Failure to Rescue in Geriatric Ground-Level Falls: The Role of Frailty on Not-So-Minor Injuries.

INTRODUCTION: The measure of mortality following a major complication (failure to rescue [FTR]) provides a quantifiable assessment of the level of care provided by trauma centers. However, there is a lack of data on the effects of patient-related factors on FTR incidence. The aim of this study was to identify the role of frailty on FTR incidence among geriatric trauma patients with ground-level falls (GLFs). METHODS: This is a retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program database (2017-2020). All geriatric (aged ≥ 65 ys) trauma patients with GLFs admitted to a level I trauma center were included. Transferred patients, those with severe head injuries (head abbreviated injury scale ≥ 3), and those who died within 24 h of admission or whose length of stay was ≤1 d were excluded. FTR was defined as death following a major complication (cardiac arrest, myocardial infarction, sepsis, acute respiratory distress syndrome, unplanned intubation, acute renal failure, cerebrovascular accident, ventilator-associated pneumonia, or pulmonary embolism). Patients were stratified into frail (F) and nonfrail (NF) based on the 11-Factor Modified Frailty Index. Multivariable regression analyses were performed to identify the independent effect of frailty on the incidence of FTR. RESULTS: Over 4 ys, 34,100 geriatric patients with GLFs were identified, of whom 9140 (26.8%) were F. The mean (standard deviation) age was 78 (7) years and 65% were female. The median injury severity score was 9 (5-10) with no difference among F and NF groups (P = 0.266). Overall, F patients were more likely to develop major complications (F: 3.6% versus NF: 2%, P < 0.001) and experience FTR (F: 1.8%% versus NF: 0.6%, P < 0.001). Moreover, among patients with major complications, F patients were more likely to die (F: 47% versus NF: 27%, P < 0.001). On multivariable regression analysis, frailty was identified as an independent predictor of major complications (adjusted odds ratio: 1.98, 95% confidence interval [1.70-2.29], P < 0.001) and FTR (adjusted odds ratio: 2.26, 95% confidence interval [1.68-3.05], P < 0.001). CONCLUSIONS: Among geriatric trauma patients with GLFs, frailty increases the risk-adjusted odds of FTR by more than two times. One in every two F patients with a major complication does not survive to discharge. Future efforts should concentrate on improving patient-related and hospital-related factors to decrease the risk of FTR among these vulnerable populations.

Outcomes of Patients With Traumatic Brain Injury Transferred to Trauma Centers.

Importance: Wide variations exist in traumatic brain injury (TBI) management strategies and transfer guidelines across the country. Objective: To assess the outcomes of patients with TBI transferred to the American College of Surgeons (ACS) level I (LI) or level II (LII) trauma centers (TCs) on a nationwide scale. Design, Setting, and Participants: In this secondary analysis of the ACS Trauma Quality Improvement Program database (2017 to 2020), adult patients with isolated TBI (nonhead abbreviated injury scale = 0) with intracranial hemorrhage (ICH) who were transferred to LI/LII TCs we re included. Data were analyzed from January 1, 2017, through December 31, 2020. Main Outcomes and Measures: Outcomes were rates of head computed tomography scans, neurosurgical interventions (cerebral monitors, craniotomy/craniectomy), hospital length of stay, and mortality. Descriptive statistics and hierarchical mixed-model regression analyses were performed. Results: Of 117 651 patients with TBI with ICH managed at LI/LII TCs 53 108; (45.1%; 95% CI, 44.8%-45.4%) transferred from other centers were identified. The mean (SD) age was 61 (22) years and 30 692 were male (58%). The median (IQR) Glasgow Coma Scale score on arrival was 15 (14-15); 5272 patients had a Glasgow Coma Scale score of 8 or less on arrival at the receiving trauma center (10%). A total of 30 973 patients underwent head CT scans (58%) and 2144 underwent repeat head CT scans at the receiving TC (4%). There were 2124 patients who received cerebral monitors (4%), 6862 underwent craniotomy/craniectomy (13%), and 7487 received mechanical ventilation (14%). The median (IQR) hospital length of stay was 2 (1-5) days and the mortality rate was 6.5%. There were 9005 patients (17%) who were discharged within 24 hours and 19 421 (37%) who were discharged within 48 hours of admission without undergoing any neurosurgical intervention. Wide variations between and within trauma centers in terms of outcomes were observed in mixed-model analysis. Conclusions: In this study, nearly half of the patients with TBI managed at LI/LII TCs were transferred from lower-level hospitals. Over one-third of these transferred patients were discharged within 48 hours without any interventions. These findings indicate the need for systemwide guidelines to improve health care resource use and guide triage of patients with TBI.

