The open abdomen in mesenteric ischemia: A tool for patients undergoing revascularization.

BACKGROUND: We examined outcomes in Acute Mesenteric Ischemia (AMI) with the hypothesis that Open Abdomen (OA) is associated with decreased mortality. METHODS: We performed a cohort study reviewing NSQIP emergency laparotomy patients, 2016-2020, with a postoperative diagnosis of mesenteric ischemia. OA was defined using flags for patients without fascial closure. Logistic regression was used with outcomes of 30-day mortality and several secondary outcomes. RESULTS: Out of 5514 cases, 4624 (83.9%) underwent resection and 387 (7.0%) underwent revascularization. The OA rate was 32.6%. 10.8% of patients who were closed required reoperation. After adjustment for demographics, transfer status, comorbidities, preoperative variables including creatinine, white blood cell count, and anemia, as well as operative time, OA was associated with OR 1.58 for mortality (95% CI [1.38, 1.81], p < 0.001). Among revascularizations, there was no such association (p = 0.528). OA was associated with ventilator support >48 h (OR 4.04, 95% CI [3.55, 4.62], and p < 0.001). CONCLUSION: OA in AMI was associated with increased mortality and prolonged ventilation. This is not so in revascularization patients, and 1 in 10 patients who underwent primary closure required reoperation. OA should be considered in specific cases of AMI. LEVEL OF EVIDENCE: Retrospective cohort, Level III.

Hemodynamic Deterioration of Trauma Patients Undergoing Interhospital Transfer.

INTRODUCTION: Organized trauma systems reduce morbidity and mortality after serious injury. Rapid transport to high-level trauma centers is ideal, but not always feasible. Thus, interhospital transfers are an important component of trauma systems. However, transferring a seriously injured patient carries the risk of worsening condition before reaching definitive care. In this study, we evaluated characteristics and outcomes of patients whose hemodynamic status worsened during the transfer process. METHODS: We conducted a retrospective cohort study using data from the Pennsylvania Trauma Outcomes Study database from 2011 to 2018. Patients were included if they had a heart rate ≤ 100 and systolic blood pressure ≥ 100 at presentation to the referring hospital and were transferred within 24 h. We defined hemodynamic deterioration (HDD) as admitting heart rate > 100 or systolic blood pressure < 100 at the receiving center. We compared demographics, mechanism of injury, injury severity, management, and outcomes between patients with and without HDD using descriptive statistics and multivariable regression analysis. RESULTS: Of 52,919 included patients, 5331 (10.1%) had HDD. HDD patients were more often moderately-severely injured (injury severity score 9-15; 40.4% versus 39.4%, P < 0.001) and injured via motor vehicle collision (23.2% versus 16.6%, P < 0.001) or gunshot wound (2.1% versus 1.3%, P < 0.001). HDD patients more often had extremity or torso injuries and after transfer were more likely to be transferred to the intensive care unit (35% versus 28.5%, P < 0.001), go directly to surgery (8.4% versus 5.9%, P < 0.001), or interventional radiology (0.8% versus 0.3%, P < 0.001). Overall mortality in the HDD group was 4.9% versus 2.1% in the group who remained stable. These results were confirmed using multivariable analysis. CONCLUSIONS: Interhospital transfers are essential in trauma, but one in 10 transferred patients deteriorated hemodynamically in that process. This high-risk component of the trauma system requires close attention to the important aspects of transfer such as patient selection, pretransfer management/stabilization, and communication between facilities.

The Role of Emergency Department Thoracotomy in Patients with Cranial Gunshot Wounds.

