Data-Driven Blood Transfusion Thresholds for Severely Injured Patients During Blood Shortages.

INTRODUCTION: Crises like the COVID-19 pandemic create blood product shortages. Patients requiring transfusions are placed at risk and institutions may need to judiciously administer blood during massive blood transfusions protocols (MTP). The purpose of this study is to provide data-driven guidance for the modification of MTP when the blood supply is severely limited. METHODS: This is a retrospective cohort study of 47 Level I and II trauma centers (TC) within a single healthcare system whose patients received MTP from 2017 to 2019. All TC used a unifying MTP protocol for balanced blood product transfusions. The primary outcome was mortality as a function of volume of blood transfused and age. Hemoglobin thresholds and measures of futility were also estimated. Risk-adjusted analyses were performed using multivariable and hierarchical regression to account for confounders and hospital variation. RESULTS: Proposed MTP maximum volume thresholds for three age groupings are as follows: 60 units for ages 16-30 y, 48 units for ages 31-55 y, and 24 units for >55 y. The range of mortality under the transfusion threshold was 30%-36% but doubled to 67-77% when the threshold was exceeded. Hemoglobin concentration differences relative to survival were clinically nonsignificant. Prehospital measures of futility were prehospital cardiac arrest and nonreactive pupils. In hospital risk factors of futility were mid-line shift on brain CT and cardiopulmonary arrest. CONCLUSIONS: Establishing MTP threshold practices under blood shortage conditions, such as the COVID pandemic, could sustain blood availability by following relative thresholds for MTP use according to age groups and key risk factors.

Factors Influencing US Physician and Surgeon Suicide Rates 2003 to 2017: Analysis of the CDC-National Violent Death Reporting System.

BACKGROUND AND OBJECTIVES: With the rate of physician suicide increasing, more research is needed to implement adequate prevention interventions. This study aims to identify trends and patterns in physician/surgeon suicide and the key factors influencing physician suicide. We hope such information can highlight areas for targeted interventions to decrease physician suicide. METHODS: Review of Centers for Disease Control and Preventions National Violent Death Reporting System (NVDRS) for 2003 to 2017 of physician and dentists dying by suicide. Twenty-eight medical, surgical, and dental specialties were included. RESULTS: Nine hundred five reported suicides were reviewed. Physician suicides increased from 2003 to 2017. Majority surgeons' suicides were middle-aged, White males. Orthopedic surgeons had the highest prevalence of suicide among surgical fields (28.2%). Black/African American surgeons were 56% less likely [odds ratio (OR) = 0.44, 95% confidence interval (CI): 0.06-3.16] and Asian/Pacific Islander were 438% more likely (OR = 5.38, 95% CI: 2.13-13.56) to die by suicide. Surgeons were 362% more likely to have a history of a mental disorder (OR = 4.62, 95% CI: 2.71-7.85), were 139% more likely to use alcohol (OR = 2.39, 95% CI: 1.36-4.21), and were 289% more likely to have experienced civil/legal issues (OR = 3.89, 95% CI: 1.36-11.11). CONCLUSIONS: The prevalence of physician suicide increased over the 2003 to 2017 time-frame with over a third of deaths occurring from 2015 to 2017. Among surgeons, orthopedics has the highest prevalence of reported suicide.Risk factors for surgeon suicide include Asian/Pacific Islander race/ethnicity, older age, history of mental disorder, alcohol use, and civil/legal issues.

The Effects of COVID-19 Pandemic on Trauma Registry and Performance Improvement Operations and Workforce Nationwide: A Survey of Trauma Center Association of America Members.

