Adherence to the TQIP Palliative Care Guidelines Among Patients With Serious Illness at a Level I Trauma Center in the US.

Importance: The American College of Surgeons Trauma Quality Improvement Program (TQIP) guidelines encourage trauma service clinicians to deliver palliative care in parallel with life-sustaining treatment and recommend goals of care (GOC) discussions within 72 hours of admission for patients with serious illness. Objective: To measure adherence to TQIP guidelines-recommended GOC discussions for trauma patients with serious illness, treated at a level I trauma center in the US. Design, Setting, and Participants: This retrospective cohort study included 674 adults admitted to a trauma service center for 3 or more days between December 2019 and June 2020. The medical records of 486 patients who met the criteria for serious illness using a consensus definition adapted to the National Trauma Data Bank were reviewed for the presence of a GOC discussion. Patients were divided into 2 cohorts based on admission before or after the guidelines were incorporated into the institutional practice guidelines on March 1, 2020. Main Outcomes and Measures: The primary outcomes were GOC completion within 72 hours of admission and during the overall hospitalization. Patient and clinical factors associated with GOC completion were assessed. Other palliative care processes measured included palliative care consultation, prior advance care planning document, and do-not-resuscitate code status. Additional end-of-life processes (ie, comfort care and inpatient hospice) were measured in a subset with inpatient mortality. Results: Of 674 patients meeting the review criteria, 486 (72.1%) met at least 1 definition of serious illness (mean [SD] age, 60.9 [21.3] years; mean [SD] Injury Severity Score, 16.9 [12.3]). Of these patients, 328 (67.5%) were male and 266 (54.7%) were White. Among the seriously ill patients, 92 (18.9%) had evidence of GOC completion within 72 hours of admission and 124 (25.5%) during the overall hospitalization. No differences were observed between patients admitted before and after institutional guideline publication in GOC completion within 72 hours (19.0% [47 of 248 patients] vs 18.9% [45 of 238]; P = .99) or during the overall hospitalization (26.2% [65 of 248 patients] vs 24.8% [59 of 238]; P = .72). After adjusting for age, GOC completion was found to be associated with the presence of mechanical ventilation (odds ratio [OR], 6.42; 95% CI, 3.49-11.81) and meeting multiple serious illness criteria (OR, 4.07; 95% CI, 2.25-7.38). Conclusions and Relevance: The findings of this cohort study suggest that, despite the presence of national guidelines, GOC discussions for patients with serious illness were documented infrequently. This study suggests a need for system-level interventions to ensure best practices and may inform strategies to measure and improve trauma service quality in palliative care.

Underutilization of Palliative Care for Patients with Advanced Peripheral Arterial Disease.

BACKGROUND: Advanced peripheral arterial disease is associated with an overall annual mortality between 20-40%. Amputees are at particularly high risk for perioperative and long-term mortality and may benefit from palliative care programs to improve quality of life and to align medical treatments with their goals of care. As studies of palliative care in vascular patients are scarce, we sought to examine palliative care utilization using below knee amputation (BKA) as a surrogate for advanced peripheral arterial disease. METHODS: All patients who underwent below knee amputation over a 5-year period at a single large academic medical center were identified through chart review. Demographics, preoperative conditions, intraoperative factors, and perioperative outcomes were recorded. The primary outcome was palliative care consultation at the time of the amputation. The secondary outcomes included one-year mortality and palliative care consultation prior to death. RESULTS: The cohort comprised 111 patients (76 men, 35 women) who received BKA for chronic limb threatening ischemia. Three patients (2.7%) received palliative care consultations at the time of their amputation. Of these, one had been obtained remotely for an oncologic condition and the others for surgical decision-making. Follow-up was available for 73 patients. One-year mortality was 21.9% (n = 16) at a mean of 102 ± 86 days after BKA. Among patients who died within 1 year of their amputation, 37.5% (n = 6) received palliative care consultations prior to their death. The median interval between amputation and palliative consultation was 26 (IQR 14-81) days. The median interval between palliative consultation and death was 9 (IQR 4-39) days. CONCLUSION: Palliative care services were rarely provided to patients with advanced peripheral arterial disease. When obtained, consultations occurred closer to death than to amputation suggesting a missed opportunity to receive the benefits of early evaluation. Future studies can be aimed at identifying a cohort of vascular patients who would most benefit from early palliative evaluation and determining if palliative consultations alter health care utilization patterns and outcomes for vascular patients.

