A value-based approach to optimize red blood cell transfusion in patients receiving extracorporeal membrane oxygenation.

INTRODUCTION: The risk, cost, and adverse outcomes associated with packed red blood cell (RBC) transfusions in patients with cardiopulmonary failure requiring extracorporeal membrane oxygenation (ECMO) have raised concerns regarding the overutilization of RBC products. It is, therefore, necessary to establish optimal transfusion criteria and protocols for patients supported with ECMO. The goal of this study was to establish specific criteria for RBC transfusions in patients undergoing ECMO. METHODS: This was a retrospective cohort study conducted at Stanford University Hospital. Data on RBC utilization during the entire hospital stay were obtained, which included patients aged ≥18 years who received ECMO support between 1 January 2017, and 30 June 2020 (n = 281). The primary outcome was in-hospital mortality. RESULTS: Hemoglobin (HGB) levels >10 g/dL before transfusion did not improve in-hospital survival. Therefore, we revised the HGB threshold to ≤10 g/dL to guide transfusion in patients undergoing ECMO. To validate this intervention, we prospectively compared the pre- and post-intervention cohorts for in-hospital mortality. Post-intervention analyses found 100% compliance for all eligible records and a decrease in the requirement for RBC transfusion by 1.2 units per patient without affecting the mortality. CONCLUSIONS: As an institution-driven value-based approach to guide transfusion in patients undergoing ECMO, we lowered the threshold HGB level. Validation of this revised intervention demonstrated excellent compliance and reduced the need for RBC transfusion while maintaining the clinical outcome. Our findings can help reform value-based healthcare in this cohort while maintaining the outcome.

The association between angioembolization and splenic salvage for isolated splenic injuries.

BACKGROUND: Recent data suggest improved splenic salvage rates when angioembolization (AE) is routinely employed for high-grade splenic injuries; however, protocols and salvage rates vary among centers. MATERIALS/METHODS: Adult patients with isolated splenic injuries were identified using the National Trauma Data Bank, 2013-2014. Patients were excluded if they underwent immediate splenectomy or died in the emergency department. To characterize patterns of AE, trauma centers were grouped into quartiles based on frequency of AE use. Unadjusted analyses and mixed-effects logistical regression controlling for center effects were performed. RESULTS: Five thousand and ninety three adult patients were identified. Overall, 705 (13.8%) underwent AE and 290 (5.7%) required a splenectomy. In unadjusted comparisons, splenectomy rates were lower for patients with severe spleen injuries who underwent AE (7% versus 11%, P = 0.02). In mixed-effect logistical regression patients with severe splenic injuries undergoing AE had a lower odds ratio (OR) for splenectomy (OR = 0.67, P = 0.04). Patients treated at centers in the highest quartile of AE use had a lower OR for splenectomy (OR = 0.58, P = 0.02). CONCLUSIONS: The use of AE in patients with isolated severe splenic injuries is associated with decreased splenectomy rates. There is an association between centers that perform AE frequently and reduced splenectomy rates.

The prevalence of psychiatric diagnoses and associated mortality in hospitalized US trauma patients.

BACKGROUND: We hypothesized that psychiatric diagnoses would be common in hospitalized trauma patients in the United States and when present, would be associated with worse outcomes. MATERIALS AND METHODS: The Nationwide Inpatient Sample (NIS, 2012) was used to determine national estimates for the number of patients admitted with an injury. Psychiatric diagnoses were identified using diagnosis codes according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. RESULTS: A total of 36.5 million patients were admitted to hospitals in the United States in 2012. Of these, 1.3 million (4%) were due to trauma. Psychiatric conditions were more common in patients admitted for trauma versus those admitted for other reasons (44% versus 34%, P < 0.001). Trauma patients who had a psychiatric diagnosis compared to trauma patients without a psychiatric diagnosis were older (mean age: 61 versus 56 y, P < 0.001), more often female (52% versus 50%, P < 0.001), and more often white (73% versus 68%, P < 0.001). For ages 18-64, drug and alcohol abuse predominated (41%), whereas dementia and related disorders (48%) were the most common in adults ≥65 y. Mortality was lower for trauma patients with a psychiatric diagnosis compared to those who did not in both unadjusted and adjusted analysis (1.9% versus 2.8%; odds ratio: 0.56, P < 0.001). CONCLUSIONS: Psychiatric conditions are present in almost half of all hospitalized trauma patients in the United States; however, the types of conditions varied with age. The frequency of psychiatric conditions in the trauma population suggests efforts should be made to address this component of patient health.