BACKGROUND: Although several society guidelines exist regarding emergency department thoracotomy (EDT), there is a lack of data upon which to base guidance for multiple gunshot wound (GSW) patients whose injuries include a cranial GSW. We hypothesized that survival in these patients would be exceedingly low. METHODS: We used Pennsylvania Trauma Outcomes Study (PTOS) data, 2002-2021, and included EDTs for GSWs. We defined EDT by ICD codes for thoracotomy or procedures requiring one, with a location flagged as ED. We defined head injuries as any head abbreviated injury scale (AIS) ≥1 and severe head injuries as head AIS ≥ 4. Head injuries were "isolated" if all other body regions AIS < 2. Descriptive statistics were performed. Discharge functional status was measured in 5 domains. RESULTS: Over 20 years in Pennsylvania, 3,546 EDTs were performed, 2,771 (78.1%) for penetrating injuries. Most penetrating EDTs (2,003, 72.3%) had suffered GSWs. Survival among patients with isolated head wounds (n = 25) was 0%. Survival was 5.3% for the non-head-injured (n = 94/1,787). In patients with combined head and other injuries, survival was driven by the severity of the head wound - 0% (0/81) with a severe head injury (p = 0.035 vs no severe head injury), and 4.5% (5/110) with a non-severe head injury. Of the 5 head-injured survivors, 2 were fully dependent for transfer mobility, and 3 were partially or fully dependent for locomotion. Of 211 patients with a cranial injury who expired, 2 (0.9%) went on to organ donation. CONCLUSIONS: Though there is clearly no role for EDT in patients with isolated head GSWs, EDT may be considered in patients with combined injuries, as most of these patients have minor head injuries and survival is not different from the non-head-injured. However, if a severe head injury is clinically apparent, even in the presence of other body cavity injuries, EDT should not be pursued. LEVEL OF EVIDENCE: Level II, retrospective observational cohort study.

Costs of Care for Operative and Nonoperative Management of Emergency General Surgery Conditions.

OBJECTIVE: Many emergency general surgery (EGS) conditions can be managed operatively or nonoperatively, with outcomes that vary by diagnosis. We hypothesized that operative management would lead to higher in-hospital costs but to cost savings over time. BACKGROUND: EGS conditions account for $28 billion in health care costs in the United States annually. Compared with scheduled surgery, patients who undergo emergency surgery are at increased risk of complications, readmissions, and death, with accompanying costs of care that are up to 50% higher than elective surgery. Our prior work demonstrated that operative management had variable impacts on clinical outcomes depending on the EGS condition. METHODS: This was a nationwide, retrospective study using fee-for-service Medicare claims data. We included patients 65.5 years of age or older with a principal diagnosis for an EGS condition 7/1/2015-6/30/2018. EGS conditions were categorized as: colorectal, general abdominal, hepatopancreaticobiliary (HPB), intestinal obstruction, and upper gastrointestinal. We used near-far matching with a preference-based instrumental variable to adjust for confounding and selection bias. Outcomes included Medicare payments for the index hospitalization and at 30, 90, and 180 days. RESULTS: Of 507,677 patients, 30.6% received an operation. For HPB conditions, costs for operative management were initially higher but became equivalent at 90 and 180 days. For all others, operative management was associated with higher inpatient costs, which persisted, though narrowed, over time. Out-of-pocket costs were nearly equivalent for operative and nonoperative management. CONCLUSIONS: Compared with nonoperative management, costs were higher or equivalent for operative management of EGS conditions through 180 days, which could impact decision-making for clinicians, patients, and health systems in situations where clinical outcomes are similar.

Effects of prior injury on long term patient reported outcomes after trauma.

