Patient education and recall regarding postsplenectomy immunizations.

BACKGROUND: The purpose of this study was to determine the rates of initial vaccinations after splenectomy for trauma, assess the effectiveness of patient education on reimmunizations, and evaluate patients' utilization of their knowledge regarding immunization after discharge. METHODS: From June 1996-December 2011, 144 patients underwent splenectomy after traumatic injury. A telephone survey was completed in 100 of 144 splenectomized patients (69%) at a mean of 7.9 y after their splenectomy. Questions were directed to determine the quality of patients' recall of the implications of splenectomy, the need for vaccinations, and the quality of the health information administered. Research electronic data capture tool was used for collecting data, and data were analyzed with Stata 11.2. RESULTS: Only 27% of participants recall receiving education on postsplenectomy vaccination and 41% of those patients rated their education as poor or minimal. Ninety-one percent of patients indicated that they would like more information in the form of a brochure. Our overall initial vaccination rates among patients who had splenectomy from 1996-2011 were 76%, 75%, and 68% for Streptococcus pneumoniae, Neisseria meningitidis, and Hemophilus influenza type b, respectively. Since 2004, 95% of those who had splenectomy between 2004 and 2007 received all three vaccines. Since 2008, our institution has maintained 100% initial vaccination rates for all three vaccines. The revaccination rates in this group of patients (from 1996-2007) were 39% and 15% for pneumococcal and meningococcal vaccines, respectively. CONCLUSIONS: Patients had poor recall of the information provided during hospitalization for splenectomy. There were low revaccination rates in our patient cohort. Specific educational and vaccination surveillance strategies are required to improve vaccination rates.

Obesity delays functional recovery in trauma patients.

BACKGROUND: Obesity is known to complicate trauma hospital stays. We hypothesize that obesity delays functional recovery in trauma patients. MATERIALS AND METHODS: Between 2005 and 2007, adult patients with a hospital length of stay >24 h were prospectively recruited for the study. Functional Independence Measurement (FIM) scores were calculated at the time of admission, discharge, and 6 mo after discharge. Patients were classified as nonobese (body mass index [BMI] <25), overweight (BMI ≥25 and <30), obese (BMI ≥30 and <35), and morbidly obese (BMI ≥35). Multivariate analyses were performed to determine the impact of obesity on FIM scores. RESULTS: Two hundred thirty-five patients met the study inclusion criteria. Average injury severity scores was >18. We recorded no mortality at the time of discharge and follow-up. During acute hospital stay stage, nonobese patients had an average of 24 points increase on FIM scores compared with morbidly obese patients with 16 points improvement (P = 0.023). Compared with nonobese patients, the rate of recovery was reduced by 30% in overweight (P = 0.034), 37% in obese (P = 0.025), and 48% in morbidly obese patients (P = 0.003). Alternatively, we found that for every unit increase in BMI, the functional recovery rate was reduced by 4% (P < 0.001). Changes in FIM scores during the postdischarge period were not significantly different by obesity classification, and all groups achieve similar functional outcome at follow-up (P = 0.482). CONCLUSIONS: Most trauma patients achieve full functional recovery some time after hospital discharge, but the recovery is delayed in obese patients and the delay is directly correlated with the severity of obesity.

Characterizing demographics, injury severity, and intubation status for patients transported by air or ground ambulance to a rural burn center.

Our study was designed to characterize intubation status among patients transported by air or ground ambulance to a rural burn center. A retrospective chart review of patients arriving at our burn center from January 1, 2005 to December 31, 2009 was completed. Descriptive and multivariate analyses were performed. During the study period, 259 air and 590 ground ambulance patients met inclusion criteria. Air ambulance patients were older and had higher total body surface area burned, lower Glasgow Coma scores, longer lengths of stay, and more frequent inhalation injuries. Approximately 10% of patients arriving by air were intubated after burn center admission, and 49% of intubated patients were extubated within 24 hours of admission. These values were 2% and 40%, respectively, for patients transported by ground. Increasing age and air ambulance transport increased the overall likelihood of change in intubation status. The likelihood of intubation by burn center providers increased with age, with suspicion of inhalation injury, and for patients transported by air. The likelihood of extubation within 24 hours of burn center admission increased with age, decreased with suspected inhalation injury, and was independent of transport mode. Among our patient population, more severely injured patients were being transported by air ambulance. However, age, suspicion of inhalation injury, and mode of transport showed a complex pattern of associations with changes in intubation status, and illustrate the need to develop better prehospital guidelines for intubation in burn patients.