BACKGROUND: Trauma Centers integrate Trauma Registrars and Performance Improvement Nurses to drive quality care. Delays in their duties could have negative impacts on outcomes and performance. We aim to investigate the impact of COVID-19 pandemic on Trauma Center operations by assessing performance of trauma registry and performance improvement processes across the United States. METHODS: A cross-sectional study was performed utilizing data from two anonymous questionnaires distributed to Trauma Center Association of America members. Descriptive statistics, Fisher's Exact Test, and multivariable logistic regression were performed with statistical significance defined as P < 0.05. RESULTS: Of 90.2% (83) of Trauma Registrars and 85.9% (67) of Performance Improvement personnel reported that their Trauma Centers have treated COVID-19 patients. Among trauma registrars, respondents did not significantly differ in the current status of completing registry cases (P> 0.05), during COVID-19 compared to prior (P> 0.05), or adjusted odds of COVID-19 delaying completion of entries (P> 0.05). Having >2 Performance Improvement Nurses was significantly associated with improved performance during the COVID-19 pandemic (P= 0.03) whereas working at a Trauma Center which treats adults-only or mixed patient population (adult and pediatric) was associated with being 1-3 months behind in closing of performance improvement cases (P= 0.02). CONCLUSIONS: The negative impact of COVID-19 on Trauma Registrars and Performance Improvement Nurses has been minimal. Adequate staffing/experience seem to mitigate delays and decreased performance. Implementation of expanded staffing, improved training, and evidenced-based revision of Trauma Center logistics may help mitigate future disruptions relating to COVID-19 and allow Trauma Centers to recover and improve their operations.

Undertriage of Geriatric Trauma Patients in Florida.

INTRODUCTION: Elderly undertriage rates are estimated up to 55% in the United States. This study examined risk factors for undertriage among hospitalized trauma patients in a state with high volumes of geriatric trauma patients. MATERIALS AND METHODS: This is a population-based retrospective cohort study of 62,557 patients admitted to Florida hospitals between 2016 and 2018 from the Agency for Healthcare Administration database. Severely injured trauma patients were defined by American College of Surgeons definitions and an International Classification of Disease Injury Severity Score <0.85. Undertriage was defined as definitive care of these severely injured patients at any Florida hospital other than a state-designated trauma center (TC). Univariate analyses were used to identify risk factors associated with inpatient mortality and undertriage. Multiple variable regression was used to estimate risk-adjusted odds of mortality after admission to either a designated or nondesignated TC. RESULTS: Undertriaged patients were more likely to have isolated traumatic brain injuries, lower International Classification of Disease Injury Severity Scores, multiple comorbidities, and older age. Trauma patients aged 65 and older were more than twice as likely to be undertriaged (34% versus 15.7%, P < 0.0001). Undertriaged patients of all ages were also more likely to suffer from pneumonia, urinary tract infection, arrhythmias, and sepsis. After risk adjustment, severely injured trauma patients admitted to non-TC were also more likely to be at risk for mortality (adjusted odds ratio, 1.27; 95% confidence interval, 1.17-1.38). CONCLUSIONS: Age and multiple comorbidities are significant predictors of mortality among undertriage of trauma patients. As a result, trauma triage guidelines should account for high-risk geriatric trauma patients who would benefit from definitive treatment at designated TCs.

A Nationwide Analysis of Popliteal Vascular Injuries and Outcomes by Hospital Teaching Status.

BACKGROUND: Popliteal artery injuries are the second most common arterial injuries below the inguinal ligament. We aimed to compare outcomes in patients with popliteal injuries by hospital teaching status utilizing the National Trauma Data Bank Research Data Set (NTDB-RDS) 2013-2016. METHODS: Four-year retrospective study using the NTDB-RDS, evaluating popliteal vascular injuries. Patients were divided by popliteal injury type and teaching status into; nonteaching hospital (NTH), community teaching (CTH), or University teaching (UTH). Demographics and outcome measures were compared between groups. Risk-adjusted mortality odds ratios (ORs) were calculated. Significance was defined as P < 0.05. RESULTS: 3,577,168 patients were in the NTDB-RDS, with 1120 having a popliteal injury, (incidence = 0.03%). There was no significant difference in the amputation rate between patients treated in NTHs, CTHs, or UTHs (P > 0.05). There was no significant difference in the raw mortality rate between patients treated in NTHs, CTHs, or UTHs. After adjusting for confounders; compared to NTH, the odds ratio for mortality for popliteal artery injuries in the CTH group was significantly higher (OR: 15.95, 95% CI: 1.19-213.84), and for the UTH group the mortality was also significantly higher (OR: 5.74, 95% CI: 0.45-72.95). CONCLUSIONS: The incidence of popliteal vascular injuries was 0.03% for 2013-2016. Patients with popliteal artery injuries treated at community teaching hospitals have a 16 times higher risk of mortality and at university teaching hospitals have a 5.7 times higher risk of mortality than patients treated at nonteaching hospitals.