The efficient application of instilling negative pressure wound therapy with a hypochlorous acid-preserved wound cleanser: a case series and practical advice.

BACKGROUND: The use of negative pressure wound therapy with instillation and dwell time (NPWTi-d) has been shown to be effective in removing nonviable tissue, reducing bioburden, and promoting granulation tissue formation in acute and chronic infected wounds. OBJECTIVE: To illustrate the clinical efficacy of the use of pure hypochlorous acid (pHA) antimicrobially preserved wound cleansing solution as the instillation fluid for NPWTi-d (NPWTi-d/pHA) in wound bed preparation in patients with complex wounds. CASE REPORT: The treatment protocol for use of NPWTi-d/pHA in preparing wound beds for final closure is demonstrated in 3 illustrative cases of patients with complex wounds resulting from necrotizing infection and trauma with heavy contamination. All 3 patients developed a healthy-appearing wound bed deemed suitable for primary closure an average of approximately 1 month following initial surgical debridement. CONCLUSION: The cases presented demonstrate the ability of a pHA antimicrobially preserved wound cleansing solution used as the instillation fluid with NPWTi-d to aid in bacterial reduction, mechanical debridement, and promotion of wound healing. Use of NPWTi-d/pHA in these cases of extensive necrotizing infection and posttraumatic injury with heavy contamination allowed for final closure an average of 1 month after initial surgical debridement.

Multidisciplinary expert consensus statements and recommendations for use of hypochlorous acid as a solution for negative pressure wound therapy with instillation.

BACKGROUND: HOCl (eg, pHAp) preserved solutions have antimicrobial properties and are considered safe and effective for wound management. NPWTi-d (or NPWTi) is an established adjunctive wound modality for a variety of wound etiologies in various anatomic locations in which an instillate solution dwells on the surface of the wound to assist in wound bed preparation. A variety of solutions have been used, including 0.9% normal saline wound cleansers and antiseptics. pHAp is growing in popularity as the solution of choice for NPWTi-d. OBJECTIVE: To evaluate consensus statements on the use of NPWTi-d with pHAp. METHODS: A 15-member multidisciplinary panel of expert clinicians in the United States, Canada, and France convened in person in April 2023 in Washington, D.C. and/or corresponded later to discuss 10 statements on the use of pHAp with NPWTi-d. The panelists then replied "agree" or "disagree" to each statement and had the option to provide comments. RESULTS: Ten consensus statements are presented, along with the proportion of agreement or disagreement and summary comments. Although agreement with the statements on NPWTi-d with pHAp varied, the statements appear to reflect individual preferences for use rather than concerns about safety or efficacy. CONCLUSION: The consensus indicates that NPWTi-d with pHAp can have a beneficial effect in wound care.

Synergistic clinical application of synthetic electrospun fiber wound matrix in the management of a complex traumatic wound: degloving left groin and thigh auger injury.

BACKGROUND: Managing complex traumatic soft tissue wounds involving a large surface area while attempting to optimize healing, avoid infection, and promote favorable cosmetic outcomes is challenging. Regenerative materials such as ECMs are typically used in wound care to enhance the wound healing response and proliferative phase of tissue formation. CASE REPORT: The case reported herein is an example of the efficacious use of an SEFM in the surgical management of a large complex traumatic wound involving the left lower extremity and lower abdominal region. The wound bed was successfully prepared for skin grafting over an area of 1200 cm2, making this among the largest applications of the SEFM reported in the literature. CONCLUSION: This case report demonstrates the clinical versatility of the SEFM and a synergistic approach to complex traumatic wound care. The SEFM was successfully used to achieve tissue granulation for a successful skin graft across a large surface in an anatomic region with complex topography.

Definitive Closure Using an Ovine Reinforced Tissue Matrix in Contaminated Penetrating Abdominal Trauma.

