Association of COVID-19 Visitor Limitations and Goals of Care Discussions in the Intensive Care Unit.

INTRODUCTION: The COVID-19 pandemic led to visitor restrictions in many hospitals. Since care in the surgical intensive care unit (SICU) often engages visitors as surrogate decision-makers, we investigated whether there was an association between COVID-19-related visitor restrictions, goals of care discussions (GOCD), and patient outcomes in SICU patients. METHODS: We conducted a retrospective review of trauma and emergency general surgery (EGS) patients admitted to a rural tertiary SICU between July 2019 and April 2021, dividing patients into those admitted during COVID-19 visitor restrictions and those admitted at other times. Using univariate and multivariate logistic regression analyses, we compared the primary outcome, incidence of GOCD, and incidence of prolonged hospital (> 14 d) and intensive care unit length of stay (LOS, > 7 d) between the two groups. RESULTS: One hundred seventy nine of 368 study patients (48.6%) presented during restricted visitation. The proportion of GOCD was 38.0% and 36.5% in the restricted and nonrestricted visitation cohorts, respectively (P = 0.769). GOCD timing and outcomes were similar in both groups. The use of telecommunication increased during restricted visitation, as did the proportion of trauma patients admitted to the SICU. On multivariable logistic regression, age and patient category were independent predictors of GOCD. On outcomes analysis, visitor restriction was associated with prolonged hospital LOS for EGS patients (odds ratio 2.44, 95% confidence interval 1.01-5.91, P value 0.048). CONCLUSIONS: Restricted visitation was not associated with changes in frequency or outcome of GOCD, but was associated with prolonged hospital LOS among EGS patients who had SICU admissions. Further investigation of patient/surrogate satisfaction with virtual GOCD in the SICU setting is needed.

Defining Risk and Risk Factors for Unplanned ICU Admission of Trauma Patients.

BACKGROUND: Unplanned ICU admissions (up-ICUad) are associated with poor outcomes. It is difficult to identify who is at risk for up-ICUad in trauma patients. This study aimed to identify injury patterns and comorbidities associated with up-ICUad and develop a predictive tool for who is at risk. METHODS: A retrospective study compared trauma patients admitted to the floor who experienced an up-ICUad to similar patients without an up-ICUad. Univariate analysis and multivariate logistic regression identified independent risk factors associated with up-ICUad. Based on those factors, a Risk Score (RS) was created and compared between the two groups. RESULTS: 2.15% of the 7206 patients experienced an up-ICUad. The up-ICUad group was older, experienced longer length of stay, and had higher mortality. Age, congestive heart failure, COPD, peptic ulcer disease, mild liver disease, CKD, and significant injuries to the thorax, spine, and lower extremities were independently associated with up-ICUad. A RS equation was created and was used for each patient. CONCLUSIONS: Trauma patients are at increased risk for up-ICUad based on specific factors. These factors can be used to calculate a RS to determine who is at greatest risk for an up-ICUad which may be helpful for preventing up-ICUad.

Frequency and Predictors of Trauma Transfer Futility to a Rural Level I Trauma Center.

INTRODUCTION: Transfer of trauma patients whose injuries are deemed unsurvivable, often results in early death or transition to comfort care and could be considered misuse of health care resources. This is particularly true where tertiary care resources are limited. Identifying riskfactors for and predicting futile transfers could reduce this impact and help to optimize triage and management. METHODS: A retrospective study of interfacility trauma transfers to a single rural Level I rauma center from 2014 to 2019. Futility was defined as death, hospice, or declaration of comfort measures within 48 h of transfer without procedural or radiographic intervention at the accepting center. Multiple logistic regressions identified independent predictors of futile transfers. The predictive power of Mechanism,Glasgow coma scale, Age, and Arterial pressure (MGAP), an injury severity score based on Mechanism, Glasgow coma scale, Age, and systolic blood Pressure, were evaluated. RESULTS: Of the 3368 trauma transfers, 37 (1.1%) met criteria as futile. Futile transfers occurred among patients who were significantly older with falls as the most common mechanism. Age, Glasgow coma scale, systolic blood Pressure and Injury Severity Score were significant (P < 0.05) independent predictors of futile transfer. MGAP had a high predictive power area under the receiver operating characteristic (AUROC 0.864, 95% confidence interval 0.803-0.925) for futility. CONCLUSIONS: A small proportion (1.1%) of transfers to a rural Level I trauma center met criteria for futility. Predictive tools, such as MGAP scoring, can provide objective criteria for evaluation of transfer necessity and prompt care pathways that involve pre-transfer communications, telemedicine, and/or patient centered goals of care discussions. Such tools could be used in conjunction with a more granular assessment regarding potential operational barriers to reduce futile transfers and to enhance optimization of resource utilization in low-resource service areas.

