Perceptions of Equity and Inclusion in Acute Care Surgery: From the #EAST4ALL Survey.

OBJECTIVES AND BACKGROUND: The aim of this study was to characterize equity and inclusion in acute care surgery (ACS) with a survey to examine the demographics of ACS surgeons, the exclusionary or biased behaviors they witnessed and experienced, and where those behaviors happen. A major initiative of the Equity, Quality, and Inclusion in Trauma Surgery Practice Ad Hoc Task Force of the Eastern Association for the Surgery of Trauma was to characterize equity and inclusion in ACS. To do so, a survey was created with the above objectives. METHODS: A cross-sectional, mixed-methods anonymous online survey was sent to all EAST members. Closed-ended questions are reported as percentages with a cutoff of α = 0.05 for significance. Quantitative results were analyzed focusing on mistreatment and bias. RESULTS: Most respondents identified as white, non-Hispanic and male. In the past 12 months, 57.5% of females witnessed or experienced sexual harassment, whereas 48.6% of surgeons of color witnessed or experienced racial/ethnic discrimination. Sexual harassment, racial/ethnic prejudice, or discrimination based on sexual orientation/sex identity was more frequent in the workplace than at academic conferences or in ACS. Females were more likely than males to report unfair treatment due to age, appearance or sex in the workplace and ACS (P ≤ 0.002). Surgeons of color were more likely than white, non-Hispanics to report unfair treatment in the workplace and ACS due to race/ethnicity (P < 0.001). CONCLUSIONS: This is the first survey of ACS surgeons on equity and inclusion. Perceptions of bias are prevalent. Minorities reported more inequity than their white male counterparts. Behavior in the workplace was worse than at academic conferences or ACS. Ensuring equity and inclusion may help ACS attract and retain the best and brightest without fear of unfair treatment.

Rectal Injury After Foreign Body Insertion: Secondary Analysis From the AAST Contemporary Management of Rectal Injuries Study Group.

BACKGROUND: Retained rectal foreign bodies are a common but incompletely studied problem. This study defined the epidemiology, injury severity, and outcomes after rectal injuries following foreign body insertion. METHODS: Twenty-two level I trauma centers retrospectively identified all patients sustaining a rectal injury in this AAST multi-institutional trial (2005-2014). Only patients injured by foreign body insertion were included in this secondary analysis. Exclusion criteria were death before rectal injury management or ≤48 h of admission. Demographics, clinical data, and outcomes were collected. Study groups were defined as partial thickness (AAST grade I) versus full thickness (AAST grades II-V) injuries. Subgroup analysis was performed by management strategy (nonoperative versus operative). RESULTS: After exclusions, 33 patients were identified. Mean age was 41 y (range 18-57), and 85% (n = 28) were male. Eleven (33%) had full thickness injuries and 22 (67%) had partial thickness injuries, of which 14 (64%) were managed nonoperatively and 8 (36%) operatively (proximal diversion alone [n = 3, 14%]; direct repair with proximal diversion [n = 2, 9%]; laparotomy without rectal intervention [n = 2, 9%]; and direct repair alone [n = 1, 5%]). Subgroup analysis of outcomes after partial thickness injury demonstrated significantly shorter hospital length of stay (2 ± 1; 2 [1-5] versus 5 ± 2; 4 [2-8] d, P = 0.0001) after nonoperative versus operative management. CONCLUSIONS: Although partial thickness rectal injuries do not require intervention, difficulty excluding full thickness injuries led some surgeons in this series to manage partial thickness injuries operatively. This was associated with significantly longer hospital length of stay. Therefore, we recommend nonoperative management after a retained rectal foreign body unless full thickness injury is conclusively identified.

Percentage of Mortal Encounters Transferred in Emergency General Surgery.

