Emergency general surgery in older adult patients: Factors associated with fragmented care.

BACKGROUND: Care fragmentation has been shown to lead to increased morbidity and mortality. We aimed to explore the factors related to care fragmentation after hospital discharge in geriatric emergency general surgery patients, as well as examine the association between care fragmentation and mortality. METHODS: We designed a retrospective study of the Nationwide Readmissions Database 2019. We included patients ≥65 years old admitted with an emergency general surgery diagnosis who were discharged alive from the index admission. The primary outcome was 90-day care fragmentation, defined as an unplanned readmission to a non-index hospital. Multivariable logistic regression was performed, adjusting for patient and hospital characteristics. RESULTS: A total of 447,027 older adult emergency general surgery patients were included; the main diagnostic category was colorectal (22.6%), and 78.2% of patients underwent non-operative management during the index hospitalization. By 90 days post-discharge, 189,622 (24.3%) patients had an unplanned readmission. Of those readmitted, 20.8% had care fragmentation. The median age of patients with care fragmentation was 76 years, and 53.2% were of female sex. Predictors of care fragmentation were living in rural counties (odds ratio 1.76, 95% confidence interval: 1.57-1.97), living in a low-income ZIP Code, discharge to intermediate care facility (odds ratio 1.28, 95% confidence interval: 1.22-1.33), initial non-operative management (odds ratio 1.17, 95% confidence interval: 1.12-1.23), leaving against medical advice (odds ratio 2.60, 95% confidence interval: 2.29-2.96), and discharge from private investor-owned hospitals (odds ratio 1.18, 95% confidence interval: 1.10-1.27). Care fragmentation was significantly associated with higher mortality. CONCLUSION: The burden of unplanned readmissions in older adult patients who survive an emergency general surgery admission is underestimated, and these patients frequently experience care fragmentation. Future directions should prioritize evaluating the impact of initiatives aimed at alleviating the incidence and complications of care fragmentation in geriatric emergency general surgery patients.

Lost in transition: Impact of interhospital transfer on outcomes after emergency general surgery in the older adult population.

BACKGROUND: Emergency general surgery performed among patients over 65 years of age represents a particularly high-risk population. Although interhospital transfer has been linked to higher mortality in emergency general surgery patients, its impact on outcomes in the geriatric population remains uncertain. We aimed to establish the effect of interhospital transfer on postoperative outcomes in geriatric emergency general surgery patients. METHODS: Emergency general surgery patients 65 years and older were identified with American College of Surgeons National Surgical Quality Improvement Program 2013 to 2019. Patients were categorized based on admission source as either directly admitted or transferred from an outside hospital inpatient unit or emergency department. The primary outcomes evaluated were in-hospital mortality, 30-day mortality, and overall morbidity. Propensity score matching was used to control for confounders, including age, race, comorbidities, and preoperative conditions. Kaplan-Meier survival analysis and the log-rank test were used to compare 30-day survival in the matched cohort. RESULTS: Among the 88,424 patients identified, 13,872 (15.7%) were transfer patients. The median age was 74, and 53% were of female sex. Transfer patients had higher rates of comorbidities and preoperative conditions, including a higher prevalence of preoperative sepsis (21.8% vs 19.3%, P < .001) and ventilator dependence (6.4% vs 2.6%, P < .001). After propensity score-matched analysis, transferred patients exhibited higher rates of in-hospital mortality, 30-day mortality, and overall morbidity. Transfer patients were also less likely to be discharged home and more likely to be discharged to an acute care facility. Kaplan-Meier survival analysis confirmed a poorer 30-day survival in transferred patients. CONCLUSION: Interhospital transfer independently contributed to overall mortality and morbidity amongst geriatric emergency general surgery patients. Further investigation into improved coordination between hospitals, tailored care plans, and comprehensive risk assessments are needed to help mitigate the observed differences in outcomes.

Two big bones, one big decision: When to fix bilateral femur fractures.