Prehospital care training in a rapidly developing economy: a multi-institutional study.

BACKGROUND: The trauma pandemic is one of the leading causes of death worldwide but especially in rapidly developing economies. Perhaps, a common cause of trauma-related mortality in these settings comes from the rapid expansion of motor vehicle ownership without the corresponding expansion of national prehospital training in developed countries. The resulting road traffic injuries often never make it to the hospital in time for effective treatment, resulting in preventable disability and death. The current article examines the development of a medical first responder training program that has the potential to reduce this unnecessary morbidity and mortality. METHODS: An intensive training workshop has been differentiated into two progressive tiers: acute trauma training (ATT) and broad trauma training (BTT) protocols. These four-hour and two-day protocols, respectively, allow for the mass education of laypersons-such as police officials, fire brigade, and taxi and/or ambulance drivers-who are most likely to interact first with prehospital victims. Over 750 ATT participants and 168 BTT participants were trained across three Indian educational institutions at Jodhpur and Jaipur. Trainees were given didactic and hands-on education in a series of critical trauma topics, in addition to pretraining and post-training self-assessments to rate clinical confidence across curricular topics. Two-sample t-test statistical analyses were performed to compare pretraining and post-training confidence levels. RESULTS: Program development resulted in recruitment of a variety of career backgrounds for enrollment in both our ATT and BTT workshops. The workshops were run by local physicians from a wide spectrum of medical specialties and previously ATT-trained police officials. Statistically significant improvements in clinical confidence across all curricular topics for ATT and BTT protocols were identified (P < 0.0001). In addition, improvement in confidence after BTT training was similar in Jodhpur compared with Jaipur. CONCLUSIONS: These results suggest a promising level of reliability and reproducibility across different geographic areas in rapidly developing settings. Program expansion can offer an exponential growth in the training rate of medical first responders, which can help curb the trauma-related mortality in rapidly developing economies. Future directions will include clinical competency assessments and further progressive differentiation into higher tiers of trauma expertise.

Use of limited transthoracic echocardiography in patients with traumatic cardiac arrest decreases the rate of nontherapeutic thoracotomy and hospital costs.

OBJECTIVES: Limited transthoracic echocardiography (LTTE) has been introduced as a hemodynamic tool for trauma patients. The aim of this study was to evaluate the utility of LTTE during the evaluation of nonsurviving patients who presented to the trauma bay with traumatic cardiac arrest. METHODS: Approval by the Institutional Review Board was obtained. All nonsurviving patients with traumatic cardiac arrest who reached the trauma bay were evaluated retrospectively for 1 year. Comparisons between groups of patients in whom LTTE was performed as part of the resuscitation effort and those in whom it was not performed were conducted. RESULTS: From January 2012 to January 2013, 37 patients did not survive traumatic cardiac arrest while in the trauma bay: 14 in the LTTE group and 23 in the non-LTTE group. When comparing the LTTE and non-LTTE groups, both were similar in sex distribution (LTTE, 86% male; non-LTTE, 74% male; P = .68), age (34.8 versus 24.1 years; P= .55), Injury Severity Score (41.0 versus 38.2; P= .48), and percentage of penetrating trauma (21.6% versus 21.7%; P = .29). Compared with the non-LTTE group, the LTTE group spent significantly less time in the trauma bay (13.7 versus 37.9 minutes; P = .01), received fewer blood products (7.1% versus 31.2%; P = .789), and were less likely to undergo nontherapeutic thoracotomy in the emergency department (7.14% versus 39.1%; P < .05). The non-LTTE group had a mean of $3040.50 in hospital costs, compared with the mean for the LTTE group of $1871.60 (P = .0054). CONCLUSIONS: In this study, image-guided resuscitation with LTTE decreased the time in the trauma bay and avoided nontherapeutic thoracotomy in nonsurviving trauma patients. Limited TTE could improve the use of health care resources in patients with traumatic cardiac arrest.

Contribution by Dr Timothy C Fabian: liver trauma.