ECMO Membrane Lung Failure due to Hypertriglyceridemia: A Case Report and Review of the Literature.

The deleterious effects of high serum lipid content on the membrane lung (ML) during extracorporeal membrane oxygenation (ECMO) are sparsely documented, and the threshold of lipemia-induced membrane failure is poorly described. We present a case of a patient on venovenous ECMO who developed ML failure after 7 days due to moderate to severe hypertriglyceridemia (700-800 mg/dL). ML failure was exhibited by impaired gas exchange and high transmembrane pressures, and there was notable lipemic layering in the circuit immediately after decannulation. This case demonstrates that in addition to patients with extreme lipemia, ML failure can also occur in patients with moderate to severe hypertriglyceridemia. Hypertriglyceridemia should be suspected in patients with high transmembrane pressures and ML failure not attributable to thrombosis, and these patients may require frequent ML changes if a prolonged ECMO run is required.

Validation of a low-cost simulation strategy for burn escharotomy training.

BACKGROUND: Escharotomy is the primary effective intervention to relieve constriction and impending vascular compromise in deep, circumferential or near-circumferential burns of the extremities and trunk. Training on escharotomy indications, technique and pitfalls is essential, as escharotomy is both an infrequent and high-risk procedure in civilian and military medical environments, including low-resource settings. Therefore, we aimed to validate an educational strategy that combines video-based instruction with a low-cost, low-fidelity simulation model for teaching burn escharotomy. METHODS: Pre-hospital and hospital-based medical personnel, with varying degrees of burn care-related experience, participated in a one-hour training session. The first part of the training consisted of video-based instruction that described the indications, preparation, steps, pitfalls and complications associated with escharotomy. The second part of the training consisted of a supervised, hands-on simulation with a previously described low-cost, low-fidelity escharotomy model. Participants were then offered two psychometrically validated instruments to assess their learning experience. RESULTS: 40 participants were grouped according to prior burn care and surgical experience: attending surgeons (6), surgery and emergency medicine residents and fellows (26), medical students (5), and pre-hospital personnel (3). On two psychometrically validated questionnaires, participants at both the attending and trainee levels overwhelmingly confirmed that our educational strategy met best educational practices on the criteria of active learning, collaboration, diverse ways of learning, and high expectations; they also highly rated their satisfaction with and self-confidence under this learning strategy. DISCUSSION: An educational strategy that combines video-based instruction and a low-cost, low-fidelity escharotomy simulation model was successfully demonstrated with participants across a broad range of prior burn care experience levels. This strategy is easily reproducible and broadly applicable to increase the knowledge and confidence of medical personnel before they are called to perform escharotomy. Important applications include resource-limited environments and deployed military settings.

Early patient deaths after transfer to a regional burn center.

INTRODUCTION: Patients who sustain burn injuries are frequently transferred to regional burn centers. Severely injured patients, unlikely to survive, may be transported far from home and family to die shortly after arrival. An examination of early deaths, those that happen within a week of transfer, may offer an opportunity to revise the way we think about critical burns and consider the best way to provide regional care. METHODS: This is a focused review of burn patients who survived ≤1 week after transfer to a regional center from 2013-2017. Originating location data such as city, state, population at origin were obtained. Transfer data, including mode of transport and distance traveled, as well as patient characteristics, Total Body Surface Area (TBSA) burned, inhalation injury, medical history with calculation of revised-Baux (r-Baux) score were analyzed. RESULTS: 25 patients (1.2%) met inclusion criteria. Patients were transferred from a wide geographic area with population ranges of 1000 to 279,000. 21 patients met criteria for burn resuscitation by TBSA; 4 (19%) were placed on comfort care upon arrival, 7 (33%) were placed on comfort care after discussion with the patient's family, and 10 (48%) received full resuscitation efforts. Of these 10 patients, 2 died as "full code", 8 were transitioned to comfort care after failed resuscitation or other events. Code status was not always addressed prior to the decision to transfer. Two patients were transferred after cardiac arrest in the field both of which had significant medical comorbidities in addition to their burn. CONCLUSIONS: Regional burn centers support a variety of populations. Transferring patients for which care is futile may have a profound impact on resource utilization from a variety of perspectives including transferring centers, receiving centers, regional Emergency Medical Services and families. Referring providers need to be supported in identifying these severely injured, potentially expectant patients. Transfer of patients may negatively impact families as a loved one may die far from home, before family can arrive. With our increasing ability to utilize telemedicine, transfer may not always provide the best support we can offer for providers, patients, and families. APPLICABILITY OF RESEARCH TO PRACTICE: Early deaths after transfer to a regional burn center, especially those that do not undergo a full resuscitation, should be critically examined to determine the appropriateness of transfer in a palliative, patient and family centered approach.