PURPOSE: For polytrauma patients with bilateral femoral shaft fractures (BFSF), there is currently no consensus on the optimal timing of surgery. This study assesses the impact of early (≤ 24 h) versus delayed (>24 h) definitive fixation on clinical outcomes, especially focusing on concomitant versus staged repair. We hypothesized that early definitive fixation leads to lower mortality and morbidity rates. METHODS: The 2017-2020 Trauma Quality Improvement Program was used to identify patients aged ≥16 years with BFSF who underwent definitive fixation. Early definitive fixation (EDF) was defined as fixation of both femoral shaft fractures within 24 h, delayed definitive fixation (DDF) as fixation of both fractures after 24 h, and early staged fixation (ESF) as fixation of one femur within 24 h and the other femur after 24 h. Propensity score matching and multilevel mixed effects regression models were used to compare groups. RESULTS: 1,118 patients were included, of which 62.8% underwent EDF. Following propensity score matching, 279 balanced pairs were formed. EDF was associated with decreased overall morbidity (12.9% vs 22.6%, p = 0.003), lower rate of deep venous thrombosis (2.2% vs 6.5%, p = 0.012), a shorter ICU LOS (5 vs 7 days, p < 0.001) and a shorter hospital LOS (10 vs 15 days, p < 0.001). When compared to DDF, early staged fixation (ESF) was associated with lower rates of ventilator acquired pneumonia (0.0% vs 4.9%, p = 0.007), but a longer ICU LOS (8 vs 6 days, p = 0.004). Using regression analysis, every 24-hour delay to definitive fixation increased the odds of developing complications by 1.05, postoperative LOS by 10 h and total hospital LOS by 27 h. CONCLUSION: Early definitive fixation (≤ 24 h) is preferred over delayed definitive fixation (>24 h) for patients with bilateral femur shaft fractures when accounting for age, sex, injury characteristics, additional fractures and interventions, and hospital level. Although mortality does not differ, overall morbidity and deep venous thrombosis rates, and length of hospital and intensive care unit stay are significantly lower. When early definitive fixation is not possible, early staged repair seems preferable over delayed definitive fixation.

The overlooked factor: The impact of disability on postoperative complications after emergency general surgery procedures.

BACKGROUND: Despite more than 61 million people in the United States living with a disability, studies on the impact of disability on health care disparities in surgical patients remain limited. Therefore, we aimed to understand the impact of disability on postoperative outcomes. METHODS: We performed a retrospective cohort study using the Nationwide Readmission Database (2019). We compared patients ≥18 years undergoing emergency general surgery procedures with a disability condition with those without a disability. In accordance with the Centers for Disease Control and Prevention, disability was defined as severe hearing, visual, intellectual, or motor impairment/caregiver dependency. The primary outcome was 30-day readmission rates. Secondary outcomes included hospital length of stay and 30-day complications and mortality. Patients were 1:1 propensity-matched using patient, procedure, and hospital characteristics. RESULTS: Among our population of 378,733 patients, 5,877 (1.6%) patients had at least 1 disability condition. A higher proportion of patients with a disability had low household income, $1 to $45,999, and an Elixhauser Comorbidity score ≥3. Among 5,768 matched pairs, patients with a disability had a significantly higher incidence of 30-day readmission (17.2% vs 12.7%; P < .001), infectious complications (29.8% vs 19.5%; P < .001), and a longer length of stay (8 vs 6 days; P < .001). Motor impairment, the most common disability, was associated with the greatest increase in patient readmission, morbidity, and length of stay. CONCLUSION: Severe intellectual, hearing, visual, or motor impairments were associated with higher readmission, morbidity, and longer length of stay. Further research is needed to understand the mechanisms responsible for these disparities and to develop interventions to ameliorate them.

Traumatic lower extremity amputation as a risk factor for venous thromboembolism.

BACKGROUND: This study aimed to evaluate whether lower extremity (LE) amputation among civilian casualties is a risk factor for venous thromboembolism. METHODS: All patients with severe LE injuries (AIS ≥3) derived from the ACS-TQIP (2013-2020) were divided into those who underwent trauma-associated amputation and those with limb salvage. Propensity score matching was used to mitigate selection bias and confounding and compare the rates of pulmonary embolism (PE) and deep vein thrombosis (DVT). RESULTS: A total of 145,667 patients with severe LE injuries were included, with 3443 patients requiring LE amputation. After successful matching, patients sustaining LE amputation still experienced significantly higher rates of PE (4.2% vs. 2.5%, p â€‹< â€‹0.001) and DVT (6.5% vs. 3.4%, p â€‹< â€‹0.001). A sensitivity analysis examining patients with isolated major LE trauma similarly showed a higher rate of thromboembolic complications, including higher incidences of PE (3.2% vs. 2.0%, p â€‹= â€‹0.015) and DVT (4.7% vs. 2.6%, p â€‹< â€‹0.001). CONCLUSIONS: In this nationwide analysis, traumatic lower extremity amputation is associated with a significantly higher risk of VTE events, including PE and DVT.

The association of disability conditions with access to minimally invasive general surgery.

