Role of Occupational Therapy Cognitive Assessment in Mild Traumatic Brain Injury: Is Universal Consultation Required?

INTRODUCTION: Mild traumatic brain injury (mTBI) or concussion is prevalent among trauma patients, but symptoms vary. Assessing discharge safety is not standardized. At our institution, occupational therapy (OT) performs cognitive assessments for mTBI to determine discharge readiness, potentially increasing resource utilization. We aimed to describe characteristics and outcomes in mTBI trauma patients and hypothesized that OT consultation was associated with increased length of stay (LOS). METHODS: This is a retrospective study at a level 1 trauma center over 17 mo. All patients with mTBI, without significant concomitant injuries, were included. We collected data regarding OT assessment, LOS, mechanism of injury, Glasgow coma score, injury severity score (ISS), concussion symptoms, and patient disposition. Statistical analysis was performed, and significance was determined when P < 0.05. RESULTS: Two hundred thirty three patients were included. Median LOS was 1 d and ISS 5. Ninety percent were discharged home. The most common presenting symptom was loss of consciousness (85%). No symptoms were associated with differences in LOS or discharge disposition (P > 0.05). OT consult (n = 114, 49%) was associated with longer LOS and higher ISS (P < 0.01). Representation with concussive symptoms, discharge disposition, mechanism of injury, and patient demographics were no different regardless of OT consultation (P > 0.05). CONCLUSIONS: mTBI is common and assessment for discharge safety is not standardized. OT cognitive assessment was associated with longer LOS and higher injury severity. Despite institutional culture, OT consultation was variable and not associated with improved concussion-related outcomes. Our data suggest that OT is not required for mTBI discharge readiness assessment. To improve resource utilization, more selective OT consultation should be considered. Further prospective data are needed to identify which patients would most benefit.

A Pathway for Increased Diversity, Equity, and Inclusion in the Surgical Infection Society.

Background: With the rise of diversity, equity, and inclusion (DEI) efforts across medicine, the Surgical Infection Society (SIS) leadership undertook a several-year mission to evaluate DEI issues within the SIS, through the formation of a DEI Ad Hoc Committee to guide the application of best practices. The purpose of this article is to describe the work of the DEI committee since its inception, as well as report on advances made during that time. Methods: Beginning in September 2020, 26 volunteer committee members met monthly to explore the current state of science and best practices around DEI, identify opportunities for the SIS, and translate opportunities into recommendations. As part of this initiative, a survey of the SIS membership was conducted. Survey results, published best practices from business and medicine, and experiences of committee members were utilized collaboratively to outline specific opportunities and recommendations. These findings were presented to the SIS Executive Council and to the membership at the SIS Annual Business Meeting. Results: Committee-identified opportunities and recommendations fell into broad categories of Membership, Leadership and Society Structure, the Annual Meeting, and Research Priorities. Several recommendations were immediately enacted, and a standing DEI committee was established to continue this work. Conclusions: Beyond the main mission of the SIS to advance the science of surgical infections, the SIS can also have a major impact on DEI within society and academic surgery at large.

Disparities in Insurance Status Are Associated With Outcomes but Not Timing of Trauma Care.

INTRODUCTION: Patient factors influence outcomes after injury. Delays in care have a crucial impact. We investigated the associations between patient characteristics and timing of transfer from the emergency department to definitive care. METHODS: This was a review of adult trauma patients treated between January 1, 2016, and December 31, 2018. Bivariate analyses were used to build Cox proportional hazards models. We built separate logistic and negative binomial regression models for secondary outcomes using mixed-step selection to minimize the Akaike information criterion c. RESULTS: A total of 1219 patients were included; 68.5% were male, 56.8% White, 11.2% Black, and 7.8% Asian/Pacific Islander. The average age was 51 ± 21 y. Overall, 13.7% of patients were uninsured. The average length of stay was 5 d and mortality was 5.9%. Shorter transfer time out of the emergency department was associated with higher tier of activation (relative risk [RR] 1.39, 95% confidence interval [CI] 1.09-1.77; P = 0.0074), Injury Severity Score between 16 and 24 points (RR 1.57, 95% CI 1.04-2.32; P = 0.0307) or ≥25 (RR 3.85, 95% CI 2.45-5.94; P = 0.0001), and penetrating injury. Longer time to event was associated with Glasgow coma scale score ≥14 points (RR 0.47, 95% CI 0.27-0.85; P = 0.0141). Uninsured patients were less likely to be admitted (odds ratio 0.29, 95% CI 0.17-0.48; P = 0.0001) and more likely to experience shorter length of stay (incidence rate ratio 0.34, 95% CI 0.24-0.51; P = 0.0001). CONCLUSIONS: Injury characteristics and insurance status were associated with patient outcomes in this retrospective, single-center study. We found no disparity in timing of intrafacility transfer, perhaps indicating that initial management protocols preserve equity.

