Fever and infections in surgical intensive care: an American Association for the Surgery of Trauma Critical Care Committee clinical consensus document.

The evaluation and workup of fever and the use of antibiotics to treat infections is part of daily practice in the surgical intensive care unit (ICU). Fever can be infectious or non-infectious; it is important to distinguish between the two entities wherever possible. The evidence is growing for shortening the duration of antibiotic treatment of common infections. The purpose of this clinical consensus document, created by the American Association for the Surgery of Trauma Critical Care Committee, is to synthesize the available evidence, and to provide practical recommendations. We discuss the evaluation of fever, the indications to obtain cultures including urine, blood, and respiratory specimens for diagnosis of infections, the use of procalcitonin, and the decision to initiate empiric antibiotics. We then describe the treatment of common infections, specifically ventilator-associated pneumonia, catheter-associated urinary infection, catheter-related bloodstream infection, bacteremia, surgical site infection, intra-abdominal infection, ventriculitis, and necrotizing soft tissue infection.

The silver lining of the pandemic in surgical education: virtual surgical education and recommendations for best practices.

Virtual education is an evolving field within the realm of surgical training. Since the onset of the COVID-19 pandemic, the application of virtual technologies in surgical education has undergone significant exploration and advancement. While originally developed to supplement in-person curricula for the development of clinical decision-making, virtual surgical education has expanded into the realms of clinical decision-making, surgical, and non-surgical skills acquisition. This manuscript aims to discuss the various applications of virtual surgical education as well as the advantages and disadvantages associated with each education modality, while offering recommendations on best practices and future directions.

Screening and intervention for intimate partner violence at trauma centers and emergency departments: an evidence-based systematic review from the Eastern Association for the Surgery of Trauma.

Background: Intimate partner violence (IPV) is a serious public health issue with a substantial burden on society. Screening and intervention practices vary widely and there are no standard guidelines. Our objective was to review research on current practices for IPV prevention in emergency departments and trauma centers in the USA and provide evidenced-based recommendations. Methods: An evidence-based systematic review of the literature was conducted to address screening and intervention for IPV in adult trauma and emergency department patients. The Grading of Recommendations, Assessment, Development and Evaluations methodology was used to determine the quality of evidence. Studies were included if they addressed our prespecified population, intervention, control, and outcomes questions. Case reports, editorials, and abstracts were excluded from review. Results: Seven studies met inclusion criteria. All seven were centered around screening for IPV; none addressed interventions when abuse was identified. Screening instruments varied across studies. Although it is unclear if one tool is more accurate than others, significantly more victims were identified when screening protocols were implemented compared with non-standardized approaches to identifying IPV victims. Conclusion: Overall, there were very limited data addressing the topic of IPV screening and intervention in emergency medical settings, and the quality of the evidence was low. With likely low risk and a significant potential benefit, we conditionally recommend implementation of a screening protocol to identify victims of IPV in adults treated in the emergency department and trauma centers. Although the purpose of screening would ultimately be to provide resources for victims, no studies that assessed distinct interventions met our inclusion criteria. Therefore, we cannot make specific recommendations related to IPV interventions. PROSPERO registration number: CRD42020219517.

Measuring the impact of simulation debriefing on the practices of interprofessional trauma teams using natural language processing.

BACKGROUND: Natural language processing (NLP) may be a tool for automating trauma teamwork assessment in simulated scenarios. METHODS: Using the Trauma Nontechnical Skills Assessment (T-NOTECHS), raters assessed video recordings of trauma teams in simulated pre-debrief (Sim1) and post-debrief (Sim2) trauma resuscitations. We developed codes through directed content analysis and created algorithms capturing teamwork-related discourse through NLP. Using a within subjects pre-post design (n = 150), we compared changes in teams' Sim1 versus Sim2 T-NOTECHS scores and automatically coded discourse to identify which NLP algorithms could identify skills assessed by the T-NOTECHS. RESULTS: Automatically coded behaviors revealed significant post-debrief increases in teams' simulation discourse: Verbalizing Findings, Acknowledging Communication, Directed Communication, Directing Assessment and Role Assignment, and Leader as Hub for Information. CONCLUSIONS: Our results suggest NLP can capture changes in trauma team discourse. These findings have implications for the expedition of team assessment and innovations in real-time feedback when paired with speech-to-text technology.