BACKGROUND: Trauma is an episodic, chronic disease with substantial, long-term physical, psychological, emotional, and social impacts. However, the effect of recurrent trauma on these long-term outcomes remains unknown. We hypothesized that trauma patients with a history of prior traumatic injury (PTI) would have poorer outcomes 6 months (6mo) after injury compared with patients without PTI. METHODS: Adult trauma patients admitted at an urban, academic, Level I trauma center were screened for inclusion (October 2020 to November 2021). Enrolled patients were administered the PROMIS-29 instrument, the primary care post-traumatic stress disorder screen, and standardized questions about prior trauma hospitalization, substance use, employment, and living situation at baseline and 6mo after injury. Assessment data was merged with clinical registry data, and outcomes were compared with respect to PTI. RESULTS: Of 3,794 eligible patients, 456 completed baseline assessments and 92 completed 6mo surveys. Between those with or without PTI, there were no differences at 6mo after injury in the proportion of patients reporting poor function in social participation, anxiety, depression, fatigue, pain interference, or sleep disturbance. Prior traumatic injury patients reported poor physical function less often than patients without PTI (10 [27.0%] vs. 33 [60.0%], p = 0.002). After controlling for age, gender, race, injury mechanism, and Injury Severity Score, PTI correlated with a fourfold decrease in poor physical function risk (adjusted odds ratio, 0.243; 95% confidence interval, 0.081-0.733; p = 0.012) in the multivariable logistic regression model. CONCLUSION: Compared with patients suffering their first injury, trauma patients with PTI have better self-reported physical function after a subsequent injury and otherwise equivalent outcomes across a range of HRQoL domains at 6mo. There remains substantial room for improvement to mitigate the long-term challenges faced by trauma patients and to facilitate their societal reintegration, regardless of the number of times they are injured. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

A tale of two cities: Policing and firearm homicides in Boston and Philadelphia.

BACKGROUND: Recent political movements have raised questions about the effectiveness of police funding, but the impact of law enforcement budgets on firearm violence is unknown. We hypothesized that department funding and measures of police activity would be associated with decreased shootings and firearm homicides (FHs) in two major cities with different police funding patterns. METHODS: We collected data from the following sources: district attorney's offices, police departments, Federal Bureau of Investigation Uniform Crime Reporting program, the Centers for Disease Control, the Annual Survey of Public Employment and Payroll, and the American Community Survey. Data included demographics, police department budgets, number of officers, homicide clearance rates, firearms recovered, shootings, and FHs, 2015 to 2020. Totals were normalized to population and number of shootings. We used panel linear regression to measure associations between policing variables, shootings, and FHs while adjusting for covariates. RESULTS: Firearm homicides significantly increased in Philadelphia. In Boston, the trend was less clear, although there was an increase in 2020. Police budget normalized to shootings trended toward a decrease in Philadelphia and an increase in Boston. The number of firearms recovered annually appeared to increase in Boston but peaked midstudy in Philadelphia. In multivariable analyses, police budget was associated with neither shootings nor FHs. However, increased firearm recovery was associated with lower shooting ( ß = -0.0004, p = 0.022) and FH ( ß = -0.00005, p = 0.004) rates. CONCLUSION: Philadelphia and Boston demonstrated differences in police funding, 2015 to 2020. While budget is not associated with shootings or FHs, firearm recovery is suggesting that removal of firearms from circulation remains key. The impact this has on vulnerable populations requires further investigation. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

National Cohort Study of Resource Utilization in Older Adults With Emergency General Surgery Conditions.

INTRODUCTION: Prior studies have sought to describe Emergency General Surgery (EGS) burden, but a detailed description of resource utilization for both operative and nonoperative management of EGS conditions has not been undertaken. METHODS: Patient and hospital characteristics were extracted from Medicare data, 2015-2018. Operations, nonsurgical procedures, and other resources (i.e., radiology) were defined using Current Procedural Terminology codes. RESULTS: One million eight hundred two thousand five hundred forty-five patients were included in the cohort. The mean age was 74.7 y and the most common diagnoses were upper gastrointestinal. The majority of hospitals were metropolitan (75.1%). Therapeutic radiology services were available in 78.4% of hospitals and operating rooms or endoscopy suites were available in 92.5% of hospitals. There was variability in resource utilization across EGS subconditions, with hepatobiliary (26.4%) and obstruction (23.9%) patients most frequently undergoing operation. CONCLUSIONS: Treatment of EGS diseases in older adults involves several interventional resources. Changes in EGS models, acute care surgery training, and interhospital care coordination may be beneficial to the treatment of EGS patients.

Funding the war in America: A look in the mirror.