BACKGROUND Cases involving penetrating abdominal trauma may be complex and often involve damage to multiple organ systems. Synthetic, biologic, and reinforced biologic matrices/reinforced tissue matrices (RBMs/RTMs) are frequently used in hernia repair and other surgical procedures requiring reinforcement, including trauma cases that require abdominal repair. CASE REPORT The first case was a 35-year-old male patient with a stab wound (SW) to the right side of the chest and the abdomen resulting in damage to the diaphragm, epicardium, liver, and duodenum. The second case was a 22-year-old male patient who suffered multiple traumas after an automated trencher accident, including a skull fracture with exposed brain and major lacerations to the shoulder and abdomen causing a large right-flank hernia. In both cases, OviTex® (TELA Bio, Inc., Malvern, PA), a reinforced tissue matrix (RTM), was used to help obtain and maintain abdominal wall closure. We also present an institutional economic analysis using data from the author's institution with average case cost and future projections for procedure volume and product usage volume through 2021. CONCLUSIONS We report favorable outcomes in a series of patients with contaminated (CDC Wound Class III) surgical fields who underwent abdominal wall closure and reinforcement with OviTex RTM. Our work adds to the growing body of literature suggesting that reinforced biologics offer a potential alternative to biological meshes in the setting of a contaminated surgical field. Additionally, in comparison to other commonly available biologic matrices, use of OviTex RTM may be a cost-effective option to achieve abdominal wall closure even in complex cases.

Burn Center Patients at Risk for Upper Extremity Amputations.

Introduction Burn center patients present not only with burn injuries but also necrotizing infections, purpura fulminans, frostbite, toxic epidermal necrolysis, chronic wounds, and trauma. Burn surgeons are often faced with the need to amputate when limb salvage is no longer a viable option. The purpose of this study was to determine factors which predispose patients to extremity amputations. Methods: This retrospective registry review (2000-2019) compared patients who required upper extremity amputations with those who did not. Cases were pair-matched by age, sex, percent total body surface area (%TBSA), and type/location of injury to control for possible confounding variables. Results: There were 77 upper extremity amputee patients (APs) and 77 pair-matched non-amputees (NAPs) with the median age 45- and 43-years, %TBSA 21 and 10, respectively; second and third degree burn injuries were similar in the 2 groups. The AP group had longer hospitalizations (median 40 vs 15 days) P < .0001, with more intensive care unit days (median 28 vs 18 days). APs presented with significantly more cardiac, renal, and pulmonary comorbidities, acquired infections (61 [64%] vs 35 [36%]), escharotomies, and fasciotomies than the NAP, P < .0001. Mortality was similar (AP 14 [18.2%] vs NAP 9 [11.7%]), P = .26. Conclusions: Escharotomies, fasciotomies, sepsis, pneumonia, wound, and urinary tract infections contributed to prolonged hospitalizations and increased risk for upper extremity amputations in the AP group.

Introduction Les patients des centres de grands brûlés ne présentent pas seulement des lésions dues aux brûlures, mais aussi des infections nécrosantes, un purpura fulminans, des gelures, une épidermolyse bulleuse toxique, des plaies chroniques et des traumatismes. Les chirurgiens pour brûlés sont souvent confrontés au besoin d'amputer quand le sauvetage d'un membre n'est plus une option valable. L'objectif de cette étude était de déterminer les facteurs prédisposant les patients aux amputations de membres. Méthodes: Cette analyse rétrospective d'un registre (2000-2019) a comparé les patients ayant nécessité une amputation d'un membre supérieur à ceux pour lesquels l'amputation n'a pas été nécessaire. Les cas ont été appariés par âge, sexe, pourcentage de la surface corporelle totale (%SCT) et le type/emplacement des lésions pour contrôler les possibles variables confondantes. Résultats: Il y a eu 77 patients amputés (PA) du membre supérieur et 77 patients non amputés (PNA) appariés ayant, respectivement, un âge médian de 45 et 43 ans et un %SCT de 21% et 10%; les lésions par brûlures des 2e et 3e degrés étaient similaires dans les deux groupes. La durée d'hospitalisation pour le groupe PA a été plus longue que pour le groupe PNA (médiane : 40 jours contre 15 jours; P < .0001) avec un plus grand nombre de jours en unité de soins intensifs (médiane : 28 jours contre 18 jours). Les patients du groupe PA avaient plus de comorbidités cardiaques, rénales et pulmonaires et d'infections acquises (61 [64%] contre 35 [36%]), d'escarrotomies et d'aponévrotomies que les patients du groupe PNA (P <.0001). La mortalité a été semblable dans les deux groupes (PA: 14 [18.2%] contre PNA: 9 [11.7%], P = .26). Conclusion: Les incisions de décharge, les aponévrotomies, le sepsis, les pneumonies, les infections des plaies et des voies urinaires ont contribué à des hospitalisations prolongées et à une augmentation du risque d'amputation du membre supérieur dans le groupe PA.

