Reliability of International Classification of Disease-9 Versus International Classification of Disease-10 Coding for Proximal Femur Fractures at a Level 1 Trauma Center.

INTRODUCTION: The Centers for Medicare & Medicaid services proposed that transitioning from the 9th to the 10th revision of the International Classification of Disease (ICD) would provide better data for research. This study sought to determine the reliability of ICD-10 compared with ICD-9 for proximal femur fractures. METHODS: Available imaging studies from 196 consecutively treated proximal femur fractures were retrospectively reviewed and assigned ICD codes by three physicians. Intercoder reliability (ICR) was calculated. Collectively, the physicians agreed on what should be the correct codes for each fracture, and this was compared with coding found in the medical and billing records. RESULTS: No significant difference was observed in ICR for both ICD-9 and ICD-10 exact coding, which were both unreliable. Less specific coding improved ICR. ICD-9 general coding was better than ICD-10. Electronic medical record coding was unreliable. Billing codes were also unreliable, yet ICD-10 was better than ICD-9. DISCUSSION: ICD-9 and ICD-10 lack reliability in coding proximal femur fractures. ICD-10 results in data that are no more reliable than those found with ICD-9. LEVEL OF EVIDENCE: Level I diagnostic.

Traumatic abdominal wall hernias: Location matters.

BACKGROUND: Because of its uncommon nature and a lack of comprehensive literature, abdominal wall hernias caused by blunt trauma continue to present a management dilemma. This study was performed to identify the incidence of associated injuries, the need for urgent operative intervention, and recurrence rates after hernia repair. METHODS: A retrospective review of patients diagnosed with a traumatic abdominal wall hernia from January 2002 to December 2014 was performed. Data were collected from the trauma registry and included patient demographics, location and type of hernia, associated injuries, operative interventions, complications, and length of stay. RESULTS: Eighty patients (64% male; median age, 36 years; mean Injury Severity Score [ISS], 22) were identified during the study period. A motor vehicle collision was the most frequent mechanism of injury (n = 58). Overall, 35 patients (44%) underwent urgent laparotomy or laparoscopy, and 10 of these (29%) were nontherapeutic excluding hernia repair. Of interest, 17 patients (49%) required bowel resection. Notably, the need for operative intervention and nontherapeutic rate differed depending on hernia location. Hernia repair was performed in 23 patients, the majority of whom (78.3%) underwent repair within 5 days of injury. There were six recurrences, four of which were repaired acutely (within 1 week of injury), with an overall first-time hernia recurrence rate of 26%. CONCLUSION: In the largest series to date, traumatic abdominal wall hernias were found to be associated with a high percentage of intra-abdominal injuries requiring urgent laparotomy or laparoscopy. Rates of therapeutic interventions varied by hernia location, with anterior abdominal hernias associated with the highest need for a therapeutic operation. Acute repair was associated with the majority of the recurrences. LEVEL OF EVIDENCE: Epidemiologic study, level III; therapeutic study, level IV.

Racial odds for amputation ratio in traumatic lower extremity fractures.

BACKGROUND: Recent studies have demonstrated that black patients receive substandard care compared with white patients across healthcare settings. The purpose of this study was to evaluate the association of race on the management (salvage vs. amputation) of traumatic lower extremity open fractures. METHODS: Data analysis was conducted using the American College of Surgeon's National Trauma Data Bank. Open tibial and fibular (OTFF) and open femoral (OFF) fractures among adults above the age of 18 were identified by International Classification of Diseases, 9th Revision codes. Injuries were identified as amputated based on the presence of one of three types of knee amputations. Statistical analysis included logistic regression stratified for sex, age, race, mechanism of injury, severity, and insurance type. RESULTS: From the National Trauma Data Bank, 10,082 OFF and 22,479 OTFF were identified. Amputation rates were 3.1% for OFF and 4.2% for OTFF. With age stratification, the ratio of amputation odds for blacks to amputation odds for whites (i.e., the Racial Odds for Amputation Ratio [ROAR]) demonstrated a significant interaction between black and age in both the OFF (p = 0.028) and OTFF (p = 0.008) groups. In younger patients, a lower ROAR (p = 0.016) favored salvage in blacks, while the ROAR in older patients favored amputation in blacks (p = 0.013). The higher prevalence of penetrating injuries in blacks only accounted for 12.7% of the lower ROAR among younger adults. CONCLUSIONS: There exists a racial disparity in the management of lower extremity open fractures. Older blacks have greater odds of amputation that is not explained by mechanism. In contrast, younger blacks have lower odds for amputation that is only partially explained by mechanism of injury.