BACKGROUND: Health care political action committees (HPACs) historically contribute more to candidates opposing firearm restrictions (FRs), clashing with their affiliated medical societies. These societies have increasingly emphasized the prevention of firearm violence and it is not known if recent contributions by their HPACs have aligned with their stated goals. We hypothesized that such HPACs still contribute similar amounts toward legislators up for reelection opposing FR. METHODS: We identified HPACs of medical societies endorsing one or both calls-to-action against firearm violence published in the Annals of Internal Medicine (2015, 2019). House of Representatives (HOR) votes on H.R.8, a background checks bill, were characterized from GovTrack. We compiled HPAC contributions between the H.R.8 vote and election to HOR members up for re-election from the National Institute on Money in Politics. Our primary outcome was total campaign contributions by H.R.8 stance. Secondary outcomes included percentage of politicians funded and total contributions. RESULTS: Nineteen societies endorsed one or both call-to-action articles. Three hundred eighty-five of 430 HOR members ran for reelection in 2020. Those endorsing H.R.8 (n = 226, 59%) received $2.8 M for $4,750 (interquartile range [IQR], $1000-$15,500) per candidate. Those opposing (n = 159, 41%) received $1.5 M for $2,500 (IQR, $0-$11,000) per candidate ( p = 0.0057). Health care political action committees donated toward a median of 20% (IQR, 7-28) of candidates endorsing H.R.8 and 9% (IQR, 4-22) of candidates opposing H.R.8 ( p = 0.0014). Those endorsing H.R.8 received 1,585 total contributions for a median of 3 (IQR, 1-10) contributions per candidate, while those opposing received 834 total contributions for a median of 2 (IQR, 0-7) contributions per candidate ( p = 0.0029). CONCLUSION: Politicians voting against background checks received substantial contributions toward reelection from the HPACs of societies advocating for firearm restrictions. However, this is the first study to suggest that HPAC's contributions have become more congruent with their respective societies. Further alignment of medical society goals and their HPAC political contributions could have a profound impact on firearm violence. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

Modifiable Factors Related to Firearm Homicides: A Broader View of Our Lane.

OBJECTIVE: This study aims to identify modifiable factors related to firearm homicide (FH). SUMMARY BACKGROUND DATA: Many socioeconomic, legislative and behavioral risk factors impact FH. Most studies have evaluated these risk factors in isolation, but they coexist in a complex and ever-changing American society. We hypothesized that both restrictive firearm laws and socioeconomic support would correlate with reduced FH rates. METHODS: To perform our ecologic cross-sectional study, we queried the Centers for Disease Control (CDC) Wide-ranging ONline Data for Epidemiologic Research (WONDER) and Federal Bureau of Investigation (FBI) Uniform Crime Reporting (UCR) for 2013-2016 state FH data. We retrieved firearm access estimates from the RAND State-Level Firearm Ownership Database. Alcohol use and access to care data were captured from the CDC Behavioral Risk Factor Surveillance System (BRFSS). Detached youth rates, socioeconomic support data and poverty metrics were captured from US Census data for each state in each year. Firearm laws were obtained from the State Firearms Law Database. Variables with significant FH association were entered into a final multivariable panel linear regression with fixed effect for state. RESULTS: A total of 49,610 FH occurred in 2013-2016 (median FH rate: 3.9:100,000, range: 0.07-11.2). In univariate analysis, increases in concealed carry limiting laws ( P =0.012), detached youth rates ( P <0.001), socioeconomic support ( P <0.001) and poverty rates ( P <0.001) correlated with decreased FH. Higher rates of heavy drinking ( P =0.036) and the presence of stand your ground doctrines ( P =0.045) were associated with increased FH. Background checks, handgun limiting laws, and weapon access were not correlated with FH. In multivariable regression, increased access to food benefits for those in poverty [ß: -0.132, 95% confidence interval (CI): -0.182 to -0.082, P <0.001] and laws limiting concealed carry (ß: -0.543, 95% CI: -0.942 to -0.144, P =0.008) were associated with decreased FH rates. Allowance of stand your ground was associated with more FHs (ß: 1.52, 95% CI: 0.069-2.960, P <0.040). CONCLUSIONS: The causes and potential solutions to FH are complex and closely tied to public policy. Our data suggests that certain types of socioeconomic support and firearm restrictive legislation should be emphasized in efforts to reduce firearm deaths in America.