Clinical application of a synthetic hybrid-scale fiber matrix in a pediatric trauma patient.

INTRODUCTION: Large soft tissue defects resulting from trauma in the pediatric population are common. MLLs are a rare subset of these injuries with no standard treatment regimen. Thorough surgical debridement of these lesions is often warranted to remove necrotic tissue and contamination, which results in a large, open soft tissue defect. STSGs may be used to provide tissue coverage; however, they have limitations, including donor site morbidity and additional surgical time and cost. CASE REPORT: A 12-year-old female with a cutaneous thermal contact burn and an MLL of the right lower medial thigh declined STSG to avoid additional operations. The wound was treated with an SHSFM that is engineered to mimic the structure and architecture of human extracellular matrix and supports cellular infiltration and proliferation with minimal inflammatory response. Over a 4-month period, the SHSFM was applied 6 times at 2- to 3-week intervals, resulting in complete regranulation and wound closure with no further surgical procedures required. CONCLUSIONS: This case demonstrates the utility of the SHSFM in the management of pediatric surgical wounds and highlights the flexibility of the SHSFM in achieving the goals of both patient and physician alike.

A synthetic hybrid-scale fiber matrix for complex surgical wounds: consensus guidelines.

Based on their own clinical experience and review of the available peer-reviewed data, the authors developed a consensus opinion on the use of an SHSFM for open wounds. The matrix has features such as varying pore sizes and fibers (ie, hybrid-scale) and is indicated for the treatment of open wounds. This report describes the design and utility of the SHSFM, its mechanism of action, and the methods of application, as well as clinical outcomes. The authors discuss their own experience and review of the published literature, then describe their protocols and rationale for the use of the SHSFM. These consensus statements include recommendations regarding appropriate wounds for use of the SHSFM, use of other wound therapies in conjunction with the SHSFM, reapplication rates, preparation methods, and additional discussions of appropriate use. This report is not a literature review, but rather is a statement of preliminary clinical experience. The consensus statements indicate that the SHSFM may be used to treat a variety of wounds and can be used to stage wounds to closure via skin grafts or by secondary intention.

Early experience and recommendations for the use of an automated estimator of solution volume for negative pressure wound therapy with instillation.

INTRODUCTION: NPWTi is a device that combines the benefits of traditional NPWT with periodic irrigation. This automated device allows for preprogrammed cycles of dwelling of a solution and negative pressure onto the wound surface. Its adoption has been hampered by the perceived difficulty of estimating the volume of solution needed per dwell cycle. A new software update includes an AESV that makes this determination for the clinician. OBJECTIVE: This case series of 23 patients presents the observations of 3 experienced users at 3 institutions who employed NPWTi with the AESV. MATERIALS AND METHODS: The authors subjectively assessed the wounds to determine whether the expected clinical result was achieved utilizing AESV on a variety of anatomical locations and wound types. RESULTS: The AESV demonstrated the ability to reliably estimate adequate solution amount in 65% (15/23) of cases. In wounds greater than 120 cm3, the AESV underestimated the amount of solution needed. CONCLUSION: To the authors' knowledge, this is the first publication describing the use of AESV for NPWTi. The benefits and limitations of this software upgrade are reported and recommendations for optimal use are provided.

The sandwich technique for quick and efficient application of negative pressure wound therapy to the feet and hands: a case report.

INTRODUCTION: NPWT is a surgical dressing that combines polyurethane foam with the subsequent application of continuous or intermittent negative pressure. NPWT facilitates granulation tissue production by macrostrain, microstrain and, if desired, fluid instillation. Sealing the polyurethane foam over the wound bed is achieved using acrylic drapes; however, this can be difficult to use in some anatomic sites. Failure to achieve an effective seal can necessitate additional supplies, which has led to increased innovation in developing a more effective NPWT seal over the target wound bed. Obtaining an effective pressure seal on the feet or hands can be difficult because these anatomic sites have distinct curvature for each digit, with multiple interdigital web spaces and independent mobility. In this case report, the authors propose a technique to apply either an acrylic drape or combination acrylic and soft silicone drape utilizing the "sandwich technique" to seal NPWT foam quickly and efficiently to the feet or hands.

Use of a Modified ABTHERA ADVANCE™ Open Abdomen Dressing with Intrathoracic Negative-Pressure Therapy for Temporary Chest Closure After Damage Control Thoracotomy.