The Morbidity and Mortality Assessment Tool (MMAT): Design and Proof of Concept.

BACKGROUND: Morbidity and Mortality Conference (MMC) is a traditional quality assessment tool among surgical residencies to evaluate complications within their care and to integrate and educate best practices. Unfortunately, it is difficult to validate and measure loop closure as a result of MMC. This may result in repeating past mistakes or worse, becoming a meeting of anecdotal experiences. The goal of this study is to present results from a morbidity and mortality assessment tool (MMAT) which provides a means of measuring and tracking factors related to those surgical complications discussed within the MMC. MATERIALS AND METHODS: Three years of MMC presentations were organized into a database and further divided and organized into variables which included case by the class year of the presenting resident, service line, month the case was presented, and potential contributing factors. Contributing factors considered for each case were categorized as: Systems-Based, Direct Patient Care, and Interpersonal Communication. Contributing factors were assigned to cases by a review committee consisting of residents and faculty members. RESULTS: The lack of knowledge, technical error, lack of experience, lack of supervision, failure to communicate with team members were present in greater than 10% of the presented cases. There was a "July Effect" in the Trauma service, where there was a statistically significant difference between the percentage of cases presented that involved Failure to Communicate errors when compared with the remainder of the year. CONCLUSIONS: MMAT allows longitudinal collection of data from each MMC to recognize patterns that facilitate improvements in systems of care and institutional memory.

Impacts and challenges of the COVID-19 pandemic on emergency medicine physicians in the United States.

BACKGROUND: Emergency medicine (EM) physicians have been on the front line of the COVID-19 pandemic. This study aims to determine the impact of COVID-19 pandemic and other related factors such as resource availability and institutional support on well-being, burnout and job-satisfaction of EM physicians in the United States. METHODS: A cross-sectional survey study of EM physicians was conducted through the Emergency Medicine Practice Research Network of the ACEP. The survey focused on resource adequacy, institutional support, well-being, and burnout. A total of 890 EM physicians were invited to participate. Both descriptive and risk adjusted, and multivariate regressions were performed with a statistical significance defined as p < 0.05. RESULTS: EM physicians' response rate was 18.7% (166) from 39 states. Burnout was reported by 74.7% (124) since the start of the pandemic. Factors contributing included work-related emotional strain and anxiety, isolation from family and friends, and increased workload. Those reporting inadequate resources felt ignored by their institutions (p < 0.0001). Physicians who felt there was inadequate institutional support, were also dissatisfied with patient care resources (p = 0.001). Physicians expressing job dissatisfaction were more likely to report feelings of burnout (p = 0.001). CONCLUSION: EM physicians face greater burnout in the COVID-19 pandemic. This may be compounded by resource scarcity, psychological stress, isolation, and job dissatisfaction. Many of the survey respondents reported inadequate mental health services and resources. The findings of this study may help identify solutions to mitigate these issues.

USMLE Scores and Clinical Rotation Role in Predicting ABSITE Performance Among Surgery Interns.

BACKGROUND: The American Board of Surgery In-training Examination (ABSITE) is an important marker of medical knowledge. It is unclear what factors predict or improve these scores. We evaluated demographics, United States Medical Licensing Examination (USMLE) step 1 and 2 scores, and surgical rotations during the intern year to determine if there were any correlations with the ABSITE performance. METHODS: This was a multicenter retrospective review during a 6-y period, investigating the correlation and association of demographics, USMLE scores, and types of rotations on the ABSITE percentile score of interns. Demographics included age, gender, race/ethnicity, U.S. versus international/foreign medical graduate for stratified analyses. Descriptive analysis was performed with ANOVA, correlation was evaluated with 95% confidence interval, and significance was defined as P < 0.05. RESULTS: Complete records obtained on 89 interns from six different general surgery programs over 6 y revealed that there was a significant correlation between USMLE 1 and 2 with the ABSITE. USMLE 2 correlation was the strongest (r = 0.44, 95% confidence interval = [0.25-0.60], P < 0.05). There was a significant difference in ABSITE performance (mean score difference of 17.3 percentile, P = 0.01) of interns who had an intensive care unit rotation before examination. Other surgical rotations were not associated with an ABSITE difference. Demographic factors such as age, gender, race/ethnicity, or medical graduate background status were not associated with ABSITE scores. CONCLUSIONS: USMLE step 2 scores had a higher correlation with intern ABSITE performance. An intensive care unit rotation before taking the ABSITE was associated with a significant difference in their percentile scores. Demographic factors were not correlated with ABSITE performance.