Trends in 393 necrotizing acute soft tissue infection patients 2000-2008.

OBJECTIVE: To determine the outcomes effect of changing trends in patients with necrotizing acute soft tissue infections (NASTI) 2000-2008. METHODS: A single institution retrospective chart review of all patients treated for NASTI. RESULTS: There were 393 patients with mean age 50 years, diabetes 53%, % body surface area excised 3.5. Wounds were located on: extremity 57%, perineum 40%, trunk 26%. Wound cultures %: polymicrobial=62, Staphylococci=48, Streptococci=31. Patients developing complications %: Pulmonary=23, renal insufficiency/failure=27. During the study period, overall mortality rate remained unchanged: 30/393=7.6% (5.5% for patients first admitted by burn/trauma/acute care surgery vs. 29% for all other services, p=0.003). Significant annual increases were found in number of patients, p=0.03, male sex, p=0.000, transfer from outside hospital, p<0.001, BMI p=0.003, ventilator requirement >24h, p=0.0005, APACHE II p=0.002, and number of patients developing any complication, p=0.04. Statistically significant decreases annually were found in: days of antibiotic use, p=0.008, number of operations required for excision, p=0.02, development of non-wound infections, p=0.002, and length of stay in days (LOS), p=0.03. CONCLUSIONS: This is the largest cohort of NASTI patients from a single institution to date, demonstrating significantly shorter LOS and decreased non-wound infection rates in the face of increasing BMI and APACHE II scores. The increasing number of patients and BMI suggests a causal relationship between NASTI and obesity. Initial care by surgeons experienced in caring for these patients provides mortality rates well below the national average.

Long-term outcomes of patients with necrotizing fasciitis.

CONTEXT: Necrotizing fasciitis is an aggressive infection affecting the skin and soft tissue. It has a very high acute mortality. The long-term survival and cause of death of patients who survive an index hospitalization for necrotizing fasciitis are not known. OBJECTIVE: To define the long-term survival of patients who survive an index admission for necrotizing fasciitis. We hypothesize that survivors will have a shorter life span than population controls. DESIGN: Long-term follow-up of a registry of patients from 1989 to 2006 who survived a hospitalization for necrotizing fasciitis. Last date of follow-up was January 1, 2008. SETTINGS: A university-based Burn and Trauma Center. PATIENTS: A prospective registry of patients with necrotizing fasciitis has been collected from 1989 to 2006. This registry was linked to data from the Department of Health, Department of Motor Vehicles, and the University Hospital Medical Records Department in January 2008 to obtain follow-up and vital status data. INTERVENTION: None. MAIN OUTCOME MEASURES: Date and cause of death were abstracted from death certificates. Date of last live follow-up was determined from the medical record and by the last driver's license renewal. The death rate of the cohort was standardized for age and sex against 2005 statewide mortality rates. Cause of death was collated into infectious and noninfectious and compared with the statewide causes of death. Statistical analysis included standardized mortality rates, Kaplan-Meier survival curves, and Aalen's additive hazard model. RESULTS: Three hundred forty-five patients of the 377 in the registry survived at least 30 days and were analyzed. Average age at presentation was 49 years (range, 1-86; median, 49). Patients were followed up an average of 3.3 years (range, 0.0-15.7; median, 2.4). Eighty-seven of these patients died (25%). Median survival was 10.0 years (95% confidence interval: 7.25-13.11). There was a trend toward higher mortality in women. Twelve of the 87 deaths were due to infectious causes. Using three different statistical analytic techniques, there was a statistically significant increase in the long-term death rate when compared with population-based controls. Infectious causes of death were statistically higher than controls as well. CONCLUSIONS: Patients who survive an episode of necrotizing fasciitis are at continued risk for premature death; many of these deaths were due to infectious causes such as pneumonia, cholecystitis, urinary tract infections, and sepsis. These patients should be counseled, followed, and immunized to minimize chances of death. Modification of other risk factors for death such as obesity, diabetes, smoking, and atherosclerotic disease should also be undertaken. The sex difference in long-term survival is intriguing and needs to be addressed in further studies.