BACKGROUND Damage control surgery (DCS) is an established emergency operative concept, initially described and most often utilized in abdominal trauma. DCS prioritizes managing acute hemorrhage and contamination, leaving the abdominal wall fascia open and covering the existing wound with a temporary abdominal wall closure, most commonly negative-pressure wound therapy (NPWT). The patient undergoes aggressive resuscitation to optimize physiology. Once achieved, the patient is returned to the operating room for definitive surgical intervention. There is limited evidence suggesting that using damage control thoracotomy within the chest cavity improves mortality and morbidity rates. Our review failed to find a case in which NPWT using ABTHERA ADVANCE™ Open Abdomen Dressing has been successfully used in the setting of thoracic trauma. CASE REPORT This case series describes 2 examples of NPWT as a form of temporary chest closure in penetrating and blunt thoracic injury. The first case was a penetrating self-inflicted stab wound to the chest. The NPWT was applied as a form of temporary thoracotomy, closure at the index surgery. The second case was a blunt injury to the chest of a polytrauma patient following a motor vehicle accident. The patient sustained rib fractures on his left side and had a bilateral pneumothorax. An emergent thoracotomy was performed due to delayed intrathoracic bleeding noted on hospital day 11, and NPWT was applied as described above, in the first case. CONCLUSIONS These cases suggest that damage control thoracotomy with intrathoracic placement of a modified ABTHERA ADVANCE™ Open Abdomen Dressing negative-pressure system may be an effective and life-saving technique with the potential for positive outcomes in these high-risk patients.

Applications of a new silicone-acrylic hybrid semiocclusive drape with negative pressure wound therapies in a burn center.

It is essential that occlusive drapes provide both an airtight, watertight seal and prevent intrusion of the external environment into a healing wound bed. Removal of an acrylic drape, however, may result in pain, reflex erythema, and a denuding of the epidermis, including the stratum corneum. Recently, a new silicone-acrylic hybrid drape was introduced for use with negative pressure wound therapy. Five unique and varied clinical cases from a burn center that used such negative pressure wound therapy dressings with the silicone-acrylic hybrid drape are presented. These cases highlight the excellent sealing capabilities of this new occlusive drape and minimal pain upon its removal. In addition, this hybrid drape may decrease waste of dressing supply because it is easily reconfigured to its original form and can be repositioned if the initial placement is suboptimal. The drape also maintains a tight seal with repositioning, making it more user-friendly to the clinical provider.

The effect of primary care clinician type and care team characteristics on health care costs.

OBJECTIVE: To evaluate health care costs as a function of assigned primary care clinician type and care team characteristics. METHODS: Administrative data were collected for 68 family medicine clinicians (40 physicians and 28 nurse practitioners [NPs]/physician assistant [PAs]), on 11 care teams (variable MD, NP and PA on teams), caring for 77,141 patients. We performed a generalized linear mixed multivariable regression model of standardized per member per month (PMPM) median cost as the outcome, with four practice sites included as random effects. RESULTS: In bivariate analysis, cost was higher in physicians than NP/PAs, in more complex patients, and associated with emergency department (ED) visit rate. On multivariate analysis, patient complexity, ED visit rate and higher patient experience ratings were independently associated with greater PMPM cost. More time in practice was associated with lower PMPM cost. In the adjusted multivariate model, physicians had 8.3% lower median PMPM costs than NP/PAs (p = 0.046). CONCLUSIONS: The primary drivers of greater PMPM cost were patient complexity, ED visits and patient satisfaction.

Synthetic Hybrid-Scale Fiber Matrix in the Trauma and Acute Care Surgical Practice.

Complex cutaneous wounds resulting from disease and trauma can be difficult to heal and may require advanced treatment options. Split-thickness skin grafts (STSGs) and other biologic allogeneic and xenogeneic skin substitutes are limited in their ability to manage these lesions, and STSGs may also be limited in availability. A synthetic hybrid-scale fiber matrix, engineered with an architecture similar to native extracellular matrix, has been shown to have excellent durability and does not carry the risks of disease transmission or inflammatory response associated with biologic materials; it may offer a new option for managing these complex wounds. In this preliminary study, the synthetic matrix was used to treat 3 patients with difficult-to-treat wounds, including lesions associated with calciphylaxis, enteroatmospheric abdominal fistula, and necrotizing fasciitis of the hand with exposed tendon. Treatment with the synthetic matrix resulted in significant reepithelialization and wound healing. The successful results suggest that the synthetic matrix enables healing of complex cutaneous wounds and may be a reasonable alternative to STSG, even in particularly challenging cases.

A guillotine amputation at the ankle level-how to quickly remove a septic foot: a case report.