Trends in the management of pelvic fractures, 2008-2010.

BACKGROUND: Bleeding from pelvic fractures can be lethal. Angioembolization (AE) and external fixation (EXFIX) are common treatments to control bleeding, but it is not known how frequently they are used. We hypothesized that AE would be increasingly more common compared with EXFIX over time. METHODS: The National Trauma Data Bank for the years from 2008-2010 were used. Patients were included in the study if they had an International Classification of Diseases, ninth edition, Clinical Modification codes for pelvic fractures and were aged ≥18 y. Patients were excluded if they had isolated acetabular fractures, were not admitted, or had minor injuries. Outcomes included receiving a procedure and in-hospital mortality. RESULTS: A total of 22,568 patients met study criteria. AE and EXFIX were performed in 746 (3.3%) and 663 (2.9%) patients, respectively. AE was performed more often as the study period progressed (2.5% in 2007 to 3.7% in 2010; P < 0.001). This remained significant in adjusted analysis (odds ratio per year 1.15; P = 0.008). Having a procedure was associated with higher mortality in unadjusted analyses compared with those with no procedure (11.0% for no procedure versus 20.5% and 13.4% for AE or EXFIX, respectively; P < 0.001). In adjusted analyses, only AE remained associated with higher mortality (odds ratio 1.63; P < 0.001). CONCLUSIONS: AE in severely injured pelvic fracture patients is increasing. AE is associated with higher mortality, which may reflect the fact that it is used for patients at higher risk of death. The role of AE for bleeding should be examined in future studies.

Cost of Health Care-Associated Infections in the United States.

BACKGROUND: Health care-associated infections (HAIs) are costly, and existing national cost estimates are out-of-date. METHODS: We retrospectively analyzed the Agency for Healthcare Cost and Utilization Project's 2016 National Inpatient Sample, the largest all-payer U.S. inpatient database. We included all inpatient encounters with primary or secondary International Classification of Disease, 10th Revision Clinical Modification diagnosis codes corresponding to infection with catheter-associated urinary tract infections (T85.511), catheter- and line-associated blood stream infections (T80.211), surgical site infections (SSIs; T81.49), ventilator-associated pneumonias (J95.851), and Infection with Clostridioides difficile (CDI; A04.7). We combined HAI incidence data from the National Inpatient Sample with additional hospital inpatient HAI cost estimates to create national cost estimates for HAI individually and collectively. RESULTS: In 2016, 7.2 to 14.9 billion U.S. dollars were spent on HAIs in the United States. For admissions with any diagnosis of HAI, the frequencies of HAI in descending order were as follows: CDI (n = 356,754 [56%]), SSI (n = 196,215 [31%]), catheter- and line-associated blood stream infection (n = 42,811 [7%]), catheter-associated urinary tract infection (n = 23,546 [4%]), and ventilator-associated pneumonia (n = 16,767 [3%]). Collectively, CDI and SSI accounted for 79% of the cost of HAI in the United States. CONCLUSIONS: Health care-associated infections remain a significant economic burden for health care systems in the United States.

Improving tracheostomy delivery for trauma and surgical critical care patients: timely trach initiative.