The liver is the most commonly injured organ within the abdomen. Dr Fabian and his associates have made remarkable contributions to our understanding and management of these injuries. The current review summarizes the contributions.

Management of acute cholecystitis in patients on anti-thrombotic therapy: A single center experience.

Background: Acute cholecystitis in patients on anti-thrombotic therapy (ATT) presents a clinical dilemma at the intersection between conflicting guidelines, specifically between timing of early operative management (OM) versus time-to-reversal of certain ATT agents. With growing recognition that nonoperative management (NOM) is associated with considerable morbidity, and evidence in the literature that early OM in patients on ATT is safe, we reviewed our own practice to examine how we addressed these conflicting guidelines. Materials and methods: We performed a retrospective review of patients with acute cholecystitis between December 2017 and March 2022. Patients were classified as ATT or non-ATT; ATT patients were subdivided into anticoagulation (AC) and antiplatelet (AP) groups. Rates of OM were compared. Results: 502 patients with acute cholecystitis were identified, 464 non-ATT and 38 ATT. 30 ATT patients were on AC, 7 on AP, and 1 on both. Non-ATT patients were significantly more likely to receive OM at index presentation compared to those on ATT: 89.9 % vs 63.2 % (p < 0.05). Subgroup analysis of the ATT group showed AP patients were significantly less likely to receive OM compared to those on AC, 12.5 % vs 77 % (p < 0.05). Conclusions: At our institution, patients on ATT were significantly less likely to undergo OM for acute cholecystitis compared with non-ATT patients. Those on AC received OM significantly more than patients on AP. Further study is needed to better define the management of this growing population so that acute cholecystitis guidelines might address this issue in the future.

Pediatric trauma mortality in India and the United States: A comparison and risk-adjusted analysis.

BACKGROUND: There is a paucity of research comparing pediatric risk-adjusted trauma mortality between high-income and low- and middle-income countries. This limits identification of populations and injury patterns for targeted interventions. We aim to compare independent predictors of pediatric trauma mortality between India and the United States (US). METHODS: A retrospective cohort study was conducted for pediatric patients (age <18 years) in India's Towards Improved Trauma Care Outcomes (TITCO) project database and the US National Trauma Data Bank (NTDB) from 2013 to 2015. Demographic, injury, physiologic, anatomic and outcome data were analyzed. Multivariable regressions were used to determine independent predictors of mortality. RESULTS: 126,678 pediatric trauma patients were included (India 3,373; US 123,305). Pediatric patients in India were on average significantly younger, with a higher median injury severity score (ISS), had lower systolic blood pressure, and suffered a higher case fatality rate (13.0% vs. 1.0%). When controlling for demographic, mechanism, physiologic, and anatomic injury characteristics, sustaining an injury in India was the strongest predictor of mortality (OR 22.70, 95% CI 18.70-27.56). On subgroup analysis, the highest relative odds of mortality in India was seen in children with lower injury and physiologic severity. CONCLUSIONS: Risk-adjusted pediatric trauma-related mortality is significantly higher in India compared to the US. The comparative odds of mortality are highest among children with lower injury and physiologic severity. This suggests that low-cost targeted interventions focused on standard timely trauma care, protocols, training and early imaging could improve pediatric injury mortality in India. TYPE OF STUDY: Retrospective Prognosis Study LEVEL OF EVIDENCE: II.

Current patterns of trauma center proliferation have not led to proportionate improvements in access to care or mortality after injury: An ecologic study.