BACKGROUND: Despite the frequent occurrence of interhospital transfers in emergency general surgery (EGS), rates of transfer of complications are undescribed. Improved understanding of hospital transfer patterns has a multitude of implications, including quality measurement. The objective of this study was to describe individual hospital transfer rates of mortal encounters. MATERIALS AND METHODS: A retrospective review was undertaken from 2013 to 2015 of the Maryland Health Services Cost Review Commission database. Two groups of EGS encounters were identified: encounters with death following transfer and encounters with death without transfer. The percentage of mortal encounters transferred was defined as the percentage of EGS hospital encounters with mortality initially presenting to a hospital transferred to another hospital before death at the receiving hospital. RESULTS: Overall, 370,242 total EGS encounters were included, with 17,003 (4.6%) of the total EGS encounters with mortality. Encounters with death without transfer encompassed 15,604 (91.8%) of mortal EGS encounters and encounters with death following transfer 1399 (8.2%). EGS disease categories of esophageal varices or perforation, necrotizing fasciitis, enterocutaneous fistula, and pancreatitis had over 10% of these total mortal encounters with death following transfer. For individual hospitals, percentage of mortal encounters transferred ranged from 0.8% to 35.2%. The percentage of mortal encounters transferred was inversely correlated with annual EGS hospital volume for all state hospitals (P < 0.001, r = -0.57). CONCLUSIONS: Broad variability in individual hospital practices exists for mortality transferred to other institutions. Application of this knowledge of percentage of mortal encounters transferred includes consideration in hospital quality metrics.

Inhibiting CARD11 translation during BCR activation by targeting the eIF4A RNA helicase.

Human diffuse large B-cell lymphomas (DLBCLs) often aberrantly express oncogenes that generally contain complex secondary structures in their 5' untranslated region (UTR). Oncogenes with complex 5'UTRs require enhanced eIF4A RNA helicase activity for translation. PDCD4 inhibits eIF4A, and PDCD4 knockout mice have a high penetrance for B-cell lymphomas. Here, we show that on B-cell receptor (BCR)-mediated p70s6K activation, PDCD4 is degraded, and eIF4A activity is greatly enhanced. We identified a subset of genes involved in BCR signaling, including CARD11, BCL10, and MALT1, that have complex 5'UTRs and encode proteins with short half-lives. Expression of these known oncogenic proteins is enhanced on BCR activation and is attenuated by the eIF4A inhibitor Silvestrol. Antigen-experienced immunoglobulin (Ig)G(+) splenic B cells, from which most DLBCLs are derived, have higher levels of eIF4A cap-binding activity and protein translation than IgM(+) B cells. Our results suggest that eIF4A-mediated enhancement of oncogene translation may be a critical component for lymphoma progression, and specific targeting of eIF4A may be an attractive therapeutic approach in the management of human B-cell lymphomas.

Development and Initial Performance of the Hospital Mental Health Risk Screen.

BACKGROUND: Patients hospitalized after emergency care are at risk for later mental health problems such as depression, anxiety, and posttraumatic stress disorder symptoms. The American College of Surgeons Committee on Trauma standards for verification require Level I and II trauma centers to screen patients at high risk for mental health problems. This study aimed to develop and examine the performance of a novel mental health risk screen for hospitalized patients based on samples that reflect the diversity of the US population. STUDY DESIGN: We studied patients admitted after emergency care to 3 hospitals that serve ethnically, racially, and socioeconomically diverse populations. We assessed risk factors during hospitalization and mental health symptoms at follow-up. We conducted analyses to identify the most predictive risk factors, selected items to assess each risk, and determined the fewest items needed to predict mental health symptoms at follow-up. Analyses were conducted for the entire sample and within 5 ethnic and racial subgroups. RESULTS: Among 1,320 patients, 10 items accurately identified 75% of patients who later had elevated levels of mental health symptoms and 71% of those who did not. Screen performance was good to excellent within each of the ethnic and racial groups studied. CONCLUSIONS: The Hospital Mental Health Risk Screen accurately predicted mental health outcomes overall and within ethnic and racial subgroups. If performance is replicated in a new sample, the screen could be used to screen patients hospitalized after emergency care for mental health risk. Routine screening could increase health and mental health equity and foster preventive care research and implementation.

Taking action to achieve health equity and eliminate healthcare disparities within acute care surgery.

Addressing disparities is crucial for enhancing population health, ensuring health security, and fostering resilient health systems. Disparities in acute care surgery (trauma, emergency general surgery, and surgical critical care) have been well documented and the magnitude of inequities demand an intentional, organized, and effective response. As part of its commitment to achieve high-quality, equitable care in all aspects of acute care surgery, the American Association for the Surgery of Trauma convened an expert panel at its eigty-second annual meeting in September 2023 to discuss how to take action to work towards health equity in acute care surgery practice. The panel discussion framed contemporary disparities in the context of historic and political injustices, then identified targets for interventions and potential action items in health system structure, health policy, the surgical workforce, institutional operations and quality efforts. We offer a four-pronged approach to address health inequities: identify, reduce, eliminate, and heal disparities, with the goal of building a healthcare system that achieves equity and justice for all.