BACKGROUND: Despite the high prevalence of disability conditions in the US, their association with access to minimally invasive surgery (MIS) remains under-characterized. OBJECTIVE: To understand the association of disability conditions with rates of MIS and describe nationwide temporal trends in MIS in patients with disability conditions. METHODS: We conducted a retrospective cohort study using the Nationwide Readmission Database (2016-2019). We included patients ≥18 years undergoing general surgery procedures. Our primary outcome was the impact of disability conditions on the rate of MIS. We performed 1:1 propensity matching, comparing patients with disability conditions with those without and adjusting for patient, procedure, and hospital characteristics. We performed a subgroup analysis among patients<65 years and with patients with each type of disability. We evaluated temporal trends of MIS in patients with disabilities. We identified predictors of undergoing MIS using mixed effects regression analysis. RESULTS: In the propensity-matched comparison, a lower proportion of patients with disabilities had MIS. In the sub-group analyses, the rate of MIS was significantly lower in patients below 65 years with disabilities and among patients with motor and intellectual impairments. There was an increasing trend in the proportion of patients with disabilities undergoing MIS (p < 0.005). The regression analysis confirmed that the presence of a disability was associated with decreased odds of undergoing MIS. CONCLUSIONS: This study characterizes the negative association of disability conditions with access to MIS. As the healthcare landscape evolves, considerations on how to equitably share new treatment modalities with a wide range of patient populations are necessary.

Timing matters: Early versus late rib fixation in patients with multiple rib fractures and pulmonary contusion.

BACKGROUND: Recent literature has shown that surgical stabilization of rib fractures benefits patients with rib fractures accompanied by pulmonary contusion; however, the impact of timing on surgical stabilization of rib fractures in this patient population remains unexplored. We aimed to compare early versus late surgical stabilization of rib fractures in patients with traumatic rib fractures and concurrent pulmonary contusion. METHODS: We selected all adult patients with isolated blunt chest trauma, multiple rib fractures, and pulmonary contusion undergoing early (<72 hours) versus late surgical stabilization of rib fractures (≥72 hours) using the American College of Surgeons Trauma Quality Improvement Program 2016 to 2020. Propensity score matching was performed to adjust for patient, injury, and hospital characteristics. Our outcomes were hospital length of stay, acute respiratory distress syndrome, unplanned intubation, ventilator days, unplanned intensive care unit admission, intensive care unit length of stay, tracheostomy rates, and mortality. We then performed sub-group analyses for patients with major or minor pulmonary contusion. RESULTS: We included 2,839 patients, of whom 1,520 (53.5%) underwent early surgical stabilization of rib fractures. After propensity score matching, 1,096 well-balanced pairs were formed. Early surgical stabilization of rib fractures was associated with a decrease in hospital length of stay (9 vs 13 days; P < .001), decreased intensive care unit length of stay (5 vs 7 days; P < .001), and lower rates of unplanned intubation (7.4% vs 11.4%; P = .001), unplanned intensive care unit admission (4.2% vs 105%, P < .001), and tracheostomy (8.4% vs 12.4%; P = .002). Similar results were also found in the subgroup analyses for patients with major or minor pulmonary contusion. CONCLUSION: These findings suggest that in patients with multiple rib fractures and pulmonary contusion, the early implementation of surgical stabilization of rib fractures could be beneficial regardless of the severity of pulmonary contusion.

Moving toward point-of-care surgery in Ukraine: testing an ultra-portable operating room in an active war zone.

PURPOSE: In conflict zones, providers may have to decide between delaying time-sensitive surgeries or performing operative interventions in the field, potentially subjecting patients to significant infection risks. We conducted a single-arm crossover study to assess the feasibility of using an ultraportable operating room (U-OR) for surgical procedures on a porcine cadaver abdominal traumatic injury model in an active war zone. METHODS: We enrolled participants from an ASSET-type course designed to train Ukrainian surgeons before deployment to active conflict zones. They performed three standardized consecutive abdominal surgical procedures (liver, kidney, and small bowel injury repair) with and without the U-OR. Primary outcomes included surgical procedure completion rate, procedure time, and airborne particle count at the start of surgery. Secondary survey-based outcomes assessed surgery task load index (SURG-TLX) and perceived operative factors. RESULTS: Fourteen surgeons performed 76 surgical procedures (38 with the U-OR, 38 without the U-OR). The completion rate for each surgical procedure was 100% in both groups. While the procedure time for the liver injury repair did not differ significantly between the two groups, the use of the U-OR was associated with a longer time for kidney (155 vs. 56 s, p = 0.002), and small bowel (220 vs. 103 s, p = 0.004) injury repair. The average airborne particle count within the U-OR was substantially lower compared to outside the U-OR (6,753,852 vs. 232,282 n/m3, p < 0.001). There was no statistically significant difference in SURG-TLX for procedures performed with and without the U-OR. CONCLUSION: The use of the U-OR did not affect the procedure completion rate or SURG-TLX. However, there was a marked difference in airborne particle counts between inside and outside the U-OR during surgery. These preliminary findings indicate the potential feasibility of using a U-OR to perform abdominal damage-control surgical procedures in austere settings.

Optimal dose of cryoprecipitate in massive transfusion following trauma.

