Low prevalence (0.13%) of COVID-19 infection in asymptomatic pre-operative/pre-procedure patients at a large, academic medical center informs approaches to perioperative care.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has resulted in reduced performance of elective surgeries and procedures at medical centers across the United States. Awareness of the prevalence of asymptomatic disease is critical for guiding safe approaches to operative/procedural services. As COVID-19 polymerase chain reaction (PCR) testing has been limited largely to symptomatic patients, health care workers, or to those in communal care centers, data regarding asymptomatic viral disease carriage are limited. METHODS: In this retrospective observational case series evaluating UCLA Health patients enrolled in pre-operative/pre-procedure protocol COVID-19 reverse transcriptase (RT)-PCR testing between April 7, 2020 and May 21, 2020, we determine the prevalence of COVID-19 infection in asymptomatic patients scheduled for surgeries and procedures. RESULTS: Primary outcomes include the prevalence of COVID-19 infection in this asymptomatic population. Secondary data analysis includes overall population testing results and population demographics. Eighteen of 4,751 (0.38%) patients scheduled for upcoming surgeries and high-risk procedures had abnormal (positive/inconclusive) COVID-19 RT-PCR testing results. Six of 18 patients were confirmed asymptomatic and had positive test results. Four of 18 were confirmed asymptomtic and had inconclusive results. Eight of 18 had positive results in the setting of recent symptoms or known COVID-19 infection. The prevalence of asymptomatic COVID-19 infection was 0.13%. More than 90% of patients had residential addresses within a 67-mile geographic radius of our medical center, the median age was 58, and there was equal male/female distribution. CONCLUSION: These data demonstrating low levels (0.13% prevalence) of COVID-19 infection in an asymptomatic population of patients undergoing scheduled surgeries/procedures in a large urban area have helped to inform perioperative protocols during the COVID-19 pandemic. Testing protocols like ours may prove valuable for other health systems in their approaches to safe procedural practices during COVID-19.

Bispectral index monitoring in the management of sedation in an intensive care unit patient with locked-in syndrome.

Locked-in syndrome is an extremely rare neurological state caused by injury of the ventral pons. The syndrome is characterized by quadriplegia and anarthria with concomitant preservation of cortical function. When a reversible underlying pathological abnormality is identified and managed aggressively, meaningful recovery is possible. Because patients retain consciousness throughout their illness, a dependable method for titrating sedation may improve their quality of life. The case presented suggests that bispectral index monitoring may be a cost-effective and reliable method for managing sedation in patients with locked-in syndrome.

Reduction of central venous catheter associated blood stream infections following implementation of a resident oversight and credentialing policy.

BACKGROUND: This study assesses the impact that a resident oversight and credentialing policy for central venous catheter (CVC) placement had on institution-wide central line associated bloodstream infections (CLABSI). We therefore investigated the rate of CLABSI per 1,000 line days during the 12 months before and after implementation of the policy. METHODS: This is a retrospective analysis of prospectively collected data at an academic medical center with four adult ICUs and a pediatric ICU. All patients undergoing non-tunneled CVC placement were included in the study. Data was collected on CLABSI, line days, and serious adverse events in the year prior to and following policy implementation on 9/01/08. RESULTS: A total of 813 supervised central lines were self-reported by residents in four departments. Statistical analysis was performed using paired Wilcoxon signed rank tests. There were reductions in median CLABSI rate (3.52 vs. 2.26; p = 0.015), number of CLBSI per month (16.0 to 10.0; p = 0.012), and line days (4495 vs. 4193; p = 0.019). No serious adverse events reported to the Pennsylvania Patient Safety Authority. CONCLUSIONS: Implementation of a new CVC resident oversight and credentialing policy has been significantly associated with an institution-wide reduction in the rate of CLABSI per 1,000 central line days and total central line days. No serious adverse events were reported. Similar resident oversight policies may benefit other teaching institutions, and support concurrent organizational efforts to reduce hospital acquired infections.

Reporting quality data on your hospital website: what? why? how?

Explore the challenges in making performance improvement data publicly available on hospital websites, and consider some practical tips and suggestions for aligning organizational goals with community and consumer needs.

Intraoperative angioembolization in the management of pelvic-fracture related hemodynamic instability.