The ribs or not the ribs: which influences mortality?

BACKGROUND: The relative impact of rib fractures on mortality risk is unclear. This study examined the respective relationships between mortality and the number of fractured ribs, patient age, and severity of intrathoracic and extrathoracic injuries. METHODS: The National Trauma Data Bank was queried, abstracting mortality, age, number of ribs fractured, associated intrathoracic and extrathoracic injury, and Abbreviated Injury Score codes. RESULTS: Multivariate logistic regression indicated the strongest influence on mortality was severity of intrathoracic injury, followed by severity of extrathoracic injury, age 65 years or older, more than 5 ribs fractured, and age 46 to 65 years. The mortality rate for isolated rib fractures ranged from 1.8% to 3.2%. CONCLUSIONS: Mortality related to rib fractures is affected independently by severe intrathoracic injury, presence of extrathoracic injury, advanced age, and more than 5 fractured ribs. Patients with these conditions may benefit from a higher level of care.

Prevention of hospital-acquired infections by selective digestive decontamination.

BACKGROUND: Selective decontamination of the digestive tract (SDD) has been advocated to prevent ventilator-associated pneumonia (VAP) and possibly other nosocomial infections. However, its incorporation into standard health care practices has been limited. METHODS: Comprehensive literature search using www.pubmed.gov and derivative cross-references. RESULTS: The abundance of basic science and clinical literature largely supports the concept that the incidence of VAP declines after the introduction of SDD, although there are some controversial aspects. Several meta-analyses and recent controlled clinical trials have supported the benefit of SDD. A few years ago, the Institute for Healthcare Improvement introduced the "ventilator bundle," a set of simple evidence-based measures designed to reduce the incidence of pneumonia. These measures have been implemented rapidly throughout the country. Of the four initial measures (elevation of the head of the bed, daily "sedation vacations" with assessment of readiness for endotracheal extubation, prophylaxis against stress-related gastric mucosal hemorrhage, and deep venous thrombosis prophylaxis), only the first two affect the development of VAP either directly or indirectly. CONCLUSIONS: The evidence supporting SDD as a prevention measure for VAP is at least as good as that supporting the ventilator bundle, if not better. At many centers, a topical oral antiseptic (e.g., chlorhexidine) has been incorporated as a fifth element of the ventilator bundle.

A review of available prosthetics for ventral hernia repair.

OBJECTIVE: To review mesh products currently available for ventral hernia repair and to evaluate their efficacy in complex repair, including contaminated and reoperative fields. BACKGROUND: Although commonly referenced, the concept of the ideal prosthetic has never been fully realized. With the development of newer prosthetics and approaches to the ventral hernia repair, many surgeons do not fully understand the properties of the available prosthetics or the circumstances that warrant the use of a specific mesh. METHODS: A systematic review of published literature from 1951 to June of 2009 was conducted to identify articles relating to ventral hernia repairs and the use of prosthetics in herniorrhaphy. RESULTS: Important differences exist between the synthetics, composites, and biologic prosthetics used for ventral hernia repair in terms of mechanics, cost, and the ideal situation in which each should be used. CONCLUSIONS: The use of synthetic mesh remains an appropriate solution for most ventral hernia repairs. Laparoscopic ventral hernia repair has created a niche for both expanded polytetrafluoroethylene and composite mesh, as they are suited to intraperitoneal placement. Preliminary studies have demonstrated that the newer biologic prosthetics are reasonable options for hernia repair in contaminated fields and for large abdominal wall defects; however, more studies need to be done before advocating the use of these biologics in other settings.