Evaluation of a standardized protocol for medical management of uncomplicated acute type B aortic dissection.

OBJECTIVES: The goals of medical management for uncomplicated acute type B aortic dissection (TBAD) are to prevent expansion of the false lumen and malperfusion syndrome. This is accomplished with antihypertensive agents, but medication selection and titration are typically provider-dependent. Given the paucity of data on evidence-based management of this population, we hypothesized that a standardized TBAD medical management protocol would reduce resource utilization and costs, without compromising patient outcomes. METHODS: A multidisciplinary team developed a goal-directed protocol to standardize the medical management of uncomplicated acute TBAD, with an emphasis on early initiation of oral medications, weaning of anti-hypertensive infusions, and frequent assessment for de-escalation of care. Implementation was in April 2018. A retrospective review of patients with acute TBAD presenting to our institution from April 2016 to April 2020 was performed. Patients requiring aortic or peripheral intervention were excluded. Included patients were analyzed based on treatment before or after protocol implementation. Patient demographics, systolic blood pressure, presence of acute kidney injury at presentation, length of stay, cost metrics, and 30-day mortality were compared. RESULTS: Thirty-nine patients were included, 21 pre- and 18 post-protocol implementation. Baseline demographics, systolic blood pressure, and presence of acute kidney injury at presentation were similar between the groups. Post-protocol patients had shorter total (8.6 vs 5.5 days; P = .02) and intensive care unit (3.2 vs 1.8 days; P = .002) length of stay. The protocol was associated with significantly decreased total hospital ($38,928 vs $28,066; P = .04), total variable ($23,115 vs $15,627; P = .02), and pharmacy ($5094 vs $1181; P < .001) costs, whereas inpatient care costs ($15,152 vs $11,467; P = .09) trended down. Post-protocol patients required fewer oral antihypertensive agents at discharge (3.8 vs 2.7; P = .005). No significant difference in 30-day mortality was observed. CONCLUSIONS: A goal-directed protocol reduces resource utilization and costs without compromising early mortality rates for patients with uncomplicated acute TBAD. Such a strategy may have broader application in medical management of acute aortic syndromes.

Which hospital-acquired conditions matter the most in trauma? An evidence-based approach for prioritizing trauma program improvement.

BACKGROUND: Prevention of hospital-acquired conditions (HACs) is a focus of trauma center quality improvement. The relative contributions of various HACs to postinjury hospital outcomes are unclear. We sought to quantify and compare the impacts of six HACs on early clinical outcomes and resource utilization in hospitalized trauma patients. METHODS: Adult patients from the 2013 to 2016 American College of Surgeons Trauma Quality Improvement Program Participant Use Data Files who required 5 days or longer of hospitalization and had an Injury Severity Score of 9 or greater were included. Multiple imputation with chained equations was used for observations with missing data. The frequencies of six HACs and five adverse outcomes were determined. Multivariable Poisson regression with log link and robust error variance was used to produce relative risk estimates, adjusting for patient-, hospital-, and injury-related factors. Risk-adjusted population attributable fractions estimates were derived for each HAC-outcome pair, with the adjusted population attributable fraction estimate for a given HAC-outcome pair representing the estimated percentage decrease in adverse outcome that would be expected if exposure to the HAC had been prevented. RESULTS: A total of 529,856 patients requiring 5 days or longer of hospitalization were included. The incidences of HACs were as follows: pneumonia, 5.2%; urinary tract infection, 3.4%; venous thromboembolism, 3.3%; surgical site infection, 1.3%; pressure ulcer, 1.3%; and central line-associated blood stream infection, 0.2%. Pneumonia demonstrated the strongest association with in-hospital outcomes and resource utilization. Prevention of pneumonia in our cohort would have resulted in estimated reductions of the following: 22.1% for end organ dysfunction, 7.8% for mortality, 8.7% for prolonged hospitalization, 7.1% for prolonged intensive care unit stay, and 6.8% for need for mechanical ventilation. The impact of other HACs was comparatively small. CONCLUSION: We describe a method for comparing the contributions of HACs to outcomes of hospitalized trauma patients. Our findings suggest that trauma program improvement efforts should prioritize pneumonia prevention. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Five-Year Outcomes After Implementing a Pain, Agitation, and Delirium Protocol in a Mixed Intensive Care Unit.