BACKGROUND: Timely access to high-level (I/II) trauma centers (HLTCs) is essential to minimize mortality after injury. Over the last 15 years, there has been a proliferation of HLTC nationally. The current study evaluates the impact of additional HLTC on population access and injury mortality. METHODS: A geocoded list of HLTC, with year designated, was obtained from the American Trauma Society, and 60-minute travel time polygons were created using OpenStreetMap data. Census block group population centroids, county population centroids, and American Communities Survey data from 2005 and 2020 were integrated. Age-adjusted nonoverdose injury mortality was obtained from CDC Wide-ranging Online Data for Epidemiologic Research and the Robert Wood Johnson Foundation. Geographically weighted regression models were used to identify independent predictors of HLTC access and injury mortality. RESULTS: Over the 15-year (2005-2020) study period, the number of HLTC increased by 31.0% (445 to 583), while population access to HLTC increased by 6.9% (77.5-84.4%). Despite this increase, access was unchanged in 83.1% of counties, with a median change in access of 0.0% (interquartile range, 0.0-1.1%). Population-level age-adjusted injury mortality rates increased by 5.39 per 100,000 population during this time (60.72 to 66.11 per 100,000). Geographically weighted regression controlling for population demography and health indicators found higher median income and higher population density to be positively associated with majority (≥50%) HLTC population coverage and negatively associated with county-level nonoverdose mortality. CONCLUSION: Over the past 15 years, the number of HLTC increased 31%, while population access to HLTC increased only 6.9%. High-level (I/II) trauma center designation is likely driven by factors other than population need. To optimize efficiency and decrease potential oversupply, the designation process should include population level metrics. Geographic information system methodology can be an effective tool to assess optimal placement. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Patient Factors Associated with High Opioid Consumption after Common Surgical Procedures Following State-Mandated Opioid Prescription Regulations.

BACKGROUND: State regulations have decreased prescribed opioids with more than 25% of patients abstaining from opioids. Despite this, 2 distinct populations of patients exist who consume "high" or "low" amounts of opioids. The aim of this study was to identify factors associated with postoperative opioid use after common surgical procedures and develop an opioid risk score. STUDY DESIGN: Patients undergoing 35 surgical procedures from 7 surgical specialties were identified at a 620-bed tertiary care academic center and surveyed 1 week after discharge regarding opioid use and adequacy of analgesia. Electronic medical record data were used to characterize postdischarge opioids, complications, demographics, medical history, and social factors. High opioid use was defined as >75th percentile morphine milligram equivalents for each procedure. An opioid risk score was calculated from factors associated with opioid use identified by backward multivariate logistic regression analysis. RESULTS: A total of 1,185 patients were enrolled between September 2017 and February 2019. Bivariate analyses revealed patient factors associated with opioid use including earlier substance use (p < 0.001), depression (p = 0.003), anxiety (p < 0.001), asthma (p = 0.006), obesity (p = 0.03), migraine (p = 0.004), opioid use in the 7 days before surgery (p < 0.001), and 31 Clinical Classifications Software Refined classifications (p < 0.05). Significant multivariates included: insurance (p = 0.005), employment status (p = 0.005), earlier opioid use (odds ratio [OR] 2.38 [95% CI 1.21 to 4.68], p = 0.01), coronary artery disease (OR 0.38 [95% CI 0.16 to 0.86], p = 0.02), acute pulmonary embolism (OR 9.81 [95% CI 3.01 to 32.04], p < 0.001), benign breast conditions (OR 3.42 [95% CI 1.76 to 6.64], p < 0.001), opioid-related disorders (OR 6.67 [95% CI 1.87 to 23.75], p = 0.003), mental and substance use disorders (OR 3.80 [95% CI 1.47 to 9.83], p = 0.006), headache (OR 1.82 [95% CI 1.24 to 2.67], p = 0.002), and previous cesarean section (OR 5.10 [95% CI 1.33 to 19.56], p = 0.02). An opioid risk score base was developed with an area under the curve of 0.696 for the prediction of high opioid use. CONCLUSIONS: Preoperative patient characteristics associated with high opioid use postoperatively were identified and an opioid risk score was derived. Identification of patients with a higher need for opioids presents an opportunity for improved preoperative interventions, the use of nonopioid analgesic therapies, and alternative therapies.

Bronchoalveolar lavage in the diagnosis of ventilator-associated pneumonia: to quantitate or not, that is the question.

Quantitative bronchoalveolar lavage (BAL) is used to diagnose ventilator-associated pneumonia (VAP). We prospectively compared semiquantitative (SQ) and quantitative (Qu) culture of BAL for VAP diagnosis. Ventilated patients suspected of VAP underwent bronchoscopic BAL. BAL fluid was examined by both Qu (colony-forming units [CFUs]/mL) and SQ culture (none, sparse, moderate, or heavy) and results were compared. VAP was defined as 105 CFU/mL or greater on Qu culture. Over 36 months, 319 BALs were performed. Sixty-three of 319 (20%) showed diagnostic growth by Qu culture identifying a total of 81 organisms causing VAP. All 63 specimens showed growth of some organism(s) on SQ culture with 79 of 81 causative organisms identified and two (Pseudomonas, one; Corynebacterium, one) not identified. The remaining 256 specimens did not meet the threshold for VAP by the Qu method. Among these, 79 did not show any growth on SQ culture. Among the 240 specimens showing some growth on SQ culture, a total of 384 organisms were identified. VAP rates in relation to strength of growth on SQ culture were: sparse, 10 of 140 (7%); moderate, 24 of 147 (16%); and heavy, 45 of 97 (46%). Sensitivity (Sn), specificity (Sp), positive (PPV), and negative (NPV) predictive values of SQ culture of BAL fluid for the diagnosis of VAP were 97, 21, 21, and 97 per cent, respectively. Nonquantitative culture of BAL fluid is fairly accurate in ruling out VAP (high Sn and NPV). It however has poor Sp and PPV and using this method will lead to unnecessary antimicrobial use with its attendant complications of toxicity, cost, and resistance.