The contemporary management of perforated appendicitis in adults: To operate or wait?

Objectives: The optimal management of perforated appendicitis remains controversial. Many studies advocate for antibiotics and an interval appendectomy whereas others suggest that performing an appendectomy at the time of presentation decreases post-operative morbidity. Confounding this argument further are the patients who fail non-operative management and end up requiring surgery during their initial hospitalization. This study aims to determine if early operative intervention should be considered for perforated appendicitis. Methods: This was a retrospective review of all patients who underwent an appendectomy (both laparoscopic or open) for perforated appendicitis between 2015 and 2020 at our institution. Results: A total of 271 patients met inclusion criteria for this study. Of this group, 250 patients underwent an immediate appendectomy whereas the remaining 21 patients underwent a trial of non-operative management and eventually required an appendectomy during their initial admission. When comparing the immediate versus delayed operative groups, there were no differences in demographic data including age and gender, and no differences in various imaging findings including AAST Grade IV or V appendicitis. Operatively, patients in the delayed group had a longer operative time (83.1 ± 32.9 vs. 64.1 ± 26.2, p = 0.01), were more likely to require an open operation (23.8 % vs. 2.8 %, p < 0.0001), and were more likely to have a drain placed intra-operatively (42.9 % vs 14.4 %, p = 0.004). While there were no differences in 30-day readmission rates, patients in the delayed group had a significantly longer hospital length of stay than patients in the immediate group (9.4 ± 7.4 vs. 3.1 ± 3.3, p = 0.008). Conclusions: Patients undergoing an immediate appendectomy for perforated appendicitis can discharge from the hospital sooner and demonstrate no increase in post-operative morbidity suggesting that surgeons can initially manage this disease process in an operative fashion.

Value in acute care surgery, part 3: Defining value in acute surgical care-It depends on the perspective.

ABSTRACT: The prior articles in this series have focused on measuring cost and quality in acute care surgery. This third article in the series explains the current ways of defining value in acute care surgery, based on different stakeholders in the health care system-the patient, the health care organization, the payer and society. The heterogenous valuations of the different stakeholders require that the framework for determining high-value care in acute care surgery incorporates all viewpoints. LEVEL OF EVIDENCE: Expert Opinion; Level V.

A core outcome set for appendicitis: A consensus approach utilizing modified Delphi methodology.

BACKGROUND: Appendicitis is one of the most common pathologies encountered by general and acute care surgeons. The current literature is inconsistent, as it is fraught with outcome heterogeneity, especially in the area of nonoperative management. We sought to develop a core outcome set (COS) for future appendicitis studies to facilitate outcome standardization and future data pooling. METHODS: A modified Delphi study was conducted after identification of content experts in the field of appendicitis using both the Eastern Association for the Surgery of Trauma (EAST) landmark appendicitis articles and consensus from the EAST ad hoc COS taskforce on appendicitis. The study incorporated three rounds. Round 1 utilized free text outcome suggestions, then in rounds 2 and 3 the suggests were scored using a Likert scale of 1 to 9 with 1 to 3 denoting a less important outcome, 4 to 6 denoting an important but noncritical outcome, and 7 to 9 denoting a critically important outcome. Core outcome status consensus was defined a priori as >70% of scores 7 to 9 and <15% of scores 1 to 3. RESULTS: Seventeen panelists initially agreed to participate in the study with 16 completing the process (94%). Thirty-two unique potential outcomes were initially suggested in round 1 and 10 (31%) met consensus with one outcome meeting exclusion at the end of round 2. At completion of round 3, a total of 17 (53%) outcomes achieved COS consensus. CONCLUSION: An international panel of 16 appendicitis experts achieved consensus on 17 core outcomes that should be incorporated into future appendicitis studies as a minimum set of standardized outcomes to help frame future cohort-based studies on appendicitis. LEVEL OF EVIDENCE: Diagnostic Test or Criteria; Level V.