Analysis of compliance and outcomes in a trauma system with a 2-hour transfer rule.

HYPOTHESIS: Minimizing time to definitive care in an effort to optimize outcomes is the goal of trauma systems. Toward this end, some systems have imposed standards on time to interfacility transfer. This study evaluates compliance and outcome in a system with a 2-hour transfer rule. DESIGN: Retrospective review. SETTING: State trauma registry data from 1999 to 2003. PATIENTS: Trauma patients who underwent interfacility transfer and those who did not. MAIN OUTCOME MEASURES: Time to transfer; Injury Severity Score; mortality; and time to operating room at second facility. These variables were then stratified by time to transfer. RESULTS: During the study period, there were 22 447 interfacility transfers. Overall transfer rate was 10.4%. Of the transfers, 4502 (20%) occurred within 2 hours. Median transfer time was 2 hours 21 minutes. Injury Severity Score, mortality, and number of patients with operation performed on same day of transfer were all higher for the group transferred within 2 hours in comparison with patients transferred on the same day of injury at greater than 2 hours. CONCLUSIONS: While the majority of transfers occur at greater than the mandated 2-hour interval, the most seriously injured patients are reaching definitive care within 2 hours. Markers of acuity for patients transferred at greater than 2 hours parallel those of the general trauma patient population. These data suggest that, in this system, provider-determined transfer time that exceeds 2 hours has no adverse effect on patient outcome. It appears to accomplish recognition and rapid transport of the most seriously ill. This may obviate the need for onerous system mandates that are not feasible or have poor compliance.

Recurrent ventilator-associated pneumonias: the gift that keeps on giving or the guest who won't leave?

BACKGROUND: An increasing number of publications related to the concept of recurrent ventilator-associated pneumonia (VAP) has emerged in recent years. The clinical relevance of this publication trend could suggest failure to prevent VAP. METHODS: Review of articles addressing recurrent VAP, which were scrutinized for their definitions and methodology, seeking to determine the actual meaning of "recurrence." RESULTS: A preponderance of the early papers on recurrent VAP used definitions that create the possibility and even, in some cases, the likelihood that what was being addressed actually was persistent VAP. These studies, mostly from the same investigator group, considered "recurrent" VAP to appear as early as three days after the initial diagnosis while patients were still receiving antibiotics to treat that initial episode. The blurring of the concepts of "recurrence" and "persistence" is apparent in the methodology and the results. CONCLUSIONS: Existing evidence-based guidelines regarding the prevention and treatment of VAP should be applied to reduce the incidence of (i.e., prevent) and treat VAP effectively. A distinction should be made between "recurrence" and "persistence" in order to determine whether clinical inadequacies exist in preventive or therapeutic practices, respectively. An objective process for defining the resolution of VAP should be developed to enable this distinction to be made.

Management of the open abdomen: from initial operation to definitive closure.

The open abdomen is a relatively new and increasingly common strategy for the management of abdominal emergencies in both trauma and general surgery. The use of an abbreviated laparotomy can reduce mortality associated with conditions such as abdominal compartment syndrome; however, the resulting open abdomen is a complex clinical problem. Modern techniques and technologies are now available that allow for improved management of the open abdomen and the progressive reduction of the fascial defect. Indeed, recent evidence indicates that a large proportion of patients treated with open abdomen can now be closed within the initial hospitalization. These techniques and technologies include the appropriate use of negative pressure therapy and synthetic or biologic repair materials. It is essential that general and trauma surgeons understand the core principles underlying the need for and management of the open abdomen. Toward this goal, an Open Abdomen Advisory Panel was established to identify core principles in the management of the open abdomen and to develop a set of recommendations based on the best available evidence. This review presents the principles and recommendations identified by the Open Abdomen Advisory Panel and provides brief case studies for the illustration of these concepts.

Use of human acellular dermal matrix for hernia repair: friend or foe?

