Description and Impact of a Comprehensive Multispecialty Multidisciplinary Intervention to Decrease Opioid Prescribing in Surgery.

INTRODUCTION: Diversion of excess prescription opioids contributes to the opioid epidemic. We sought to describe and study the impact of a comprehensive departmental initiative to decrease opioid prescribing in surgery. METHODS: A multispecialty multidisciplinary initiative was designed to change the culture of postoperative opioid prescribing, including: consensus-built opioid guidelines for 42 procedures from 11 specialties, provider-focused posters displayed in all surgical units, patient opioid/pain brochures setting expectations, and educational seminars to residents, advanced practice providers, residents and nurses. Pre- (April 2016-March 2017) versu post-initiative (April 2017-May 2018) analyses of opioid prescribing at discharge [median oral morphine equivalent (OME)] were performed at the specialty, prescriber, patient, and procedure levels. Refill prescriptions within 3 months were also studied. RESULTS: A total of 23,298 patients were included (11,983 pre-; 11,315 post-initiative). Post-initiative, the median OME significantly decreased for 10 specialties (all P values < 0.001), the percentage of patients discharged without opioids increased from 35.7% to 52.5% (P < 0.001), and there was no change in opioids refills (0.07% vs 0.08%, P = 0.9). Similar significant decreases in OME were observed when the analyses were performed at the provider and individual procedure levels. Patient-level analyses showed that the preinitiative race/sex disparities in opioid-prescribing disappeared post-initiative. CONCLUSION: We describe a comprehensive multi-specialty intervention that successfully reduced prescribed opioids without increase in refills and decreased sex/race prescription disparities.

Urban Telemedicine: The Applicability of Teleburns in the Rehabilitative Phase.

Telemedicine has been successfully used in many areas of medicine, including triage and evaluation of the acute burn patient. The utility of telemedicine during the rehabilitative phase of burn care has yet to be evaluated; therefore, we expanded our telemedicine program to link our burn center with a rehabilitation facility. The goal of this project was to demonstrate cost-effective improvements in the transition and quality of care. A retrospective review was performed on all patients enrolled in our telemedicine/rehabilitation program between March 2013 and March 2014. Data collected included total number of encounters, visits, type of visit, physician time, and readmissions. Transportation costs were based on local ambulance rates between the two facilities. The impact of telemedicine was evaluated with respect to the time saved for the physician, burn center, and burn clinic, as well as rehabilitative days saved. A patient satisfaction survey was also administered. A total of 29 patients participated in 73 virtual visits through the telemedicine project. Virtual visits included new consults, preoperative evaluations, and postoperative follow-ups. A total of 146 ambulance transports were averted during the study period, totaling $101,110. Virtual visits saved 6.8 outpatient burn clinic days, or 73 clinic appointments of 30-min duration. The ability to perform more outpatient surgery resulted in 80 inpatient bed days saved at the burn hospital. The rehabilitation hospital saved an average of 2 to 3 patient days secondary to unnecessary travel. Satisfaction surveys demonstrated patient satisfaction with the encounters, primarily related to time saved. The decrease in travel time for the patient from the rehabilitation hospital to outpatient burn clinic improved adherence to the rehabilitation care plan and resulted in increased throughput at the rehabilitation facility. Videoconferencing between a burn center and rehabilitation hospital streamlined patient care and reduced health care costs, while maintaining quality of care and patient satisfaction. This program has improved inpatient burn rehabilitation by maximizing time spent in therapy and avoiding unnecessary patient travel to offsite appointments.

Methods in obtaining split-thickness skin grafts from skin reduction surgery specimens.

BACKGROUND: To devise a method for obtaining bacterial culture-negative split-thickness skin grafts from specimens removed from living donors undergoing skin reduction surgery. METHODS: Specimens were obtained from patients undergoing abdominal skin reduction surgery in inpatient and outpatient surgical settings. Skin specimens were cleaned in a method adapted from the former Yale Skin Bank's methods. The specimens were attached to the autoclave container for the dermatome using towel clips or sutures to provide tension. Normal saline clysis was injected subdermally and a Padgett Electric Dermatome was used to obtain skin grafts. These were then photographed and discarded. RESULTS: Eight specimens were obtained from seven women and one man. The mean age was 46.6 years and mean weight at time of surgery was 87.7 kg. Bacterial cultures obtained from all specimens were negative. All procured grafts were transparent, with visible dermis, suggesting that they could be used in a clinical setting. CONCLUSION: Bacterial culture-negative split-thickness skin grafts can be obtained from skin reduction surgery specimens, offering a potential source of split-thickness allograft during regional or national shortages.