BACKGROUND: While cryoprecipitate (Cryo) is commonly included in massive transfusion protocols for hemorrhagic shock, the optimal dose of Cryo transfusion remains unknown. We evaluated the optimal red blood cell (RBC) to RBC to Cryo ratio during resuscitation in massively transfused trauma patients. METHODS: Adult patients in the American College of Surgeon Trauma Quality Improvement Program (2013-2019) receiving massive transfusion (≥4 U of RBCs, ≥1 U of fresh frozen plasma, and ≥1 U of platelets within 4 hours) were included. A unit of Cryo was defined as a pooled unit of 100 mL. The RBC:Cryo ratio was calculated for blood products transfused within 4 hours of presentation. The association between RBC:Cryo and 24-hour mortality was analyzed with multivariable logistic regression adjusting for the volume of RBC, plasma and platelet transfusions, global and regional injury severity, and other relevant variables. RESULTS: The study cohort included 12,916 patients. Among those who received Cryo (n = 5,511 [42.7%]), the median RBC and Cryo transfusion volume within 4 hours was 11 U (interquartile range, 7-19 U) and 2 U (interquartile range, 1-3 U), respectively. Compared with no Cryo administration, only RBC:Cryo ratios ≤8:1 were associated with a significant survival benefit, while lower doses of Cryo (RBC:Cryo >8:1) were not associated with decreased 24-hour mortality. Compared with the maximum dose of Cryo administration (RBC:Cryo, 1:1-2:1), there was no difference in 24-hour mortality up to RBC:Cryo of 7:1 to 8:1, whereas lower doses of Cryo (RBC:Cryo, >8:1) were associated with significantly increased 24-hour mortality. CONCLUSION: One pooled unit of Cryo (100 mL) per 7 to 8 U of RBCs could be the optimal dose of Cryo in trauma resuscitation that provides a significant survival benefit while avoiding unnecessary blood product transfusions. LEVEL OF EVIDENCE: Prognostic and Epidemiologic; Level IV.

Safety of the injectable expanding biopolymer foam for non-compressible truncal bleeding in swine.

BACKGROUND: A novel hydrophobically modified chitosan (hm-chitosan) polymer has been previously shown to improve survival in a non-compressible intra-abdominal bleeding model in swine. We performed a 28-day survival study to evaluate the safety of the hm-chitosan polymer in swine. METHODS: Female Yorkshire swine (40-50 kg) were used. A mild, non-compressible, closed-cavity bleeding model was created with splenic transection. The hm-chitosan polymer was applied intra-abdominally through an umbilical nozzle in the same composition and dose previously shown to improve survival. Animals were monitored intraoperatively and followed 28 days postoperatively for survival, signs of pain, and end-organ function. Gross pathological and microscopic evaluations were performed at the conclusion of the experiment. RESULTS: A total of 10 animals were included (hm-chitosan = 8; control = 2). The 2 control animals survived through 28 days, and 7 of the 8 animals from the hm-chitosan group survived without any adverse events. One animal from the hm-chitosan group required early termination of the study for signs of pain, and superficial colonic ulcers were found on autopsy. Laboratory tests showed no signs of end-organ dysfunction after exposure to hm-chitosan after 28 days. On gross pathological examination, small (<0.5 cm) peritoneal nodules were noticed in the hm-chitosan group, which were consistent with giant-cell foreign body reaction in microscopy, presumably related to polymer remnants. Microscopically, no signs of systemic polymer embolization or thrombosis were noticed. CONCLUSION: Prolonged intraperitoneal exposure to the hm-chitosan polymer was tolerated without any adverse event in the majority of animals. In the single animal that required early termination, the material did not appear to be associated with end-organ dysfunction in swine. Superficial colonic ulcers that would require surgical repair were identified in 1 out of 8 animals exposed to hm-chitosan.

Negative pressure wound therapy for emergency laparotomy incisions: A national database propensity matched study.