Objective: Assess for continued improvements in patient outcomes after updating our institutional sedation and analgesia protocol to include recommendations from the 2013 Society of Critical Care Medicine (SCCM) Pain, Agitation, and Delirium (PAD) guidelines. Methods: Retrospective before-and-after study in a mixed medical/surgical intensive care unit (ICU) at an academic medical center. Mechanically ventilated adults admitted from September 1, 2011 through August 31, 2012 (pre-implementation) and October 1, 2012 through September 30, 2017 (post-implementation) were included. Measurements included number of mechanically ventilated patients, APACHE IV scores, age, type of patient (medical or surgical), admission diagnosis, ICU length of stay (LOS), hospital LOS, ventilator days, number of self-extubations, ICU mortality, ICU standardized mortality ratio, hospital mortality, hospital standardized mortality ratio, medication data including as needed (PRN) analgesic and sedative use, and analgesic and sedative infusions, and institutional savings. Results: Ventilator days (Pre-PAD = 4.0 vs. Year 5 post = 3.2, P < .0001), ICU LOS (Pre-PAD = 4.8 days vs. Year 5 post = 4.1 days, P = .0004) and hospital LOS (Pre-PAD = 14 days vs. Year 5 post = 12 days, P < .0001) decreased after protocol implementation. Hospital standardized mortality ratio (Pre-PAD = 0.69 vs. Year 5 post = 0.66) remained constant; while, APACHE IV scores (Pre-PAD = 77 vs. Year 5 post = 89, P < .0001) and number of intubated patients (Pre-PAD = 1146 vs. Year 5 post = 1468) increased over the study period. Using the decreased ICU and hospital LOS estimates, it is projected the institution saved $4.3 million over the 5 years since implementation. Conclusions: Implementation of an updated PAD protocol in a mixed medical/surgical ICU was associated with a significant decrease in ventilator time, ICU LOS, and hospital LOS without a change in the standardized mortality ratio over a five-year period. These favorable outcomes are associated with a significant cost savings for the institution.

Postoperative Outcomes after Index vs Interval Cholecystectomy for Perforated Cholecystitis.

BACKGROUND: Gallbladder perforation is a known morbid sequela of acute cholecystitis, yet evidence for its optimal management remains conflicting. This study compares outcomes in patients with perforated cholecystitis who underwent cholecystectomy at the time of index hospital admission with those in patients who underwent interval cholecystectomy. STUDY DESIGN: A retrospective analysis was conducted of 654 patients from the American College of Surgeons NSQIP database who underwent cholecystectomy for perforated cholecystitis (2006-2018). Primary outcomes were 30-day postoperative major and minor morbidity, 30-day mortality, and need for prolonged hospitalization. Patient and procedure characteristics and outcomes were compared using Mann-Whitney rank sum test for continuous variables and Pearson chi-square tests for categorical variables. A subset analysis was conducted of patients matched on propensity for undergoing interval cholecystectomy. RESULTS: The 30-day postoperative mortality rate of matched cohort patients undergoing index cholecystectomy was 7% vs 0% of patients undergoing interval cholecystectomy (p = 0.01). The 30-day minor morbidity rates were 2% for index and 8% for interval patients (p = 0.06), and the major morbidity rates were 33% for index and 14% for interval patients (p = 0.003). Of the index patients, 27% required prolonged hospitalization compared with 6% of interval patients (p < 0.001). Results showed similar trends in the unmatched analysis. CONCLUSIONS: Patients who underwent index cholecystectomy had significantly longer postoperative hospitalizations and higher 30-day postoperative major morbidity and mortality. There were no differences in 30-day minor morbidity. Selected patients with perforated cholecystitis can benefit from operative management on an interval, rather than urgent, basis.

Gastric Adenocarcinoma Arising from Heterotopic Pancreas Presenting as Gastric Outlet Obstruction 10 Years after the First Diagnosis.

Gastric heterotopic pancreas is a relatively uncommon incidental finding. On the other hand, the presentation of gastric adenocarcinoma arising from a heterotopic pancreas is rare. This paper reports a case of gastric adenocarcinoma arising from a heterotopic pancreas that presented as a gastric outlet obstruction 10 years after the initial diagnosis of a suspicious submucosal tumor. Endoscopy revealed a pyloric stricture with prepyloric wall thickening and a complete gastric outlet obstruction. Abdominal and pelvic computed tomography exposed a severely distended gastric lumen at the antrum with heterogeneously enhancing circumferential wall thickening in the prepyloric antrum and pylorus. Because conservative treatment was ineffective and a malignancy could not be excluded, laparoscopic subtotal gastrectomy with a gastrojejunostomy was performed for histological confirmation and treatment. The histopathology diagnosis was advanced gastric carcinoma arising from heterotopic pancreatic tissue.