BACKGROUND: Tracheostomy is recommended within 7 days of intubation for patients with severe traumatic brain injury (TBI) or requiring prolonged mechanical ventilation. A quality improvement project aimed to decrease time to tracheostomy to ≤7 days after intubation for eligible patients requiring tracheostomy in the surgical intensive care unit (SICU). LOCAL PROBLEM: From January 2017 to June 2018, approximately 85% of tracheostomies were performed >7 days after intubation. The tracheostomy was placed a median of 10 days after intubation (range: 1-57). METHODS: Quality improvement principles were applied at an American College of Surgeons-verified level I trauma centre to introduce and analyse interventions to improve tracheostomy timing. Using the electronic health record, we analysed changes in tracheostomy timing, hospital length of stay (LOS), ventilator-associated pneumonia and peristomal bleeding rates for three subgroups: patients with TBI, trauma patients and all SICU patients. INTERVENTIONS: In July 2018, an educational roll-out for SICU residents and staff was launched to inform them of potential benefits of early tracheostomy and potential complications, which they should discuss when counselling patient decision-makers. In July 2019, an early tracheostomy workflow targeting patients with head injury was published in an institutional Trauma Guide app. RESULTS: Median time from intubation to tracheostomy decreased for all patients from 14 days (range: 4-57) to 8 days (range: 1-32, p≤0.001), and median hospital LOS decreased from 38 days to 24 days (p<0.001, r=0.35). Median time to tracheostomy decreased significantly for trauma patients after publication of the algorithm (10 days (range: 3-21 days) to 6 days (range: 1-15 days), p=0.03). Among patients with TBI, family meetings were held earlier for patients who underwent early versus late tracheostomy (p=0.008). CONCLUSIONS: We recommend regular educational meetings, enhanced by digitally published guidelines and strategic communication as effective ways to improve tracheostomy timing. These interventions standardised practice and may benefit other institutions.

Precautions for Operating Room Team Members During the COVID-19 Pandemic.

BACKGROUND: The novel coronavirus SARS-CoV-2 (COVID-19) can infect healthcare workers. We developed an institutional algorithm to protect operating room team members during the COVID-19 pandemic and rationally conserve personal protective equipment (PPE). STUDY DESIGN: An interventional platform (operating room, interventional suite, and endoscopy) PPE taskforce was convened by the hospital and medical school leadership and tasked with developing a common algorithm for PPE use, to be used throughout the interventional platform. In conjunction with our infectious disease experts, we developed our guidelines based on potential patterns of spread, risk of exposure, and conservation of PPE. RESULTS: A decision tree algorithm describing our institutional guidelines for precautions for operating room team members was created. This algorithm is based on urgency of operation, anticipated viral burden at the surgical site, opportunity for a procedure to aerosolize virus, and likelihood a patient could be infected based on symptoms and testing. CONCLUSIONS: Despite COVID-19 being a new threat, we have shown that by developing an easy-to-follow decision tree algorithm for the interventional platform teams, we can ensure optimal health care worker safety.

Commitment to COT verification improves patient outcomes and financial performance.

BACKGROUND: After an unsuccessful American College of Surgery Committee on Trauma visit, our level I trauma center initiated an improvement program that included (1) hiring new personnel (trauma director and surgeons, nurse coordinator, orthopedic trauma surgeon, and registry staff), (2) correcting deficiencies in trauma quality assurance and process improvement programs, and (3) development of an outreach program. Subsequently, our trauma center had two successful verifications. We examined the longitudinal effects of these efforts on volume, patient outcomes and finances. METHODS: The Trauma Registry was used to derive data for all trauma patients evaluated in the emergency department from 2001 to 2007. Clinical data analyzed included number of admissions, interfacility transfers, injury severity scores (ISS), length of stay, and mortality for 2001 to 2007. Financial performance was assessed for fiscal years 2001 to 2007. Data were divided into patients discharged from the emergency department and those admitted to the hospital. RESULTS: Admissions increased 30%, representing a 7.6% annual increase (p = 0.004), mostly due to a nearly fivefold increase in interfacility transfers. Severe trauma patients (ISS >24) increased 106% and mortality rate for ISS >24 decreased by 47% to almost half the average of the National Trauma Database. There was a 78% increase in revenue and a sustained increase in hospital profitability. CONCLUSION: A major hospital commitment to Committee on Trauma verification had several salient outcomes; increased admissions, interfacility transfers, and acuity. Despite more seriously injured patients, there has been a major, sustained reduction in mortality and a trend toward decreased intensive care unit length of stay. This resulted in a substantial increase in contribution to margin (CTM), net profit, and revenues. With a high level of commitment and favorable payer mix, trauma center verification improves outcomes for both patients and the hospital.

Mean glucose values predict trauma patient mortality.