Acute Care Surgery: Defining the Economic Burden of Emergency General Surgery.

BACKGROUND: Trauma centers (TCs) have been shown to provide lifesaving, but more expensive, care when compared with non-TCs (NTC). Limited data exist about the economic impact of emergency general surgery (EGS) patients on health care systems. We hypothesized that the economic burden would be higher for EGS patients managed at TCs vs NTCs. METHODS: The Maryland Health Services Cost Review Commission database was queried from 2009 to 2013. The American Association for the Surgery of Trauma EGS ICD-9 codes were used to define the top 10 EGS diagnoses. Demographic characteristics, TC designation, severity of illness, and hospital charge data were collected. Differences in total charges between TCs and NTCs were analyzed by Wilcoxon test using SAS 9.3 software (SAS Institute). RESULTS: A total of 435,623 patients were included. Median age was 61 years (interquartile range 47 to 76 years) and 55.9% were female. Median length of stay was 4 days; 90.3% were admitted via emergency department; and overall mortality was 5.1%. Overall median charges were $11,081 for TC vs $8,264 for NTC (p < 0.0001). Minor, moderate, major, and extreme severities of illness all had higher charges at TC vs NTC with no ICU admissions, respectfully ($5,908 vs $5,243; $7,051 vs $6,003; $10,501 vs $8,777; and $23, 997 vs $18,381; p < 0.001). Care at TCs was nearly twice as expensive if patients were admitted to the ICU, even when stratifying by severity of illness. CONCLUSIONS: Emergency general surgery patients treated at TCs incurred increased costs compared with NTCs, independent of patient severity. These costs nearly doubled for those admitted to the ICU. As acute care surgery grows as a specialty, additional investigation is required to better understand the reasons for this cost differential.

Emergency General Surgery: Defining Burden of Disease in the State of Maryland.

Acute care surgery services continue expanding to provide emergency general surgery (EGS) care. The aim of this study is to define the characteristics of the EGS population in Maryland. Retrospective review of the Health Services Cost Review Commission database from 2009 to 2013 was performed. American Association for the Surgery of Trauma-defined EGS ICD-9 codes were used to define the EGS population. Data collected included patient demographics, admission origin [emergency department (ED) versus non-ED], length of stay (LOS), mortality, and disposition. There were 3,157,646 encounters. In all, 817,942 (26%) were EGS encounters, with 76 per cent admitted via an ED. The median age of ED patients that died was 74 years versus 61 years for those that lived (P < 0.001). Twenty one per cent of ED admitted patients had a LOS > 7 days. Of 78,065 non-ED admitted patients, the median age of those that died was 68 years versus 59 years for those that lived (P < 0.001). Twenty eight per cent of non-ED admits had LOS > 7 days. In both ED and non-ED patients, there was a bimodal distribution of death, with most patients dying at LOS ≤ 2 or LOS > 7 days. In this study, EGS diagnoses are present in 26 per cent of inpatient encounters in Maryland. The EGS population is elderly with prolonged LOS and a bimodal distribution of death.

Making the financial case for a surgeon-directed critical care ultrasound program.

BACKGROUND: We sought to demonstrate that a well-staffed, surgeon-directed, critical care ultrasound program (CCUP) is financially sustainable and provides administrative and educational support for point-of-care ultrasound. METHODS: The CCUP provides a clinical service and training as well as conducts research. Initial costs, annual costs (C), revenue (R), and savings (S) were prospectively recorded. Using data from the first 3 years, we calculated the projected C, R, and S at 5 years. We determined CCUP sustainability by C < R and C < R + S at 3 years and 5 years. RESULTS: During 36 months, the CCUP covered four surgical intensive care units (55 beds). Start-up costs included one basic and one cardiovascular device per 25 beds and a data storage system linking reports and images to the electronic medical record ($203,650). Billing increased threefold from Years 1 to 3, with a 21% increase between Years 2 to 3. Yearly costs included 0.5 full-time equivalent (FTE) sonographer and 0.2 FTE surgeon ($106,025); this was increased to 1 FTE and 0.25 FTE, respectively, for Years 4 and 5. The total 3-year cost was $521,725 and projected to be $863,325 by Year 5. The total 3-year revenue was $290,775 and projected to be $891,600 at 5 years. The total 3-year savings associated with the CCUP was $600,035 and is projected to be $1,194,220. With the use of the C < R, the CCUP meets operating expenses at Year 3 and covers overall cost at 5 years. If savings are included, then the CCUP is sustainable by its third year and is potentially profitable by Year 5. CONCLUSION: A surgeon-directed CCUP is financially sustainable, addresses administrative issues, and provides valuable training in point-of-care ultrasound.