Utilization of a specimen retrieval bag during laparoscopic appendectomy for both uncomplicated and complicated appendicitis is not associated with a decrease in postoperative surgical site infection rates.

BACKGROUND: To determine whether utilization of a retrieval bag during laparoscopic appendectomy for uncomplicated and complicated appendicitis (perforation/abscess) is associated with postoperative surgical site infection rates. METHODS: We studied patients presented in the database of the 2016 Appendectomy-Targeted American College of Surgeons National Surgical Quality Improvement Program who underwent laparoscopic appendectomy for pathology-confirmed appendicitis. The primary predictor variable was intraoperative utilization of a specimen retrieval bag for removal of the appendix from the peritoneal cavity. The primary outcome variable was 30-day postoperative surgical site infection. Logistic regression analysis was used to determine the association between use of a specimen retrieval bag and postoperative surgical site infection rate after adjustment for patient- and disease-related variables. RESULTS: A total of 10,357 patients were included for analysis. Of these procedures, 9,585 (92.6%) included the use of a specimen bag and 772 (7.5%) did not. The 30-day incidence of postoperative surgical site infection was 4.2% in the group in which no bag was used and 3.6% in the group in which a bag was used (adjusted odds ratio of surgical site infection with no bag utilization was 1.15 [95% confidence interval 0.78-1.69; P = .49]). The lack of a statistically significant association between bag utilization and postoperative surgical site infection incidence was also demonstrated for a subgroup of patients with perforated appendicitis. CONCLUSION: Utilization of a retrieval bag during laparoscopic appendectomy is not associated with a statistically significant decrease in postoperative surgical site infection for either uncomplicated or complicated acute appendicitis.

Rib Fracture Location Should Be Evaluated When Predicting Morbidity and Mortality in Trauma Patients.

Rib fractures represent up to 55 per cent of thoracic blunt traumatic injuries and lead to significant mortality and morbidity. The aim of this study is to determine whether not only number but also the location of rib fractures can be used to risk stratify patients. This is a retrospective study of all blunt trauma patients who presented with rib fractures from January 1, 2013 to April 1, 2015 and underwent chest CT. Rib fractures were categorized by location. Primary outcome was mortality, secondary outcomes were total hospital length of stay (LOS), intensive care unit LOS, and disposition. Multivariate regressions were performed to determine whether mortality and morbidity was dependent on the number of rib fractures as related to location. Nine hundred and twenty-nine patients were reviewed, 669 fit inclusion criteria, and 35 patients died. Mean Injury Severity Score (18 ± 10), total number of rib fractures (6 ± 5), and age (54 ± 19) significantly correlated with mortality. LOS correlated with the number of rib fractures (P < 0.001). Flail chest of indeterminate location significantly increased mortality (P = 0.002). Controlling for age, gender, and Injury Severity Score and for every lateral rib fracture, patients were 1.13 times (OR; P = 0.001) more likely to die. Posterior rib fractures only effected patient outcome if the patient has three or more posterior ribs broken and the patient was 45 years of age or older (P = 0.044); these patients were 12 times more likely to die. When evaluating blunt force trauma in patients with rib fractures, it is imperative to look at rib fracture location and not only the number of rib fractures sustained to predict outcomes.

Examining the Impact of Using the SIMPL Application on Feedback in Surgical Education.