BACKGROUND: Surgeons continue to search for the ideal prosthetic material to repair complex abdominal wall hernias. Recently, a new biologic material was introduced into the surgeon's arsenal. The purpose of this study is to review a single institution's experience with the use of human acellular dermal matrix (HADM [AlloDerm]) for repair of hernias. METHODS: This was a retrospective review of all patients who received HADM for repair of an abdominal wall hernia. Patient demographics, comorbidities, wound contamination, operative technique, complications, and hernia recurrence were analyzed. RESULTS: Between May 2004 and October 2007, HADM was implanted in a total of 46 patients undergoing repair of a ventral hernia. The average age was 54 years (range, 26-77), with an average American Society of Anesthesiologists classification of 2.5 (range, 1-4). Indications for use of HADM included complex ventral hernia repair (n = 34), mesh infection/enterocutaneous fistula (n = 10), and peritonitis (n = 2). The incidences of comorbidities were hypertension in 47%, diabetes mellitus in 16%, and coronary artery disease in 11%. The majority (87%; n = 40) of the procedures were performed on an elective basis. Seventeen procedures were performed in contaminated wounds. The HADM was placed as reinforcement to the hernia repair in 26 patients and as a "bridge" between the fascial edges in 20 patients. The average follow-up was 12.1 months. Wound complications were frequent at 54%. There were 6 recurrent hernias and 8 patients with eventration of the bioprosthesis so that the recurrent hernia rate was 30%. None of the recurrences were associated with a postoperative wound infection. The majority (88%) of patients who developed eventration of the HADM had a repair using the bioprosthesis to "bridge" an abdominal wall defect. Hernia recurrence and eventration were not associated with use of HADM in a contaminated/infected wound. CONCLUSIONS: HADM is a suitable prosthesis for repair of complex and routine abdominal wall defects. This bioprosthesis can incorporate into contaminated tissue without becoming infected. Eventration occurs when HADM is utilized as a fascial replacement rather than as a reinforcement.

Broken bones and orthopedist groans: can an acute care surgeon fix both?

BACKGROUND: Increasing reluctance of specialty surgeons to participate in trauma care has placed undue burden on orthopedic traumatologists at Level I trauma centers and prompted the exploration of an expanded role for general trauma surgeons in the initial management of select orthopedic injuries (OI) as an acute care surgeon. This study characterizes OI sustained by trauma patients (TPs) to analyze the feasibility of this concept. METHODS: The National Trauma Data Bank was queried for specific information relating to the profile of OI. International Classification of Diseases-9th Revision codes were used to select patients for the study who sustained OI alone or in combination with other injuries as well as to determine body region of injury and a status of open or closed fractures. Skeletal Abbreviated Injury Scale scores were used to determine the severity of fractures, and International Classification of Diseases-9th Revision procedure codes were used to identify the nature of initial operative management. RESULTS: Of the 1,130,093 patients studied, 557,541 (49%) had one or more reported OI. Open injuries constituted 11.4% of all OIs and occurred in 7.5% of all TPs. Distribution of OIs was 23% upper extremity (18% open) and 35% lower extremity (also 18% open). These represent a 15% and 22% occurrence in TP. Pelvic and acetabular fractures occurred in 13% of OI patients (4% open) and 6% of all TP. The mean skeletal Abbreviated Injury Scale of all OIs was 2.3. For upper extremities it was 2.2, for lower extremities and for pelvic or acetabular injuries it was 2.4. Closed reduction of joint dislocation was performed in 2% of OI and 1% of all TPs. Of these, 45% were on the hip, 8% on the knee, 15% on the ankle, 13% on the elbow, and 20% on the shoulder. The distribution of initial interventions for all patients with OI was irrigation and debridement (I&D) 13%, external fixator (ex-fix) application 25%, closed reduction 41%, and closed joint relocation 10%. Of all open injuries, 17% underwent I&D and 31% underwent ex-fix application. The median time to I&D or ex-fix application was 7.2 hours. One percent of these procedures were performed within 1 hour of hospital admission, 11% within 6 hours of hospital admission. CONCLUSION: OI occur in a significant portion of TP reported to the National Trauma Data Bank. They most commonly involve the lower extremities and are of moderate severity. Given this profile, it seems feasible to propose that some initial procedures can be mastered by nonorthopedic surgeons and that select OI management be within the purview of a properly trained and credentialed acute care surgeon.

