Unleashing surgical skills: Ultra-high fidelity trauma thoracotomy training on knowledge donor platform.

BACKGROUND: Resuscitative thoracotomies are a time-sensitive emergency surgical procedure with an immediate risk of mortality. We hypothesize that a high-fidelity whole-body donor simulation model, referred to as a Knowledge Donor (KD), with mechanical lung ventilation and expired human blood perfusion could increase learner confidence in performing this critical procedure. METHODS: General surgery residents and faculty were invited to participate in KD training. Surveys were collected to track participation and confidence. RESULTS: Simulated resuscitative thoracotomies were performed involving PGY levels I-IV. Mean confidence was highest for residents with both KD and Live Patient experience (5.6 â€‹± â€‹1.7), followed by Live Patient only (4.3 â€‹± â€‹2.5), and KD only (2.6 â€‹± â€‹1.3). The mean confidence rating for residents with neither training opportunity was 1.4 â€‹± â€‹1.0. CONCLUSIONS: The KD platform is a hyper-realistic training modality that closely replicates live surgery. This platform allows residents to practice complex surgical procedures in a safe environment, without risking patient safety. This pilot program yielded early results in improving resident procedural confidence for high-risk surgical procedures, specifically resuscitative thoracotomies.

Abdominal computed tomography scoring systems and experienced radiologists in the radiological diagnosis of small bowel and mesenteric injury.

PURPOSE: Blunt bowel and/or mesenteric injury requiring surgery presents a diagnostic challenge. Although computed tomography (CT) imaging is standard following blunt trauma, findings can be nonspecific. Most studies have focused on the diagnostic value of CT findings in identifying significant bowel and/or mesenteric injury (sBMI). Some studies have described scoring systems to assist with diagnosis. Little attention, has been given to radiologist interpretation of CT scans. This study compared the discriminative ability of scoring systems (BIPS and RAPTOR) with radiologist interpretation in identifying sBMI. METHODS: We conducted a retrospective chart review of trauma patients with suspected sBMI. CT images were reviewed in a blinded fashion to calculate BIPS and RAPTOR scores. Sensitivity and specificity were compared between BIPS, RAPTOR, and the admission CT report with respect to identifying sBMI. RESULTS: One hundred sixty-two patients were identified, 72 (44%) underwent laparotomy and 43 (26.5%) had sBMI. Sensitivity and specificity were: BIPS 49% and 87%, AUC 0.75 (0.67-0.81), P < 0.001; RAPTOR 46% and 82%, AUC 0.72 (0.64-0.79), P < 0.001; radiologist impression 81% and 71%, AUC 0.82(0.75-0.87), P < 0.001. The discriminative ability of the radiologist impression was higher than RAPTOR (P = 0.04) but not BIPS (P = 0.13). There was not a difference between RAPTOR vs. BIPS (P = 0.55). CONCLUSION: Radiologist interpretation of the admission CT scan was discriminative of sBMI. Although surgical vigilance, including evaluation of the CT images and patient, remains fundamental to early diagnosis, the radiologist's impression of the CT scan can be used in clinical practice to simplify the approach to patients with abdominal trauma.

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) prior to interfacility transfer: Who might benefit in a statewide trauma system?

BACKGROUND: Rural trauma patients are often seen at lower-level trauma centers before transfer and have higher mortality than those seen initially at a Level 1 Trauma Center. This study aims to describe the potential for Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) to bridge this mortality gap. METHODS: We queried the Arizona Trauma Registry between 2014 and 2017 for hypotensive patients who were later transported to a level 1 center. REBOA candidates were identified as those with injuries consistent with major infra-diaphragmatic torso hemorrhage as the likely cause of death. RESULTS: Of 17,868 interfacility transfers during the study period, 333 met inclusion criteria and had sufficient data for evaluation. 26 of the 333 patients were identified as REBOA candidates. CONCLUSIONS: Our study suggests that REBOA may be an effective means to extend survivability to those severely injured trauma patients needing interfacility transfer to a higher level of care.

Surgeon compassion may mitigate quality of life disparities associated with health literacy.