Rectal Injury After Foreign Body Insertion: Secondary Analysis From the AAST Contemporary Management of Rectal Injuries Study Group.

BACKGROUND: Retained rectal foreign bodies are a common but incompletely studied problem. This study defined the epidemiology, injury severity, and outcomes after rectal injuries following foreign body insertion. METHODS: Twenty-two level I trauma centers retrospectively identified all patients sustaining a rectal injury in this AAST multi-institutional trial (2005-2014). Only patients injured by foreign body insertion were included in this secondary analysis. Exclusion criteria were death before rectal injury management or ≤48 h of admission. Demographics, clinical data, and outcomes were collected. Study groups were defined as partial thickness (AAST grade I) versus full thickness (AAST grades II-V) injuries. Subgroup analysis was performed by management strategy (nonoperative versus operative). RESULTS: After exclusions, 33 patients were identified. Mean age was 41 y (range 18-57), and 85% (n = 28) were male. Eleven (33%) had full thickness injuries and 22 (67%) had partial thickness injuries, of which 14 (64%) were managed nonoperatively and 8 (36%) operatively (proximal diversion alone [n = 3, 14%]; direct repair with proximal diversion [n = 2, 9%]; laparotomy without rectal intervention [n = 2, 9%]; and direct repair alone [n = 1, 5%]). Subgroup analysis of outcomes after partial thickness injury demonstrated significantly shorter hospital length of stay (2 ± 1; 2 [1-5] versus 5 ± 2; 4 [2-8] d, P = 0.0001) after nonoperative versus operative management. CONCLUSIONS: Although partial thickness rectal injuries do not require intervention, difficulty excluding full thickness injuries led some surgeons in this series to manage partial thickness injuries operatively. This was associated with significantly longer hospital length of stay. Therefore, we recommend nonoperative management after a retained rectal foreign body unless full thickness injury is conclusively identified.

Outpatient opioid use of burn patients: A retrospective review.

INTRODUCTION: Opioid overuse is a growing patient safety issue but continue to be integral to burn pain management. This study aims to characterize opioid use in discharged patients and factors for predictive of long term use. METHODS: Participants with burns admitted to a single center from 2006 to 2015 were included. Total outpatient morphine equivalent dose (MED) was recorded at discharge and each clinic visit. Burn size, percent grafted, age, sex, and preadmission drug use were collected. For each time point, multivariate logistic regression was performed to examine the relationship of discharge MED and long-term opioid use, adjusting for age, sex, burn size, and percent grafted. MED was divided into low (0-150 mg per day), medium (151-300 mg per day), and high (greater than 301 mg) groups on day of discharge. RESULTS: At discharge, 366 (90%) patients received opioids. At day 14, both the medium MED (OR 2.72; CI 1.18-6.23) and high MED (OR 2.74; CI 1.02-7.37) groups had an increased risk for continued opioid use. On day 60, only the high MED group (OR 6.06; CI 1.60-22.97) had an increased risk. History of drug use was significant at 60 days (OR 7.67; 1.67-35.26) and alcohol use was significant at 14 days (OR 3.14; CI 1.25-7.93) and 30 days (OR 5.92; CI 1.81-19.36). CONCLUSIONS: Whereas opioids are widely prescribed upon discharge, most patients no longer use them 30 days later. Higher opiate utilization at discharge increases risk of long term use, as does pre-injury drug and alcohol use, but only temporarily.

The frailty tipping point: Determining which patients are targets for intervention in a burn population.

