Increasing the Rate of Venous Thromboembolism Chemoprophylaxis Administration Using the Electronic Medical Record.

Introduction: Venous thromboembolism (VTE) remains a leading cause of preventable harm among hospitalized patients. Pharmacologic VTE prophylaxis reduces the rate of in-hospital VTE by 60%, but medication administration is often missed for various reasons. Electronic medical record (EMR) prompts may be a useful tool to decrease withholding of critical VTE chemoprophylaxis medications. Methods: In August 2021, an EMR prompt was implemented at a tertiary referral academic medical center mandating nursing staff to contact a provider for approval before withholding VTE chemoprophylaxis. A pre-intervention group from August 2020 to August 2021 was compared to a post-intervention group from August 2021 to August 2022. Rates of VTE chemoprophylaxis withholding were compared between the groups with a P < .01 considered significant. Results: A total of 16,395 patients prescribed VTE chemoprophylaxis were reviewed, with 13,395 (81.7%) receiving low molecular weight heparin. Of the 16,395 patients included, 10,701 (65.3%) were medical and 5694 (34.7%) were surgical. Patients in the pre-intervention cohort (n = 8803) and post-intervention cohort (n = 7592) were similar in hospital length of stay and duration of DVT prophylaxis. In the post-intervention group, the frequency of surgical patients with at least one missed dose had increased by 4.2% (P = .002), with the trauma and acute care surgery (TACS) show an increase of 6.6% (P < .001). However, the frequency of medical patients and non-TACS patients with missed doses decreased by 3.1% (P = .002) and 1.0% (<.001), respectively. Conclusions: EMR prompts appear to be a low-cost intervention that increases the rate of VTE prophylaxis administration among medical and elective surgery patients.

Risk factors for recurrence in blunt traumatic abdominal wall hernias: A secondary analysis of a Western Trauma association multicenter study.

BACKGROUND: Few studies have investigated risk factors for recurrence of blunt traumatic abdominal wall hernias (TAWH). METHODS: Twenty trauma centers identified repaired TAWH from January 2012 to December 2018. Logistic regression was used to investigate risk factors for recurrence. RESULTS: TAWH were repaired in 175 patients with 21 (12.0%) known recurrences. No difference was found in location, defect size, or median time to repair between the recurrence and non-recurrence groups. Mesh use was not protective of recurrence. Female sex, injury severity score (ISS), emergency laparotomy (EL), and bowel resection were associated with hernia recurrence. Bowel resection remained significant in a multivariable model. CONCLUSION: Female sex, ISS, EL, and bowel resection were identified as risk factors for hernia recurrence. Mesh use and time to repair were not associated with recurrence. Surgeons should be mindful of these risk factors but could attempt acute repair in the setting of appropriate physiologic parameters.

Early pneumonia diagnosis decreases ventilator-associated pneumonia rates in trauma population.

BACKGROUND: Ventilator-associated pneumonia (VAP) is a source of morbidity and mortality for trauma patients. Aspiration events are also common because of traumatic brain injury, altered mental status, or facial trauma. In patients requiring mechanical ventilation, early pneumonias (EPs) may be erroneously classified as ventilator associated. METHODS: A prospective early bronchoscopy protocol was implemented from January 2020 to January 2022. Trauma patients intubated before arrival or within 48 hours of admission underwent bronchoalveolar lavage (BAL) within 24 hours of intubation. Patients with more than 100,000 colony-forming units on BAL were considered to have EP. RESULTS: A total of 117 patients underwent early BAL. Ninety-three (79.5%) had some growth on BAL with 36 (30.8%) meeting criteria for EP. For the total study population, 29 patients (24.8%) were diagnosed with VAP later in their hospital course, 12 of which had previously been diagnosed with EP. Of EP patients (n = 36), 21 (58.3%) were treated with antibiotics based on clinical signs of infection. Of EP patients who had a later pneumonia diagnosed by BAL (n = 12), seven (58.3%) grew the same organism from their initial BAL. When these patients were excluded from VAP calculation, the rate was reduced by 27.6%. Patients with EP had a higher rate of smoking history (41.7% vs. 19.8%, p < 0.001) compared with patients without EP. There was no difference in median hospital length of stay, intensive care unit length of stay, ventilator days, or mortality between the two cohorts. CONCLUSION: Early pneumonia is common in trauma patients intubated within the first 48 hours of admission and screening with early BAL identifies patients with aspiration or pretraumatic indicators of pneumonia. Accounting for these patients with early BAL significantly reduces reported VAP rates. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Management of blunt traumatic abdominal wall hernias: A Western Trauma Association multicenter study.

