Enhancing the wellness of caregivers of individuals with epilepsy: The effects of a brief stress management course.

PURPOSE: To determine whether a brief stress management video can improve the quality of life of caregivers of persons with epilepsy (PWE). METHODS: Thirty-three adult caregivers of PWE who scored 5 or higher on the Caregiver Self-Assessment Questionnaire (CSAQ) completed a 30-min stress management video. This was preceded by a pre-intervention assessment, followed by post-intervention assessment at 1 month, and a delayed post-intervention assessment evaluation 3 months after video was viewed. Measures of program acceptability were also obtained. RESULTS: There was significant improvement when comparing pre- and post-intervention CSAQ scores. This improvement was sustained at 3 months post intervention. Measures of program acceptability were favorable. CONCLUSION: A brief stress management course can help improve the quality of life of caregivers of PWE.

Seprafilm slurry does not increase complication rates after laparoscopic colectomy.

BACKGROUND: The ability of the Seprafilm adhesion barrier to prevent adhesion formation after abdominal and pelvic operations has been proved. With laparoscopy, a major technical roadblock with these sheets is their delivery into the peritoneal cavity. This study aimed to evaluate the incidence of postoperative complications and death after laparoscopic placement of Seprafilm slurry in patients who underwent laparoscopic colectomy. METHODS: A total of 100 laparoscopic colectomies performed by a single surgeon were analyzed. For 50 patients, Seprafilm was delivered into the peritoneal cavity as a slurry. Group characteristics were evaluated in terms of age, sex, body mass index (BMI), and American Society of Anesthesiology (ASA) score. Complications within the first 30 days after surgery were reviewed. The relative risks with 95% confidence intervals were calculated to determine whether differences in the complication rates between the groups were statistically significant. RESULTS: Both groups were statistically similar in terms of age, sex, BMI, and ASA score. The differences between the control and experimental groups were examined for abdominal or pelvic abscess (4 vs. 2%), anastomotic leak (4% in both groups), subcutaneous abscess (2% in both groups), wound infection (8 vs. 0%), reoperative rate (8 vs. 6%), and readmission rate (6 vs. 8%). Although the mortality rate was slightly higher in group 2, all the deaths were unrelated to intraabdominal complications. The relative risks for complications were not statistically significant. CONCLUSION: The initial data regarding Seprafilm slurry indicate no significant difference in complication rates between the control and experimental groups. This is the first study to evaluate the safety of Seprafilm slurry for patients undergoing laparoscopic colectomy.

Application of International Classification Injury Severity Score to National Surgical Quality Improvement Program defines pediatric trauma performance standards and drives performance improvement.

BACKGROUND: The American College of Surgeons National Surgical Quality Improvement Program is becoming a core methodology to define performance as a ratio of observed to expected events. We hypothesized that application of this using International Classification of Injury Severity Score (ICISS) for individual patient risk stratification to a group of hospitals contributing data to the National Pediatric Trauma Registry (NPTR) would apply objective evidence of actual injuries to define an expected standard and identify performance outliers. METHODS: Using a blinded code, children entered into phase III of the NPTR were aggregated by treating hospital. Individual patient ICISS survival probability (Ps) were calculated using survival risk ratios (SRR) derived from the phase II NPTR dataset (n = 53,253). For each center, sample size, observed mortality, and ICISS Ps were calculated. Probability of mortality (Pm) was computed as 1 - Ps. Logistic regression was used to develop a predictive model for mortality. Logit transformation of Pm was performed to adjust for the skew of minor injury in children and reduce overestimation of low Pm fatalities. Mean Pm was computed for each center and multiplied by its volume to determine expected frequency. Observed to expected ratio (O/E) and 95% confidence interval were calculated to define expected performance and outliers above or below 1 SD of the mean O/E. RESULTS: Patients treated at 30 pediatric trauma centers (mean volume = 451 +/- 258/patients per center) were evaluated. Mean O/E was 1.001 with SD = 0.404. Twenty-two centers fell within the reference range; O/E of 12 centers exceeded 1, suggesting performance below expectation. Trauma center volume, as reflected by sample, did not correlate to O/E performance. CONCLUSIONS: Application of ICISS Ps from a national pediatric benchmark population simplifies determination of expected mortality necessary to compute the expected component of National Surgical Quality Improvement Program. Analysis of these ratios of expected to observed mortality demonstrates variance among centers, defines performance against peers using the same benchmarks, and can drive performance improvement based on the objective evidence of injury diagnoses actually encountered.