Protective effect of Lactobacillus fermentum CQPC04 on dextran sulfate sodium-induced colitis in mice is associated with modulation of the nuclear factor-κB signaling pathway.

Colitis severely affects the quality of life of patients, and lactic acid bacteria have been reported to be able to improve or treat colitis. In this study, we selected a strain of Lactobacillus fermentum (CQPC04) with good resistance in vitro to evaluate its effect on improvement in mice with dextran sulfate sodium (DSS)-induced colitis. We analyzed the effects of L. fermentum CQPC04 on mice with colitis macroscopically via colon length and histopathology. We also used conventional biochemical and ELISA kits, real-time quantitative PCR (RT-qPCR), and Western blotting to analyze microscopically the effects of L. fermentum CQPC04 on related oxidant indices and pro- and anti-inflammatory cytokines in serum and colon tissue of mice. The results indicated that L. fermentum CQPC04 notably increased colon length and ameliorated pathological damage of colon tissue in colitic mice. Serum indices showed that L. fermentum CQPC04 increased the enzyme activity of total superoxide dismutase (T-SOD) and catalase (CAT) and decreased the content of malondialdehyde (MDA) and the activity of myeloperoxidase (MPO). In addition, it inhibited the release of the pro-inflammatory cytokines tumor necrosis factor-α (TNF-α), IFN-γ, IL-1ß, IL-6, and IL-12, and increased the release of the anti-inflammatory cytokine IL-10 in serum. The RT-qPCR experiments confirmed that L. fermentum CQPC04 downregulated the expression of pro-inflammatory cytokine nuclear factor-κB-p65 (NF-κBp65), NF-κB inhibitor-α (IκB-α), TNF-α, IFN-γ, IL-1ß, IL-6, cyclooxygenase 2 (COX-2), and inducible nitric oxide synthase (iNOS), and upregulated the expression of IL-10 in colon tissue. Western blot analysis indicated that L. fermentum CQPC04 significantly reduced expression of NF-κBp65, TNF-α, IL-1ß, COX-2, and iNOS in mouse colon tissues, and increased expression of IκB-α and superoxide dismutase 2 (SOD2). Thus, L. fermentum CQPC04 could effectively alleviate the symptoms of DSS-induced colitis mice and is a potential probiotic for human experiments.

Benchmarking statewide trauma mortality using Agency for Healthcare Research and Quality's patient safety indicators.

BACKGROUND: Improving clinical outcomes of trauma patients is a challenging problem at a statewide level, particularly if data from the state's registry are not publicly available. Promotion of optimal care throughout the state is not possible unless clinical benchmarks are available for comparison. Using publicly available administrative data from the State Department of Health and the Agency for Healthcare Research and Quality (AHRQ) patient safety indicators (PSIs), we sought to create a statewide method for benchmarking trauma mortality and at the same time also identifying a pattern of unique complications that have an independent influence on mortality. METHODS: Data for this study were obtained from State of Florida Agency for Health Care Administration. Adult trauma patients were identified as having International Classification of Disease ninth edition codes defined by the state. Multivariate logistic regression was used to create a predictive inpatient expected mortality model. The expected value of PSIs was created using the multivariate model and their beta coefficients provided by the AHRQ. Case-mix adjusted mortality results were reported as observed to expected (O/E) ratios to examine mortality, PSIs, failure to prevent complications, and failure to rescue from death. RESULTS: There were 50,596 trauma patients evaluated during the study period. The overall fit of the expected mortality model was very strong at a c-statistic of 0.93. Twelve of 25 trauma centers had O/E ratios <1 or better than expected. Nine statewide PSIs had failure to prevent O/E ratios higher than expected. Five statewide PSIs had failure to rescue O/E ratios higher than expected. The PSI that had the strongest influence on trauma mortality for the state was PSI no. 9 or perioperative hemorrhage or hematoma. Mortality could be further substratified by PSI complications at the hospital level. CONCLUSIONS: AHRQ PSIs can have an integral role in an adjusted benchmarking method that screens at risk trauma centers in the state for higher than expected mortality. Stratifying mortality based on failure to prevent PSIs may identify areas of needed improvement at a statewide level.