Limited transthoracic echocardiogram: so easy any trauma attending can do it.

BACKGROUND: Limited transthoracic echocardiogram (LTTE) represents an attractive alternative to formal transthoracic echocardiogram (TTE), because it does not require an echocardiogram machine. Our hypothesis is that trauma attendings can learn LTTE effectively with minimal training. METHODS: Seven attendings at a Level I trauma center received didactic and hands-on training in LTTE and performed this test on hypotensive patients to evaluate for contractility, fluid status, and pericardial effusion. Therapy to improve perfusion (administration of fluids, ionotropes, or vasopressors) was guided by LTTE findings. Perfusion status was determined by serum lactate level before and 6 hours after LTTE. Findings were compared with cardiology-performed TTE. RESULTS: Range of postresidency training was 1 year to 29 years. LTTE teaching entailed 70 minutes of didactics and 25 minutes of hands-on. In all, 52 LTTEs were performed; two patients were excluded due to blunt trauma arrest. Age ranged from 22 years to 89 years with an average of 55 years. Admission diagnosis was blunt trauma (n = 34), penetrating trauma (n = 3), and intra-abdominal sepsis (n = 13). Average time for LTTE was 4 minutes 38 seconds. Cardiology-performed TTE was obtained in all patients, and correlation with LTTE was 100%. A total of 37 patients received intravenous fluid, 9 received vasopressors, and 4 received ionotropes as guided by LTTE findings, with lactate reduction in all patients (p < 0.00001). Attendings scored a mean of 88% in a written test after training. CONCLUSIONS: Trauma attendings can successfully learn LTTE with minimal training and use the technique as a resuscitation tool in the hypotensive patient.

Canadian Cervical Spine rule compared with computed tomography: a prospective analysis.

BACKGROUND: The Canadian cervical spine rule (CCS) has been found to be an effective tool to determine the need for radiographic evaluation of the cervical spine (c-spine) incorporating both clinical findings and mechanism. Previously, it has been validated only through clinical follow-up or selective use of X-rays. The purpose of this study was to validate it using computed tomography (CT) as the gold standard to identify fractures. METHODS: Prospective evaluation was performed on 3,201 blunt trauma patients who were screened by CCS and were compared with a complete c-spine CT. CSS positive indicated at least one positive clinical or mechanism finding, whereas CT positive indicated presence of a fracture. RESULTS: There were 192 patients with c-spine fractures versus 3,009 without fracture on CT. The fracture group was older (42.7 ± 19.0 years vs. 37.8 ± 17.5 years, p = 0.0006), had a lower Glasgow Coma Scale score (13.8 ± 4.2 vs. 14.4 ± 4.3, p < 0.0001), and lower systolic blood pressure (133.3 ± 23.8 mm Hg vs. 139.5 ± 23.1 mm Hg, p = 0.0023). The sensitivity of CCS was 100% (192/192), specificity was 0.60% (18/3009), positive predictive value was 6.03% (192/3183), and negative predictive value was 100% (18/18). Logistic regression identified only 8 of the 19 factors included in the CCS to be independent predictors of c-spine fracture. CONCLUSIONS: CCS is very sensitive but not very specific to determine the need for radiographic evaluation after blunt trauma. Based on this study, the rule should be streamlined to improve specificity while maintaining sensitivity.

National Emergency X-Radiography Utilization Study criteria is inadequate to rule out fracture after significant blunt trauma compared with computed tomography.