BACKGROUND: Blunt traumatic abdominal wall hernias (TAWH) occur in approximately 15,000 patients per year. Limited data are available to guide the timing of surgical intervention or the feasibility of nonoperative management. METHODS: A retrospective study of patients presenting with blunt TAWH from January 2012 through December 2018 was conducted. Patient demographic, surgical, and outcomes data were collected from 20 institutions through the Western Trauma Association Multicenter Trials Committee. RESULTS: Two hundred and eighty-one patients with TAWH were identified. One hundred and seventy-six (62.6%) patients underwent operative hernia repair, and 105 (37.4%) patients underwent nonoperative management. Of those undergoing surgical intervention, 157 (89.3%) were repaired during the index hospitalization, and 19 (10.7%) underwent delayed repair. Bowel injury was identified in 95 (33.8%) patients with the majority occurring with rectus and flank hernias (82.1%) as compared with lumbar hernias (15.8%). Overall hernia recurrence rate was 12.0% (n = 21). Nonoperative patients had a higher Injury Severity Score (24.4 vs. 19.4, p = 0.010), head Abbreviated Injury Scale score (1.1 vs. 0.6, p = 0.006), and mortality rate (11.4% vs. 4.0%, p = 0.031). Patients who underwent late repair had lower rates of primary fascial repair (46.4% vs. 77.1%, p = 0.012) and higher rates of mesh use (78.9% vs. 32.5%, p < 0.001). Recurrence rate was not statistically different between the late and early repair groups (15.8% vs. 11.5%, p = 0.869). CONCLUSION: This report is the largest series and first multicenter study to investigate TAWHs. Bowel injury was identified in over 30% of TAWH cases indicating a significant need for immediate laparotomy. In other cases, operative management may be deferred in specific patients with other life-threatening injuries, or in stable patients with concern for bowel injury. Hernia recurrence was not different between the late and early repair groups. LEVEL OF EVIDENCE: Therapeutic/care management, Level IV.

Late Operative Rib Fixation is Inferior to Nonoperative Management.

BACKGROUND: Operative rib fixation (ORF) of traumatic rib fractures has been shown to decrease hospital length of stay (LOS), ventilator days, and mortality. ORF performed within 1 day of admission has been shown to have favorable outcomes compared to later ORF. This report examines the ORF experience over 10 years at a level I trauma center. METHODS: ORF patients from January 2007-January 2018 were matched to nonoperative controls in a 1:2 ratio based on age, injury severity score (ISS), chest Abbreviated Injury Score (AIS), and head AIS. Patient demographic, injury, and outcome data were collected from the trauma registry and medical records. Hospital day of ORF was identified for each ORF patient. Hospital LOS, ICU LOS, ventilator days, and mortality were compared against matched nonoperative controls. RESULTS: Ninety-five ORF patients were matched to 190 nonoperative patients. ORF patients had a higher number of rib fractures (9.6 vs 6.4, P < .001). ORF patients with short time to operation (0-2 days) had a shorter average hospital stay than those with delayed operations (11.8 vs 12.6 vs 13.4 vs 19.6 days, P = .003). ORF patients with operations performed 3-4 days and >6 days after admission also had statistically significant longer ICU LOS and ventilator days. Patient mortality was higher when ORF was performed after 6 days. DISCUSSION: Early ORF may improve pulmonary function, patient outcomes, and decrease LOS. Shifting practice toward early fixation may help further solidify the benefits of this procedure in the treatment of blunt chest trauma.

Acute Kidney Injury in the Critically Ill.

Acute kidney injury (AKI) occurs frequently in the surgical intensive care unit and results in significant morbidity and mortality. AKI needs to be identified early and underlying causes treated or eliminated. Sepsis, major surgery such as coronary artery bypass, and hypovolemia are the most common causes and patients with underlying comorbidities have increased susceptibility. Treatment should begin by ensuring that patients are adequately resuscitated and all contributing causes are replaced or eliminated. After stabilization of hemodynamic status and elimination of contributing causes, treatment becomes largely supportive and may require the use of a renal replacement therapy.

An Update on the Current Management of Perforated Diverticulitis.