BACKGROUND: This case series report discusses patients presenting with hemorrhage and hemodymanic compromise due to severe pelvic fractures and undergoing intraoperative angioembolization (IAE) with other resuscitative procedures. METHODS: We used portable digital subtraction fluoroscopy units for IAE in patients with severe pelvic hemorrhage and hemodynamic instability (5/03-4/09). Data was collected on demographics, injury severity, resource utilization, and outcomes at our Level 1 trauma center. RESULTS: There were 6,538 adult admissions with 912 having pelvic fractures and 65 of these undergoing pelvic angioembolization. Twelve hemodynamically compromised patients (10 males, 2 females) had intraoperative pelvic angiography (age: 22-79 years; mean 51.3 ± 17.4). Injury severity score (ISS) was 37.5 ± 8.4 (22-50). Mean emergency department (ED) length of stay (LOS) was 57.4 min ± 47.9 with 10 patients transported directly to the OR and 2 to the SICU prior to OR. Ten of 12 patients underwent exploratory laparotomy followed by angioembolization. Mortality was 50%. Among the 6 survivors (ISS 22 - 50), all had a pre-op CT scan, five had an initial base deficit <13, and four were transfused ≤ 6 units pre-incision/pre-procedure. Four of the 6 survivors had unilateral embolization. In contrast, all 6 non-survivors (ISS 29-41) required massive transfusion prior to OR (>6 units PRBCs) with 4 having a based deficit >13. Three of these patients bypassed CT and five underwent bilateral internal iliac embolization (BIIE). CONCLUSIONS: IAE for severe pelvic hemorrhage can be successfully performed concurrently with exploratory laparotomy, pelvic packing or other resuscitative procedures. Patients most likely to benefit have a base deficit <13, and do not require massive transfusion prior to IAE or suffer from a vertically unstable pelvis fracture.

Resource utilization and outcomes of intoxicated drivers.

BACKGROUND: The high risk behavior of intoxicated drivers, impaired reaction time, lack of seat belt use, and increased incidence of head injury raises questions of whether pre-hospital use of alcohol leads to a higher injury severity score and worse clinical outcomes. We therefore compared intoxicated and non-intoxicated drivers of motor vehicle crashes with respect to outcome measurements and also describe the resources utilized to achieve those outcomes at our Level 1 trauma center. METHODS: Retrospective descriptive study (Jan 2002-June 2007) of our trauma registry and financial database comparing intoxicated drivers with blood alcohol levels (BAC) > 80 mg/dl (ETOH > 80) with drivers who had a BAC of 0 mg/dl (ETOH = 0). Drivers without a BAC drawn or who had levels ranging from 1 mg/dL to 80 mg/dL were excluded. Data was collected on demographic information (age, gender, injury severity score or ISS), outcome variables (mortality, complications, ICU and hospital LOS, ventilator days) and resource utilization (ED LOS, insurance, charges, costs, payments). STATISTICAL ANALYSIS: p < 0.05 vs. ETOH > 80; stratified chi square. RESULTS: Out of 1732 drivers, the combined study group (n = 987) of 623 ETOH = 0 and 364 ETOH > 80 had a mean age of 38.8 +/- 17.9, ISS of 18.0 +/- 12.1, and 69.8%% male. There was no difference in ISS (p = 0.67) or complications (p = 0.38). There was a trend towards decreased mortality (p = 0.06). The ETOH = 0 group had more patients with a prolonged ICU LOS (>/= 5 days), ventilator days (>/= 8 days), and hospital LOS (> 14 days) when compared to the ETOH > 80 group (p < 0.05). The ETOH > 80 group tended to be self pay (4.9% vs. 0.7%, p < 0.5) and less likely to generate payment for hospital charges (p < 0.5). Hospital charges and costs were higher in the ETOH = 0 group (p < 0.5). CONCLUSIONS: The data suggests that intoxicated drivers may have better outcomes and a trend towards reduced mortality. They appeared to be less likely to have prolonged hospital LOS, ICU LOS, and ventilator days. We also observed that intoxicated drivers were more likely to be self-pay, less likely to have charges > $50K, and less likely to pay >/= 90% of the charges. Further research using multivariable analysis is needed to determine if these apparent outcomes differences are driven by acute intoxication, and the tendency for endotracheal intubation and ICU admission, rather than injury severity.

