCLUSIONS: There is significant incidence of SSI in contaminated and dirty traumatic abdominal wounds; however, wound management strategies vary widely within this cohort. Closure by secondary intention requires significantly more resource utilization. Isolating risk factors for SSI may allow additional patients to undergo primary skin closure and avoid the morbidity of closure by secondary intention.

Early declaration of death by neurologic criteria results in greater organ donor potential.

BACKGROUND: Aggressive management of patients prior to and after determination of death by neurologic criteria (DNC) is necessary to optimize organ recovery, transplantation, and increase the number of organs transplanted per donor (OTPD). The effects of time management are understudied but potentially pivotal component. The objective of this study was to analyze specific time points (time to DNC, time to procurement) and the time intervals between them to better characterize the optimal timeline of organ donation. METHODS: Using data over a 5-year time period (2011-2015) from the largest US OPO, all patients with catastrophic brain injury and donated transplantable organs were retrospectively reviewed. Active smokers were excluded. Maximum donor potential was seven organs (heart, lungs [2], kidneys [2], liver, and pancreas). Time from admission to declaration of DNC and donation was calculated. Mean time points stratified by specific organ procurement rates and overall OTPD were compared using unpaired t-test. RESULTS: Of 1719 Declaration of Death by Neurologic Criteria organ donors, 381 were secondary to head trauma. Smokers and organs recovered but not transplanted were excluded leaving 297 patients. Males comprised 78.8%, the mean age was 36.0 (±16.8) years, and 87.6% were treated at a trauma center. Higher donor potential (>4 OTPD) was associated with shorter average times from admission to brain death; 66.6 versus 82.2 hours, P = 0.04. Lung donors were also associated with shorter average times from admission to brain death; 61.6 versus 83.6 hours, P = 0.004. The time interval from DNC to donation varied minimally among groups and did not affect donation rates. CONCLUSIONS: A shorter time interval between admission and declaration of DNC was associated with increased OTPD, especially lungs. Further research to identify what role timing plays in the management of the potential organ donor and how that relates to donor management goals is needed.