Risk stratification simplified: the worst injury predicts mortality for the injured children.

BACKGROUND: The International Classification Injury Severity Score (ICISS) uses anatomic injury diagnoses to predict probability of survival (Ps) computed as the product of the survival risk ratios (SRR) of the three most severe injuries. SRRs are derived as the proportion of fatalities for every International Classification of Diseases-9th Revision-Clinical Modification diagnosis in a "benchmark" population. Pediatric-specific SRRs were computed from 103,434 entries in the National Pediatric Trauma Registry. We hypothesized that ICISS was a valid pediatric outcome predictor, and that the child's most severe injury; i.e., the lowest SRR, is the major driver of outcome, which can be used alone to predict survival. METHODS: Receiver operator characteristic analysis was used to assess the predictive validity of ICISS. SRRs derived from 53,235 phase II patients were used as the training set to calculate the Ps for 50,199 phase III children comprising the test set. The survival probability (Ps) computed from the standard three diagnoses was compared with that computed from only the worst injury (lowest SRR). Records with a single diagnosis or Ps of 1, indicating no mortality potential, were excluded from the analysis. Nagelkerke pseudo R2 defined what proportion of the predicted Ps was the effect of the worst injury alone versus the traditional Ps. RESULTS: A total of 25,239 records with at least two diagnoses with SRRs indicating risk of mortality were analyzed. The area under the receiver operator characteristic curve for traditional Ps was 0.935, compared with 0.932 for that calculated using only the lowest SRR. The difference of 0.003 was not significant (z = 1.061, p = 0.2888, NS). Nagelkerke pseudo R2 for the lowest SRR was 0.455 compared with 0.462 for the traditional three diagnosis Ps, which shows that the majority of Ps predictive power is related to the single injury with the lowest SRR. Further analysis demonstrated that this effect was related to frequency of coexistent injuries with no mortality risk rather than definable difference in severity. CONCLUSION: These data validate ICISS as predictive of pediatric injury survival. The dominant effect of the worst injury reflects an epidemiologic characteristic of pediatric trauma that will identify specific injuries for best practice analysis and focused injury prevention.

Survival advantage associated with treatment of injury at designated trauma centers: a bivariate probit model with instrumental variables.

This article analyzes the effectiveness of designated trauma centers in Florida concerning reduction in the mortality risk of severely injured trauma victims. A bivariate probit model is used to compute the differential impact of two alternative acute care treatment sites. The alternative sites are defined as (1) a nontrauma center (NC) or (2) a designated trauma center (DTC). An instrumental-variables method was used to adjust for prehospital selection bias in addition to the influence of age, gender, race, risk of mortality, and type of injury. Treatment at a DTC was associated with a reduction of 0.13 in the probability of mortality.

Analysis of trends in the Florida Trauma System (1991-2003): changes in mortality after establishment of new centers.

BACKGROUND: This study analyzes trends in hospitalization and outcome for adult, elderly, and pediatric trauma victims in the Florida Trauma System (FTS) from 1991 to 2003, during which time the number of centers nearly doubled from 11 to 20. METHODS: Administrative data was queried for all admissions with at least one trauma related discharge. Patients were stratified by age as pediatric (age, 0 to 15 years), adult (age, 16 to 64 years), or elderly (age, >64 years). Volume of admissions, severity, and mortality were analyzed over time. A logistic regression model was used to test the existence of an organizational experience curve after the designation of a new trauma center. RESULTS: Injury-related hospitalizations increased for the elderly, stayed the same for adults, and declined for children. As the system matured, a larger percentage of victims, particularly the most severely injured, were triaged to trauma centers, indicating more effective triage. In contrast to adults and pediatric patients, the majority of elderly trauma victims were managed at non-trauma centers. The trauma mortality rate per 1,000 population among the elderly increased during the study period (P < .01). Multivariate analysis indicated that for adult and pediatric victims it took up to 3 years after the designation of trauma center status before the odds of mortality reached parity with that of established centers. CONCLUSIONS: The FTS has grown with its population and has matured to treat a larger percentage of trauma victims. Trauma victims transported to established trauma centers (4+ years) have a survival advantage compared to their counterparts transported to newly created centers. The reduction in the odds of mortality does not occur immediately after trauma center designation.