Weight-based enoxaparin thromboprophylaxis in young trauma patients: analysis of the CLOTT-1 registry.

Introduction: Optimal venous thromboembolism (VTE) enoxaparin prophylaxis dosing remains elusive. Weight-based (WB) dosing safely increases anti-factor Xa levels without the need for routine monitoring but it is unclear if it leads to lower VTE risk. We hypothesized that WB dosing would decrease VTE risk compared with standard fixed dosing (SFD). Methods: Patients from the prospective, observational CLOTT-1 registry receiving prophylactic enoxaparin (n=5539) were categorized as WB (0.45-0.55 mg/kg two times per day) or SFD (30 mg two times per day, 40 mg once a day). Multivariate logistic regression was used to generate a predicted probability of VTE for WB and SFD patients. Results: Of 4360 patients analyzed, 1065 (24.4%) were WB and 3295 (75.6%) were SFD. WB patients were younger, female, more severely injured, and underwent major operation or major venous repair at a higher rate than individuals in the SFD group. Obesity was more common among the SFD group. Unadjusted VTE rates were comparable (WB 3.1% vs. SFD 3.9%; p=0.221). Early prophylaxis was associated with lower VTE rate (1.4% vs. 5.0%; p=0.001) and deep vein thrombosis (0.9% vs. 4.4%; p<0.001), but not pulmonary embolism (0.7% vs. 1.4%; p=0.259). After adjustment, VTE incidence did not differ by dosing strategy (adjusted OR (aOR) 0.75, 95% CI 0.38 to 1.48); however, early administration was associated with a significant reduction in VTE (aOR 0.47, 95% CI 0.30 to 0.74). Conclusion: In young trauma patients, WB prophylaxis is not associated with reduced VTE rate when compared with SFD. The timing of the initiation of chemoprophylaxis may be more important than the dosing strategy. Further studies need to evaluate these findings across a wider age and comorbidity spectrum. Level of evidence: Level IV, therapeutic/care management.

Penetrating trauma in urban women: patterns of injury and violence.

BACKGROUND: Penetrating trauma is known to occur with less frequency in women than in men, and this difference has resulted in a lack of characterization of penetrating injury patterns involving women. We hypothesized that the nature of penetrating injury differs significantly by gender and that these injuries in women are associated with important psychosocial and environmental factors. MATERIALS AND METHODS: A level 1 urban trauma center registry was queried for all patients with penetrating injuries from 2002-2010. Patient and injury variables (demographics and mechanism of injury) were abstracted and compared between genders; additional social and psychiatric histories and perpetrator information were collected from the records of admitted female patients. RESULTS: Injured women were more likely to be Caucasian, suffer stab wounds instead of gunshot wounds, and present with a higher blood alcohol level than men. Compared with women with gunshot wounds, those with stab wounds were three times more likely to report a psychiatric or intimate partner violence history. Women with self-inflicted injuries had a significantly greater incidence of prior penetrating injury and psychiatric and criminal history. Male perpetrators outnumbered female perpetrators; patients frequently not only knew their perpetrator but also were their intimate partners. Intimate partner violence and random cross-fire incidents each accounted for about a quarter of injuries observed. CONCLUSIONS: Penetrating injuries in women represent a nonnegligible subset of injuries seen in urban trauma centers. Psychiatric and social risk factors for violence play important roles in these cases, particularly when self-infliction is suspected. Resources allocated for urban violence prevention should proportionately reflect the particular patterns of violence observed in injured women.

Association Between Fecal Contamination and Outcomes After Emergent General Surgery Colorectal Resection: A Post Hoc Analysis of an Eastern Association for the Surgery of Trauma (EAST) Multicenter Study.