OBJECTIVE: The System for Improving and Measuring Procedural Learning (SIMPL) smartphone application allows physicians to provide dictated feedback to surgical residents. The impact of this novel feedback medium on the quality of feedback is unknown. Our objective was to compare the delivery and quality of best-case operative performance feedback given via SIMPL to feedback given in-person. DESIGN: We collected operative performance feedback given both in-person and via SIMPL from surgeons to residents over 6 weeks. Feedback transcripts were coded using Verbal Response Modes speech acts taxonomy to compare the delivery of feedback. We evaluated quality of feedback using a validated resident survey and third-party assessment form. SETTING: University of Wisconsin School of Medicine and Public Health, a large academic medical institution. PARTICIPANTS: Four surgical attendings and 9 general surgery residents. RESULTS: Nineteen SIMPL and 18 in-person feedback encounters were evaluated. Feedback via SIMPL was more directive (containing thoughts, perceptions, evaluations of resident behavior, or advice) and contained more presumptuous utterances (in which the physician reflected on and assessed resident performance or offered suggestions for improvement) than in-person feedback (p = 0.01). The resident survey showed no significant difference between the quality of feedback given via SIMPL and in-person (p = 0.07). The mean score was 47.74 (SD = 3.00) for SIMPL feedback and 45.33 (SD = 4.77) for in-person feedback, with a total possible score of 50. Third-party assessment showed no significant difference between the quality of feedback given via SIMPL and in-person (p = 0.486). The mean score was 23.40 (SD = 3.75) for SIMPL feedback and 22.25 (SD = 5.94) for in-person feedback, with a total possible score of 30. CONCLUSIONS: Although feedback given via SIMPL was more direct and based on the attendings' perspectives, the quality of the feedback did not differ significantly. Use of the dictation feature of SIMPL to deliver resident operative performance feedback is a reasonable alternative to in-person feedback.

Does a Written Tool to Guide Structured Debriefing Improve Discourse? Implications for Interprofessional Team Simulation.

PURPOSE: Timely debriefing following a simulated event supports learners in critically reflecting on their performance and areas for improvement. Content of debriefing has been shown to affect learner skill acquisition and retention. The use of good judgment statements from debriefing facilitators is considered superior to judgmental or nonjudgmental statements. Ideally, the majority of the conversation will consist of learner self-reflection and focused facilitation rather than directive performance feedback. We hypothesized that the introduction of a written tool to help facilitate high-quality debriefing techniques could improve the ratio of judgmental, nonjudgmental, and good judgment statements from facilitators, as well as shift the percentage of talk in the debrief away from directive performance feedback and toward self-assessment and focused facilitation. METHODS: The University of Wisconsin Joint Trauma Simulation Program is an interdisciplinary project to improve quality of trauma care through simulation. Simulations use teams of five trauma trainees: two surgery residents, an emergency medicine resident, and two nurses. Three faculty members conducted the scenarios and debriefings. Debriefings were video recorded. Videos were transcribed and dialogue analyzed according to the teaching/learning strategy used in each turn of talk. Discourse was coded into three categories: (1) learner self-assessment; (2) focused facilitation; and (3) directive performance feedback. Each facilitation statement was coded as either (1) judgmental; (2) nonjudgmental, or (3) good judgment. The TEAM Debrief Tool is a written guide designed to help facilitators adhere to best practices, with example structure and phrasing, similar to the Promoting Excellence and Reflective Learning in Simulation tool. Pre- and post-implementation analysis was completed to assess for efficacy of the tool. RESULTS: Seven videos before the implementation of the tool and seven videos after implementation were analyzed. The percentage of learner self-assessment increased significantly with tool use (7.23% vs 24.99%, p = 0.00004), and directive performance feedback decreased significantly (56.13% vs 32.75%, p = 0.0042). There was no significant change in the percentage of talk using focused facilitation. After implementation of the tool, there was a significant decrease in use of the nonjudgmental debriefing style (60.63% vs 37.31%, p = 0.00017), and a significant increase in the use of good judgment debriefing (38.77% vs 59.82%, p = 0.00038). There was also a slight increase in judgmental debriefing (0.60% vs 2.87%, p = 0.0027). CONCLUSIONS: The discourse in our interprofessional trauma simulation debriefings unaided by a written debriefing tool skewed heavily toward direct performance feedback, with a preponderance of nonjudgmental statements. After introduction of the tool, dialogue shifted significantly toward learner self-assessment, and there was a large increase in utilization of debriefing with good judgment. This shift toward higher quality debriefing styles demonstrates the utility of such a tool in the debriefing of interprofessional simulations.

Primary prevention of contact sports-related concussions in amateur athletes: a systematic review from the Eastern Association for the Surgery of Trauma.