Medicare's "Global" terrorism: where is the pay for performance?

BACKGROUND: Medicare and Medicaid Services (CMS) payment policies for surgical operations are based on a global package concept. CMS' physician fee schedule splits the global package into preoperative, intraoperative, and postoperative components of each procedure. We hypothesized that these global package component valuations were often lower than comparable evaluation and management (E&M) services and that billing for E&M services instead of the operation could often be more profitable. METHODS: Our billing database and Trauma Registry were queried for the operative procedures and hospital lengths of stay for trauma patients during the past 5 years. Determinations of preoperative, intraoperative, and postoperative payments were calculated for 10-day and 90-day global packages, comparing them to CMS payments for comparable E&M codes. RESULTS: Of 90-day and 10-day Current Procedural Terminology codes, 88% and 100%, respectively, do not pay for the comprehensive history and physical that trauma patients usually receive, whereas 41% and 98%, respectively, do not even meet payment levels for a simple history and physical. Of 90-day global package procedures, 70% would have generated more revenue had comprehensive daily visits been billed instead of the operation ($3,057,500 vs. $1,658,058). For 10-day global package procedures, 56% would have generated more revenue with merely problem-focused daily visits instead of the operation ($161,855 vs. $156,318). CONCLUSIONS: Medicare's global surgical package underpays E&M services in trauma patients. In most cases, trauma surgeons would fare better by not billing for operations to receive higher reimbursement for E&M services that are considered "bundled" in the global package payment.

Clinician vs mathematical statistical models: which is better at predicting an abnormal chest radiograph finding in injured patients?

OBJECTIVE: The purpose of this study was to determine if statistical models for prediction of chest injuries would outperform the clinician's (MD) ability to identify injured patients at risk for a thoracic injury diagnosed by chest radiograph (CXR). DESIGN: A prospective observational study was done during a 12-month period. SETTING: The study was conducted in a level I trauma center. PATIENTS: Injured patients meeting trauma team activation criteria were enrolled to the study. INTERVENTIONS: Physical examination findings by a clinician were interpreted and CXR was performed. OUTCOME MEASURES: The accuracy of 2 mathematical models is compared against the accuracy of clinician's clinical judgment in predicting an injury by CXR. Two newly constructed multivariate models, binary logistic regression (LR) and classification and regression tree (CaRT) analysis, are compared to previously published data of clinician clinical assessment of probability of thoracic injury identified by CXR. RESULTS: Data for 757 patients were analyzed. Classification and regression tree analysis developed a stepwise decision tree to determine which signs/symptoms were indicative of an abnormal CXR finding. The sensitivity (CaRT, 36.6%; LR, 36.3%; MD, 58.7%), specificity (CaRT, 98.3%; LR, 98.2%; MD, 96.4%), and error rates (CaRT, 0.93; LR, 0.94; MD, 0.82) show that the mathematical decision aids are less sensitive and risk more misclassification compared to clinician judgment in predicting an injury by CXR. CONCLUSION: Clinician judgment was superior to mathematical decision aids for predicting an abnormal CXR finding in injured patients with chest trauma.

Socioeconomic factors, medicolegal issues, and trauma patient transfer trends: Is there a connection?