Objectives: Patients with health literacy (HL) disparities are less likely to comprehend hospital discharge instructions and less satisfied with physician communication. In this prospective cohort study, we sought to examine the interaction of HL, physician communication, and quality of life after hospital discharge among postoperative emergency surgery and trauma patients. Methods: Emergency surgery and trauma surgery patients were prospectively enrolled between December 2020 and December 2021 at an urban level 1 trauma center. Newest Vital Sign (NVS) instrument was used to measure HL during hospitalization. After discharge, patients were administered Revised Trauma Quality of Life (RT-QOL) and Interpersonal Processes of Care (IPC) instruments. An adjusted regression model was used to determine associations among NVS the emotional well-being subscale on the RT-QOL, and patient perception of physician compassion and respect on the IPC. Results: 94 patients completed all instruments. HL was proficient (high HL) in 59.6% and less than proficient (low HL) in 40.4%. HL was positively associated with RT-QOL emotional well-being, r(94)=0.212, p=0.040. However, higher rating of surgeon compassion and respect on IPC moderated the relationship between HL and emotional well-being such that patients with low HL and high perception of physician compassion and respect had similar emotional well-being as the high HL group (p=0.042). Conclusion: Favorable patient perception of surgeon compassion and respect was correlated with higher emotional well-being, independent of HL proficiency. Although the allocation of resources toward improving HL disparities remains warranted, improving patient perception of caregiver compassion during hospitalization may be a target of opportunity with respect to improving quality of life after hospital discharge. Level of evidence: Level III.

Full-face motorcycle helmets to reduce injury and death: A systematic review, meta-analysis, and practice management guideline from the Eastern Association for the Surgery of Trauma.

BACKGROUND: While motorcycle helmets reduce mortality and morbidity, no guidelines specify which is safest. We sought to determine if full-face helmets reduce injury and death. METHODS: We searched for studies without exclusion based on: age, language, date, or randomization. Case reports, professional riders, and studies without original data were excluded. Pooled results were reported as OR (95% CI). Risk of bias and certainty was assessed. (PROSPERO #CRD42021226929). RESULTS: Of 4431 studies identified, 3074 were duplicates, leaving 1357 that were screened. Eighty-one full texts were assessed for eligibility, with 37 studies (n = 37,233) eventually included. Full-face helmets reduced traumatic brain injury (OR 0.40 [0.23-0.70]); injury severity for the head and neck (Abbreviated Injury Scale [AIS] mean difference -0.64 [-1.10 to -0.18]) and face (AIS mean difference -0.49 [-0.71 to -0.27]); and facial fracture (OR 0.26 [0.15-0.46]). CONCLUSION: Full-face motorcycle helmets are conditionally recommended to reduce traumatic brain injury, facial fractures, and injury severity.

Can we really make catheter-associated urinary tract infections a never event? A level 1 trauma center's experience with prophylactic antibiotic bladder irrigation.

BACKGROUND: Hospital-acquired catheter-associated urinary tract infections (CAUTIs) are considered "never events" and are reportable to Centers for Medicare and Medicaid Services as a quality indicator. Despite protocols to determine appropriate removal of urinary catheters as soon as possible, severely injured trauma patients often require prolonged catheterization during ongoing resuscitation or develop retention requiring catheter replacement, exposing them to risk for CAUTI. We evaluated whether prophylactic antibiotic bladder irrigation reduces the incidence of CAUTI in critically ill trauma patients. METHODS: As a quality initiative, gentamicin bladder catheter irrigation (GBCI) was performed on a level 1 trauma center's patients at risk for CAUTI in 2021, defined by indwelling Foley catheterization for a minimum of 3 days. We then conducted a retrospective study using a comparison cohort of 2020 admissions as the control group. Catheter-associated urinary tract infection rates per 1,000 catheterized days were compared between these two groups. Patients with traumatic bladder injuries were excluded. RESULTS: Our cohort included 342 patients with a median hospitalization of 11 (7-17) days, Injury Severity Score of 17 (10-26), and 6 (4-11) days of catheterization. Eighty-six patients, catheterized for 939 at-risk days, received twice-daily GBCI compared with 256, catheterized for 2,114 at-risk days, who did not. Zero patients in the GBCI group versus nine patients in the control group developed CAUTI. The incidence of CAUTI in the GBCI group was significantly less than in the control group (0/1,000 vs. 4.3/1,000 catheterized days, p = 0.018). CONCLUSION: Prophylactic antibiotic bladder irrigation was associated with a zero incidence of CAUTI among trauma patients at risk for CAUTI. This practice holds promise as effective infection prophylaxis for such patients. The optimal duration and frequency of irrigation remain to be determined. LEVEL OF EVIDENCE: Therapeutic/care management, Level III.