OBJECTIVE: Elderly burn patients vary in physiologic age and frailty. While previous evidence suggests that frailty on admission is associated with poor outcomes, changes in frailty during hospitalization for a burn injury have not been reported. METHODS: We performed a two-year retrospective review of all elderly (≥65years) burn-patients admitted to our burn center. Patients who died during admission were excluded. Data collected include: demographics, injury characteristics, outcomes, and discharge disposition. Canadian Study on Health and Aging Clinical Frailty Scores (CFS) were calculated on admission and at discharge. Change in frailty was calculated for each patient. Mean values are represented as mean±standard deviation, median values are represented as median (IQR). RESULTS: Seventy-nine patients, mean age of 75±8years, with a mean admission CFS was 4.3±1.2 and discharge CFS was 5.1±1.2 were included in the study. The mean change in CFS was -0.55±0.93. Forty-six patients (59%) had no change or an improvement in frailty during hospitalization while 32 (41%) had worsened CFS at discharge. Patients whose CFS was worse at discharge had larger burns (12.8±10.7% vs. 6.28±5.7%), lower admission CFS (3.88±1.5 vs. 4.93±1.0), and longer ICU stays (15.6±18.9 vs. 7.64± 10.6 days) than patients without change in CFS. On multivariate regression analysis TBSA (OR 1.2 (1.07-1.3)) and admission CFS of 1-4 (OR 7.9 (2.2-28)) were significant predictors of worsened CFS at discharge. CONCLUSIONS: In our study population, patients with low admission frailty scores are at greatest risk for worsened frailty at discharge and should be targeted for the development of future frailty prevention programs.

Traumatic rectal injuries: Is the combination of computed tomography and rigid proctoscopy sufficient?

BACKGROUND: There are no clear guidelines for the best test or combination of tests to identify traumatic rectal injuries. We hypothesize that computed tomography (CT) and rigid proctoscopy (RP) will identify all injuries. METHODS: American Association for the Surgery of Trauma multi-institutional retrospective study (2004-2015) of patients who sustained a traumatic rectal injury. Patients with known rectal injuries who underwent both CT and RP as part of their diagnostic workup were included. Only patients with full thickness injuries (American Association for the Surgery of Trauma grade II-V) were included. Computed tomography findings of rectal injury, perirectal stranding, or rectal wall thickening and RP findings of blood, mucosal abnormalities, or laceration were considered positive. RESULTS: One hundred six patients were identified. Mean age was 32 years, 85(79%) were male, and 67(63%) involved penetrating mechanisms. A total of 36 (34%) and 100 (94%) patients had positive CT and RP findings, respectively. Only 3 (3%) patients had both a negative CT and negative RP. On further review, each of these three patients had intraperitoneal injuries and had indirect evidence of rectal injury on CT scan including pneumoperitoneum or sacral fracture. CONCLUSION: As stand-alone tests, neither CT nor RP can adequately identify traumatic rectal injuries. However, the combination of both test demonstrates a sensitivity of 97%. Intraperitoneal injuries may be missed by both CT and RP, so patients with a high index of suspicion and/or indirect evidence of rectal injury on CT scan may necessitate laparotomy for definitive diagnosis. LEVEL OF EVIDENCE: Diagnostic, level IV.

Frailty score on admission predicts mortality and discharge disposition in elderly trauma patients over the age of 65 y.

BACKGROUND: Although many frailty scales exist, a single scale has not been agreed upon to define frailty. Herein, we determined whether the Canadian Study on Health and Aging Clinical Frailty Scale (CSHA CFS) can predict the risk of elderly patients for hospital mortality and discharge to skilled nursing facilities (SNFs) following traumatic injury. METHODS: Charts from trauma patients aged ≥65 y admitted from December 1, 2011 to December 31, 2013 were retrospectively examined. Age, mechanism of injury, Glasgow coma score, systolic blood pressure and heart rate on arrival, injury severity score, hospital mortality, length of stay, and discharge disposition were recorded. Frailty scores were determined from admission data using the CSHA CFS. Univariate and multivariate analyses were performed. RESULTS: A total of 1403 patients were included. The mean age was 77.6 ± 8.6 y. Patients with falls presented higher frailty scores than patients who sustained injuries through other mechanisms (4.58 ± 1.2 versus 3.52 ± 1.15; P < 0.00001) and were significantly older (79.5 ± 8.6 versus 73.4 ± 7.4; P <0.00001). Frailty scores of nonsurvivors were significantly higher than those of survivors (4.6 ± 1.3 versus 4.2 ± 1.2; P <0.01). Age, Glasgow coma score, and CSHA CFS combined were associated with mortality (odds ratio: 1.52; confidence interval: 1.37-1.69). A higher frailty score was associated with earlier death and increased mortality. CONCLUSIONS: CSHA CFS is simple and provides frailty scores that can help identifying elderly patients at high risk for in-hospital mortality and discharge to SNF following traumatic injury.

