Serious Illness Communication Training for Surgical Critical Care Fellows: A Pilot Implementation Study.

OBJECTIVE: Effective communication about serious illness is pivotal in delivering surgical palliative care-a crucial component of comprehensive surgical critical care (SCC). However, limited educational strategies exist for fellow-level trainees, who are often directing clinical decision-making and building mutual trust with patients and families. This pilot study assess implications of a novel serious illness communication training opportunity tailored specifically for SCC fellows. DESIGN: Prospective implementation of a multimodal training session (1 hour-didactic lecture, 2 hours-live-action simulation), using pre- and postcourse surveys to assess self-perceived confidence. SETTING: University of Michigan in Ann Arbor, Michigan. PARTICIPANTS: Eleven ACGME-accredited SCC fellows during the 2023 to 2024 academic year participated and completed all 3 survey assessments. RESULTS: Following the course, 6 of 7 confidence domains showed improvement, with 2 reaching statistical significance-communication skills to discuss goals of care and/or code status (3.73 vs. 4.36, p = 0.018) and end-of-life care or transition to comfort-focused care (3.36 vs. 4.18, p = 0.023) with a patient or family member. At 6-month follow up, fellows reported further increases in all queried domains, though changes were nonsignificant. Greatest absolute increases were noted in delivering serious news (4.18 vs. 4.55, p = 0.143) and expressing nonverbal empathy (4.09 vs. 4.50, p = 0.197). The majority (91%) of respondents felt more comfortable having serious illness conversations with patients and families due to their training course experience. CONCLUSION: Implementation of a 3-hour training course tailored for SCC fellows significantly boosted both the immediate and long-term confidence in their serious illness communication skills and ability to manage complex care scenarios.

The impact of different co-morbidities on clinical outcomes and resource utilization in critically ill burn and surgical patients: A population-based analysis of social determinants of health.

BACKGROUND: This study aims to establish the significance of social determinants of health and prevalent co-morbidities on multiple indicators for quality of care in patients admitted to the Burn and Surgical Intensive Care Unit (ICU). METHODS: We performed a retrospective analysis of population group data for patients admitted at the Burn and Surgical ICU from January 1, 2016, to November 18, 2019. The primary outcomes were length of hospital stay (LOS), mortality, 30-day readmission, and hospital charges. Pearson's chi-square test for categorical variables and t-test for continuous variables were used to compare population health groups. RESULTS: We analyzed a total of 487 burn and 510 surgical patients. When comparing ICU patients, we observed significantly higher mean hospital charges and length of stay (LOS) in BICU v. SICU patients with a history of mental health ($93,259.40 v. $50,503.36, p = 0.013 and 16.28 v. 9.16 days, p = 0.0085), end-stage-renal-disease (ESRD) ($653,871.05 v. $75,746.35, p = 0.0047 and 96.15 v. 17.53 days, p = 0.0104), sepsis ($267,979.60 v. $99,154.41, p = <0.001 and 39.1 v. 18.42 days, p = 0.0043), and venous thromboembolism (VTE) ($757,740.50 v. $117,816.40, p = <0.001 and 93.11 v. 20.21 days, p = 0.002). Also, higher mortality was observed in burn patients with ESRD, ST-Elevation Myocardial Infarction (STEMI), sepsis, VTE, and diabetes mellitus. 30-day-readmissions were greater among burn patients with a history of mental health, drug dependence, heart failure, and diabetes mellitus. CONCLUSIONS: Our study provides new insights into the variability of outcomes between burn patients treated in different critical care settings, underlining the influence of comorbidities on these outcomes. By comparing burn patients in the BICU with those in the SICU, we aim to highlight how differences in patient backgrounds, including the quality of care received, contribute to these outcomes. This comparison underscores the need for tailored healthcare strategies that consider the unique challenges faced by each patient group, aiming to mitigate disparities in health outcomes and healthcare spending. Further research to develop relevant and timely interventions that can improve these outcomes.

Palliative Care Training During Surgical Critical Care Fellowship: A Preliminary Needs Assessment at a Major Academic Center.