BACKGROUND: Surgical site infections (SSI) are a common complication of laparotomy incisions. The role of Negative Pressure Wound Therapy (NPWT) in preventing SSIs has not yet been explored in a nationwide analysis. We aimed to evaluate the association of the prophylactic use of NPWT with SSIs in patients undergoing an emergency laparotomy procedure. METHODS: We conducted a retrospective cohort study using the National Surgery Quality Initiative Program (NSQIP) database from 2013 to 2020. We included patients ≥18 years undergoing an emergency laparotomy. We performed a 1:1 propensity matching adjusting for patient age, sex, race, ethnicity, BMI, comorbid conditions, ASA status, diagnosis, preoperative factors and laboratory variables, procedure type, wound class, and intraoperative variables. We compared NPWT with standard dressings in two patient populations: 1. patients with completely closed (skin and fascia) laparotomy incisions and 2. patients with partially closed (fascia only) laparotomy incisions. Our primary outcome was the rate of incisional SSI. Secondary outcomes included the type of SSI, postoperative 30-day complications, postoperative hospital length of stay, and discharge disposition. RESULTS: We included 65,803 patients with completely closed incisions of whom 387 patients received NPWT. There was no significant difference in the rate of total SSIs (13.4 â€‹% vs. 11.9 â€‹%; p â€‹= â€‹0.52) in the matched population of 387 pairs. We included 7285 patients with partially closed incisions of whom 477 patients received NPWT. There was no significant difference in the rate of total SSIs (3.6 â€‹% vs. 4.4 â€‹%; p â€‹= â€‹0.51) in the matched population of 477 pairs. Secondary outcomes did not differ significantly in either group. CONCLUSION: The rate of SSIs was not significantly different when prophylactic NPWT was used compared to standard dressings for patients with a closed or partially closed laparotomy incision.

From admission to vaccination: COVID-19 vaccination patterns and their relationship with hospitalization in trauma patients.

BACKGROUND: COVID-19 vaccination rates in the hospitalized trauma population are not fully characterized and may lag behind the general population. This study aimed to outline COVID-19 vaccination trends in hospitalized trauma patients and examine how hospitalization influences COVID-19 vaccination rates. METHODS: We conducted a retrospective institutional study using our trauma registry paired with the COVID-19 vaccination ENCLAVE registry. We included patients ≥18 years admitted between April 21, 2021 and November 30, 2022. Our primary outcome was the change in vaccination posthospitalization, and secondary analyzed outcomes included temporal trends of vaccination in trauma patients and predictors of non-vaccination. We compared pre and posthospitalization weekly vaccination rates. We performed joinpoint regression to depict temporal trends and multivariate regression for predictors of nonvaccination. RESULTS: The rate of administration of the first vaccine dose increased in the week after hospitalization (P = .018); however, this increase was not sustained in the following weeks. The percentage of unvaccinated patients declined faster in the general population in Massachusetts compared to the hospitalized trauma population. By the conclusion of the study, 27.1% of the trauma population was unvaccinated, whereas <5% of the Massachusetts population was unvaccinated. Urban residence, having multiple hospitalizations, and experiencing moderate to severe frailty were associated with vaccination. Conversely, being in the age groups 18 to 45 years and 46 to 64 years, as well as having Medicaid or self-pay insurance, were linked to being unvaccinated. CONCLUSION: Hospitalization initially increased the rate of administration of the first vaccine dose in trauma patients, but the effect was not sustained. By the conclusion of the study period, a greater percentage of trauma patients were unvaccinated compared to the general population of Massachusetts. Strategies for sustained health care integration need to be developed to address this ongoing challenge in the high-risk trauma population.

Missing Narrative: Examining the Impact of Disability on Post-Operative Infectious Complications.

Background: More than 20% of the population in the United States suffers from a disability, yet the impact of disability on post-operative outcomes remains understudied. This analysis aims to characterize post-operative infectious complications in patients with disability. Patients and Methods: This was a retrospective review of the National Readmission Database (2019) among patients undergoing common general surgery procedures. As per the U.S. Centers for Disease Control and Prevention (CDC), disability was defined as severe hearing, visual, intellectual, or motor impairment/caregiver dependency. A propensity-matched analysis comparing patients with and without a disability was performed to compare outcomes, including post-operative septic shock, sepsis, bacteremia, pneumonia, catheter-associated urinary tract infection (CAUTI), urinary tract infection (UTI), catheter-associated blood stream infection, Clostridioides Difficile infection, and superficial, deep, and organ/space surgical site infections during index hospitalization. Patients were matched using age, gender, comorbidities, illness severity, income, neighborhood, insurance, elective procedure, and the hospital's bed size and type. Results: A total of 710,548 patients were analysed, of whom 9,451(1.3%) had at least one disability. Motor disability was the most common (3,762; 40.5%), followed by visual, intellectual, and hearing impairment. Patients with disability were older (64 vs. 57 years; p < 0.001), more often insured under Medicare (65.2% vs. 37.3% p < 0.001) and had more medical comorbidities (Elixhauser comorbidity score ≥3; 69.2% vs. 41.9%; p < 0.001). After matching, 9,292 pairs were formed. Patients with a disability had a higher incidence of pneumonia (10.1% vs. 6.5%; p < 0.001), aspiration pneumonia (5.2% vs. 1.4%; p < 0.001), CAUTI (1.0% vs. 0.4%; p < 0.001), UTI (10.4% vs. 6.2%; p < 0.001), and overall infectious complications (21.8% vs. 14.5%; p < 0.001). Conclusions: Severe intellectual, hearing, visual, or motor impairments were associated with a higher incidence of infectious complications. Further investigation is needed to develop interventions to reduce disparities among this high-risk population.