A predictive nomogram-based model for lower extremity compartment syndrome after trauma in the United States: a retrospective case-control study.

Purpose: The aim of this study was to utilize the American College of Surgeons Trauma Quality Improvement Program (TQIP) database to identify risk factors associated with developing acute compartment syndrome (ACS) following lower extremity fractures. Specifically, a nomogram of variables was constructed in order to propose a risk calculator for ACS following lower extremity trauma. Methods: A large retrospective case-control study was conducted using the TQIP database to identify risk factors associated with developing ACS following lower extremity fractures. Multivariable regression was used to identify significant risk factors and subsequently, these variables were implemented in a nomogram to develop a predictive model for developing ACS. Results: Novel risk factors identified include venous thromboembolism prophylaxis type particularly unfractionated heparin (odds ratio [OR], 2.67; 95% confidence interval [CI], 2.33-3.05; P<0.001), blood product transfusions (blood per unit: OR 1.13 [95% CI, 1.09-1.18], P<0.001; platelets per unit: OR 1.16 [95% CI, 1.09-1.24], P<0.001; cryoprecipitate per unit: OR 1.13 [95% CI, 1.09-1.22], P=0.003). Conclusions: This study provides evidence to believe that heparin use and blood product transfusions may be additional risk factors to evaluate when considering methods of risk stratification of lower extremity ACS. We propose a risk calculator using previously elucidated risk factors, as well as the risk factors demonstrated in this study. Our nomogram-based risk calculator is a tool that will aid in screening for high-risk patients for ACS and help in clinical decision-making.

Development of a genomic metric that can be rapidly used to predict clinical outcome in severely injured trauma patients.

OBJECTIVE: Many patients have complicated recoveries following severe trauma due to the development of organ injury. Physiological and anatomical prognosticators have had limited success in predicting clinical trajectories. We report on the development and retrospective validation of a simple genomic composite score that can be rapidly used to predict clinical outcomes. DESIGN: Retrospective cohort study. SETTING: Multi-institutional level 1 trauma centers. PATIENTS: Data were collected from 167 severely traumatized (injury severity score >15) adult (18-55 yr) patients. METHODS: Microarray-derived genomic data obtained from 167 severely traumatized patients over 28 days were assessed for differences in messenger RNA abundance among individuals with different clinical trajectories. Once a set of genes was identified based on differences in expression over the entire study period, messenger RNA abundance from these subjects obtained in the first 24 hours was analyzed in a blinded fashion using a rapid multiplex platform, and genomic data reduced to a single metric. RESULTS: From the existing genomic dataset, we identified 63 genes whose leukocyte expression differed between an uncomplicated and complicated clinical outcome over 28 days. Using a multiplex approach that can quantitate messenger RNA abundance in less than 12 hours, we reassessed total messenger RNA abundance from the first 24 hours after trauma and reduced the genomic data to a single composite score using the difference from reference. This composite score showed good discriminatory capacity to distinguish patients with a complicated outcome (area under a receiver-operator curve, 0.811; p <0.001). This was significantly better than the predictive power of either Acute Physiology and Chronic Health Evaluation II or new injury severity score scoring systems. CONCLUSIONS: A rapid genomic composite score obtained in the first 24 hours after trauma can retrospectively identify trauma patients who are likely to develop complicated clinical trajectories. A novel platform is described in which this genomic score can be obtained within 12 hours of blood collection, making it available for clinical decision making.

Outcomes After Definitive Surgery for Nonagenarians with Isolated Hip Fractures within 24 hours of Admission.