The variable role of damage control laparotomy over 19 years of trauma care in Pennsylvania.

BACKGROUND: Damage control laparotomy emphasizes physiologic stabilization of critically injured patients and allows staged surgical management. However, there is little consensus on the optimal criteria for damage control laparotomy. We examined variability between centers and over time in Pennsylvania. METHODS: We analyzed the Pennsylvania Trauma Outcomes Study data between 2000 and 2018, excluding centers performing <10 laparotomies/year. Laparotomy was defined using International Classification of Diseases codes, and damage control laparotomy was defined by a code for "reopening of recent laparotomy" or a return to the operating room >4 hours from index laparotomy that was not unplanned. We examined trends over time and by center. Multivariable logistic regression models were developed to predict both damage control laparotomy and mortality, generate observed:expected ratios, and identify outliers for each. We compared risk-adjusted mortality rates to center-level damage control laparotomy rates. RESULTS: In total, 18,896 laparotomies from 22 centers were analyzed; 3,549 damage control laparotomies were performed (18.8% of all laparotomies). The use of damage control laparotomy in Pennsylvania varied from 13.9% to 22.8% over time. There was wide variation in center-level use of damage control laparotomy, from 11.1% to 29.4%, despite adjustment. Factors associated with damage control laparotomy included injury severity and admission vital signs. Center identity improved the model as demonstrated by likelihood ratio test (P < .001), suggesting differences in center-level practices. There was minimal correlation between center-level damage control laparotomy use and mortality. CONCLUSION: There is wide center-level variation in the use of damage control laparotomy among centers, despite adjustment for patient factors. Damage control laparotomy is both resource intensive and highly morbid; regional resources should be allocated to address this substantial practice variation to optimize damage control laparotomy use.

The traveling pelvic bullet: a case of retrograde ballistic migration through the venous system.

Migration of a ballistic missile through the vasculature is rare but important to recognize. It can lead to diagnostic confusion and seemingly unexplainable bullet trajectories. We have described the case of a young man with a gunshot wound to the axillary vein and initial embolus to the inferior vena cava. The bullet subsequently migrated to the right common iliac vein, allowing for straightforward retrieval.

Operative trauma volume is not related to risk-adjusted mortality rates among Pennsylvania trauma centers.

BACKGROUND: Higher center-level operative volume is associated with lower mortality after complex elective surgeries, but this relationship has not been robustly demonstrated for operative trauma. We hypothesized that trauma centers in Pennsylvania with higher operative trauma volumes would have lower risk-adjusted mortality rates than lower volume institutions. METHODS: We queried the Pennsylvania Trauma Outcomes Study database (2017-2019) for injured patients 18 years or older at Level I and II trauma centers who underwent an International Classification of Diseases, Tenth Revision (ICD-10), procedure code -defined operative procedure within 6 hours of admission. The primary exposure was tertile of center-level operative volume. The primary outcome of interest was inpatient mortality. We entered factors associated with mortality in univariate analysis (age, injury severity, mechanism, physiology) into multivariable logistic regression models with tertiles of volume accounting for center-level clustering. We conducted secondary analyses varying the form of the association between the volume and mortality to including dichotomous and fractional polynomial models. RESULTS: We identified 3,650 patients at 29 centers meeting the inclusion criteria. Overall mortality was 15.9% (center-level range, 6.7-34.2%). Operative procedure types were cardiopulmonary (7.3%), vascular (20.1%), abdominopelvic (24.3%), and multiple (48.3%). The mean annual operative volume over the 3 years of data was 10 to 21 operations for low-volume centers, 22 to 47 for medium-volume centers, and 47 to 158 for high-volume centers. After controlling for patient demographics, physiology, and injury characteristics, there was no significant difference in mortality between highest and lowest tertile centers (odds ratio, 0.92; confidence interval, 0.57-1.49). Secondary analyses similarly demonstrated no relationship between center operative volume and mortality in key procedure subgroups. CONCLUSION: In a mature trauma system, we found no association between center-level operative volume and mortality for patients who required early operative intervention for trauma. Efforts to standardize the care of seriously injured patients in Pennsylvania may ensure that even lower-volume centers are prepared to generate satisfactory outcomes. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

Beyond pain and disability: The lasting effects of trauma on life after injury.