Commonly performed pelvic binder modifications for femoral access may hinder binder efficacy.

BACKGROUND: Pelvic fractures are common and potentially life-threatening. Pelvic circumferential compression devices (PCCD) can temporize hemorrhage, but more invasive strategies that involve femoral access may be necessary for definitive treatment. The aim of our study was to evaluate the efficacy of PCCDs reducing open book pelvic fractures when utilizing commonly described modifications and placement adjustments that allow for access to the femoral vasculature. METHODS: Open book pelvic fractures were created in adult cadavers. Three commercially available PCCDs were used to reduce fractures. The binders were properly placed, moved caudally, or moved cranially and modified. Fracture reduction rates were then recorded. RESULTS: The pelvic fracture was completely reduced with every PCCD tested when properly placed. Reduction rates decreased with improper placement and modifications. CONCLUSION: Modifying PCCD placement to allow femoral access decreased the effectiveness of these devices Clinicians should be aware of this possibility when caring for critically injured trauma patients with pelvic fractures.

Length of stay and trauma center finances: A disparity of payer source at a Level I trauma center.

BACKGROUND: In an effort to reduce costs, hospitals focus efforts on reducing length of stay (LOS) and often benchmark LOS against the geometric LOS (GMLOS) as predicted by the assigned diagnosis-related group (DRG) used by the Centers for Medicare and Medicaid Services. The objective of this cross-sectional study was to evaluate the impact of exceeding GMLOS on hospital profit/loss with respect to payer source. METHODS: Contribution margin for each insured patient admitted to a Level I trauma center between July 1, 2016, and June 30, 2019, was determined. Age, ethnicity, race, DRG weight, DRG version, injury severity, intensive care unit admission status, mechanical ventilation, payer, exceeding GMLOS, and the interaction between payer and exceeding the GMLOS were regressed on contribution margin to determine significant predictors of positive contribution margin. RESULTS: Among 2,449 insured trauma patients, the distribution of payers was Medicaid (54.6%), Medicare (24.0%), and commercial (21.4%). Thirty-five percent (n = 867) of patient LOS exceeded GMLOS. Exceeding GMLOS by 10 or more days was significantly more likely for Medicaid and Medicare patients in stepwise fashion (commercial, 2.7%; Medicaid, 4.5%; Medicare, 6.0%; p = 0.030). Median contribution margin was positive for commercially insured patients ($16,913) and negative for Medicaid (-$8,979) and Medicare (-$2,145) patients. Adjusted multivariate modeling demonstrated that when exceeding GMLOS, Medicare and Medicaid cases were less likely than commercial payers to have a positive contribution margin (p < 0.001 and p < 0.001). CONCLUSION: Government-insured patients, despite having a payer source, are a financial burden to a trauma center. Excess LOS among government insured patients, but not the commercially insured, exacerbates financial loss. A shift toward a greater proportion of government insured patients may result in a significant fiscal liability for a trauma center. LEVEL OF EVIDENCE: Economic and Value-Based Evaluation, Level III.

Trauma patient transport times unchanged despite trauma center proliferation: A 10-year review.

INTRODUCTION: In certain regions of the United States, there has been a dramatic proliferation of trauma centers. The goal of our study was to evaluate transport times during this period of trauma center proliferation. METHODS: Aggregated data summarizing level I trauma center admissions in Arizona between 2009 and 2018 were provided to our institution by the Arizona Department of Health Services. We evaluated patient demographics, transport times, and injury severity for both rural and urban injuries. RESULTS: Data included statistics summarizing 266,605 level I trauma admissions in the state of Arizona. The number of state-designated trauma centers during this time increased from 14 to 47, with level I centers increasing from 8 to 13. Slight decreases in mean Injury Severity Score (rural, 9.4 vs. 8.4; urban, 7.9 vs. 7.0) were observed over this period. Median transport time for cases transported from the injury scene directly to a level I center remained stable in urban areas at 0.9 hours in both 2009 and 2018. In rural areas, transport times for these cases were approximately double but also stable, with median times of 1.8 and 1.9 hours. Transport times for cases requiring interfacility transfer before admission at a level I center increased by 0.3 hours for urban injuries (5.3-5.6 hours) and 0.9 hours for rural injuries (5.6-6.5 hours). CONCLUSION: Despite the threefold increase in the number of state-designated trauma centers, transport time has not decreased in urban or rural areas. This finding highlights the need for regulatory oversight regarding the number and geographic placement of state-designated trauma centers. LEVEL OF EVIDENCE: Care management, level IV, Epidemiological, level III.