BACKGROUND: Tight glycemic control in a mixed surgical intensive care unit patient population has been associated with improved survival. We postulated targeted therapy to achieve glucose levels <140 mg/dL would reduce infectious complications and mortality in trauma patients admitted to the intensive care unit (ICU). METHODS: Adult trauma patients admitted to our American College of Surgeons Level I Trauma Center ICU from July 2004 through June 30, 2006 were studied. Insulin therapy was instituted for ICU patients admitted after July 1, 2005 with glucose >140 mg/dL. Data on infections and all glucose values were collected. Multivariate analysis adjusting for age, Injury Severity Score, Glasgow Coma Scale Score, admit blood pressure, and intubation status was performed. RESULTS: Five thirty-one ICU patients were admitted with a mean Injury Severity Score of 23 +/- 13 and mean age of 45 years +/- 19 years. The admission, mean, and maximum glucoses were 141, 129, and 192 respectively. In multivariate analyses, increases in all three glucose values were associated with a significantly higher mortality, with the best model achieved using mean glucose with a receiver operating curve of 0.90. For mean glucose categories of >200 mg/dL, 141 mg/dL to 200 mg/dL, and

National Readmission Patterns of Isolated Splenic Injuries Based on Initial Management Strategy.

IMPORTANCE: Options for managing splenic injuries have evolved with a focus on nonoperative management. Long-term outcomes, such as readmissions and delayed splenectomy rate, are not well understood. OBJECTIVE: To describe the natural history of isolated splenic injuries in the United States and determine whether patterns of readmission were influenced by management strategy. DESIGN, SETTING, AND PARTICIPANTS: The Healthcare Cost and Utilization Project's Nationwide Readmission Database is an all-payer, all-ages, longitudinal administrative database that provides data on more than 35 million weighted US discharges yearly. The database was used to identify patients with isolated splenic injuries and the procedures that they received. Adult patients with isolated splenic injuries admitted from January 1 through June 30, 2013, and from January 1 through June 30, 2014, were included. Those who died during the index hospitalization or who had an additional nonsplenic injury with an Abbreviated Injury Score of 2 or greater were excluded. Univariate and mixed-effects logistic regression analysis controlling for center effect were used. Weighted numbers are reported. EXPOSURES: Initial management strategy at the time of index hospitalization, including nonprocedural management, angioembolization, and splenectomy. MAIN OUTCOMES AND MEASURES: All-cause 6-month readmission rate. Secondary outcome was delayed splenectomy rate. RESULTS: A weighted sample of 3792 patients (2146 men [56.6%] and 1646 women [43.4%]; mean [SE] age, 48.5 [0.7] years) with 5155 admission events was included. During the index hospitalization, 825 (21.8%) underwent splenectomy, 293 (7.7%) underwent angioembolization, and 2673 (70.5%) had no procedure. The overall readmission rate was 21.1% (799 patients). Readmission rates did not differ based on initial management strategy (195 patients undergoing splenectomy [23.6%], 70 undergoing angioembolism [23.9%], and 534 undergoing no procedure [20%]; P = .33). Splenectomy was performed in 36 of 799 readmitted patients (4.5%) who did not have a splenectomy at their index hospitalization, leading to an overall delayed splenectomy rate of 1.2% (36 of 2967 patients). In mixed-effects logistic regression analysis controlling for patient, injury, clinical, and hospital characteristics, the choice of splenectomy (odds ratio, 0.93; 95% CI, 0.66-1.31) vs angioembolization (odds ratio, 1.19; 95% CI, 0.72-1.97) as initial management strategy was not associated with readmission. CONCLUSIONS AND RELEVANCE: This national evaluation of the natural history of isolated splenic injuries from index admission through 6 months found that approximately 1 in 5 patients are readmitted within 6 months of discharge after an isolated splenic injury. However, the chance of readmission for splenectomy after initial nonoperative management was 1.2%. This finding suggests that the current management strategies used for isolated splenic injuries in the United States are well matched to patient need.

Trauma center care is associated with reduced readmissions after injury.