The management of perforated diverticulitis is a challenging aspect of general surgery. The prevalence of colonic diverticular disease has increased over the last decade and will continue to increase as the baby boomers add to the elderly population. Improvements in diagnostic imaging modalities, efforts to maintain intestinal continuity, and percutaneous drainage procedures now result in several alternatives when selecting a management strategy for complicated presentations. Specifically, laparoscopic lavage and resection with primary anastomosis have emerged as options for treatment of Hinchey III and IV diverticulitis in place of diversion in the appropriately selected patient. Percutaneous drainage of Hinchey II diverticulitis in centers equipped with interventional radiology provides another minimally invasive adjunct. The objective of this paper is to provide an update on the current management of perforated diverticulitis, with a focus on the advantages and disadvantages of the surgical options for the treatment of Hinchey III and IV diverticulitis.

A single-center retrospective review of postoperative infectious complications in the surgical management of mandibular fractures: Postoperative antibiotics add no benefit.

BACKGROUND: Mandibular fractures are common facial injuries and treatment may be complicated by post-operative infection. Risk of infection from contamination with oral flora is well established but no consensus exists regarding antibiotic prophylaxis. The purpose of this study is to assess risk factors and perioperative antibiotics on surgical site infection (SSI) rates following mandibular fracture surgery. METHODS: Retrospective medical record review was completed for trauma patients of any age surgically treated for mandibular fractures at a Level I Trauma Center from September 2006 to June 2012. Outcomes analysis was performed to determine SSI rates related to perioperative antibiotic use and other risk factors that may contribute to SSI. RESULTS: 359 patients met inclusion criteria for analysis. 76% were male. Mean age was 30.5 years. Thirty-eight patients developed SSI (10.6%). SSI rate was lower in closed versus open surgery (3.2% vs. 16.3%, p=0.0001), and in closed versus open fractures (1% vs. 14%, p=0.0005). SSI rate increased in patients with tobacco, alcohol, and drug use (14.6%, 13.2%, 53.6%, p<0.0001), traumatic dental injuries (19.6%, p=0.0110), and patients in motor vehicle crashes (12.2%, p=0.0062). SSI rates stratified by Injury Severity Score (ISS) less than or equal to 16 (23/255 [9%]) versus ISS greater than 16 (15/104 [14%]) trended toward more severely injured patients developing SSI, p=0.1347. SSI rate was similar in patients who did and did not receive post-operative antibiotics (14.7% vs. 9.6%, p=0.2556). Type of antibiotic, duration of post-operative antibiotic administration, and duration between injury and surgery did not effect SSI rate. CONCLUSIONS: Findings suggest that following surgical treatment of mandible fractures, open surgery, open fractures, and risk factors including substance abuse, traumatic dental injury, and mechanism of injury significantly increase SSI rates, while post-operative antibiotics do not appear to provide additional benefit compared to pre-operative antibiotics alone. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Preliminary experience with laparoscopic peritoneal lavage for complicated diverticulitis: a new algorithm for treatment?

Patients with findings suggestive of a perforated diverticulitis may be subject to colostomy with the attendant morbidity and quality-of-life concerns. Recent literature demonstrates decreased use of laparotomy and colostomy when diagnostic laparoscopy reveals absence of fecal peritonitis. Ten patients presenting with diverticulitis between May 2009 and February 2012 underwent diagnostic laparoscopy. The indication for surgery in nine patients was failure of medical management with or without percutaneous drainage and one had significant pneumoperitoneum at presentation. A comprehensive algorithm was subsequently developed governing medical and surgical management of diverticulitis including the use of diagnostic laparoscopy and laparoscopic peritoneal lavage for patients with Hinchey Stage 3 diverticulitis or abscess formation not amenable to percutaneous drainage. Eight patients underwent diagnostic laparoscopy and laparoscopic peritoneal lavage, whereas two patients underwent diagnostic laparoscopy with conversion to open procedures (low-anterior resection with diverting ileostomy and Hartmann's procedure). Mortality was 0 per cent. Four patients were subsequently readmitted for relapse or recurrence. Two required laparotomy at the time of readmission, ultimately receiving a diagnosis of adenocarcinoma. Two were managed medically and later underwent elective laparoscopic sigmoid colon resection. Diagnostic laparoscopy and laparoscopy peritoneal lavage appear feasible and safe and may be an alternative to more invasive surgery, avoiding laparotomy and colostomy and staging patients for elective laparoscopic resection. Based on our institutional experience, we propose a novel algorithm for the treatment of hospitalized patients with diverticulitis, which incorporates diagnostic laparoscopy and laparoscopic peritoneal lavage while emphasizing patient selection based on clinical examination and imaging.

Errors in administrative-reported ventilator-associated pneumonia rates: are never events really so?