BACKGROUND: The impact of traumatic injury likely extends beyond direct physical consequences and lasts well beyond the acute injury phase. Data collection is sparse after hospital discharge, however. In this observational study, we hypothesized that sequelae of injury would last at least 6 months and sought to prospectively determine patient-reported physical, emotional, and social outcomes during this postinjury period. METHODS: We surveyed patients admitted to our Level I trauma center (July 2019 to October 2020) regarding baseline functioning and quality of life after injury, using the Patient-Reported Outcomes Measurement Information System (PROMIS-29) instrument, a primary care posttraumatic stress disorder screen, and questions on substance use, employment, and living situation. Patients were re-surveyed at 6 months. PROMIS-29 scores are reported as t scores compared with the US population. Differences between groups were analyzed using χ 2 , signed-rank, and t tests, with paired tests used for changes over time. RESULTS: Three hundred sixty-two patients completed the baseline, 130 of whom completed 6-month follow-up. Those completing the 6-month survey were similar ages (43.3 ± 17.8 vs. 44.4 ± 19.0, p = 0.57), mechanism (24.7% vs. 28.0% shot or stabbed, p = 0.61), and severities (median Injury Severity Score, 9 vs. 9; p = 0.15) as those who only completed the baseline. There were 55.0% reported being hospitalized for an injury previously. Patients reported decreases in ability to participate in social roles and activities (mean t score 51.4 vs. 55.3; p = 0.011) and increases in anxiety (53.8 vs. 50.5, p = 0.011) and depression (51.0 vs. 48.7, p = 0.025). There were 26.2% that screened positive for posttraumatic stress disorder at 6 months. Employment decreased at 6 months, with 63.9% reporting being "occasionally" employed or unemployed at 6 months versus 44.6% preinjury ( p < 0.001). CONCLUSION: The effects of injury extend beyond pain and disability, impacting several realms of life for at least 6 months following trauma. These data support the development of screening and intervention protocols for postinjury patients. LEVEL OF EVIDENCE: Prognostic and Epidemiologic; Level IV.

Top Ten Tips Palliative Care Clinicians Should Know About Trauma and Emergency Surgery.

There is growing interest in, and need for, integrating palliative care (PC) into the care of patients undergoing emergency surgery and those with traumatic injury. Thus, PC consults for these populations will likely grow in the coming years. Understanding the nuances and unique characteristics of these two acutely ill populations will improve the care that PC clinicians can provide. Using a modified Delphi technique, this article offers 10 tips that experts in the field, based on their broad clinical experience, believe PC clinicians should know about the care of trauma and emergency surgery patients.

Pain Interference and Decreased Physical Function After Emergency General Surgery: Measuring Patient-Reported Outcomes.