BACKGROUND: Isolated hip fractures are a common orthopedic injury in the elderly population. Estimates are that there will be over 21 million hip fractures globally by 2050. Current recommendations are early operative fixation within 48 hours. Despite evidence showing that fixation of hip fractures within 24 hours is beneficial in the elderly population, the effect this has on the nonagenarian population has yet to be examined. METHODS: This is a single institution retrospective cohort study examining isolated hip fractures from 2014 to 2020 from an American College of Surgeons verified trauma center. Patients ≥65 years old with IHF were included. A total number of 1150 isolated hip fracture patients 65 years or older were included in this study. Three cohorts were examined: (1) patients ≥90 years old; (2) patients 65-89 years old; and (3) patients stratified by ≥90 vs 65-75 years old and ≥90 vs 75-89 years old. Patients were then sub stratified by timing of surgery whether it was performed ≤24 hours or >24 hours. The primary outcome was inpatient mortality. RESULTS: Nonagenarians who had delayed surgery had higher mortality rates compared to nonagenarians with early surgery (15.2% vs 4.2%; P = .02). Patients aged 65-75 had higher complication rates with delayed surgery (12.9% vs 4.1%; P = .01) as did those aged 76-89 (9.0% vs 3.2%, P = .004). DISCUSSION: Early surgical intervention of isolated hip fractures in the nonagenarian population within 24 hours is associated with good clinical outcomes as well as a lower inpatient mortality that approaches significance.

Hospital Volume of Emergency General Surgery and its Impact on Inpatient Mortality for Geriatric Patients: Analysis From 3994 Hospitals.

BACKGROUND: Previous investigations have shown a positive association between hospital volume of operations and clinical outcomes. However, it is unclear whether such relationships also apply to emergency surgery. We sought to examine the association between hospital case volume and inpatient mortality for 7 common emergency general surgery (EGS) operations among geriatric patients. METHODS: This is a population based retrospective cohort study using the Centers of Medicare and Medicaid Services (CMS) Limited Dataset Files (LDS) from 2011 to 2013. The 7 most common emergency surgeries included (1) partial colectomy, (2) small-bowel resection (SBR), (3) cholecystectomy, (4) appendectomy, (5) lysis of adhesions (LOA), (6) operative management of peptic ulcer disease (PUD), and (7) laparotomy with the primary outcome being inpatient mortality. Risk-adjusted inpatient mortality was plotted against operative volume. Subsequently an operative volume threshold was calculated using a best fit regression method. Based on these estimates, high- and low-volume hospitals were compared to examine significance of outcomes. Significance was defined as P-value < .05. RESULTS: The final cohort comprised of 414 779 patients from 3994 hospitals. The standardized mortality ratio (SMR) for high-volume centers were lower in 6 out of 8 surgeries examined. Small-bowel resection and partial colectomy operations had a significant decrease in mortality based on a volume threshold. CONCLUSION: We observed decreased mortality with higher surgical volume for small-bowel resection and partial colectomy operations. Such differences may be related to practice patterns during the perioperative period, as complications related to the perioperative care were significantly lower for high-volume centers.

Operative Confidence Among U.S General Surgery Residents.

BACKGROUND: General surgery residents (GSRs) must develop operative autonomy skills to practice independently after graduation. We aim to investigate perceived confidence and operative autonomy of GSR physicians in order to identify and address influential factors. METHODS: A 28-question anonymous online survey was distributed to 23 United States general surgery residency programs. Multivariable logistic regression was used for calculating the adjusted odds ratio (aOR) for binary outcomes. Significance was defined as P-values ≤ .05 or 95% confidence intervals (CIs) >1 or <1. RESULTS: There were 120/558 (21.5%) GSR respondents. General surgery residents with >200 overall operative case volume reported significantly higher confidence with minor cases (P = .05) and major cases (P = .02). General surgery residents that performed both minor and major surgeries reported higher confidence with minor cases at 85.7% compared to GSRs that performed mostly minor surgeries (64.7%) and mostly major surgeries (62.5%). General surgery residents who performed >50 minor surgeries during their PGY 1 and 2 were less confident with major cases than GSRs who performed <50 minor surgeries (aOR: 19.98, 95% CI: 1.26, 318). General surgery residents from community teaching hospitals reported higher confidence with major and minor cases than GSRs from university teaching hospitals and combined programs. CONCLUSION: Increased case volume, predominant case type, early surgical experience during PGY 1 and 2 years, and training at community teaching hospitals were identified as the most important factors that positively influence perception of operative confidence and autonomy among GSRs. These may have important implications in the development of future surgeons.