Surgical palliative care (PC) facilitates communication between surgeons and patients/family about prognosis, symptom control, and therapeutic goals. Surgical critical care (SCC) fellows are at the forefront of the intensive care team; thus, we aim to assess previous and ongoing experiences in delivering PC by surveying fellows at a large academic center. Seventeen surveys were completed in which 59% of fellows reported no previous PC education. Six fellows (35%) reported participating in goals of care/end-of-life (GOC/EOL) discussions "a few times a year" during residency, while 41% responded the same for transitioning patients to comfort-focused care (CFC). When asked if respondents felt comfortable facilitating GOC/EOL discussions prior to fellowship, 7 (41%) answered "disagree" or "strongly disagree." Most fellows reported that more training in navigating GOC/EOL discussions (88%) and transitioning patients to CFC (76%) is needed. This assessment demonstrates variability in fellows' prior PC exposure and a strong desire for more structured training.

Trends in Surgical Critical Care Fellowship Match: An Analysis of National Resident Matching Program Data.

INTRODUCTION: Surgical Critical Care (SCC) fellowship applications are made through March-July the year prior to the fellowship, while the match process takes place through the National Resident Matching Program (NRMP). There is paucity of high quality data on matching trends in SCC fellowship in the United States. METHODS: We conducted a retrospective cohort study of all applicants in the SCC match over a period of fifteen years (2009-2023). Publicly published data about the SCC fellowship match were retrieved from the NRMP online portal. Mann Kendall trend test was used to obtain a Tau statistic and p-values for temporal trends over time. Chi-square test was used to investigate association between categorical variables. RESULTS: From 2009 to 2023, the number of SCC fellowship positions increased from 143 to 340 (138% increase) while the number of applicants rose from 95 to 289 (204% increase). The overall match rate for applicants significantly rose from 89.5% to 93.4% (7.7% increase; t = 0.600, p = 0.002). The percentage of positions filled also increased from 59.4% in 2009 to 79.4% in 2023. The match rate over the past five years (2019-2023) was 90.8%. US-MD applicants had a significantly higher 94.8% match rate throughout the study period than non-US MD applicants (94.8% vs. 87.3%, p<0.001). While the match rate for US-MD applicants has stayed consistent from 2009 to 2023 (τ = 0.371, p = 0.054), the match rate for non-US-MD applicants increased from 77.3% in 2009 to 86.9% in 2023 (τ = 0.771, p<0.001). CONCLUSION: SCC fellowship continues to grow with more positions and applicants. Match rates into SCC fellowships have increased over the past fifteen years, primarily helping non-US MDs match successfully.

What should we make of candidates for surgical critical care and acute care surgery fellowships recounting so many penetrating trauma cases in their personal statements?

A large proportion of surgical residents that are applying to surgical critical care(SCC) and acute care surgery(ACS) fellowships are describing cases where they cared for patients with injuries from penetrating trauma in their personal statements. These cases appear to have served as an inspiration for their fellowship and career decision. However a substantial percentage of training in these fellowships occurs in the ICU and there also have been steadily decreasing rates of operative penetrating trauma throughout the United States over the last several decades. This incongruity is explored and suggestions are made for formal mentorship to occur between surgical residents interested in further training in SCC and ACS and attendings practicing within these fields.

Is There a Community Microbial Community? A Comparison of Pathogens Between Two Hospital Surgical Intensive Care Units in a Single City.

Background: Nosocomial and health-care-associated infections drive increased healthcare costs and negatively affect patient outcomes. The human microbiome has been heavily explored in recent years with incomplete data regarding hospital-specific and community-specific microbial communities. Although bacterial species differ between intensive care units in the same hospital, it is unclear if they differ between similar units in similar hospitals in the same community. Our hypothesis is that pathogens in surgical intensive care units (SICUs) are distinct between hospitals, even in the same community. Methods: From 2017 to 2021, data were collected prospectively from the SICUs of two 400-bed hospitals located three miles apart in the same city (Hospital A and Hospital B). Infections defined using U.S. Centers for Disease Control and Prevention (CDC) criteria were recorded for trauma and general surgery patients, as well as patient demographics, Acute Physiology and Chronic Health Evaluation (APACHE) II score, and causative organism. Results: Overall, Escherichia coli was the most commonly isolated pathogen in Hospital A, whereas Staphylococcus aureus was most commonly isolated at Hospital B. Enterococci were more common in Hospital A, and Haemophilus influenzae and Enterobacter spp. were more common in Hospital B. After stratification between trauma and non-trauma patients, however, these differences disappeared, with the exception of more overall gram-positive organisms and fewer gram-negative organisms among Hospital A trauma patients compared to Hospital B. There were no differences in rates of isolation of either fungi or resistant bacteria between hospitals. Conclusions: At a species level, admission diagnosis appears to be a greater determinant of pathogen isolation than hospital when comparing similar intensive care units (ICUs) in the same geographic area, but a larger body of data is needed to flesh out a distinct microbial map of the organisms occupying a certain geographic region. Further areas for investigation include comparison between hospital units, specific anatomic sites, and ICU versus floor patients.