INTRODUCTION: There is increasing emphasis on patient-reported outcomes (PROs) measures in healthcare, but this area remains largely unexplored in emergency general surgery (EGS) conditions. We hypothesized that postoperative patients in our EGS clinic would report detrimental changes in several domains of health-related quality of life (HRQoL). METHODS: We administered the PROMIS-29, a HRQoL measurement tool, to postoperative patients in our EGS clinic (11/2019-4/2020). Patients responded to measures of 7 domains. Domain scores were converted to t-scores, allowing comparison to average values within the general US population (set to 50 by definition). We report the mean scores within each domain. Higher scores in negatively worded domains (e.g., "Depression") are worse; vice versa for positively worded domains (e.g., "Physical Function"). Changes in scores at subsequent clinic visits were analyzed using the paired t-test. RESULTS: There were 97 patients who completed the PROMIS-29 at the first postoperative visit. Mean (SD) age was 54.1 (16.2) years; 51% were male. There was no difference in our patients from the average US population in the domains of Ability to Participate in Social Roles and Activities, Anxiety, Fatigue, and Sleep Disturbance. However, EGS patients experienced significantly greater Pain Interference (56.1 [54.1, 58.1]) and worse Physical Function (40.6 [38.4, 42.7]) than average. For patients seen in follow-up twice (13 patients, median interval between clinic visits 21 days), there were improvements in the domains of Physical Function (42.9 vs 37.3; p = 0.04) and Fatigue. CONCLUSION: We demonstrate room for improvement in the domains of pain interference and physical function. While positive changes over a relatively short period of time are encouraging, consideration should be given to patient perceptions of illness and lifestyle impact when managing EGS patients.

Firearm Violence, Access to Care, and Gentrification: A Moving Target for American Trauma Systems.

OBJECTIVE: We aimed to determine whether gentrification predicts the movement of shooting victims over time and if this process has decreased access to care. BACKGROUND: Trauma centers remain fixed in space, but the populations they serve do not. Nationally, gentrification has displaced disadvantaged communities most at risk for violent injury, potentially decreasing access to care. This process has not been studied, but an increase of only 1 mile from a trauma center increases shooting mortality up to 22%. METHODS: We performed a cross-sectional study utilizing Philadelphia Police Department (PPD) and Pennsylvania trauma systems outcome (PTOS) data 2006-2018. Shootings were mapped and grouped into census tracts. They were then cross-mapped with gentrification data and hospital location. PPD and PTOS shooting data were compared to ensure patients requiring trauma care were captured. Census tracts with ≥500 residents with income and median home values in the bottom 40th percentile of the metropolitan area were eligible to gentrify. Tracts were gentrified if residents ≥25 with a bachelor's degree increased and home price increased to the top third in the metropolitan area. Change in distribution of shootings and its relation to gentrification was our primary outcome while proximity of shootings to a trauma center was our secondary outcome. RESULTS: Thirty-two percent (123/379) of eligible tracts gentrified and 31,165 shootings were captured in the PPD database. 9090 (29.2%) patients meeting trauma criteria were captured in PTOS with an increasing proportion over time. The proportion of shootings within gentrifying tracts significantly dropped 2006-2018 (40%-35%, P < 0.001) and increased in non-gentrifying tracts (52%-57%, P < 0.001). In evaluation of shooting densities, a predictable redistribution occurred 2006-2018 with incident density decreasing in gentrified areas and increasing in non-gentrified areas. Shootings within 1 mile of a trauma center increased overall, but proportional access decreased in gentrified areas. CONCLUSIONS: Shootings in Philadelphia predictably moved out of gentrified areas and concentrated in non-gentrified ones. In this case study of a national crisis, the pattern of change paradoxically resulted in an increased clustering of shootings around trauma centers in non-gentrified areas. Repetition of this work in other cities can guide future resource allocation and be used to improve access to trauma care.

Efficient evaluation of center-level emergency surgery performance using a high-yield procedure set: A step towards an EGS registry.

BACKGROUND: Emergency general surgery (EGS) lacks mechanisms to compare performance between institutions. Focusing on higher-risk procedures may efficiently identify outliers. METHODS: EGS patients were identified from the 2016 State Inpatient Databases of Florida, New York, and Kentucky. Risk-adjusted mortality was calculated as an O:E ratio, generating expected mortality from a model including demographic and procedural factors. Outliers were centers whose 90% confidence intervals excluded 1. This was repeated in several subsets, to determine if these yielded outliers similar to the overall dataset. RESULTS: We identified 45,430 EGS patients. Overall, 3 high performing centers and 5 low performing centers were identified. Exclusion of appendectomies and cholecystectomies resulted in a remaining data set of 13,569 patients (29.9% of the overall data set), with 2 high performers and 5 low performers. One low performer in the limited data set was not identified in the overall set. CONCLUSION: Evaluation of 5 procedures, making up less than a third of EGS, identifies most outliers. A streamlined monitoring procedure may facilitate maintenance of an EGS registry.