BACKGROUND: Trauma center care has been associated with improved mortality. It is not known if access to trauma center care is also associated with reduced readmissions. We hypothesized that receiving treatment at a trauma center would be associated with improved care and therefore would be associated with reduced readmission rates. METHODS: We conducted a retrospective analysis of all hospital visits in California using the Office of Statewide Health Planning and Development Database from 2007 to 2008. All hospital admissions and emergency department visits associated with injury were longitudinally linked. Regions were categorized by whether they had trauma centers. We excluded all patients younger than 18 years. We performed univariate and multivariate regression analyses to determine if readmissions were associated with patient characteristics, length of stay for initial hospitalization, trauma center access, and triage patterns. RESULTS: A total of 211,504 patients were included in the analysis. Of these, 5,094 (2%) died during the index hospitalization. Of those who survived their initial hospitalization, 79,123 (38%) experienced one or more readmissions to any hospital within 1 year. The majority of these were one-time readmissions (62%), but 38% experienced multiple readmissions. Over 67% of readmissions were unplanned and 8% of readmissions were for a trauma. After controlling for patient variables known to be associated with readmissions, primary triage to a trauma center was associated with a lower odds of readmission (odds ratio, 0.89; p < 0.001). The effect of transport to a trauma center remained significantly associated with decreased odds of readmission at 1 year (odds ratio, 0.96; p < 0.001). CONCLUSION: Readmissions after injury are common and are often unscheduled. While patient factors play a role in this, care at a trauma center is also associated with decreased odds for readmission, even when controlling for severity of injury. This suggests that the benefits of trauma center care extend beyond improvements in mortality to improved long-term outcomes. LEVEL OF EVIDENCE: Epidemiologic study, level III; therapeutic/care management study, level IV.

Perioperative issues: myocardial ischemia and protection--beta-blockade.

Approximately one third of patients undergoing noncardiac surgery have coronary artery disease, and cardiovascular complications are an important cause of perioperative morbidity and mortality. Several algorithms are available to assess the risk for peri-operative cardiac events. Although preoperative risk assessment is useful in identifying patients at greatest risk for cardiac complications, recent investigations have provided additional guidance in choosing interventions to improve perioperative outcomes. These investigations show that perioperative beta-blockers significantly reduce morbidity and mortality in noncardiac surgery and appear to offer the greatest benefit to high-risk patients. Because of the lower complication rate in intermediate- and low-risk patients and the absence of large randomized controlled trials, the role of beta-blockers in this population is less well-defined.

Payer status is associated with the use of prophylactic inferior vena cava filter in high-risk trauma patients.

BACKGROUND: It is controversial whether patients at high risk for pulmonary embolism (PE) should receive prophylactic inferior vena cava filters (IVC) filters. This lack of clarity creates the potential for variability and disparities in care. We hypothesized there would be differential use of prophylactic IVC filters for patients at high risk for PE on the basis of insurance status. METHODS: We performed a retrospective analysis using the National Trauma Databank (2002-2007). We included adult patients at high risk for PE (traumatic brain injury or spinal cord injury) and excluded patients with a diagnosis of deep venous thrombosis (DVT) or PE. Logistic regression was performed to control for confounders and a hierarchical mixed effects model was used to control for center. RESULTS: A prophylactic filter was placed in 3,331 (4.3%) patients in the study cohort. Patients without insurance had an IVC filter placed less often compared with those with any form of insurance (2.7% vs 4.9%, respectively). After adjusting for confounders, we found that patients without insurance were less likely to receive a prophylactic IVC filter, even when we controlled for center (OR 5.3, P < .001). CONCLUSION: When guidelines lack clarity, unconscious bias has the potential to create a system with different levels of care based on socioeconomic disparities.

Early outcomes of deliberate nonoperative management for blunt thoracic aortic injury in trauma.

OBJECTIVE: Traumatic blunt aortic injury has traditionally been viewed as a surgical emergency, whereas nonoperative therapy has been reserved for nonsurgical candidates. This study reviews our experience with deliberate, nonoperative management for blunt thoracic aortic injury. METHODS: A retrospective chart review with selective longitudinal follow-up was conducted for patients with blunt aortic injury. Surveillance imaging with computed tomography angiography was performed. Nonoperative patients were then reviewed and analyzed for survival, evolution of aortic injury, and treatment failures. RESULTS: During the study period, 53 patients with an average age of 45 years (range, 18-80 years) were identified, with 28% presenting to the Stanford University School of Medicine emergency department and 72% transferred from outside hospitals. Of the 53 patients, 29 underwent planned, nonoperative management. Of the 29 nonoperative patients, in-hospital survival was 93% with no aortic deaths in the remaining patients. Survival was 97% at a median of 1.8 years (range, 0.9-7.2 years). One patient failed nonoperative management and underwent open repair. Serial imaging was performed in all patients (average = 107 days; median, 31 days), with 21 patients having stable aortic injuries without progression and 5 patients having resolved aortic injuries. CONCLUSIONS: This experience suggests that deliberate, nonoperative management of carefully selected patients with traumatic blunt aortic injury may be a reasonable alternative in the polytrauma patient; however, serial imaging and long-term follow-up are necessary.