Race and Insurance Status Disparities in Post-discharge Disposition After Hospitalization for Major Trauma.

BACKGROUND: Investigations detailing predictive measures of hospital disposition after traumatic injury are scarce. We aim to examine the discharge practices among trauma centers in the US and to identify factors that may influence post-hospital disposition. METHODS: A retrospective analysis of trauma patients using the American College of Surgeons-Trauma Quality Improvement Program dataset from 2007-2017. Primary study outcome was hospital disposition (including long term care facility [LTC], others). Secondary outcomes included: Intensive Care Unit (ICU)-length of stay (LOS), complications, others). RESULTS: 6 899 538 patients were analyzed. Odds of LTC discharge was significantly higher for Black patients (aOR = 1.30, 95% CI:1.24-1.37), abbreviated injury score (AIS) ≥3 (aOR = 4.22, 95% CI: 4.05-4.39), and higher injury severity score (ISS) (aOR = 9.41, 95% CI:9.03-9.80). Significantly more self-pay patients were discharged home compared to other insurance types (P < .0001). Significantly longer hospital- and ICU-LOS were experienced by those who had an AIS ≥3 (hospital: 4.8 days (±7.1) vs. 7.9 (±10.1); ICU: 4.6 (±6.9) vs. 5.9 (±7.9), P < .0001) and had a high ISS (hospital: 4.5 days (±5.9) vs. 16.8 (±17.9); ICU: 3.6 (±5.0) vs. 10.2 (±11.5), P < .0001). CONCLUSIONS: Patient race, insurance status, and injury severity were predictive of post-hospitalization care discharge. Self-pay and Black patients were less likely to be discharged to secondary care facilities. These findings have the potential to improve in-hospital patient management and predict discharge secondary care needs, and necessitate the need for future research to investigate the extent of inequalities in access to trauma care.

Practice Patterns of Transesophageal Echocardiography Use Among Trauma Patients: A Multi-Institutional Retrospective Study.

Transesophageal echocardiography (TEE) can be utilized for hemodynamic monitoring and resuscitation. In order to study the pattern of TEE use in trauma patients, a multi-institutional retrospective cohort study was performed comparing adult trauma patients who underwent TEE or those who underwent traditional invasive hemodynamic monitoring (TIHM). TIHM was defined as the use of arterial line, central venous line, or pulmonary artery catheter without TEE. Mortality rates were obtained and multivariable logistic regression was used to risk adjust for age, gender, race, insurance status, Glasgow coma scale (GCS), ICD Injury severity score (ICISS). Compared to TIHM group, more patients in TEE group had a history of congestive heart failure (CHF) or chronic pulmonary disease (CPD). Mortality rate was lower in the TEE group 7 versus 23% (P-value < .0001). After adjusting for GCS and ICISS in multivariable analysis, inpatient mortality was significantly lower in the TEE cohort.

Glasgow Coma Scale Intubation Thresholds and Outcomes of Patients With Traumatic Brain Injury: The Need for Tailored Practice Management Guidelines.