Ventilator-associated pneumonia (VAP) is a common problem in an intensive care unit (ICU), although the incidence is not well established. This study aims to compare the VAP incidence as determined by the treating surgical intensivist with that detected by the hospital Infection Control Service (ICS). Trauma and surgical patients admitted to the surgical critical care service were prospectively evaluated for VAP during a 5-month time period. Collected data included the surgical intensivist's clinical VAP (SIS-VAP) assessment using Centers for Disease Control and Prevention (CDC) VAP criteria. As part of the hospital's VAP surveillance program, these patients' medical records were also reviewed by the ICS for VAP (ICS-VAP) using the same CDC VAP criteria. All patients suspected of having VAP underwent bronchioalveolar lavage (BAL). The SIS-VAP and ICS-VAP were then compared with BAL-VAP. Three hundred twenty-nine patients were admitted to the ICU during the study period. One hundred thirty-three were intubated longer than 48 hours and comprised our study population. Sixty-two patients underwent BAL evaluation for the presence of VAP on 89 occasions. SIS-VAP was diagnosed in 38 (28.5%) patients. ICS-VAP was identified in 11 (8.3%) patients (P < 0.001). The incidence of VAP by BAL criteria was 23.3 per cent. When compared with BAL, SIS-VAP had 61.3 per cent sensitivity and ICS-VAP had 29 per cent sensitivity. VAP rates reported by hospital administrative sources are significantly less accurate than physician-reported rates and dramatically underestimate the incidence of VAP. Proclaiming VAP as a never event for critically ill for surgical and trauma patients appears to be a fallacy.

Experience with vacuum-pack temporary abdominal wound closure in 258 trauma and general and vascular surgical patients.

BACKGROUND: Temporary closure of an open abdominal wound by vacuum-pack is the method of choice for patients requiring open abdomen management in our institution. We have previously reported our experience with a vacuum-pack in trauma patients and have expanded its use to general and vascular surgery patients. STUDY DESIGN: This is a descriptive study performed through review of medical records of all patients undergoing vacuum-pack closure after celiotomy from January 1999 to May 2006. Clinical and demographic data were collected. RESULTS: Seven hundred seventeen vacuum-pack closures were performed in 258 surgical patients (116 trauma versus 142 general and vascular surgery). The most common indication for open abdomen management was damage control in trauma patients and planned reexploration in general and vascular surgery patients. Total abdominal complication rate was 15.5% (14.7% trauma versus 16.2% general and vascular surgery). Fistulas occurred in 13 (5%), intraabdominal abscesses in 9 (3.5%), bowel obstruction in 3 (1.2%), abdominal compartment syndrome in 3 (1.2%), and evisceration in 1 (0.4%). Two hundred twenty-six patients survived to permanent abdominal wound closure. Of these, 154 (68.1%) patients underwent primary fascial closure of their abdominal wounds. Seventy-two patients (31.9%) required delayed closure. In-hospital mortality rate was 26.0% (25.9% trauma versus 26.1% general and vascular surgery). The cost of vacuum-pack materials is less than $50. CONCLUSIONS: Indication for open abdomen management varied between general and vascular surgery and trauma patients. Complication rates were similar. Primary closure of open abdominal wounds was achieved in 68.4% of patients. Vacuum-pack temporary abdominal wound closure, initially used in trauma patients, continues to demonstrate ease of mastery, effectiveness in patient care and comfort, consistently low associated complication rate, and low cost in both general and vascular surgery and trauma patients.

Trauma nurse specialists' performance of advanced skills positively impacts surgical residency time constraints.

The Accreditation Council for Graduate Medical Education imposed 80-hour work week constraints on residency programs in July 2003. Certain programs were granted an additional 10 per cent for specific educational purposes, bringing restrictions to 88 hours per week. The increased demand for residents to leave the hospital has placed teaching institutions in exhaustive situations to provide comprehensive patient care. In response to the work hour constraints among residents and emergency room staff, a unique group of registered nurses, trauma nurse specialists (TNSs), were credentialed with advanced practice skill sets. Governed by practice guidelines and overseen by a medical director, TNSs perform invasive procedures that are normally the responsibility of the surgical resident. The purpose of this study was to evaluate work hours saved for surgery residents using credentialed nurses (TNSs). Procedure logs were maintained by the TNSs over a 6-month period, and surgical house staff (postgraduate year 1-3) over a 4-month period. A total of 423 procedures were recorded, reflecting time taken for attempted/completed procedures and complications. Resident procedures numbered 98; TNS procedures numbered 325. TNSs spent an average of 42 hours per month (10.6 hours per week) completing advanced procedures with no statistical difference in time or complications compared with surgical residents. By using the TNSs, work hours for surgery residents were saved while maintaining a safe and reliable work atmosphere for patients.