BACKGROUND: A number of forces have come together to effect a perceived change in the volume and nature of transfers to Level I trauma centers recently. These may have little to do with the actual clinical need. This study seeks to verify whether a change in the profile of trauma transfers has occurred and to characterize the nature of any changes. METHODS: Retrospective review of state trauma registry data from 1999 through 2003 including day and time of transfer, Injury Severity Score (ISS), primary ICD-9, payor status, and mortality. The transfer group (TTP) was compared with the general population of trauma patients (ATP) and variables trended. Analysis employed descriptive statistics and logistic regression. Average malpractice insurance premium charges and measures of subspecialty surgeon participation in trauma care were also trended. RESULTS: During the study period ATP increased by 6% and TTP by 34%. The majority of transfers were from Level II to Level I trauma centers. Mean ISS increased from 9.1 to 10.0 (1.2%) in ATP and from 11.3 to 12.8 (2%) in TTP. The mortality rate over time was essentially unchanged for both groups; 4% ATP versus 5% TTP. Proportion of self-pay patients in each group remained relatively static between 20% to 25%. The number of patients with head injury (HI) increased by 14%, their transfer rate increased by 44%. Orthopedic injury (OI) prevalence increased 25% whereas transfers increased by 48%. Mean ISS increased from 13.7 to 14.8 and 11.1 to 12.9, respectively. The variables most significant for predicting transfer were arrival at initial emergency department between 3:00 pm and 7:00 am and OI or HI. Concomitantly, the mean malpractice insurance premium paid by general, orthopedic, and neurosurgeons each rose by approximately 90% during the study period. Waivers of regulatory compliance were requested by 28% of trauma centers (72% Level II) with 39% of requests related to lack of neurosurgery services. CONCLUSION: During the study period, a disproportionate increase in TTP occurred in comparison to ATP. This finding is more pronounced in patients with HI and OI. Findings do not appear attributable to changes in severity or proportion of self payors. The ISS of TTP is below 16. Concomitantly, there was a precipitous rise in malpractice premiums and a functional decrease in neurosurgeons. This suggests a multifactorial reluctance or inability of initial hospitals to care for patients they are theoretically capable of treating, placing undo burden on Level I centers.

Nutritional gain versus financial gain: The role of metabolic carts in the surgical ICU.

BACKGROUND: Adequate nutritional replacement of critically ill and injured patients is of paramount importance, as it decreases infectious morbidity and mortality. However, multiple methods of determining nutritional requirements exist, including mathematical formulas, weight based calculations, and the use of metabolic cart measurements, the latter of which is associated with significant labor and equipment costs. We hypothesized that metabolic cart measurements, despite increasing the cost of care, would more accurately determine nutritional requirements in a critically ill population than formulaic or weight-based calculations. METHODS: Consecutive metabolic cart measurements were prospectively obtained on 59 critically ill surgery and trauma patients, and compared with predicted values as determined by the Harris-Benedict equation and weight-based calculations. Comparison was made to actual resting energy expenditure data acquired via indirect calorimetry data obtained from serial metabolic carts. RESULTS: There were 59 patients who formed the study population, with 37% of the population having two or more metabolic cart readings (total number of cart readings was 106). There was no statistically significant difference between the metabolic cart results, the predicted resting energy expenditure as calculated by the Harris-Benedict equation adjusted with a factor of 1.5, and a weight based calculation at 30 kcal/kg adjusted body weight. Metabolic requirements were stable over time (4-48 days) without significant variation. Nutritional parameters, as evaluated by the visceral proteins prealbumin and transferrin significantly increased with time in injured patients. CONCLUSIONS: Either 30 kcal/kg adjusted body weight or the resting energy expenditure calculated from the Harris-Benedict equation multiplied by 1.5 adequately predicts the nutritional requirements of critically ill surgery and trauma patients. The addition of metabolic cart data does not provide any additional information in the determination of caloric needs in the critically ill and injured patient. In this population, omission of metabolic cart data would have saved 33,000 dollars without adversely affecting patient outcome.

Trauma surgeons practice what they preach: The NTDB story on solid organ injury management.

BACKGROUND: Recent studies advocate a nonoperative approach for hepatic and splenic trauma. The purpose of this study was to determine whether the literature has impacted surgical practice and, if so, whether or not the overall mortality of these injuries had changed. METHODS: The American College of Surgeons' National Trauma Data Bank (NTDB 4.0) was analyzed using trauma admission dates ranging from 1994 to 2003. All hepatic and splenic injuries were identified by ICD-9 codes. As renal trauma management has not changed during the study period, renal injuries were included as a control. Nonoperative management (NOM) rates and overall mortality were determined for each organ. Proportions were compared using chi analysis with significance set at p < 0.05. RESULTS: There were 87,237 solid abdominal organ injuries reported and included: 35,767 splenic, 35,510 hepatic, 15,960 renal injuries. There was a significant (p < 0.00000000005) increase in percentage of NOM for hepatic and splenic trauma whereas renal NOM remained stable for the study period. Despite an increase in NOM for splenic and hepatic injuries, mortality has remained unchanged. CONCLUSIONS: This study demonstrates that the management of hepatic and splenic injuries has significantly changed in the past 10 years with no appreciable effect on mortality. NOM has become the standard of care for the management of hepatic and splenic trauma. The NTDB can be used to monitor changes in trauma care in response to new knowledge regarding improved outcomes.