Burden of Social and Behavioral Determinants of Health on Infectious Complications in Emergency General Surgery.

Background: Infectious complications lead to worse post-operative outcomes and are used to compare hospital performance in pay-for-performance programs. However, the impact of social and behavioral determinants of health on infectious complication rates after emergency general surgery (EGS) remains unclear. Patients and Methods: All patients undergoing EGS in the 2019 Nationwide Readmissions Database were included. The primary outcome of the study was the rate of infectious complications within 30 days, defined as a composite outcome including all infectious complications occurring during the index hospitalization or 30-day re-admission. Secondary outcomes included specific infectious complication rates. Multivariable regression analyses were used to study the impact of patient characteristics, social determinants of health (insurance status, median household income in the patient's residential zip code), and behavioral determinants of health (substance use disorders, neuropsychiatric comorbidities) on post-operative infection rates. Results: Of 367,917 patients included in this study, 20.53% had infectious complications. Medicare (adjusted odds ratio [aOR], 1.3; 95% confidence interval [CI], 1.26-1.34; p < 0.001), Medicaid (aOR, 1.24; 95% CI,1.19-1.29; p < 0.001), lowest zip code income quartile (aOR, 1.17; 95% CI, 1.13-1.22; p < 0.001), opioid use disorder (aOR,1.18; 95% CI,1.10-1.29; p < 0.001), and neurodevelopmental disorders (aOR, 2.16; 95% CI, 1.90-2.45; p < 0.001) were identified as independent predictors of 30-day infectious complications. A similar association between determinants of health and infectious complications was also seen for pneumonia, urinary tract infection (UTI), methicillin-resistant Staphylococcus aureus (MRSA) sepsis, and catheter-association urinary tract infection (CAUTI). Conclusions: Social and behavioral determinants of health are associated with a higher risk of developing post-operative infectious complications in EGS. Accounting for these factors in pay-for-performance programs and public reporting could promote fairer comparisons of hospital performance.

Delayed hemothorax readmissions after rib fracture in blunt trauma patients.

Background: Rib fractures are the most common traumatic injury. Hemothorax is one of the widespread complications associated with a rib fracture and occurs in 10-37 % of all rib fractures. Delayed hemothorax (DHTX) is defined as an accumulation of blood within the pleural cavity. Although there is extensive literature on hemothorax, there is limited literature on rib fractures and DHTX readmissions. The objective of this study was to identify potential risk factors for DHTX readmission and examine descriptive information on readmission. Methods: Using the 2016-2019 National Readmission Database (NRD), patients that experienced an admission with a blunt traumatic rib fracture were included. It was determined if the patients experienced DHTX by screening for an admission containing an ICD-10 code for hemothorax within 30 days after an admission containing a ICD-10 code for rib fracture. Univariable and multivariable analysis was performed to determine independent risk factors associated with DHTX readmission. Additionally, information on the clinical and financial characteristics of DHTX readmissions were examined. Results: A total of 242,071 patients were included, of whom 635 experienced DHTX readmission ≤30 days after discharge. Diagnosed with hemothorax on the index admission had the largest odds ratio for DHTX readmission (7.43 [6.14-8.99], P < 0.001). Complications found during DHTX readmission included acute respiratory failure (16.9 %), sepsis (6.9 %), and empyema (4.3 %). Treatment mainly consisted of pleural drainage (62.2 %) and video-assisted thoracoscopic surgery (VATS) evacuation of hemothorax (10.1 %). Conclusion: Patients admitted for a rib fracture have a low incidence for DHTX readmission within 30 days. However, multivariable analysis has demonstrated some risk and protective factors associated with DHTX readmission. Further studies should focus on exploring these risk factors to screen for potential DHTX readmission and/or protective factors to decrease the change for DHTX readmission.

Evaluating the impact of timing to rib fixation in patients with traumatic brain injury: A nationwide analysis.