BACKGROUND: EAST guidelines now recommend computed tomography (CT) to evaluate cervical spine (c-spine) fractures after blunt trauma in patients who do not meet National Emergency X-Radiography Utilization Study criteria (NC), yet no imaging is required in those patients who do meet these criteria. NC are based on patients with both minor and severe (trauma team activation [TTA]) trauma. The purpose of this study was to evaluate the NC using CT as the gold standard in TTA patients. METHODS: We prospectively evaluated 2,606 blunt TTA patients at our Level I trauma center. NC defined as alertness (Glasgow Coma Scale [GCS] score = 15), evidence of intoxication, clinically distracting injury, midline c-spine tenderness, or neurologic deficits were documented. CT was used to determine the accuracy of these criteria. RESULTS: There were 157 patients with c-spine fractures and 2,449 patients without c-spine fractures. The fracture group was older (age, 43.4 years ± 19.3 years fracture group vs. 37.7 years ± 17.5 years no fracture group, p = 0.0003) with a lower GCS score (fracture group 13.7 ± 4.5 vs. no fracture group 14.4 ± 3.6, p = 0.0001) and initial systolic blood pressure (132.5 mm Hg ± 23.4 mm Hg vs. 139.9 mm Hg vs. 23.5 mm Hg, p = 0.0009). The sensitivity and specificity of clinical examination for all patients were 82.8% (130 of 157) and 45.7% (1,118 of 2,449), respectively. The positive predictive value (PPV) and negative predictive value (NPV) were 8.9% (130 of 1,461) and 97.6% (1,118 of 1,145), respectively. Patients with a GCS score of 15 had a sensitivity of 77%, specificity of 52.3%, PPV of 8.5%, and NPV of 97.5% for clinical examination. In those patients with the GCS score of 15, no intoxication or distracting injury, clinical examination had a sensitivity of 59.4%, specificity of 79.5%, PPV of 12.5%, and NPV of 97.5%. Of 26 patients with missed injuries based on NC, 19 (73.1%) required further intervention (16 collars, 2 OR, 1 Halo). CONCLUSION: As in our previous trial, NC is inaccurate compared with CT to diagnose c-spine fractures in TTA patients. CT should be used in all blunt TTA patients regardless of whether they meet NC.

Defining the limits of resuscitative emergency department thoracotomy: a contemporary Western Trauma Association perspective.

BACKGROUND: Since the promulgation of emergency department (ED) thoracotomy>40 years ago, there has been an ongoing search to define when this heroic resuscitative effort is futile. In this era of health care reform, generation of accurate data is imperative for developing patient care guidelines. The purpose of this prospective multicenter study was to identify injury patterns and physiologic profiles at ED arrival that are compatible with survival. METHODS: Eighteen institutions representing the Western Trauma Association commenced enrollment in January 2003; data were collected prospectively. RESULTS: During the ensuing 6 years, 56 patients survived to hospital discharge. Mean age was 31.3 years (15-64 years), and 93% were male. As expected, survival was predominant in those with thoracic injuries (77%), followed by abdomen (9%), extremity (7%), neck (4%), and head (4%). The most common injury was a ventricular stab wound (30%), followed by a gunshot wound to the lung (16%); 9% of survivors sustained blunt trauma, 34% underwent prehospital cardiopulmonary resuscitation (CPR), and the presenting base deficit was >25 mequiv/L in 18%. Relevant to futile care, there were survivors of blunt torso injuries with CPR up to 9 minutes and penetrating torso wounds up to 15 minutes. Asystole was documented at ED arrival in seven patients (12%); all these patients had pericardial tamponade and three (43%) had good functional neurologic recovery at hospital discharge. CONCLUSION: Resuscitative thoracotomy in the ED can be considered futile care when (a) prehospital CPR exceeds 10 minutes after blunt trauma without a response, (b) prehospital CPR exceeds 15 minutes after penetrating trauma without a response, and (c) asystole is the presenting rhythm and there is no pericardial tamponade.

Comparing trauma mortality of injured patients in India and the USA: a risk-adjusted analysis.