Miami-Dade County Juvenile Weapons Offenders Program (JWOP): a potential model to reduce firearm crime recidivism nationwide.

INTRODUCTION: Youth firearm violence has been a growing problem in the USA. Several programs across the country aimed at reducing recurrent gun violence in this vulnerable population have published recidivism rates of 40% to 50%. For the past 18 years, the Juvenile Weapons Offenders Program (JWOP) in Miami-Dade County has provided a unique multidisciplinary intervention encompassing 100 hours of violence education, behavioral modification, and social mentoring. The present study defines its outcomes as a national model for youth firearm recidivism prevention. METHODS: Retrospective analysis of Florida Juvenile Justice Department records from 2008 to 2016 defined a group of youths convicted of firearm-related crimes and subsequently enrolled in the program. Cohorts were those who demonstrated successful completion of the JWOP program versus those who partially completed the program. At 6 and 12 months after release, records were cross-referenced with Florida Department of Justice criminal record system to prospectively capture rates of new all-comer and firearm-specific criminal charges. RESULTS: 215 youth were included in the prospectively followed cohort at 6 months and 163 youth followed at 12 months after release. The 6-month recidivism rate for any criminal charge was 20.1% for program completers versus 32.9% for those who did not complete the program (p=0.047). When excluding unarmed criminal offenses, the recidivism rate dropped to 10.1% versus 22.4%, respectively (p=0.008). At 12 months, all-comers recidivism was 33.6% for the GATE program completion cohort versus 50% for the incomplete cohort (p=0.045). When excluding unarmed offenses, the recidivism rates were 18.6% versus 33.9%, respectively (p=0.035). CONCLUSION: The JWOP program has one of the lowest recidivism rates for reoffense for firearm and non-firearm-related offenses. Further investigation into details of the program's efficacy and its applicability for expansion to other state and national jurisdictions should serve a model for decreasing youth gun violence across the country.

Minor change in initial PEEP setting decreases rates of ventilator-associated events in mechanically ventilated trauma patients.

BACKGROUND: Surveillance of ventilator-associated events (VAEs) as defined by the National Healthcare Safety Network (NHSN) is performed at many US trauma centers and considered a measure of healthcare quality. The surveillance algorithm relies in part on increases in positive end-expiratory pressure (PEEP) to identify VAEs. The purpose of this cohort study was to evaluate the effect of initiating mechanically ventilated trauma patients at marginally higher PEEP on incidence of VAEs. METHODS: Analysis of level-1 trauma center patients mechanically ventilated 2+ days from 2017 to 2018 was performed after an institutional ventilation protocol increased initial PEEP setting from 5 (2017) to 6 (2018)cm H2O. Incidence of VAEs per 1000 vent days was compared between PEEP groups. Logistic regression modelling was performed to evaluate the impact of the PEEP setting change adjusted to account for age, ventilator days, injury mechanism and injury severity. RESULTS: 519 patients met study criteria (274 PEEP 5 and 245 PEEP 6). Rates of VAEs were significantly reduced among patients with initial PEEP 5 versus 6 (14.61 per 1000 vent days vs. 7.13 per 1000 vent days; p=0.039). Logistic regression demonstrated that initial PEEP 6 was associated with 62% reduction in VAEs. CONCLUSIONS: Our data suggest that an incrementally increased baseline PEEP setting was associated with a significantly decreased incidence of VAEs among trauma patients. This minor change in practice may have a major impact on a trauma center's quality metrics. LEVEL OF EVIDENCE: IV.

Are all trauma centers created equal? Level 1 to level 1 trauma center patient transfers in the setting of rapid trauma center proliferation.