BACKGROUND: Early surgical stabilization of rib fractures (SSRF) is associated with improved inpatient outcomes in patients with multiple rib fractures. However, there is still a paucity of data examining the optimal timing of SSRF in patients with concomitant traumatic brain injury (TBI). This study aimed to assess whether earlier SSRF was associated with improved outcomes in patients with multiple rib fractures and TBI. METHODS: We performed a retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program 2017-2020, including adult patients with TBI and multiple rib fractures who had undergone SSRF. The outcomes were post-procedural length of stay (LOS), hospital LOS, intensive care unit (ICU) LOS, in-hospital mortality, ventilator days, and tracheostomy rate. Multilevel mixed-effects regression analyses accounting for patient, injury, and hospital characteristics as well as institutional SSRF volume were used to assess the association between timing to SSRF and the outcomes of interest. As a sensitivity analysis, propensity-score matching was performed to compare patients who underwent early (<72 hours) versus late SSRF (≥72 hours). RESULTS: Of 1,041 patients included in this analysis, 430 (41.3%) underwent SSRF within the first 72 hours from admission. Delay to SSRF was associated with an increase in post-procedural LOS (partial regression coefficient (ß) = 0.011; p = 0.036; 95% confidence interval [CI], 0.001-0.023), longer hospital LOS (ß = 0.053; p < 0.001; 95% CI, 0.042-0.064), prolonged ICU LOS (ß = 0.032; p < 0.001; 95% CI, 0.025-0.038), and more ventilator days (ß = 0.026, p < 0.001; 95% CI, 0.020-0.032). CONCLUSION: In patients with concurrent multiple rib fractures and TBI, a delay in SSRF is associated with an increase in postprocedural LOS, hospital LOS, ICU LOS, and ventilator days. These findings suggest that the early patient selection and implementation of SSRF may play a beneficial role in patients presenting with concomitant TBI and multiple rib fractures. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Timing of regional analgesia in elderly patients with blunt chest-wall injury.

BACKGROUND: Rib fractures represent a typical injury pattern in older people and are associated with respiratory morbidity and mortality. Regional analgesia modalities are adjuncts for pain management, but the optimal timing for their initiation remains understudied. We hypothesized that early regional analgesia would have similar outcomes to late regional analgesia. METHODS: We retrospectively reviewed the American College of Surgeons Trauma Quality Improvement Program database from 2017 to 2019. We included patients ≥65 years old admitted with blunt chest wall trauma who received regional analgesia. We divided patients into 2 groups: (1) early regional analgesia (within 24 hours of admission) and (2) late regional analgesia (>24 hours). The outcomes evaluated were ventilator-associated pneumonia, mortality, unplanned intensive care unit admission, unplanned intubation, discharge to home, and duration of stay. Univariable analysis and multivariable logistic regression adjusting for patient and injury characteristics, trauma center level, and respiratory interventions were performed. RESULTS: In the study, 2,248 patients were included. The mean (standard deviation) age was 75.3 (6.9), and 52.7% were male. The median injury severity score (interquartile range) was 13 (9-17). The early regional analgesia group had a decreased incidence of unplanned intubation (2.7% vs 5.3%, P = .002), unplanned intensive care unit admission (4.9% vs 8.4%, P < .001), and shorter mean duration of stay (5.5 vs 6.5 days, P = .002). In multivariable analysis, early regional analgesia was associated with decreased odds of unplanned intubation (odds ratio, 0.58; 95% confidence interval, 0.36-0.94; P = .026), unplanned intensive care unit admission (odds ratio, 0.60; 95% confidence interval, 0.041-0.86; P = .006), and increased odds of discharge to home (odds ratio, 1.27; 95% confidence interval, 1.04-1.55; P = .019). After multivariable adjustment, no significant difference was found for ventilator-associated pneumonia or mortality (odds ratio, 0.60; 95% confidence interval, 0.34-1.04; P = .070). CONCLUSION: Early regional analgesia initiation is associated with improved outcomes in older people with blunt chest wall injuries. Geriatric trauma care bundles targeting early initiation of regional analgesia can potentially decrease complications and resource use.

Low-molecular-weight heparin is superior to unfractionated heparin in lowering the risk of venous thromboembolism after traumatic lower extremity amputation.

BACKGROUND: Patients undergoing lower extremity amputation after trauma are at high risk of venous thromboembolism. Practice variations persist regarding the optimal pharmacologic agent for venous thromboembolism prophylaxis in this patient population. We aimed to compare the efficacy of unfractionated heparin versus low-molecular-weight heparin in preventing venous thromboembolism. METHODS: Using the 2013 to 2019 American College of Surgeons Pediatric Trauma Quality Improvement Program database, all trauma patients (≥18) who underwent lower limb amputation and received venous thromboembolism thromboprophylaxis in the form of unfractionated heparin or low-molecular-weight heparin were included. We excluded patients who died within 24 hours of admission or those who received no thromboprophylaxis. The primary outcome was the rate of venous thromboembolism. Multivariable logistic regression was used to evaluate the independent relationship between the type of pharmacologic prophylaxis and the risk of venous thromboembolism. RESULTS: A total of 4,103 patients who underwent lower extremity amputation were identified. Patients were primarily young (median age 43 years) with blunt injuries (83%). The overall rate of venous thromboembolism was 8.6%. Most (77%) patients received low-molecular-weight heparin-based prophylaxis. Compared with patients without venous thromboembolism, the venous thromboembolism cohort had a greater injury severity score (19 vs 13, P < .001), had more patients undergoing above-the-knee amputation (48% vs 36%, P < .001), and less frequently received low-molecular-weight heparin (64% vs 78%, P < .001). Multivariable analysis showed that low-molecular-weight heparin was associated with a significantly lower venous thromboembolism rate than unfractionated heparin (odds ratio: 0.65 [0.51-0.83], P < .001). CONCLUSION: Thromboprophylaxis with low-molecular-weight heparin was found to be superior to unfractionated heparin in lowering the risk of venous thromboembolism among traumatic amputees and should be the preferred pharmacologic agent in this patient population prone to venous thromboembolism.