Background: The impact of fecal contamination on clinical outcomes in patients undergoing emergent colorectal resection is unclear. We hypothesized that fecal contamination is associated with worse clinical outcomes regardless of operative technique. Patients and Methods: This is a post hoc analysis for an Eastern Association for the Surgery of Trauma-sponsored multicenter study that prospectively enrolled emergency general surgery patients undergoing urgent/emergent colorectal resection. Subjects were categorized according to presence versus absence of intra-operative fecal contamination. Propensity score matching (1:1) by age, weight, Charlson comorbidity index, pre-operative vasopressor use, and method of colonic management (primary anastomosis [ANST] vs. ostomy [STM]) was performed. χ2 analysis was then performed to compare the composite outcome (surgical site infection and fascial dehiscence). Results: A total of 428 subjects were included, of whom 147 (34%) had fecal contamination. Propensity score matching (1:1) resulted in a total of 147 pairs. After controlling for operative technique, fecal contamination was still associated with higher odds of the composite outcome (odds ratio [OR], 2.47; 95% confidence interval [CI], 1.45-4.2; p = 0.001). Conclusions: In patients undergoing urgent/emergent colorectal resection, fecal contamination, regardless of operative technique, is associated with worse clinical outcomes. Selection bias is possible, thus randomized controlled trials are needed to confirm or refute a causal relation.

Quality care is equitable care: a call to action to link quality to achieving health equity within acute care surgery.

Health equity is defined as the sixth domain of healthcare quality. Understanding health disparities in acute care surgery (defined as trauma surgery, emergency general surgery and surgical critical care) is key to identifying targets that will improve outcomes and ensure delivery of high-quality care within healthcare organizations. Implementing a health equity framework within institutions such that local acute care surgeons can ensure equity is a component of quality is imperative. Recognizing this need, the AAST (American Association for the Surgery of Trauma) Diversity, Equity and Inclusion Committee convened an expert panel entitled 'Quality Care is Equitable Care' at the 81st annual meeting in September 2022 (Chicago, Illinois). Recommendations for introducing health equity metrics within health systems include: (1) capturing patient outcome data including patient experience data by race, ethnicity, language, sexual orientation, and gender identity; (2) ensuring cultural competency (eg, availability of language services; identifying sources of bias or inequities); (3) prioritizing health literacy; and (4) measuring disease-specific disparities such that targeted interventions are developed and implemented. A stepwise approach is outlined to include health equity as an organizational quality indicator.

Power of mentorship for civilian and military acute care surgeons: identifying and leveraging opportunities for longitudinal professional development.

Across disciplines, mentorship has been recognized as a key to success. Acute care surgeons, focused on the care of trauma surgery, emergency general surgery and surgical critical care, practice in a wide variety of settings and have unique mentorship needs across all phases of their career. Recognizing the need for robust mentorship and professional development, the American Association for the Surgery of Trauma (AAST) convened an expert panel entitled 'The Power of Mentorship' at the 81st annual meeting in September 2022 (Chicago, Illinois). This was a collaboration between the AAST Associate Member Council (consisting of surgical resident, fellow and junior faculty members), the AAST Military Liaison Committee, and the AAST Healthcare Economics Committee. Led by two moderators, the panel consisted of five real-life mentor-mentee pairs. They addressed the following realms of mentorship: clinical, research, executive leadership and career development, mentorship through professional societies, and mentorship for military-trained surgeons. Recommendations, as well as pearls and pitfalls, are summarized below.

Utilization of trauma nurse screening procedure for triage of the injured patient.

PURPOSE: The treatment of trauma patients requires significant hospital resources. Numerous protocols exist to triage the injured patient and determine the level of care they may require. The purpose of this work is to describe an institutional trauma nurse screening procedure and to evaluate its effectiveness in triaging injured patients. METHODS: This retrospective study was conducted at a large, tertiary trauma center from January to June 2021. Patients were assessed by trauma nurse clinicians (TNC) utilizing a standardized screening process to determine suitability for trauma activation. If the patient did not meet activation criteria, they were sent to the main Emergency Department for evaluation and treatment. Patients could be activated later by the emergency physician. The primary variables of interest were number of activations after initial "rule out," injury severity score (ISS) for patients who were activated, mechanism of injury, and disposition. RESULTS: A total of 1874 TNC screenings were performed. Of these, 1449 (77%) patients did not meet trauma activation criteria. Only 41 (2.8%) patients initially ruled out were later activated by the emergency physician and admitted for treatment of injuries. The average ISS of all activated patients was 9 ± 6. Thirty-six patients had an ISS ≤ 15, four between 16 and 25, and only one patient had an ISS > 25. Twenty-seven patients were admitted to the ward, five went to step-down units, and five required intensive care unit admission. Four patients required operative intervention for their injuries. CONCLUSION: These results suggest that nursing screening protocols can be safe, effective tools for triage of trauma patients.