Characteristics of patients with injury secondary to smoking on home oxygen therapy transferred intubated to a burn center.

BACKGROUND: The aim of this study was to compare outcomes of patients who sustained burn and ostensible inhalation injuries while on home oxygen therapy with those suffering equivalent injuries via other mechanisms. STUDY DESIGN: Between December 2002 and January 2006, 109 burn patients were transferred to our center intubated. Their charts were retrospectively reviewed. Patients who sustained injuries while on home oxygen therapy were age and total body surface area matched to patients with inhalation and burn injuries secondary to other mechanisms. RESULTS: Fourteen of 109 patients were injured while smoking on home oxygen therapy (15.26%). All 14 had COPD. Mean age was 63 years (range 53 to 77 years) and average total body surface area burned was 4% (range 0% to 10%). Charges for the 14 hospitalizations totaled $1,097,860 ($8,003 to $284,835; mean $78,418 per admission). Average time to extubation was 5.7 ± 10.2 days and average length of stay was 11.4 ± 15.2 days. No significant differences in the average time to extubation, length of stay, cost of hospitalization, or clinical signs of inhalation injury (ie, soot and edema in the pharynx) were noted between our series and the control group. CONCLUSIONS: Injury secondary to smoking on home oxygen therapy is a perennial problem, and guidelines for prescribing home oxygen therapy for smokers should be reassessed. Despite underlying lung disease, patients in our series did as well as patients without COPD who sustained similar injuries.

Factors associated with survival following blunt chest trauma in older patients: results from a large regional trauma cooperative.

HYPOTHESIS: We hypothesized that patient factors, injury patterns, and therapeutic interventions influence outcomes among older patients incurring traumatic chest injuries. DESIGN: Patients older than 50 years with at least 1 rib fracture (RF) were retrospectively studied, including institutional data, patient data, clinical interventions, and complications. Univariable and multivariable analyses were performed. SETTING: Eight trauma centers. PATIENTS: A total of 1621 patients. MAIN OUTCOME MEASURE: Survival. RESULTS: Patient data collected include the following: age (mean, 70.1 years), number of RFs (mean, 3.7), Abbreviated Injury Scale chest score (mean, 2.7), Injury Severity Score (mean, 11.7), and mortality (overall, 4.6%). On univariable analysis, increased mortality was associated with admission to high-volume trauma centers and level I centers, preexisting coronary artery disease or congestive heart failure, intubation or development of pneumonia, and increasing age, Injury Severity Score, and number of RFs. On multivariable analysis, strongest predictors of mortality were admission to high-volume trauma centers, preexisting congestive heart failure, intubation, and increasing age and Injury Severity Score. Using this predictive model, tracheostomy and patient-controlled analgesia had protective effects on survival. CONCLUSIONS: In a large regional trauma cooperative, increasing age and Injury Severity Score were independent predictors of survival among older patients incurring traumatic RFs. Admission to high-volume trauma centers, preexisting congestive heart failure, and intubation added to mortality. Therapies associated with improved survival were patient-controlled analgesia and tracheostomy. Further regional cooperation should allow development of standard care practices for these challenging patients.

Management of the most severely injured spleen: a multicenter study of the Research Consortium of New England Centers for Trauma (ReCONECT).

OBJECTIVE: To determine the rate and predictors of failure of nonoperative management (NOM) in grade IV and V blunt splenic injuries (BSI). DESIGN: Retrospective case series. SETTING: Fourteen trauma centers in New England. PATIENTS: A total of 388 adult patients with a grade IV or V BSI who were admitted between January 1, 2001, and August 31, 2008. MAIN OUTCOME MEASURES: Failure of NOM (f-NOM). RESULTS: A total of 164 patients (42%) were operated on immediately. Of the remaining 224 who were offered a trial of NOM, the treatment failed in 85 patients (38%). At the end, 64% of patients required surgery. Multivariate analysis identified 2 independent predictors of f-NOM: grade V BSI and the presence of a brain injury. The likelihood of f-NOM was 32% if no predictor was present, 56% if 1 was present, and 100% if both were present. The mortality of patients for whom NOM failed was almost 7-fold higher than those with successful NOM (4.7% vs 0.7%; P = .07). CONCLUSIONS: Nearly two-thirds of patients with grade IV or V BSI require surgery. A grade V BSI and brain injury predict failure of NOM. This data must be taken into account when generalizations are made about the overall high success rates of NOM, which do not represent severe BSI.