Outcome assessment of blunt trauma patients who are undertriaged.

BACKGROUND: We investigated the outcomes of injured patients who were undertriaged and compared them with those meeting full trauma team activation (TTA) criteria. METHODS: Blunt trauma patients (July 2002-January 2008) meeting full TTA criteria and had a partial TTA were in the undertriage group (UTG). Data was collected on demographics, injury severity, OR delays, resource utilization, and outcomes. Excluded: penetrating trauma, transfers, burns, age <18 years. STATISTICS: Chi square, P < .05, mean +/- SD. RESULTS: One thousand four hundred and twenty-four patients with 318 (22.3%) in the UTG and 1,106 in the correctly triaged group (CTG). The CTG was 70.4% male (vs 67.1%; P = .26), 41.5 +/- 19.8 years old (vs 45.8 +/- 20.5; P < .01), and had an injury severity score (ISS) of 24.7 (vs 17.0; P < .0001). The CTG was more likely to require ED intubation (34.9% vs 8.2%; P < .0001), ICU admission (49.0% vs 37.1%; P < .0001), longer ICU/hospital LOS, and more ventilator days (P < .0001) with no differences in OR delays. The UTG had a lower mortality (6.0% vs 16.7%; P < .0001) and were discharged home more often (65.3% vs 52.2%; P = .02). CONCLUSION: The UTG had a lower ISS and improved outcomes compared to the CTG with no differences in OR delays. Despite inherent challenges in TTA protocols, patients who were undertriaged at our institution appear to have satisfactory outcomes.

Repeal of the Pennsylvania motorcycle helmet law: reflections on the ethical and political dynamics of public health reform.

BACKGROUND: In June of 2003 the Commonwealth of Pennsylvania passed S. 259 which repealed the state's 35-year old motorcycle helmet safety law. Motorcycle helmets are now only required for riders who are under the age of 21 and for those who are 21 years or older who have had a motorcycle operator's license for less than two years, or who have not completed an approved motorcycle safety course. DISCUSSION: Prior to the repeal, and in the years that have followed, there has been intense debate and controversy regarding Pennsylvania's decision to repeal the law that required universal and mandatory use of motorcycle helmets for all riders. Proponents of the helmet repeal have argued in favor of individual rights and freedom, whereas advocates for mandatory helmet laws have voiced concerns over public health and safety based on available data. SUMMARY: This commentary will discuss the policy-making process that led to Pennsylvania's repeal of the motorcycle helmet safety law from an ethical, political, and economic perspective.

Percutaneous retrieval of a biliary stent after migration and ileal perforation.

We present a case of a migrated biliary stent that resulted in a distal small bowel perforation, abscess formation and high grade partial small bowel obstruction in a medically stable patient without signs of sepsis or diffuse peritonitis. We performed a percutaneous drainage of the abscess followed by percutaneous retrieval of the stent. The entero-peritoneal fistula closed spontaneously with a drain in place. We conclude, migrated biliary stents associated with perforation distal to the Ligament of Trietz (LOT), may be treated by percutaneous drainage of the abscess and retrieval of the stent from the peritoneal cavity, even when associated with a large intra-abdominal abscess.

Does acuity matter?--Optimal timing of tracheostomy stratified by injury severity.

BACKGROUND: A number of conflicting studies have been conducted to analyze the relationship between the timing of tracheostomy and mortality, intensive care unit (ICU) length of stay (LOS), hospital LOS, and the incidence of pneumonia. In contrast to previous studies, this relationship was investigated in the context of expected survival based on probability of survival (Ps) greater than 25%. METHODS: Trauma patients were screened using a statewide registry during a 5-year period (January 2001 to December 2005). Burn patients, transfer patients, permanent tracheostomies, and patients who underwent multiple surgical airways were excluded from the study. Data were collected on patient demographics, Trauma and Injury Severity Score, days to tracheostomy, mortality, ICU LOS, total ventilator days, pneumonia, and hospital LOS. STATISTICAL ANALYSES: log-linear modeling, chi2, p < 0.05. RESULTS: A total of 125,533 trauma patients were analyzed. Out of these, 82,148 patients met inclusion criteria and had complete data for analysis. There were 6,880 patients intubated at the scene, during transport, or at admission to the emergency department, with 685 receiving a temporary tracheostomy. There was a significantly higher mortality rate (48.9%) associated with patients with low Ps (<0.25) receiving early tracheostomy (ET), <4 days. Among high-Ps patients, the ET group demonstrated reduced ICU LOS, total ventilator days, pneumonia, and hospital LOS (p < 0.05). CONCLUSION: ET in patients with low Ps may not be beneficial given the substantially high mortality rate before post injury day 4. However, ET in high-Ps patients reduces ICU and hospital LOS, total ventilator days, and the incidence of pneumonia. This suggests an increased benefit in ET to trauma patients with high Ps.