The evolution of emergency general surgery: its time for a dedicated program manager.

BACKGROUND: Emergency general surgery (EGS) is emerging as a distinct sub-specialty of acute care surgery but continues to exist without essential processes that drive modern trauma programs. An EGS-specific quality program was created with service-based Advanced Practice Provider (SB APP) administrative oversight, thus validating the need for a dedicated EGS program manager. METHODS: In 2017, a quality structure was formalized with primary focus on scheduled quality meetings, peer review and outcomes review. All admission, service-specific dashboards, and readmission data were manually audited by SB APPs to confirm accuracy and identify opportunities for process improvement. RESULTS: Surgical quality metrics including patient volume, mortality, complications, readmission and infection prevention indicators, were reviewed by SBAPPs. Annual EMR data for all EGS patients was compared to data collected via manual review with a novel registry logic. Comparison of EMR generated data versus EGS registry data identified under-representation of total admissions: in 2016, the EMR identified 130 admissions with registry logic identifying 625 actual EGS admissions. The EMR identified 515 admissions in 2017 and 485 admission in 2018 with registry logic identifying 777 and 712, respectively. Review of readmission data revealed an error of 14 patients in 2017 and 11 patients in 2018. CONCLUSIONS: The quest to improve quality of care for the EGS patient requires timely review of high-quality, accurate data by dedicated and trained personnel. Our process revealed the vital functions of an EGS PM are crucial in the evolution of the EGS specialty. LEVEL OF EVIDENCE: Level IV economic and value-based evaluations.

Value in acute care surgery, part 2: Defining and measuring quality outcomes.

ABSTRACT: The prior article in this series delved into measuring cost in acute care surgery, and this subsequent work explains in detail how quality is measured. Specifically, objective quality is based on outcome measures, both from administrative and clinical registry databases from a multitude of sources. Risk stratification is key in comparing similar populations across diseases and procedures. Importantly, a move toward focusing on subjective outcomes like patient-reported outcomes measures and financial well-being are vital to evolving surgical quality measures for the 21st century.

Tissue plasminogen activator resistance is an early predictor of posttraumatic venous thromboembolism: A prospective study from the CLOTT research group.

BACKGROUND: Venous thromboembolism (VTE) remains a frequent postinjury complication with well established but nonmodifiable risk factors. We hypothesized that fibrinolysis shutdown (SD) as measured by thromboelastography (TEG) would be an independent risk factor for VTE in trauma patients. METHODS: A subgroup of patients enrolled in the CLOTT-2 (Consortium of Leaders in the Study of Traumatic Thromboembolism 2), multicenter prospective cohort study had kaolin TEG and tissue plasminogen activator (tPA)-TEG data at 12 and 24 hours postadmission. Patients underwent a screening duplex venous ultrasound examination during the first week unless clot was already detected on computed tomography. Injury factors associated with early fibrinolysis SD (defined as kaolin TEG Ly30 ≤0.3%) and/or tPA resistance (tPA-R) (defined as kaolin TEG with tPA 75 ng Ly30 <2.1%) were investigated as was the association of the TEG measurements with the development of VTE. RESULTS: A total of 141 patients had both TEG measurements at 24 hours, and 135 had both TEG measurements at 12 hours. Shutdown was evident at 12 hours in 71 of 135 (52.6%) patients and in 62 of 141 (44%) at 24 hours. Tissue plasminogen activator resistance was found in 61 of 135 (45.2%) at 12 hours and in 49 of 141 (34.3%) at 24 hours. Factors significantly associated with SD included receiving >4 U of FFP in the first 24 hours, the presence of a major brain injury or pelvic fracture, and the need for major surgery. In contrast, factors significantly associated with early tPA-R included >4 U of red blood cells transfused in the first 24 hours and the presence of a major chest injury or long bone fracture. Deep vein thrombosis was detected in 15 patients and pulmonary clots in 5 (overall VTE rate, 14.2%). Tissue plasminogen activator resistance at 12 hours was found to be an independent risk factor for VTE (hazard ratio, 5.57; 95% confidence interval, 1.39-22.39). CONCLUSION: Early development of a hypercoagulable state as defined by tPA-R at 12 hours after admission represents a potentially modifiable risk factor for postinjury VTE. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level II.