OBJECTIVES: Comparisons of risk-adjusted trauma mortality between high-income countries and low and middle-income countries (LMICs) can be used to identify specific patient populations and injury patterns for targeted interventions. Due to a paucity of granular patient and injury data from LMICs, there is a lack of such comparisons. This study aims to identify independent predictors of trauma mortality and significant differences between India and the USA. METHODS: A retrospective cohort study of two trauma databases was conducted. Demographic, injury, physiologic, anatomic and outcome data were analyzed from India's Towards Improved Trauma Care Outcomes project database and the US National Trauma Data Bank from 2013 to 2015. Multivariate logistic regression analyses were performed to determine significant independent predictors of mortality. RESULTS: 687 407 adult trauma patients were included (India 11 796; USA 675 611). Patients from India were significantly younger with greater male preponderance, a higher proportion presented with physiologic abnormalities and suffered higher mortality rates (23.2% vs. 2.8%). When controlling for age, sex, physiologic abnormalities, and injury severity, sustaining an injury in India was the strongest predictor of mortality (OR 13.85, 95% CI 13.05 to 14.69). On subgroup analyses, the greatest mortality difference was seen in patients with lower Injury Severity Scores. CONCLUSION: After adjusting for demographic, physiologic abnormalities, and injury severity, trauma-related mortality was found to be significantly higher in India. When compared with trauma patients in the USA, the odds of mortality are most notably different among patients with lower Injury Severity Scores. While troubling, this suggests that relatively simple, low-cost interventions focused on standard timely trauma care, early imaging, and protocolized treatment pathways could result in substantial improvements for injury mortality in India, and potentially other LMICs. LEVEL OF EVIDENCE: Level 3, retrospective cohort study.

Using performance frontiers to differentiate elective and capacity-based surgical services.

BACKGROUND: Acute care surgery (ACS) model of care delivery has many benefits. However, since the ACS surgeon has limited control over the volume, timing, and complexity of cases, traditional metrics of operating room (OR) efficiency almost always measure ACS service as "inefficient." The current study examines an alternative method-performance fronts-of evaluating changes in efficiency and tests the following hypotheses: (1) in an institution with a robust ACS service, performance front methodology is superior to traditional metrics in evaluating OR throughput/efficiency, and (2) introduction of an ACS service with block time allocation will improve OR throughput/efficiency. METHODS: Operating room metrics 1-year pre-ACS implementation and post-ACS implementation were collected. Overall OR efficiency was calculated by mean case volumes for the entire OR and ACS and general surgery (GS) services individually. Detailed analysis of these two specific services was performed by gathering median monthly minutes-in block, out of block, after hours, and opportunity unused. The two services were examined using a traditional measure of efficiency and the "fronts" method. Services were compared with each other and also pre-ACS implementation and post-ACS implementation. RESULTS: Overall OR case volumes increased by 5% (999 ± 50 to 1,043 ± 46: p < 0.05) with almost all of the increase coming through ACS (27 ± 4 to 68 ± 16: p < 0.05). By traditional metrics, ACS had significantly worse median efficiency versus GS in both periods: pre (0.67 [0.66-0.71] vs. 0.80 [0.78-0.81]) and post (0.75 [0.53-0.77] vs. 0.83 [0.84-0.85]) (p < 0.05). As compared with the pre, GS efficiency improved significantly in post (p < 0.05), but ACS efficiency remained unchanged (p > 0.05). The alternative fronts chart demonstrated the more accurate picture with improved efficiency observed for GS, ACS, and combined. CONCLUSION: In an institution with a busy ACS service, the alternative fronts methodology offers a more accurate evaluation of OR efficiency. The provision of an OR for the ACS service improves overall throughput/efficiency.

Delay in ICU transfer is protective against ICU readmission in trauma patients: a naturally controlled experiment.