Differences Between Center-level Outcomes in Emergency and Elective General Surgery.

BACKGROUND: Center-level outcome metrics have long been tracked in elective surgery (ELS). Despite recent interest in measuring emergency general surgery (EGS) quality, centers are often compared based on elective or combined outcomes. Therefore, quality of care for emergency surgery specifically is unknown. METHODS: We extracted data on EGS and ELS patients from the 2016 State Inpatient Databases of Florida, New York, and Kentucky. Centers that performed >100 ELS and EGS operations were included. Risk-adjusted mortality, complication, and failure to rescue (FTR, death after complication) rates were calculated and observed-to-expected ratios were calculated by center for ELS and EGS patients. Centers were determined to be high or low outliers if the 90% CI for the observed: expected ratio excluded 1. We calculated the frequency with which centers demonstrated a different performance status between EGS and ELS. Kendall's tau values were calculated to assess for correlation between EGS and ELS status. RESULTS: A total of 204 centers with 45,500 EGS cases and 49,380 ELS cases met inclusion criteria. Overall mortality, complication, and FTR rates were 1.7%, 8.0%, and 14.5% respectively. There was no significant correlation between mortality performance in EGS and ELS, with 36 centers in a different performance category (high outlier, low outlier, as expected) in EGS than in ELS. The correlation for complication rates was 0.20, with 60 centers in different categories for EGS and ELS. For FTR rates, there was no correlation, with 16 centers changing category. CONCLUSIONS: There was minimal correlation between outcomes for ELS and EGS. High performers in one category were rarely high performers in the other. There may be important differences between the processes of care that are important for EGS and ELS outcomes that may yield meaningful opportunities for quality improvement.

Pulmonary complications in trauma: Another bellwether for failure to rescue?

BACKGROUND: Pulmonary complications are the most common adverse event after injury and second greatest cause of failure to rescue (death after pulmonary complications). It is not known whether readily accessible trauma center data can be used to stratify center-level performance for various complications. Performance variation between trauma centers would allow sharing of best practices among otherwise similar hospitals. We hypothesized that high-, average-, and low-performing centers for pulmonary complication and failure to rescue could be identified and that hospital factors associated with success and failure could be discovered. METHODS: Pennsylvania state trauma registry data (2007-2015) were abstracted for pulmonary complications. Burns and age <17 were excluded. Multivariable logistic regression models were developed for pulmonary complication and failure to rescue, using demographics, comorbidities, and injuries/physiology. Expected event rates were compared with observed rates to identify outliers. Center-level variables associated with outcomes of interest were taken from the American Hospital Association Annual Survey Database and assessed for inclusion. RESULTS: Included in the study were 283,121 patients (male [60%] blunt trauma [92%]). Of these patients, 3% (8,381 of 283,121) developed pulmonary complications (center-level range 0.18%-5.8%). The percentage of failure-to-rescue patients was 13.4% (1,120/8,381, center-level range 0.0%-22.6%). For pulmonary complications, 13 out of 27 centers were high performers (95% CI for O:E ratio <1) and 7 out of 27 were low (95% CI for an O:E ratio >1). For failure-to-rescue patients, 2 out of 27 centers were low performers and the remainder average. There was little concordance between performance for pulmonary complications and failure to rescue. Research programs, large non-teaching hospitals, those with advanced practice providers, and those with health maintenance organizations had reduced failure-to-rescue patients. CONCLUSION: Factors associated with complications were distinct from those affecting failure to rescue and center-level success in reducing complications often did not translate into success in preventing death once they occurred. Our data demonstrate that high- and low-performing centers and the factors driving success or failure are identifiable. This work serves as a guide for comparing practices and improving outcomes with readily available data.