BACKGROUND: Awareness of the magnitude of contact sports-related concussions has risen exponentially in recent years. Our objective is to conduct a prospectively registered systematic review of the scientific evidence regarding interventions to prevent contact sports-related concussions. METHODS: Using the Grading of Recommendations Assessment, Development, and Evaluation methodology, we performed a systematic review of the literature to answer seven population, intervention, comparator, and outcomes (PICO) questions regarding concussion education, head protective equipment, rules prohibiting high-risk activity and neck strengthening exercise for prevention of contact sports-related concussion in pediatric and adult amateur athletes. A query of MEDLINE, PubMed, Scopus, Cumulative Index of Nursing and Allied Health Literature, and Embase was performed. Letters to the editor, case reports, book chapters, and review articles were excluded, and all articles reviewed were written in English. RESULTS: Thirty-one studies met the inclusion criteria and were applicable to our PICO questions. Conditional recommendations are made supporting preventive interventions concussion education and rules prohibiting high-risk activity for both pediatric and adult amateur athletes and neck strengthening exercise in adult amateur athletes. Strong recommendations are supported for head protective equipment in both pediatric and adult amateur athletes. Strong recommendations regarding newer football helmet technology in adult amateur athletes and rules governing the implementation of body-checking in youth ice hockey are supported. CONCLUSION: Despite increasing scientific attention to sports-related concussion, studies evaluating preventive interventions remain relatively sparse. This systematic review serves as a call to focus research on primary prevention strategies for sports-related concussion. LEVEL OF EVIDENCE: IV. PROSPERO REGISTRATION NUMBER: #42016043019.

Socioeconomics affecting quality outcomes in Asian trauma patients within the United States.

INTRODUCTION: Asian-Americans and Pacific Islanders are often considered as a uniform group when examining race in health outcomes. However, the generally favorable economic outcomes in this group belie significant socioeconomic variance between its heterogeneous subgroups. This study evaluates the impact of socioeconomic status on the health outcomes of Asian trauma patients. METHODS: From 2012 to 2015, 52,704 Asians who presented to trauma centers were registered with the National Trauma Data Bank with known disposition. Chi2 and multivariate logistic regression analysis for mortality were performed controlling for age, gender, comorbidities, injury severity, insurance, race, and ethnicity. Negative binomial regression analysis with margins for length of stay (LOS) was performed. Subgroup analysis was done for polytrauma (Injury Severity Score >15, n = 14,787). RESULTS: Asians represent 1.8% of the trauma population. Uninsured Asians were 1.9 times more likely to die than privately insured Asians (P < 0.001). Medicare patients were 1.8 times more likely to die (P < 0.001). Eighty-one Asians identified themselves as Hispanic, and there was no significant difference in their mortality or LOS for this group (P = 0.06, P = 0.18). Bleeding disorders, diabetes, cirrhosis, hypertension, respiratory disease, cancer, esophageal varices, angina, cerebrovascular accident, and dependent health care before trauma all individually affected mortality and were controlled for in this model (P < 0.05). LOS was 1.7 d longer in Medicaid patients (2.2 d with polytrauma) and 1.1 d longer in workman's compensation patients (2.1 d with polytrauma). Uninsured had a shorter LOS (P < 0.005). Asian males with polytrauma stayed 1.6 d longer than females (P < 0.001), and age did not affect LOS for this group. CONCLUSIONS: Noteworthy socioeconomic disparities influence Asian trauma patients independent of their race. Mortality is affected by insurance status, despite controlling for injury severity and comorbidities.

Socioeconomic disparities in the thoracic trauma population.

BACKGROUND: Health-care disparities based on socioeconomic status have been well documented in the trauma literature; however, there is a paucity of data on how these factors affect outcomes in patients experiencing severe thoracic trauma. This study aims to identify the effect of insurance status and race on patient mortality and disposition after thoracic trauma. METHODS: The National Trauma Data Bank was queried from 2007 to 2012 for patients with sternal fractures, rib fractures, and flailed chest. Demographics data were examined for the cohort based on insurance status. Univariate and multivariate logistic regression models were used, controlling for patient comorbidities, age, injury severity score, and associated injuries, to determine the impact of race and insurance status on length of stay, mortality, and discharge disposition. RESULTS: A total of 152,655 thoracic traumas were included in our analysis. As compared to privately insured patients, uninsured patients with thoracic trauma were 1.9 times more likely to die (odds ratio [OR]: 1.91, confidence interval [CI]: 1.76-2.09) and 4.6 times more likely to leave against medical advice (OR: 4.61, CI: 3.14-6.79). When compared to Caucasians, Hispanics had slightly higher in-hospital mortality (OR: 1.14, CI: 1.02-1.27), but there was no survival difference seen in black patients (OR: 0.95, CI: 0.86-1.05). CONCLUSIONS: Insurance status appears to have a more significant effect on thoracic trauma patient outcomes than race, but substantial socioeconomic disparities were seen in this patient population. Further studies are needed to show reproducibility of our findings and to investigate the impact of universal health care and expansion of insurance availability on thoracic trauma outcomes. LEVEL OF EVIDENCE: Level 3, economic/decision.