Ventilator-associated pneumonia, like real estate: location really matters.

INTRODUCTION: Previous work has demonstrated an increased risk of ventilator-associated pneumonia (VAP) in trauma patients after prehospital (field) intubation as compared with emergency department (ED) intubations. However, this population was not compared with patients intubated as inpatients, making data interpretation difficult. We sought to further examine predictors for the development of VAP after trauma. METHODS: A 10-year retrospective review of all patients mechanically ventilated greater than 24 hours after injury was performed. RESULTS: In all, 1,628 patients were identified, of which 1,213 (75%) were intubated as inpatients and 415 were emergently intubated (353 ED, 62 field). Overall, those intubated emergently were younger (p = 0.03) and less injured as seen by higher Glasgow Coma Scale scores (p = 0.0002), lower Injury Severity Scores (p = 0.01) and higher Revised Trauma Scores (p < 0.0001). Despite a lower injury severity, those patients emergently intubated were more likely to develop pneumonia as 22% of ED intubations and 15% of field intubations developed pneumonia, as compared with the inpatient rate of 6.5%. Pneumonia after field intubation was more likely to be community-acquired (p < 0.0001) with a significantly lower percentage of infecting enteric gram-negative rods (p < 0.0001) as compared with the inpatient and ED groups. Forward logistic regression analysis (with VAP = 1) identified inpatient intubation as protective against VAP (odds ratio 0.28, 95% CI = 0.2-0.4). Backwards logistic regression analysis further identified both field airway (odds ratio 2.29, 95% CI = 1.1-4.9) and ED airway (odds ratio 3.61, 95% CI = 2.5-5.2) as predictive of VAP. CONCLUSIONS: Compared with a population of trauma patients as inpatients, and excluding those patients mechanically ventilated less than 24 hours, patients intubated in the ED or field have a higher incidence of pneumonia, despite equivalent or lower injury severity.

Predictors of the need for nephrectomy after renal trauma.

BACKGROUND: Initial management of solid organ injuries in hemodynamically stable patients is nonoperative. Therefore, early identification of those injuries likely to require surgical intervention is key. We sought to identify factors predictive of the need for nephrectomy after trauma. METHODS: This is a retrospective review of renal injuries admitted over a 12-year period to a Level I trauma center. RESULTS: Ninety-seven patients (73% male) sustained a kidney injury (mean age, 27 +/- 16; mean Injury Severity Score, 13 +/- 10). Of the 72 blunt trauma patients, 5 patients (7%) underwent urgent nephrectomy, 3 (4%) had repair and/or stenting, and 89% were observed despite a 29% laparotomy rate for associated intraabdominal injuries in this group. Twenty-five patients with penetrating trauma underwent eight nephrectomies (31%), one partial nephrectomy, and two renal repairs. Regardless of the mechanism of injury, patients requiring nephrectomy were in shock, had a higher 24-hour transfusion requirement, and were more likely to have a high-grade renal laceration (all p < 0.05). Bluntly injured patients requiring nephrectomy had more concurrent intraabdominal injuries (p < 0.0001). Overall, patients after penetrating trauma were more severely injured, had higher 24-hour transfusion requirements, and a higher nephrectomy rate (all p < 0.05). Despite a higher injury severity in the penetrating group, however, mortality was higher in the bluntly injured group (p < 0.0001). Univariate predictors for nephrectomy included: revised trauma score, injury severity score, Glasgow Coma Scale score, shock on presentation, renal injury grade, and 24-hour transfusion requirement. No patient with a mild or moderate renal injury required nephrectomy, whereas 6 of 12 (50%) grade 4 injuries and 7 of 8 (88%) grade 5 injuries required nephrectomy. Multiple logistic regression analysis confirmed penetrating injury, renal injury grade, and Glasgow Coma Scale score as predictive of nephrectomy. CONCLUSION: Overall, injury severity, severity of renal injury grade, hemodynamic instability, and transfusion requirements are predictive of nephrectomy after both blunt and penetrating trauma. Nephrectomy is more likely after penetrating injury.