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.

Incidence and Outcomes of Undiagnosed and Untreated Diabetes Mellitus in Trauma Patients.

Diabetes is a major determinate for mortality in trauma patients. Many diabetics are undiagnosed or poorly controlled. Trauma patients disproportionately come from lower socioeconomic status, making missed diagnoses more likely. We aimed to quantify the incidence of undiagnosed or poorly controlled diabetics assessed at a Level 1 Trauma Center. We did a retrospective chart review of admitted trauma patients over a one-month period. Past Medical History, home medication lists, and Hemoglobin A1c on admission were recorded for each patient. We determined that 30 of 173 trauma patients qualifying for the study were diabetic. Furthermore, 30% of these diabetics were undiagnosed or had poorly controlled diabetes. Undiagnosed pre-diabetics made up 20% of the entire study group. Our data show that 26% of trauma patients would benefit from an intervention for improved glucose control. Trauma centers should consider creating routine clinical practice guidelines to identify at-risk patients and provide intervention for long-term management.

Methicillin-Resistant Staphylococcus aureus Nasal Swab Is Insufficient to Withhold Empiric Methicillin-Resistant Staphylococcus aureus Pneumonia Coverage in a Trauma Population.

INTRODUCTION: Methicillin-resistant staphylococcus aureus (MRSA) nasal colonization is a predictor of MRSA pneumonia in intensive care unit (ICU) patients. Negative nasal swabs have shown up to a 97% negative predictive value for MRSA pneumonia in nontrauma populations, though little investigation has been pursued in trauma patients. MATERIALS AND METHODS: All trauma patients admitted to the ICU from April 2018 to February 2019 were screened for MRSA colonization by nasal swab. Patients with suspicion for pneumonia underwent bronchoalveolar lavage or quantitative sputum culture and were started on empiric antibiotic therapy based on the swab result. Swab-positive patients were started on empiric MRSA coverage and swab-negative patients were not. RESULTS: MRSA nasal swab screening was performed in 601 trauma ICU patients. Ninety-six patients subsequently underwent pneumonia workup and were started on an empiric antibiotic regimen based on nasal swab results. Seventeen (17.7%) patients were MRSA nasal swab positive on screening, and 22 (22.9%) patients subsequently had significant growth of MRSA on quantitative respiratory culture. The sensitivity of nasal swab was 50.0% and the specificity was 91.9%. Eleven patients had a negative MRSA nasal swab but a positive MRSA pneumonia (11.5%). Patients with inadequate antibiotic coverage had statistically longer hospital length of stay, ICU length of stay, ventilator days, and rates of unplanned intubation compared to patients with adequate antibiotic coverage. CONCLUSIONS: Nasal swab screening was not sensitive enough in a trauma population with a high endemic incidence of MRSA colonization to warrant withholding empiric antibiotic MRSA coverage in patients with suspected pneumonia.

The clinical use of urinary mitochondrial DNA in adult surgical critical care patients with acute kidney injury.

Acute kidney injury (AKI) affects 47% of adult surgical critical care patients (ASCCPs). AKI is induced through a common oxidative stress pathway resulting in mitochondrial and tubular cell injury with increased urinary mitochondrial DNA (UmtDNA) excretion. UmtDNA is an emerging and readily sampled novel biomarker for varied surgical critical care cohorts. This review aimed to determine the clinical use of UmtDNA genes (ND1 and COX3) in AKI in ASCCPs. PubMed, MEDLINE and Web of Science databases were searched. Eligibility criteria were based on the patient/problem, intervention, comparison and outcome framework. Methodological quality of studies was assessed with the Newcastle-Ottawa Quality Assessment Scale. WebPlot Digitizer version 4.4 was used to extract UmtDNA data from graphs and UmtDNA ratios were statistically analysed with PRISM version 9.1.0 (GraphPad Software). Six human studies (n = 391) with three translational murine models (n = 112) satisfied inclusion criteria. One sample t test suggested significantly high UmtDNA-ND1 ratios in progressive/severe AKI (or delayed renal transplant graft function) to no AKI (or immediate renal transplant graft function) and increased UmtDNA-COX3 ratios approached significance. Sensitivities and specificities for UmtDNA ranged from 68% to 85% and 52% to 83.6%, respectively, comparable with new biomarkers, neutrophil gelatinase-associated lipocalin and kidney injury molecule-1. Weak correlation was observed with serum creatinine. These findings were complemented in translational murine AKI experiments with significantly elevated ND1 and COX3. From bench to clinical practice, UmtDNA appears to be a promising novel biomarker of progressive/severe AKI (or delayed graft function). Large prospective, multi-centre studies reporting standardised UmtDNA findings should clarify use of UmtDNA in ASCCP-AKI management.