Management of destructive bowel injury in the open abdomen.

BACKGROUND: Little attention has been focused on destructive injuries of the bowel in patients requiring open abdominal management. We therefore reviewed our institutional experience for destructive bowel injury requiring open abdominal management with the vacuum pack technique (vac). METHODS: The trauma registry at a Level I trauma center was used to identify patients sustaining destructive bowel injury for an 11-year period beginning in May 1990. Patients were assessed for pertinent clinical and demographic information, and individuals requiring open abdominal management were compared with those who did not. RESULTS: One hundred four patients required bowel resection and constitute the study population. Twenty-nine patients had vacs placed, with 22 (75.9%) of the total eventually obtaining delayed fascial closure. Nineteen (183%) patients had resection and primary repair (PR) of large and/or small bowel in conjunction with a vac, 10 (9.6%) patients had stoma formation in conjunction with a vac, 62 (59.6%) patients had resection and PR of small and/or large bowel in conjunction with primary fascial closure, and 13 (12.5%) patients had stoma formation and primary fascial closure. There were no differences in abdominal abscess or leak rates between groups. There were four deaths, none of which was secondary to failure of an anastomosis. CONCLUSION: Bowel resection with PR appears to be a safe alternative after destructive bowel injury and results in acceptable morbidity when performed in conjunction with open abdominal management.

A prospective assessment of diagnostic efficacy of blind protective bronchial brushings compared to bronchoscope-assisted lavage, bronchoscope-directed brushings, and blind endotracheal aspirates in ventilator-associated pneumonia.

BACKGROUND: The purpose of this study is to compare techniques for the diagnosis of suspected ventilator-associated pneumonia in the trauma patient. Per the literature, bronchoscope protected brushings and bronchoalveolar lavage were set as the standards for comparison because of their high specificity and sensitivity. We hypothesized that blind protected brushings were equivalent to bronchoscope-directed techniques and that endotracheal aspirates (ETA) were not. METHODS: With informed consent, 90 trauma patients with two or more of the following were accepted into the study: 48 hours or more on the ventilator, new or increasing infiltrate on chest radiograph, excess or purulent secretions, suspected aspiration, temperature of 38.5 degrees C or above, white blood cell count greater than or equal to 12,000/mm3, and respiratory distress. Four samplings were performed on each patient using bronchoscope-assisted and nonbronchoscopic techniques. Each patient had cultures obtained by and significances quantified as follows: ETA, moderate/many/abundant; bronchoscope-directed protected brushings (BDPB), 103 colony-forming units [CFU]/mL; blind protected brushing via endotracheal tube (BPB), 103 CFU/mL; and bronchoscopic bronchoalveolar lavage (BAL), 104 CFU/mL. Quantitative cultures were obtained and compared for the following pathogens: gram-positive cocci, gram-positive rods, gram-negative cocci, gram-negative rods, anaerobic bacteria, and yeast. An assessment of agreement for cultured pathogens between the sampling modalities was completed using kappa (kappa) analysis, and significance was set at p < or = 0.05. RESULTS: With patients used as their own controls, Gram's stain and pathogens cultured from the various sampling techniques were compared for agreement by kappa analysis. BDPB and BAL were set as the "gold standards" for comparison against each other and against the BPB and ETA. Kappa analysis was used to measure the strength of agreement for these findings; individual values from the comparisons of Gram's stain were then averaged for descriptive purposes of the data. Most kappa values were associated with a statistically significant value of p < 0.05. The greatest strength of agreement was found to be moderate comparing Gram's stain results of BPB and BDPB (kappa = 0.467), ETA and BAL (kappa = 0.535), and BPB and BAL (kappa = 0.547). Fair kappa values were shown in comparing Gram's stain results of ETA and BDPB (kappa = 0.382) and BAL and BDPB (kappa = 0.390). CONCLUSION: A quantitative analysis of bacteriologic cultures obtained by four standard sampling techniques has demonstrated with statistical significance that no difference exists between modality of sampling in reliability or in obtaining clinically significant pathogens. In reviewing the literature, this study is the first assessment of agreement for cultured pathogens between the four different sampling modalities and the largest to assess the efficacy of the blind protected brush technique.