Massive transfusion protocols: the role of aggressive resuscitation versus product ratio in mortality reduction.

BACKGROUND: Exsanguinating hemorrhage necessitating massive blood product transfusion is associated with high mortality rates. Recent data suggest that altering the fresh frozen plasma to packed red blood cell ratio (FFP:PRBC) results in significant mortality reductions. Our purpose was to evaluate mortality and blood product use in the context of a newly initiated massive transfusion protocol (MTP). STUDY DESIGN: In July 2005, our American College of Surgeons-verified Level I trauma center implemented an MTP supporting a 1:1.5 FFP:PRBC ratio, improved communications, and enhanced systems flow to optimize rapid blood product availability. During the 4 years surrounding protocol implementation, we reviewed data on trauma patients directly admitted through the emergency department and requiring 10 or more units PRBCs during the first 24 hours. RESULTS: For the 2 years before and subsequent to MTP initiation, there were 4,223 and 4,414 trauma activations, of which 40 and 37 patients, respectively, met study criteria. The FFP:PRBC ratios were identical, at 1:1.8 and 1:1.8 (p = 0.97). Despite no change in FFP:PRBC ratio, mortality decreased from 45% to 19% (p = 0.02). Other significant findings included decreased mean time to first product: cross-matched RBCs (115 to 71 minutes; p = 0.02), FFP (254 to 169 minutes; p = 0.04), and platelets (418 to 241 minutes; p = 0.01). CONCLUSIONS: MTP implementation is associated with mortality reductions that have been ascribed principally to increased plasma use and decreased FFP:PRBC ratios. Our study found a significant reduction in mortality despite unchanged FFP:PRBC ratios and equivalent overall mean numbers of transfusions. Our data underscore the importance of expeditious product availability and emphasize that massive transfusion is a complex process in which product ratio and time to transfusion represent only the beginning of understanding.

Restrictive red blood cell transfusion: not just for the stable intensive care unit patient.

BACKGROUND: Multiple studies report that patients receiving red blood cell (RBC) transfusion in the intensive care unit (ICU) are more likely to experience complications. Despite these findings, surgical patients are frequently transfused for operative procedures, trauma, and burns. We hypothesized that a RBC transfusion guideline would safely decrease our use of RBC transfusions in the ICU and lower the hematocrit at which our trauma and burn patients were transfused, both in the stable and symptomatic patient. METHODS: For each episode of RBC transfusion, the pretransfusion vital signs and reasons for transfusion were recorded prospectively from August 2003 through April 2004. Before institution of the transfusion guideline, which stressed withholding transfusion for hematocrit over 23 in asymptomatic patients, intensive education of all caregivers occurred. Data from all transfusions during 2005 were also reviewed for long-term compliance with the guideline. RESULTS: Eighty-two of 316 ICU patients (26%) had 315 RBC transfusion events during the initial study period. Mean transfusion hematocrits decreased from 26.6 +/- 4.7 to 23.9 +/- 2.6 (P < .0003) for all patients. For the follow-up period in 2005, 94 of 523 patients (18%) were transfused in the ICU at a mean transfusion hematocrit of 24.1 for symptomatic (P < .0001) and 22.5 for asymptomatic patients (P < .0001). Low hematocrit was the most frequently cited reason for transfusion for all patients in the first part of the study, whereas hemodynamic instability (n = 91 events) and perioperative losses (n = 49 events) ranked highest for symptomatic patients. CONCLUSION: A transfusion guideline accompanied by intensive education is effective in reducing RBC transfusions in a trauma-burn ICU. A lower hematocrit was well tolerated in both the symptomatic and asymptomatic groups of surgical patients. With education and follow-up, the changes in transfusion practices were durable and affected transfusion practices for both asymptomatic and symptomatic patients.