INTRODUCTION: This study aims to re-evaluate the GCS threshold for intubation in patients presenting to the ED with a traumatic brain injury to optimize outcomes and provide evidence for future practice management guidelines. METHODS: We retrospectively reviewed the ACS-TQIP-Participant Use File (PUF) 2015-2019 for adult trauma patients 18 years and older who experienced a blunt traumatic head injury and received computerized tomography. Multivariable regressions were performed to assess associations between outcomes and GCS intubation thresholds of 5, 8, and 10. RESULTS: In patients with a GCS ≤5, there were no differences in mortality (GCS ≤5: 26.3% vs GCS >5: 28.3%, adjusted P = .08), complication rates (GCS ≤5: 9.1% vs GCS >5: 10.3%, adjusted P = .91), or ICU length of stay (GCS ≤5: 5.4 vs GCS >5: 4.7, adjusted P = .36) between intubated and non-intubated patients. Intubated patients at GCS thresholds ≤8 (26.2% vs 19.1%, adjusted P < .0001) and ≤10 (25.6% vs 15.8%, adjusted P < .0001) had significantly higher mortality rates than non-intubated patients. Intubation at all GCS thresholds >5 resulted in higher rates of complications, H-LOS, and ICU-LOS when compared to non-intubated patients with the same GCS score. CONCLUSION: A GCS ≤5 was the threshold at which intubation in TBI patients conferred an additional benefit in disposition without worsened outcomes of mortality, H-LOS, or ICU-LOS. Trauma societies and hospital institutions should consider revisiting existing guidelines and protocols concerning the appropriate GCS threshold for safer intubation and better outcomes among these patient population.

Optimal timing and outcomes among COVID-19 patients undergoing tracheostomy.

BACKGROUND: Patients who require mechanical ventilation secondary to severe COVID-19 infection have poor survival. It is unknown if the benefit of tracheostomy extends to COVID-19 patients. If so, what is the optimal timing? METHODS: Retrospective cohort study within a large hospital system in the United States. The population included patients with COVID-19 from January 1, 2020 to September 30, 2020. In total, 93,918 cases were identified. They were excluded if no intubation or tracheostomy, underwent tracheostomy before intubation, <18 years old, hospice patients before admission, and bacterial pneumonia. In total, 5,911 patients met the criteria. Outcomes between patients who underwent endotracheal intubation only versus tracheostomy were compared. The primary outcome was inpatient mortality. All patients who underwent tracheostomy versus intubation only were compared. Three cohort analysis compared early (<10 days) versus late (>10 days) tracheostomy versus control. Eight cohort analysis compared days 0-2, days 3-6, days 7-10, days 11-14, days 15-18, days 19-22, and days 23+ to tracheostomy versus control. RESULTS: There was an overall inpatient mortality rate of 37.5% in the tracheostomy cohort compared to 54.4% in the control group (P < .0001). There was an early tracheostomy group inpatient mortality rate of 44.7% (adjusted odds ratio 0.73, 95% confidence interval 0.52-1.01) compared to 33.1% (adjusted odds ratio 0.44, 95% confidence interval 0.34-0.58) in the late tracheostomy group. CONCLUSION: COVID-19 patients with tracheostomy had a significantly lower mortality rate compared to intubated only. Optimal timing for tracheostomy placement for COVID-19 patients is 11 days or later. Future studies should focus on early tracheostomy patients.

Frailty Score as a Predictor of Outcomes in Geriatric Patients with Isolated Hip Fractures.

BACKGROUND: Isolated hip fractures (IHFs) are a cause of morbidity and mortality in the geriatric population aged >65 years. Frailty has been identified as a determinant for patient outcomes in other surgical specialties. The purpose of this study is to determine if frailty severity is a predictor of outcomes in IHF in the geriatric population. METHODS: This is a retrospective study in a state and ACS Level 2 trauma center. Patients with IHF were reviewed between January 2018 and January 2020. Primary outcome was in-patient mortality. Secondary outcomes include perioperative outcome measures such as UTI, HCAP, DVT, readmission, length of stay, ICU length of stay, nutritional status, and discharge destination. Patients were stratified into mild (1-2), moderate (3-5), and severe (5-7) frailty using the Rockwood Frailty Score (RFS). Clinical characteristics and outcomes were analyzed. RESULTS: We identified 470 patients with IHF who were stratified by mild (N=316), moderate (N-123), and severe (N=31) frailty. Frailty worsened with increasing age (P < .0001). Those who were less frail were more likely discharged home (P < .04). Severely frail patients were more likely discharged to hospice (P < .01). Severely frail patients also were more likely to develop DVT (P < .04) and have poorer nutritional status (P < .02). There were no differences among groups for in-patient mortality. CONCLUSION: Severely frail patients are more likely to be malnourished at baseline and be discharged to hospice care. The RFS is a reliable objective tool to identify high-risk patients and guide goals of care discussion for operative intervention in isolated traumatic hip fractures.