As of 2014, diabetes is estimated to affect 422 million people globally. It is well recognised that lower extremity amputations secondary to diabetes have a high mortality rate perioperatively. The purpose of this article is to provide a simple, step-by-step guide to surgeons who need to perform a transtibial amputation. The case report of a 62-year-old female patient with poorly controlled diabetes who developed necrotising fasciitis of the lower extremity and systemic sepsis is used to illustrate the procedure. Knowing how to complete this operation is essential due to its effectiveness in quickly eliminating a source of pedal sepsis.

Designing for Effective and Safe Multidisciplinary Primary Care Teamwork: Using the Time of COVID-19 as a Case Study.

Effective medical teamwork can improve the effectiveness and experience of care for staff and patients, including safety. Healthcare organizations, and especially primary care clinics, have sought to improve medical teamwork through improved layout and design, moving staff into shared multidisciplinary team rooms. While co-locating staff has been shown to increase communication, successful designs balance four teamwork needs: face-to-face communications; situational awareness; heads-down work; perception of teamness. However, precautions for COVID-19 make it more difficult to conduct face-to-face communications. In this paper we describe a model for understanding how layout affects these four teamwork needs and describe how the perception of teamwork by staff changed after COVID-19 precautions were put in place. Observations, interviews and two standard surveys were conducted in two primary care clinics before COVID-19 and again in 2021 after a year of precautions. In general, staff felt more isolated and found it more difficult to conduct brief consults, though these perceptions varied by role. RNs, who spent more time on the phone, found it convenient to work part time-from home, while medical assistants found it more difficult to find providers in the distanced clinics. These cases suggest some important considerations for future clinic designs, including greater physical transparency that also allow for physical separation and more spaces for informal communication that are distanced from workstations.

Clinician Care Team Composition and Health Care Utilization.

OBJECTIVE: To test the hypothesis that a greater proportion of physician time on primary care teams are associated with decreased emergency department (ED) visits, hospital admissions, and readmissions, and to determine clinician and care team characteristics associated with greater utilization. PATIENTS AND METHODS: We retrospectively analyzed administrative data collected from January 1 to December 31, 2017, of 420 family medicine clinicians (253 physicians, 167 nurse practitioners/physician assistants [NP/PAs]) with patient panels in an integrated health system in 59 Midwestern communities serving rural and urban areas in Minnesota, Wisconsin, and Iowa. These clinicians cared for 419,581 patients through 110 care teams, with varying numbers of physicians and NP/PAs. Primary outcome measures were rates of ED visits, hospitalizations, and readmissions. RESULTS: The proportion of physician full-time equivalents on the team was unrelated to rates of ED visits (rate ratio [RR] = 0.826; 95% confidence interval [CI], 0.624 to 1.063), hospitalizations (RR = 0.894; 95% CI, 0.746 to 1.072), or readmissions (RR = -0.026; 95% CI, 0.364 to 0.312). In separate multivariable models adjusted for clinician and practice-level characteristics, the rate of ED visits was positively associated with mean panel hierarchical condition category (HCC) score, urban vs rural setting, NP/PA vs physician, and lower years in practice. The rate of inpatient admissions was associated with HCC score, and 30-day hospital readmissions were positively associated with HCC score, lower years in practice, and male clinicians. CONCLUSION: Care team physician and NP/PA composition was not independently related to utilization. More complex panels had higher rates of ED visits, hospitalization, and readmissions. Statistically significant differences between physician and NP/PA panels were only evident for ED visits.

Rare Operative Intervention for Urinary and Fecal Incontinence-Associated Dermatitis.

Incontinence-associated dermatitis (IAD) is considered a cause of moisture-associated skin damage after prolonged exposure to urinary and fecal incontinence. While partial-thickness burns are often managed with topical therapies, daily dressing changes, patient positioning, hydration, nutrition, and pain management, deep partial-thickness and full-thickness burn injuries require surgical excision and, ultimately, skin grafting. The elderly and very young as well as those with medical comorbidities can develop urinary and fecal incontinence. Urinary ammonia and gastrointestinal lipolytic enzymes and proteases can produce caustic damage to weakened elderly or immature skin. In this report, 2 cases of IAD are presented as chemical burns. After a prolonged interval of urinary and fecal incontinence, an incapacitated 65-year-old male with 14% total body surface area (TBSA) partial-thickness wounds, and an 85-year-old female with 4% TBSA full-thickness wounds were admitted to the burn center and underwent operative management.