Palliative Care in the Trauma and Surgical Critical Care Settings: A Narrative Review.

BACKGROUND: We aimed to conduct a narrative review of available literature to understand the use of palliative care in the trauma and surgical critical care setting. METHODS: PubMed, EMBASE, and Google Scholar databases were searched for studies investigating the use of palliative care in the trauma and surgical critical care setting. The search included all studies published through January 9th, 2022. The risk of bias of included studies was assessed using the Joanna Briggs Institute Critical Appraisal Checklist tools. Outcomes were summarized in tables and synthesized qualitatively. RESULTS: A total of 22 studies were included in this review. Key elements of successful palliative care include communication, shared decision-making, family involvement, pain control, establishing a patient's prognosis, and end-of-life management. Approaches to implementation based upon these key elements include best-case/worst-case scenarios, consultation trigger systems, and integrated institutional palliative care programs. Palliative care may reduce hospital length of stay, improve symptom management, and increase patient satisfaction, but the impact on mortality is unclear. CONCLUSION: The core elements of palliative care have been identified and palliative care has been shown to improve outcomes in trauma and surgical critical care. However, the approaches for implementation still require development. The underutilization of palliative care for trauma patients reveals the need for refining criteria for use of palliative care and improvement in the education of surgical critical care teams to provide primary palliative care services.

Content and Accessibility of Surgical Critical Care Fellowship Websites in the United States.

BACKGROUND: Resident physicians are using the Internet to gather information about graduate medical education programs. The content of fellowship websites has been demonstrated to influence applicants' decisions. The purpose of this study was to evaluate the content of the surgical critical care fellowship (SCCF) program websites. METHODS: A list of Eastern Association for the Surgery of Trauma (EAST) and American Association for the Surgery of Trauma (AAST) SCCF programs was obtained, and compared to the Accreditation Council for Graduate Medical Education (ACGME) list of accredited programs. The accessibility of each website was assessed through Google®. Content areas were assessed for each SCCF website. RESULTS: At the time of this study, 76 SCCF were listed on the EAST website and an additional 14 were supplied by the AAST database. 125 programs were listed in the ACGME database. Of the 76 SCCF listed by EAST, 44 (58%), 32 (42%), and 7 (9%) of SCCF programs had an EAST listing that was 3, 5, or 10 years or more out of date, respectively. Of the 90 SCCF programs listed on EAST or AAST sites, 36 programs (40%) had an inaccurate PD named on their listing. One hundred and nineteen of the 125 (95%) SCCF programs had websites accessible through Google®. Only 25 (20%) programs had a website containing a program description, faculty list, curriculum, and current/past fellows list. CONCLUSIONS: Many SCCF websites lacked information regarding program specifics. Valuable information for potential applicants was inadequate across SCCF websites.

The State of Global Trauma and Acute Care Surgery/Surgical Critical Care.

Trauma is a leading cause of morbidity and mortality globally, with a significant burden attributable to the low- and middle-income countries (LMICs), where more than 90% of injury-related deaths occur. Road injuries contribute largely to the economic burden from trauma and are prevalent among adolescents and young adults. Trauma systems vary widely across the world in their capacity of providing basic and critical care to injured patients, with delays in treatment being present at multiple levels at LMICs. Strengthening existing systems by providing cost-effective and efficient solutions can help mitigate the injury burden in LMICs.

Presentation, clinical course and complications in trauma patients with concomitant COVID-19 infection.