The triad that matters: palliative medicine, code status, and health care costs.

INTRODUCTION: Delayed discussion of a patient's code status can lead to shortsighted care plans that increase hospital length of stay (LOS) and costs. METHODS: Retrospective study compared intensive care unit (ICU) patients who accepted verses rejected palliation and examined the relationships between 5 predictor variables with the outcome variables ICU LOS and total hospital LOS, and total direct and variable hospital cost. RESULTS: A significant number of patients who accepted palliative care agreed to a hospice referral or expired in the hospital. The relationships between days until a family conference, do-not-resuscitate (DNR) order, and the number of invasive procedures were significant. CONCLUSIONS: The amount of time that expires until the issue of code status was settled to clearly related to utilization of hospital resources.

Timing of surgical intervention in necrotizing enterocolitis can be determined by trajectory of metabolic derangement.

PURPOSE: Seven metrics of metabolic derangement were evaluated as contributors to clinical decision support for operative intervention in infants with suspected necrotizing enterocolitis (NEC). METHODS: Records of infants with suspected NEC without radiologic evidence of free air were queried for presence of 7 components of metabolic derangement (CMD), consisting of positive blood culture, acidosis, bandemia, thrombocytopenia, hyponatremia, hypotension, or neutropenia. Cases were stratified by clinical decision after each surgical evaluation as observation (OBS) or intervention (INT). Good outcome was defined as full enteric feeding by discharge and bad outcome as death or ongoing parenteral alimentation. Eleven infants undergoing operative intervention after an initial decision to observe were evaluated as matched pairs. Components of metabolic derangement/case and frequency of each CMD were determined for OBS and INT. Mann-Whitney U test was used to compare proportions of CMD in each group. Outcome was compared using chi(2). Observation was then stratified by outcome to determine whether 3 or more metabolic derangements warranting operative intervention would have changed initial clinical decision. The 11 matched cases were similarly analyzed using Wilcoxon-matched pairs. RESULTS: Between March 2005 and July 2008, 35 infants with NEC received 53 surgical evaluations. A median of 1 CMD/case was defined in 32 instances of OBS. Surgical intervention was carried out in 19 infants with a median of 3 CMD/case. Mann-Whitney U test indicated significant difference in the frequencies of each CMD component in OBS vs INT (P = .04). Good outcome was achieved in 75% of OBS and 63% of INT (non-significant, NS). Analysis of OBS by outcome demonstrated a median 1 CMD/case of 25 with good outcome and 3 CMD/case in infants with bad outcome. Frequency of CMD was significantly higher in infants with bad outcome (P = .02). Wilcoxon-matched pair analysis of the 11 infants with paired evaluations demonstrated a similar distribution and frequency of CMD. CONCLUSION: Progressive metabolic derangement of infants with NEC can be clinically tracked. The appearance of any 3 of these 7 metrics indicates timely operative intervention. Application of CMD trajectory to timing of surgical intervention may improve outcome and define the relationship between specific CMD and operative risk.

Trajectory of metabolic derangement in infants with necrotizing enterocolitis should drive timing and technique of surgical intervention.