Comparison of trauma mortality between two hospitals in Turkey to one trauma center in the US.

OBJECTIVES: The development of comprehensive international trauma case registries could be used to perform outcomes analysis and comparisons between countries with the goal of improving trauma care worldwide. METHODS: A retrospective study (April 2004 to April 2005) of injured patients from a Pennsylvania state trauma center (PSTC) were case matched according to age, sex, and injury severity score with two Turkish hospitals. Patients' demographics (age, sex), prehospital information (mechanism of injury, mode of transportation), injury severity (injury severity score and Glasgow coma score), and outcomes (intensive care unit length of stay, hospital length of stay, mortality) were collected. STATISTICAL ANALYSIS: P value of less than 0.05, odds ratio (OR), chi2 test, two-sample t-test, mean+/-SD. RESULTS: Medical records from 506 Turkish trauma patients were abstracted and compared with 506 injured patients in the PSTC registry. Patients in Turkey presented more commonly with a Glasgow coma score of less than or equal to 8 (13.09 vs. 4.26%, P<0.01, OR 3.38) had increased mortality (8.30 vs. 0.79%, P<0.01, OR 11.36) and required mechanical ventilation more than 1 day more often (16.44 vs. 8.75%, P<0.01, OR 2.05). Motor vehicle crashes were the leading cause of injury in both groups. Assaults and falls were more frequent in the PSTC. Pedestrian injuries were more common and had higher mortality rates in Turkey (P<0.05). CONCLUSION: This study demonstrates significantly worse outcomes in trauma care and higher mortality rates in Turkey versus PSTC. Developing a trauma registry to monitor improvements in patient care and to target injury prevention strategies should be a high priority for the Turkish healthcare system.

Current concepts in simulation-based trauma education.

The use of simulation-based technology in trauma education has focused on providing a safe and effective alternative to the more traditional methods that are used to teach technical skills and critical concepts in trauma resuscitation. Trauma team training using simulation-based technology is also being used to develop skills in leadership, team-information sharing, communication, and decision-making. The integration of simulators into medical student curriculum, residency training, and continuing medical education has been strongly recommended by the American College of Surgeons as an innovative means of enhancing patient safety, reducing medical errors, and performing a systematic evaluation of various competencies. Advanced human patient simulators are increasingly being used in trauma as an evaluation tool to assess clinical performance and to teach and reinforce essential knowledge, skills, and abilities. A number of specialty simulators in trauma and critical care have also been designed to meet these educational objectives. Ongoing educational research is still needed to validate long-term retention of knowledge and skills, provide reliable methods to evaluate teaching effectiveness and performance, and to demonstrate improvement in patient safety and overall quality of care.

Prophylactic inferior vena cava filters: do they make a difference in trauma patients?

BACKGROUND: Inferior vena cava filters (IVCF) are used in trauma patients to reduce the incidence of pulmonary embolism (PE). This study investigates the efficacy of prophylactic IVCF (PIVCF) placement from implantation through outpatient follow-up. METHODS: Data were prospectively collected on PIVCF placed in trauma patients > or =18-years old from 2004 to 2006. Exclusion criteria include therapeutic IVCF, major burns, deviated from a modified EAST protocol, and deaths. Data were collected on age, gender, Injury Severity Score (ISS), filter type, total implant days, PE, deep venous thrombosis (DVT), and filter-related complications. STATISTICAL ANALYSIS: p < 0.05*, chi square test, mean +/- SD. RESULTS: Of 4,936 patients, 280 had an IVCF with 244 meeting inclusion criteria. Study group demographics: 63.5% men; 98.8% blunt; mean age 43.8 +/- 20.3; ISS 26.7 +/- 12.8. There were 176 of 244 (72.1%) patients who met traditional EAST guidelines for PIVCF. PIVCF increased significantly from 29 in 2004 to 127 in 2006 with no difference in the PE rate (0.7% to 0.4%). There were 4 PEs (1.6%) on postprocedure days 7, 14, 18, and 23. Five technical complications occurred: two filter fractures, two caudal migrations, and one filter tilt. A total of 140 retrievable filters had the opportunity for outpatient follow-up for 18 months with 58.6% removed, 15.7% declared permanent, 12.1% lost to follow-up, and 13.6% still considered potential removal candidates. Days to implant: 0 to 32; 3.89 +/- 4.79. Implant days: 15 to 838; mean 231 +/- 162. CONCLUSIONS: PIVCF increased significantly without impacting the overall PE rate. There was a 1.6% PE rate among PIVCF, high retrieval rate (59%), low complication rate (0.1%), and satisfactory compliance with traditional EAST guidelines.