BACKGROUND: This study investigated the impact of COVID-19 infection on hospitalized trauma patients. METHODS: A retrospective review of hospitalized trauma patients at a level I trauma center was performed from March-December 2020. Data pertaining to patient demographics, presentation and hospital course was compared between COVID positive and negative trauma patients. RESULTS: There were 4,912 patients and 179 (3.64%) were COVID-19 positive. Demographics and clinical presentation did not differ significantly between those with and without concomitant COVID-19. However, COVID positive trauma patients had higher rates of acute kidney injury (p = 0.016), sepsis (p = 0.016), unplanned intubation (p = 0.002) and unplanned return to the ICU (p = 0.01). The COVID positive cohort also had longer hospital stays (p < 0.01) with no significant difference in mortality. CONCLUSIONS: In the setting of an ongoing pandemic, awareness of the complications COVID positive trauma patients are predisposed to is important for providers.

Maintaining Zone 1 Occlusion is a Dynamic Process: The Effects of Proximal Pressure and Blood Transfusion During REBOA.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) provides hemodynamic support to patients with non-compressible truncal hemorrhage. As cardiac output increases due to aortic occlusion (AO), aortic diameter will increase as a function of compliance, potentially causing unintended flow around the balloon. MATERIALS AND METHODS: Swine (N = 10) were instrumented to collect proximal mean arterial blood pressure (pMAP), distal MAP (dMAP), balloon pressure (bP), balloon volume (bV), and distal aortic flow (Qaorta). A 7-Fr automated REBOA catheter was positioned in Zone 1. At T0, animals underwent 30% total blood volume hemorrhage over 30 min followed by balloon inflation to complete AO. Automated balloon inflation occurred from T30-T60 when Qaorta was detected. Period of interest was T55-T60, while the balloon actively worked to maintain AO during transfusion of shed blood. RESULTS: Median weight of the cohort was 73.75 [IQR:71.58-74.45] kg. During T40-T55 and T55-T60, median pMAP was 88.95 [IQR:76.80-109.92] and 108.13 [IQR:99.13-119.51] mmHg, P = 0.07. Median Qaorta during T40-T55, and T55-T60 was 0.81 [IQR:0.41-0.96], and 1.53 [IQR:1.07-1.96] mL/kg/min, P = 0.06. Median number of balloon inflations during T40-T55 was 0.00 [IQR:0.00-0.75] and increased during active transfusion to 10.00 [IQR:5.25-14.00], P = 0.001. DISCUSSION: In clinical practice, following initial establishment of AO, progressive balloon inflations are required to maintain AO in response to intrinsic and transfusion-mediated increases in cardiac output, blood pressure, and aortic diameter.

Non-invasive evaluation of new-onset atrial fibrillation after cardiac surgery: a protocol for the BigMap study.

AIMS: New-onset atrial fibrillation (NOAF) is the most common complication after cardiac surgery, occurring in 25-50% of patients. It is associated with post-operative stroke, increased mortality, prolonged hospital length of stay, and higher treatment costs. Previous small observational studies have identified the left atrium as a source of the electrical rotors and foci maintaining NOAF, but confirmation by a large prospective clinical study is still missing. The aim of the proposed study is to investigate whether the source of NOAF lies in the left atrium. The correct identification of NOAF-maintaining structures in cardiac surgical patients might offer potential therapeutic targets for prophylactic perioperative ablation strategies. METHODS AND RESULTS: This is a prospective single-centre observational study of patients developing NOAF after cardiac surgery. The primary outcome is the description of NOAF-maintaining structures within the atria. Key secondary outcomes include overall mortality, intensive care unit length of stay, hospital-ventilator-free days, and proportion of persistent NOAF. In NOAF patients, the non-invasive electrophysiological mapping will be conducted using a 252-electrode electrocardiogram vest. After mapping, a low-dose computed tomography scan of the chest will be performed to integrate the electrophysiological mapping results into a 3D picture of the heart. The study will include approximately 570 patients, of whom 30% (n = 170) are expected to develop NOAF. Sample size calculation revealed that 157 NOAF patients are necessary to assess the primary outcome. Patients will be tracked for a total of 5 years. CONCLUSIONS: This is the largest prospective study to date describing the electrophysiological mechanisms of NOAF using non-invasive mapping.

Coronavirus-Associated Coagulopathy After Trauma.

Coronavirus disease 2019 (COVID-19) is linked with a hypercoagulable state called COVID-19-associated coagulopathy (CAC). Due to elevated levels of factor VIII and fibrinogen as well as inflammation-linked hyperviscosity of blood, the risk for venous thromboembolism is increased in patients who have CAC. We report the case of a patient with recent COVID-19 infection and no other past medical history who presented after a motorcycle collision with left middle and distal femur fractures, who underwent retrograde intramedullary nailing, and then developed immediate massive bilateral pulmonary emboli. The patient was treated with tissue plasminogen activator administration via bilateral pulmonary artery thrombolysis catheters without improvement, and was then placed on venoarterial extracorporeal membrane oxygenation for subsequent cardiogenic shock. During a 58-day hospital stay, the patient recovered and was discharged with a good long-term prognosis. In this report, we discuss CAC, the role of surgical critical care in the management of the disease, and issues specific to this patient's disease process and treatment.