Implementing computerized provider order entry with an existing clinical information system.

BACKGROUND: There are numerous barriers to successfully implementing computerized provider order entry (CPOE), and it is not entirely clear to what degree the proposed benefits extend to older, commercially available systems in place at most hospitals. METHODS: In 2000, Loyola University Health System leadership chartered a project to implement CPOE for hospitalized patients' medications. The impact of CPOE on workflow was analyzed before implementation. Hardware availability was ensured and input screens were customized for users when possible. A formal education and communication plan was implemented to help reduce resistance to change. RESULTS: Full implementation took 20 months. Transcription-related errors per month decreased by 97% from 72.4 to 2.2 per month. During the pilot period, prescribing-related errors increased by 22% from 150 per month to 184 per month-and subsequently decreased to an average of 80 per month, a 47% reduction compared with the baseline error rate. Pharmacist time saved was estimated at 23 hours per month. DISCUSSION: Using an existing CPOE system can provide an affordable, intermediate step on the journey toward implementing a new, state-of-the-art system that provides advanced clinical decision support.

Half-a-dozen ribs: the breakpoint for mortality.

BACKGROUND: We hypothesized that the number of rib fractures independently impacted patient pulmonary morbidity and mortality. METHODS: The National Trauma Data Bank (NTDB, v. 3.0 American College of Surgeons, Chicago, IL) was queried for patients sustaining 1 or more rib fractures. Data abstracted included the number of rib fractures by International Classification of Diseases-9 code, Injury Severity Score, the occurrence of pneumonia, acute respiratory distress syndrome, pulmonary embolus, pneumothorax, aspiration pneumonia, empyema, and associated injuries by abbreviated injury score, the need for mechanical ventilation, number of ventilator days, intensive care unit (ICU) length of stay (LOS), hospital LOS, mortality, and use of epidural analgesia. Statistical analysis was performed using the Student t test and linear regression analysis. Statistical significance was defined as a P value of less than .05. RESULTS: The NTDB included 731,823 patients. Of these, 64,750 (9%) had a diagnosis of 1 or more fractured ribs. Thirteen percent (n = 8,473) of those with rib fractures developed 13,086 complications, of which 6,292 (48%) were related to a chest-wall injury. Mechanical ventilation was required in 60% of patients for an average of 13 days. Hospital LOS averaged 7 days and ICU LOS averaged 4 days. The overall mortality rate for patients with rib fractures was 10%. The mortality rate increased (P < .02) for each additional rib fracture. The same pattern was seen for the following morbidities: pneumonia (P < .01), acute respiratory distress syndrome (P < .01), pneumothorax (P < .01), aspiration pneumonia (P < .01), empyema (P < .04), ICU LOS (P < .01), and hospital LOS for up to 7 rib fractures (P < .01). An association between increasing hospital LOS and number of rib fractures was not shown (P = .19). Pulmonary embolism also was not related to the number of rib fractures (P = .06). Epidural analgesia was used in 2.2% (n = 1,295) of patients with rib fractures. A reduction in mortality with epidural analgesia was shown at 2, 4, and 6 through 8 rib fractures. The use of epidural analgesia had no impact on the frequency of pulmonary complications. When stratifying data by Injury Severity Score and the presence or absence of rib fractures the mortality rates were similar. CONCLUSIONS: Increasing the number of rib fractures correlated directly with increasing pulmonary morbidity and mortality. Patients sustaining fractures of 6 or more ribs are at significant risk for death from causes unrelated to the rib fractures. Epidural analgesia was associated with a reduction in mortality for all patients sustaining rib fractures, particularly those with more than 4 fractures, but this modality of treatment appears to be underused.