Is severe traumatic brain injury no longer a contraindication for surgical stabilization of rib fractures in patients with multiple rib fractures? A propensity-matched analysis.

BACKGROUND: Traumatic brain injury (TBI) is often considered a contraindication to surgical stabilization of rib fractures (SSRF). In this study, we hypothesized that, compared with nonoperative management, SSRF is associated with improved outcomes in TBI patients. METHODS: Using the American College of Surgeons Trauma Quality Improvement Program 2016-2019, we performed a retrospective analysis of patients with concurrent TBI and multiple rib fractures. Following propensity score matching, we compared patients who underwent SSRF with those who were managed nonoperatively. Our primary outcome was mortality. Secondary outcomes included ventilator-associated pneumonia, hospital and intensive care unit (ICU) length of stay (LOS), ventilator days, tracheostomy rate, and hospital discharge disposition. In a subgroup analysis, we stratified patients into mild and moderate TBI (GCS score >8) and severe TBI (GCS score ≤8). RESULTS: Of 36,088 patients included in this study, 879 (2.4%) underwent SSRF. After propensity-score matching, compared with nonoperative management, SSRF was associated with decreased mortality (5.4% vs. 14.5%, p < 0.001), increased hospital LOS (15 days vs. 9 days, p < 0.001), increased ICU LOS (12 days vs. 8 days, p < 0.001), and increased ventilator days (7 days vs. 4 days, p < 0.001). In the subgroup analyses, in mild and moderate TBI, SSRF was associated with decreased in-hospital mortality (5.0% vs. 9.9%, p = 0.006), increased hospital LOS (13 days vs. 9 days, p < 0.001), ICU LOS (10 days vs. 7 days, p < 0.001), and ventilator days (5 days vs. 2 days, p < 0.001). In patients with severe TBI, SSRF was associated with decreased mortality (6.2% vs. 18%, p < 0.001), increased hospital LOS (20 days vs. 14 days, p = 0.001), and increased ICU LOS (16 days vs. 13 days, p = 0.004). CONCLUSION: In patients with TBI and multiple rib fractures, SSRF is associated with a significant decrease in in-hospital mortality and with longer hospital and ICU LOSs. These findings suggest that SSRF should be considered in patients with TBI and multiple rib fractures. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Open Abdomen in Elderly Patients With Surgical Sepsis: Predictors of Mortality.

INTRODUCTION: Elderly patients are frequently presenting with emergency surgical conditions. The open abdomen technique is widely used in abdominal emergencies needing rapid control of intrabdominal contamination. However, specific predictors of mortality identifying candidates for comfort care are understudied. METHODS: The 2013-2017 the American College of Surgeons-National Surgical Quality Improvement Program database was queried for emergent laparotomies performed in geriatric patients with sepsis or septic shock in whom fascial closure was delayed. Patients with acute mesenteric ischemia were excluded. The primary outcome was 30-d mortality. Univariable analysis, followed by multivariable logistic regression, was performed. Mortality was computed for combinations of the five predictors with the highest odds ratios (OR). RESULTS: A total of 1399 patients were identified. The median age was 73 (69-79) y, and 54.7% were female. 30-d mortality was 50.6%. In the multivariable analysis, the most important predictors were as follows: American Society of Anesthesiologists status 5 (OR = 4.80, 95% confidence interval [CI], 1.85-12.49 P = 0.002), dialysis dependence (OR = 2.65, 95% CI 1.54-4.57, P < 0.001), congestive hearth failure (OR = 2.53, 95% CI 1.52-4.21, P < 0.001), disseminated cancer (OR = 2.61, 95% CI 1.55-4.38, P < 0.001), and preoperative platelet count of <100,000 cells/µL (OR = 1.87, 95% CI 1.15-3.04, P = 0.011). The presence of two or more of these factors resulted in over 80% mortality. The absence of all these risk factors results in a survival rate of 62.1%. CONCLUSIONS: In elderly patients, surgical sepsis or septic shock requiring an open abdomen for surgical management is highly lethal. The presence of several combinations of preoperative comorbidities is associated with a poor prognosis and can identify patients who can benefit from timely initiation of palliative care.