BACKGROUND: Unplanned intensive care unit (ICU) readmission-ICU bounce back (ICUbb)-is associated with worse outcomes. Patients not requiring organ system support or intensive nursing are deemed 'ICU discharge ready' and transfer orders are placed. However, actual transfer only occurs when an appropriate, non-ICU bed is available. This is dependent on inherent system inefficiencies resulting in a naturally controlled experiment between when patients actually transfer: Early (<24 hours) or Delayed (>24 hours) transfers, after order placement. This study leverages that natural experiment to determine if additional ICU time is protective against ICUbb. We hypothesize that Delayed transfer is protective against ICUbb. METHODS: Using a retrospective, cohort design, we queried a trauma research repository and electronic medical record during a 10-year period to capture traumatized patients admitted to the ICU. Patients were categorized into Early (<24 hours) or Unintended-Delayed (>24 hours) groups based on actual transfer time after order placement. Patient characteristics (age, Charlson Comorbidity Index (CCI)) and Injury Severity Score (ISS) were analyzed. Univariate and multivariate analyses were performed to compare ICUbb rates among Early and Unintended-Delayed groups. RESULTS: Of the 2004 patients who met the criteria, 1690 fell into the Early group, and 314 fell into the Delayed. The Early group was younger (mean age 52±23 vs. 55±22 years), had fewer comorbidities (median CCI score 1 (0, 3) vs. 2 (1, 3)), and was less injured (median ISS 17 (10-22) vs. 17 (13-25)), all p<0.05. Overall, 113 (5.6%) patients experienced ICUbb: Early 109 (6.5%) versus Unintended-Delay 4 (1.3%), p<0.05. By regression analysis, age, CCI, and ISS were independently associated with ICUbb while Delayed transfer was protective. DISCUSSION: Despite higher age, CCI score, and ISS, the Unintended-Delayed group experienced fewer ICUbb. After controlling for age, CCI and ISS, Delayed transfer reduced ICUbb risk by 78%. Specific care elements affording this protection remain to be elucidated. LEVEL OF EVIDENCE: Level III. STUDY TYPE: Therapeutic study.

Geographic Coverage and Verification of Trauma Centers in a Rural State: Highlighting the Utility of Location Allocationfor Trauma System Planning.

BACKGROUND: Care at verified trauma centers has improved survival and functional outcomes, yet determining the appropriate location of potential trauma centers is often driven by factors other than optimizing system-level patient care. Given the importance of transport time in trauma, we analyzed trauma transport patterns in a rural state lacking an organized trauma system and implemented a geographic information system to inform potential future trauma center locations. STUDY DESIGN: Data were collected on trauma ground transport during a 3-year period (2014 through 2016) from the Statewide Incident Reporting Network database. Geographic information system mapping and location-allocation modeling of the best-fit facility for trauma center verification was computed using trauma transport patterns, population density, road network layout, and 60-minute emergency medical services transport time based on current transport protocols. RESULTS: Location-allocation modeling identified 2 regional facilities positioned to become the next verified trauma centers. The proportion of the Vermont population without access to trauma center care within 60 minutes would be reduced from the current 29.68% to 5.81% if the identified facilities become verified centers. CONCLUSIONS: Through geospatial mapping and location-allocation modeling, we were able to identify gaps and suggest optimal trauma center locations to maximize population coverage in a rural state lacking a formal, organized trauma system. These findings could inform future decision-making for targeted capacity improvement and system design that emphasizes more equitable access to trauma center care in Vermont.

Frequency and importance of small amount of isolated pelvic free fluid detected with multidetector CT in male patients with blunt trauma.

PURPOSE: To retrospectively determine the frequency and importance of a small amount of isolated pelvic free fluid seen at multidetector computed tomography (CT) in male patients who have blunt trauma without an identifiable cause. MATERIALS AND METHODS: Institutional review board approval was obtained, and the requirement for informed consent was waived for this HIPAA-compliant study. One thousand male patients with blunt trauma who underwent abdominopelvic CT at a level 1 trauma center between January 2004 and June 2006 were entered into this study. The CT images of the 1000 patients were reviewed independently by two abdominal radiologists. CT scan assessment included evaluation for presence or absence of pelvic free fluid, any traumatic or nontraumatic cause of the free fluid, pelvic free fluid attenuation and volume measurements, and determination of the location of pelvic free fluid. Interobserver agreement was determined with kappa statistics, and the Student t test was used to assess differences in the mean volume and mean attenuation of the pelvic free fluid in the patients with and those without injury. RESULTS: Pelvic free fluid was identified in 10.2% (102 of 1000) of patients. A small amount of isolated pelvic free fluid without any identifiable cause was identified in 4.8% (48 of 1000) of patients by reader 1 and in 5.0% (50 of 1000) of patients by reader 2 (kappa value, 0.76) and was located at or below the level of the third sacral vertebral body in all 49 patients with isolated pelvic free fluid. The mean volume and mean attenuation of the small amount of isolated pelvic free fluid were 2.3 mL +/- 1.5 (standard deviation) and 8.1 HU +/- 3.9, respectively. None of the patients in this group had an undiagnosed bowel and/or mesenteric injury. CONCLUSION: In male patients with blunt trauma, a small amount of isolated pelvic free fluid with attenuation equal to that of simple fluid and located in the deep region of the pelvis likely is not a sign of bowel and/or mesenteric injury.