Acute Myeloid Leukemia With Central Nervous System Involvement Following Routine Surgical Procedures: A Bridge Between Surgical, Medical, and Neurological Critical Care.

Acute myeloid leukemia (AML) is a rare and aggressive malignancy that can present with a broad range of clinical manifestations. Central nervous system (CNS) involvement is rarely documented and may alter the treatment course and overall prognosis. Although several etiologies have been suggested, the exact mechanism of CNS involvement remains unclear. Furthermore, little is known about the impact of surgical stress on the development of AML. Surgeons should be aware of this potential outcome following surgery, particularly if a leukemoid reaction develops post-operatively, as early detection can prevent delays in appropriate treatment. Further data are needed to better understand the pathogenesis and underlying inflammatory cascades following surgical trauma that possibly contribute to the development of AML.

Early feeding after percutaneous endoscopic gastrostomy tube placement in patients who require trauma and surgical intensive care: A retrospective cohort study.

BACKGROUND: Critically ill patients experience interruptions in enteral nutrition (EN). For ventilated patients who undergo percutaneous endoscopic gastrostomy (PEG) tube placement, postprocedure fasting times vary from 1 to 24 h depending on the surgeon's preference. There is no evidence to support delayed feeding (DF) after PEG placement. This study's purpose was to determine if there is an increased complication rate associated with early feeding (EF) after PEG. METHODS: 150 adult ventilated patients in the trauma and surgical intensive care unit (TSICU) at a level I trauma center underwent PEG placement in March 2015 through May 2018 by one of six surgical intensivists. Retrospective review revealed variable post-PEG fasting practices: one started EN at 1 h, two started at 4 h, two started at 6 h, and one started at 24 h. Time to initiation of EN and complication rates were assessed. Patients were divided into EF (<4) and DF (≥4 h) groups. RESULTS: Median postprocedure fasting time was 5.5 h. The overall complication rate was 3.3%, with a feeding intolerance rate of 0.7% and aspiration rate of 0%. There was no difference in complication rate for EF (3.1%) as compared with DF (3.4%) (odds ratio, 0.92; 95% CI, 0.10-8.52; P = 0.7). CONCLUSION: Complication rates following PEG placement in ventilated TSICU patients are low and do not change with EF compared with DF. EF is probably safe.

Communication and Palliation in Trauma Critical Care: Impact of Trainee Education and Mentorship.

BACKGROUND: Surgical residency training requires Advance Care Planning (ACP) and Palliative Care (PC) education. To meet education needs and align with American College of Surgeons guidelines, our Surgical Intensivists and PC faculty developed courses on communication and palliation for residents (2017-18) and fellows (2018-19). We hypothesized that education in ACP would increase ACP communication and documentation. METHODS: The trauma registry of an academic, level 1trauma center was queried for ICU admissions from 2016-2019, excluding incarcerated and pregnant patients. A retrospective chart review was performed, obtaining frequency of ACP documentation, ACP meetings, time from admission to documentation, and PC consultation. We collected ICU quality measures as secondary outcomes: ICU Length Of Stay (LOS), hospital LOS, ventilator days, invasive procedures, discharge disposition, and mortality. Comparisons were made between years prior to (Y 1) and following implementation (Y 2: residents, Y 3: fellows). RESULTS: For 1732 patients meeting inclusion criteria, patient demographics, injuries, and injury severity score were comparable. ACP documentation increased from 19.5% in Y 1 to 57.2% in Y 3 (P < 0.001). Time to ACP documentation was reduced from 47.6 to 13.1 h (P < 0.001) from time of admission. ICU LOS decreased from 6 to 4.8 d (P = 0.004). Patients in Y 3 had fewer tracheostomies and percutaneous endoscopic gastrostomies. PC consultations decreased. Mortality was unchanged. CONCLUSION: Following trainee education, we observed increases in ACP documentation, earlier communication and improvements in ICU quality measures. Our findings suggest that trainee education positively impacts ACP documentation, reduces LOS, and improves trauma critical care outcomes.