BACKGROUND: Seven clinical metrics of metabolic derangement (MD7) have improved the timing of surgical intervention in infants with necrotizing enterocolitis (NEC). We compared surgical NEC outcomes based on MD7 at our center (unit S) with a similar center (unit B) that based its intervention on abdominal radiograph. STUDY DESIGN: Premature infants undergoing surgical care for NEC were evaluated. MD7 included positive blood culture, acidosis, bandemia, hyponatremia, thrombocytopenia, hypotension, and neutropenia. Surgical recommendations were stratified as observation or intervention. Good outcomes included full enteric feeding by discharge and poor outcomes were death or dependence on parenteral nutrition. For unit S and unit B, the frequency, median, and mode of MD7 component per case were determined for observation and intervention. Mann-Whitney U test and Wilcoxon matched pairs were used to compare positive MD7 frequency for observation with intervention. Institutional mortality was compared and metabolic severity of unit cohorts was evaluated by incidence of MD7 in each. RESULTS: From March 2005 to July 2008, forty-one infants at unit S underwent 62 surgical evaluations. Observation was elected in 38 (median 1 MD7 per case, mode 0). Operative intervention occurred in 24 (median 4 MD7 per case, mode 4). Proportional MD7 difference between observation and intervention was significant (p = 0.018, U = 6). From February 2007 to December 2008, sixty-five unit B infants received 81 evaluations, recommending 37 observations (median 2 MD7 per case, mode 2), and 44 interventions (median 3 MD7 per case, mode 3). MD7 proportions between observation and intervention were not significant (p = 0.318, U = 16). Poor outcomes rates for unit S and unit B infants were 24% and 66%, respectively (p = 0.0001). Severity of MD7 did not differ between institutions (p = 0.53, U = 19). CONCLUSIONS: These data demonstrate variability in surgical approach to NEC. The MD7 panel describes the trajectory of metabolic derangement, defines more timely surgical intervention, and demonstrates that waiting for free air is too late.

Surgical quality improvement: a simplified method to apply national standards to pediatric trauma care.

BACKGROUND: The emerging "pay for performance" national initiative mandates the development of valid metrics for risk stratification and performance assessment. The International Classification Injury Severity Score (ICISS) predicts survival from injury and is calculated as the product of survival risk ratios (SRRs) for a patient's 3 worst injuries. Survival risk ratios are derived as the proportion of fatalities for every International Classification of Diseases, Ninth Edition, Clinical Modification, diagnosis in a "benchmark" population. We hypothesized that the ICISS prediction model derived from the National Pediatric Trauma Registry (NPTR) would accurately predict mortality in an independent sample from a single pediatric trauma center (PTC) and could be applied to the NSQIP methodology to analyze performance. METHODS: The ICISS survival probabilities (Ps) were calculated for PTC patients using SRRs computed from 102,608 NPTR records. Records with a single diagnosis and Ps of 1 were excluded from the analysis. Receiver operator characteristics analysis (ROC) was used to evaluate the accuracy of Ps to predict mortality. The Hosmer-Lemeshow statistic was used to determine the degree that the NPTR-derived expected probabilities matched the observed mortality profile at the PTC. Program performance from 2000 to 2004 was then evaluated using Ps adjusted by logit transformation to predict expected mortality (E) for each year cohort. Observed mortality divided by expected mortality (O/E) was calculated for each year group to compare PTC performance to the NSQIP standard of one. The influence of injury severity on these results was determined by evaluating the correlation between O/E and mean Ps of each year cohort. RESULTS: A total of 1523 records were analyzed. The ROC area under the curve (AUC ) for Ps was .947 (confidence interval, .934-.957). The Hosmer-Lemeshow statistic (chi(2) = 5.102; df = 8; P = .747, not significant) indicated the model fit the data well. Adjusted O/E ratio after logit transformation of Ps for the PTC demonstrated initial performance slightly below standard (1.000778) followed by performance better than expected for the subsequent 4 years (range, .6466-.9784). The ratio of observed (O) to expected (E) demonstrated no correlation to mean Ps (r(2) = .378; P = .208). CONCLUSION: These data validate the application of injury diagnosis derived survival probabilities as objective metrics for determining performance using the NSQIP methodology. Incorporation of these objective predictors of expected outcome to calculation of the risk adjusted O/E ratio enables trend analysis of program performance over time. The lack of significant correlation between O/E and mean Ps demonstrates that NSQIP does indeed reflect process of care while adjusting for severity of patient pathologic condition.

The effect of delay in rehabilitation on outcome of severe traumatic brain injury.

BACKGROUND: Expeditious care within minutes of severe injury improves outcome and is the driving force for development of trauma care systems. Transition from hospital care to rehabilitation is an important step in recovery after trauma-related injury. We hypothesize that delay in the transition from acute care to rehabilitation adversely affects outcome and diminishes recovery after traumatic brain injury (TBI). METHODS: After institutional review board approval, the trauma registry of our regional level I pediatric trauma center was queried for all children with severe blunt TBI (initial Glasgow Coma Scale score