Frailty Is Associated With Mortality in Patients Aged 50 Years and Older.

Recent evidence indicates that increased frailty is associated with increased mortality in patients with burn over the age of 65 years. However, the effect of frailty may not be restricted to those over the age of 65 years. We hypothesize that admission frailty is associated with mortality in patients with burn ≥50 years of age. We performed a 5-year (2008-2013) retrospective review of patients with acute burn aged 50 years or older. Data collected included demographics, injury characteristics, outcomes, and discharge disposition. Frailty scores (FS) were calculated using the Canadian Study of Health and Aging Clinical Frailty Scale. Values are expressed as mean ± SD. About 502 patients with a mean age of 63.5 ± 10.7 years were ansalyzed. Mean TBSA was 11.7 ± 14.1%, 47 patients (9.4%) died, and mean FS was 3.7 ± 1.2 (7 being worst and 1 best). Multivariate logistic regression demonstrated an independent association between mortality and FS of ≥5 (odds ratio [OR], 1.94; 95% confidence interval [CI], 1.3 to 2.8). Patients who were ≥65-years-old had significantly higher FS (4.2 ± 1.2 vs 3.5 ± 1.1), and more deaths (26 vs 21 patients). Multivariate logistic regression revealed that increased admission FS is associated with increased mortality to a greater extent in the 50- to 65-year-old group (age 50-65 years: OR, 2.5; 95% CI, 1.4 to 4.6; age ≥ 65 years: OR, 1.63; 95% CI, 1.003 to 2.7). FS on admission allow for an improved assessment of preinjury physiological condition in patients with burn aged ≥50 years. Poor preinjury physiological fitness is associated with increased risk of death in patients with burn aged ≥50 years.

Contemporary management of rectal injuries at Level I trauma centers: The results of an American Association for the Surgery of Trauma multi-institutional study.

INTRODUCTION: Rectal injuries have been historically treated with a combination of modalities including direct repair, resection, proximal diversion, presacral drainage, and distal rectal washout. We hypothesized that intraperitoneal rectal injuries may be selectively managed without diversion and the addition of distal rectal washout and presacral drainage in the management of extraperitoneal injuries are not beneficial. METHODS: This is an American Association for the Surgery of Trauma multi-institutional retrospective study from 2004 to 2015 of all patients who sustained a traumatic rectal injury and were admitted to one of the 22 participating centers. Demographics, mechanism, location and grade of injury, and management of rectal injury were collected. The primary outcome was abdominal complications (abdominal abscess, pelvic abscess, and fascial dehiscence). RESULTS: After exclusions, there were 785 patients in the cohort. Rectal injuries were intraperitoneal in 32%, extraperitoneal in 58%, both in 9%, and not documented in 1%. Rectal injury severity included the following grades I, 28%; II, 41%; III, 13%; IV, 12%; and V, 5%. Patients with intraperitoneal injury managed with a proximal diversion developed more abdominal complications (22% vs 10%, p = 0.003). Among patients with extraperitoneal injuries, there were more abdominal complications in patients who received proximal diversion (p = 0.0002), presacral drain (p = 0.004), or distal rectal washout (p = 0.002). After multivariate analysis, distal rectal washout [3.4 (1.4-8.5), p = 0.008] and presacral drain [2.6 (1.1-6.1), p = 0.02] were independent risk factors to develop abdominal complications. CONCLUSION: Most patients with intraperitoneal injuries undergo direct repair or resection as well as diversion, although diversion is not associated with improved outcomes. While 20% of patients with extraperitoneal injuries still receive a presacral drain and/or distal rectal washout, these additional maneuvers are independently associated with a three-fold increase in abdominal complications and should not be included in the treatment of extraperitoneal rectal injuries. LEVEL OF EVIDENCE: Therapeutic study, level III.

Substituted azaquinazolinones as modulators of GHSr-1a for the treatment of type II diabetes and obesity.

Substituted azaquinazolinones were identified as antagonists of the GHSr-1A receptor for the treatment of type II diabetes and obesity. Optimisation for potency and LogD lead to the identification of orally bioavailable, potent antagonists with improved selectivity over hERG.