The current crisis in emergency care and the impact on disaster preparedness.

BACKGROUND: The Homeland Security Act (HSA) of 2002 provided for the designation of a critical infrastructure protection program. This ultimately led to the designation of emergency services as a targeted critical infrastructure. In the context of an evolving crisis in hospital-based emergency care, the extent to which federal funding has addressed disaster preparedness will be examined. DISCUSSION: After 9/11, federal plans, procedures and benchmarks were mandated to assure a unified, comprehensive disaster response, ranging from local to federal activation of resources. Nevertheless, insufficient federal funding has contributed to a long-standing counter-trend which has eroded emergency medical care. The causes are complex and multifactorial, but they have converged to present a severely overburdened system that regularly exceeds emergency capacity and capabilities. This constant acute overcrowding, felt in communities all across the country, indicates a nation at risk. Federal funding has not sufficiently prioritized the improvements necessary for an emergency care infrastructure that is critical for an all hazards response to disaster and terrorist emergencies. SUMMARY: Currently, the nation is unable to meet presidential preparedness mandates for emergency and disaster care. Federal funding strategies must therefore be re-prioritized and targeted in a way that reasonably and consistently follows need.

The road to developing an advanced degree program in public health preparedness.

The master of homeland security (MHS) degree in public health preparedness at the Pennsylvania State University College of Medicine is the first degree program of its kind offered by any U.S. medical school. The field of public health preparedness has been increasingly viewed as a new, emerging professional discipline, which academic medicine is well positioned to complement. The process by which the MHS program has evolved from conception to realization is a case study in the mission-based alignment of core values and leadership between the government and academic medicine. Recognizing the need for multidisciplinary involvement, the program architects reconsidered the traditional approach to the development and implementation of new graduate degree programs. Instead, a more flexible, loosely connected network of strategic partners and alliances was adopted. These partnerships were developed and cultivated by vested individuals who excelled in specific core competencies and came together to create value. This allowed for both the expertise and flexibility needed to adapt quickly to the evolving homeland security environment in the United States. To that end, this article describes the 10-step multidisciplinary program-development process that spanned three years and culminated in the establishment of this new graduate degree program. The MHS program as it now stands focuses on public health preparedness, including epidemiological evaluation, disaster communication and psychology, agricultural biosecurity, and critical infrastructure protection. The program is geared toward the practicing professional already working in the field, and its graduates are positioned to be among the top leaders, educators, and researchers in homeland security.

Trauma team activation and the impact on mortality.