BACKGROUND: Level 1 trauma centers should provide definitive care for every aspect of injury. However, in environments that have experienced trauma center proliferation, not all level 1 centers may have the resources or expertise needed for every patient, necessitating transfer to another trauma center. The purpose of this study was to assess the incidence of such transfers and associated impact on patient outcome and burden on the receiving level 1 center. METHODS: In a metropolitan area experiencing trauma center proliferation, we performed a 5.5-year review of patient transfers to an established level 1 (index center) from other state designated level 1 centers. American College of Surgeons verification level was identified for each facility. Comparisons were performed between the cohort of transferred patients and patients with similar demographics, injury patterns, and severity managed at the index center using propensity score matching. RESULTS: A total of 104 patients were received from other state level 1 centers (39% American College of Surgeons level 2, 61% American College of Surgeons level 1). Nearly 70% of patients were transferred for definitive evaluation and/or management of brain, spine, or cerebrovascular injury. For 76% of this subgroup, specialty consultation was available, but the injury was deemed beyond their capability. Comparison of the transfer cohort propensity score matched to the control cohort (93 vs. 558 patients) demonstrated increased length of stay (6.5 days vs. 4.6 days, p = 0.001) and cost (US $36,027 vs. US $30,654, p = 0.033) associated with the transfer cohort, with similar mortality (12.1% vs. 9.7%, p = 0.492). CONCLUSION: The number of level 1 to level 1 transfers observed imply a disparity in resources and capability among level 1 trauma centers in the region. The majority of transfers were for neurosurgical care, suggestive of a deficit of adequate neurosurgical coverage in the setting of trauma center proliferation. Both patients and established trauma centers bear the burden for these transfers with respect to increased cost and length of stay. LEVEL OF EVIDENCE: Care management, level IV.

Vitamin C and thiamine are associated with lower mortality in sepsis.

BACKGROUND: The efficacy of vitamin C (VitC) and thiamine (THMN) in patients admitted to the intensive care unit (ICU) with sepsis is unclear. The purpose of this study was to evaluate the effect of VitC and THMN on mortality and lactate clearance in ICU patients. We hypothesized that survival and lactate clearance would be improved when treated with thiamine and/or VitC. METHODS: The Philips eICU database version 2.0 was queried for patients admitted to the ICU in 2014 to 2015 for 48 hours or longer and patients with sepsis and an elevated lactate of 2.0 mmol/L or greater. Subjects were categorized according to the receipt of VitC, THMN, both, or neither. The primary outcome was in-hospital mortality. Secondary outcome was lactate clearance defined as lactate less than 2.0 mmol/L achieved after maximum lactate. Univariable comparisons included age, sex, race, Acute Physiology Score III, Acute Physiology and Chronic Health Evaluation (APACHE) IVa score, Sequential Organ Failure Assessment, surgical ICU admission status, intubation status, hospital region, liver disease, vasopressors, steroids, VitC and THMN orders. Kaplan-Meier curves, logistic regression, propensity score matching, and competing risks modeling were constructed. RESULTS: Of 146,687 patients from 186 hospitals, 7.7% (n = 11,330) were included. Overall mortality was 25.9% (n = 2,930). Evidence in favor of an association between VitC and/or THMN administration, and survival was found on log rank test (all p < 0.001). After controlling for confounding factors, VitC (adjusted odds ratio [AOR], 0.69 [0.50-0.95]) and THMN (AOR, 0.71 [0.55-0.93]) were independently associated with survival and THMN was associated with lactate clearance (AOR, 1.50 [1.22-1.96]). On competing risk model VitC (AOR, 0.675 [0.463-0.983]), THMN (AOR, 0.744 [0.569-0.974]), and VitC+THMN (AOR, 0.335 [0.13-0.865]) were associated with survival but not lactate clearance. For subgroup analysis of patients on vasopressors, VitC+THMN were associated with lactate clearance (AOR, 1.85 [1.05-3.24]) and survival (AOR, 0.223 [0.0678-0.735]). CONCLUSION: VitC+THMN is associated with increased survival in septic ICU patients. Randomized, multicenter trials are needed to better understand their effects on outcomes. LEVEL OF EVIDENCE: Therapeutic Study, Level IV.