Using epistemic network analysis to identify targets for educational interventions in trauma team communication.

BACKGROUND: Epistemic Network Analysis (ENA) is a technique for modeling and comparing the structure of connections between elements in coded data. We hypothesized that connections among team discourse elements as modeled by ENA would predict the quality of team performance in trauma simulation. METHODS: The Modified Non-technical Skills Scale for Trauma (T-NOTECHS) was used to score a simulation-based trauma team resuscitation. Sixteen teams of 5 trainees participated. Dialogue was coded using Verbal Response Modes (VRM), a speech classification system. ENA was used to model the connections between VRM codes. ENA models of teams with lesser T-NOTECHS scores (n = 9, mean = 16.98, standard deviation [SD] = 1.45) were compared with models of teams with greater T-NOTECHS scores (n = 7, mean = 21.02, SD = 1.09). RESULTS: Teams had different patterns of connections among VRM speech form codes with regard to connections among questions and edifications (meanHIGH = 0.115, meanLOW = -0.089; t = 2.21; P = .046, Cohen d = 1.021). Greater-scoring groups had stronger connections between stating information and providing acknowledgments, confirmation, or advising. Lesser-scoring groups had a stronger connection between asking questions and stating information. Discourse data suggest that this pattern reflected increased uncertainty. Lesser-scoring groups also had stronger connections from edifications to disclosures (revealing thoughts, feelings, and intentions) and interpretations (explaining, judging, and evaluating the behavior of others). CONCLUSION: ENA is a novel and valid method to assess communication among trauma teams. Differences in communication among higher- and lower-performing teams appear to result from the ways teams use questions. ENA allowed us to identify targets for improvement related to the use of questions and stating information by team members.

Barriers to Hospice Care in Trauma Patients: The Disparities in End-of-Life Care.

INTRODUCTION: End-of-life and palliative care are important aspects of trauma care and are not well defined. This analysis evaluates the racial and socioeconomic disparities in terms of utilization of hospice services for critically ill trauma patients. METHODS: Trauma patients ≥15 years old from 2012 to 2015 were queried from the National Trauma Databank. Chi-square and multivariate logistic regression analyses for disposition to hospice were performed after controlling for age, gender, comorbidities, injury severity, insurance, race, and ethnicity. Negative binomial regression analysis with margins for length of stay (LOS) was calculated for all patients discharged to hospice. RESULTS: Chi-square analysis of 2 966 444 patient's transition to hospice found patients with cardiac disease, bleeding and psychiatric disorders, chemotherapy, cancer, diabetes, cirrhosis, respiratory disease, renal failure, cirrhosis, and cerebrovascular accident (CVA) affected transfer ( P < .0001). Logistic regression analysis after controlling for covariates showed uninsured patients were discharged to hospice significantly less than insured patients (odds ratio [OR]: 0.71; P < .0001). Asian, African American, and Hispanic patients all received less hospice care than Caucasian patients (OR: 0.65, 0.60, 0.73; P < .0001). Negative binomial regression analysis with margins for LOS showed Medicare patients were transferred to hospice 1.2 days sooner than insured patients while uninsured patients remained in the hospital 1.6 days longer ( P < .001). When compare to Caucasians, African Americans patients stayed 3.7 days longer in the hospital and Hispanics 2.4 days longer prior to transfer to hospice ( P < .0001). In all patients with polytrauma, African Americans stayed 4.9 days longer and Hispanics 2.3 days longer as compared to Caucasians ( P < .0001). CONCLUSIONS: Race and ethnicity are independent predictors of a trauma patient's transition to hospice care and significantly affect LOS. Our data demonstrate prominent racial and socioeconomic disparities exist, with uninsured and minority patients being less likely to receive hospice services and having a delay in transition to hospice care when compared to their insured Caucasian counterparts.