BACKGROUND: Trauma centers use injury mechanism, physiology, and anatomic criteria to determine the extent of trauma team activation (TTA). We examined whether physiologic variables in our three-tier TTA system stratified patients appropriately by injury severity and mortality. METHODS: The trauma registry at our Level I trauma center was retrospectively reviewed for full (level 1 or L1), partial (level 2 or L2), and limited (level 3) adult TTA. Data were collected on age, injury severity score (ISS), hospital length of stay, systolic blood pressure (SBP), heart rate, respiratory rate (RR), Glasgow coma score (GCS), and intubation status. Penetrating injuries, traumatic arrests, and interfacility transfers were excluded. Data are median (25%75%). Statistical analysis included hazard ratios (HzR), Kruskal-Wallis, chi, and survival analyses. The p value overall was <0.05, and pair wise was <0.05 versus L1. RESULTS: There were 494 adult TTAs for blunt injury from the scene out of 1,969 admissions. Variables associated with mortality (HzR; 95% confidence interval) by univariate analysis include SBP <90 (9.4; 4.2, 21.2), RR >29 or <10 (17.8; 4.8, 66.0), intubation status (4.5; 2.3, 8.9), and GCS <8 (9.7; 4.8, 19.9). When combined in a multivariate model to evaluate multiple predictors simultaneously, SBP <90 and GCS <8 appear to be the strongest predictors of mortality (RR and intubation were not significant in the presence of SBP and GCS). The three-tier system identified patients with increased ISS and early (< or =4 weeks) mortality risk. There was a statistically significant difference in survival between L1 and L2 at 38 days, but not for >38 days (p = 0.739). CONCLUSIONS: TTA criteria selected patients with greater ISS and early mortality, but impact on long-term survival may not be appreciated. Full TTA criteria for blunt injury may be limited to GCS <8, SBP <90, RR >29 or <10, and intubation status.

Increased hospital morbidity among trauma patients with diabetes mellitus compared with age- and injury severity score-matched control subjects.

HYPOTHESIS: We hypothesized that patients with diabetes mellitus (DM) have worse outcomes following trauma compared with patients without a history of DM. DESIGN: Retrospective data analysis of the Pennsylvania Trauma Systems Foundation database that compiles data from 27 accredited trauma centers in Pennsylvania. SETTING: We used the Pennsylvania Trauma Systems Foundation database of 295 561 patients to compare outcomes in patients with DM vs those in patients who did not have DM. PATIENTS: A total of 12 489 patients with DM from January 1984 to December 2002 were matched by sex, age, and Injury Severity Score with 12 489 patients who did not have DM. MAIN OUTCOME MEASURES: Differences in the length of hospital stay, intensive care unit stay, ventilatory assistance days, complications, and mortality rates. RESULTS: Patients with DM spent more days in the intensive care unit and receiving ventilator support. They were more likely to have a complication (23.0% in the DM group vs 14.0% in the non-DM group [odds ratio, 1.80; 95% confidence interval, 1.69-1.92]). No difference in mortality rates or length of hospital stay was noted. CONCLUSION: Patients with DM exposed to trauma have greater hospital morbidity resulting from longer intensive care unit stay, increased ventilator support, and more complications.

Do early ionized calcium levels really matter in trauma patients?

BACKGROUND: Age, injury severity, and base deficit are commonly used prognostic indicators in trauma. This study investigates the relationship between ionized calcium (iCa) levels drawn on arrival to the emergency department, with injury severity, acidosis, hypotension, and mortality. METHODS: Adult trauma team activations requiring the highest level of response were identified retrospectively from January 2000 to December 2002. Patients were stratified into two groups: iCa < or = 1 and iCa > 1 mmol/L. The relationship between iCa and injury severity (Trauma Injury Severity Score, Injury Severity Score [ISS], Revised Trauma Scale, Glasgow Coma Scale), age, sampling time, shock (systolic blood pressure [SBP] < 90 at the scene, transport, and admission; base deficit), resource utilization (hospital and intensive care unit length of stay, ventilator days) and mortality was examined. Statistical analysis included chi2 tests, Wilcoxon rank sum tests, p < 0.05 versus iCa > 1, median (25th-75th percentile), and odds ratio (OR). RESULTS: In all, 396 out of 2,367 patients were identified. Mortality was significantly increased in the iCa < or = 1 group (26.4% versus 16.7%, p < 0.05; OR 1.92). Time to death in iCa < or = 1 was significantly shorter, 0.50 (0-1) versus 1.0 (0-6) days. Mortality was predicted using iCa < or = 1 alone (p < 0.02, OR 3.28), iCa < or = 1 + base deficit (p < 0.02, OR 2.00), and base deficit alone (p = 0.06, OR 1.5). Low iCa was associated with SBP < 90 at the scene and transport (p < 0.01). The incidence of base deficit was higher in the iCa < or = 1 group (p < 0.05). CONCLUSIONS: Low iCa is associated with prehospital hypotension regardless of age, ISS, or sampling time and is a better predictor of mortality than base deficit. Since acidosis reduces calcium binding to serum protein and actually increases iCa, the association between base deficit and iCa in this study requires further investigation.