Pediatric Trauma Care Disparities: Association of Race and Sex With High Acuity Trauma Hospital Admissions.

INTRODUCTION: For adult trauma patients, the likelihood of receiving treatment at a hospital properly equipped for trauma care can vary by race and sex. This study examines whether a pediatric patient's race/ethnicity and sex are associated with treatment at a high acuity trauma hospital (HATH). MATERIALS AND METHODS: Using the 2017 National Inpatient Sample, we identified pediatric trauma patients ( ≤16 y) using International Classification of Diseases-10 codes. Because trauma centers are not defined in National Inpatient Sample, we defined HATHs as hospitals which transferred 0% of pediatric neurotrauma. We used logistic regression to examine associations between race/ethnicity, sex, age, and treatment at a HATH, adjusted for factors including Injury Severity Score, mechanism of injury, and region. RESULTS: Of 18,085 injured children (median Injury Severity Score 3 [IQR 1-8]), 67% were admitted to a HATH. Compared to White patients, Hispanic (odds ratio [OR] 0.85 [95% confidence interval [CI] 0.79-0.93]) and other race/ethnicity patients (OR 0.85 [95% CI 0.78-0.93]) had a significantly lower odds of treatment at a HATH. Children aged 2-11 (OR 1.36 [95% CI 1.27-1.46]) were more likely to be treated at a HATH compared to adolescents (age 12-16). After adjustment for other factors, sex was not associated with treatment at a HATH. CONCLUSIONS: Our study demonstrated racial and ethnic disparities in access to HATHs for pediatric trauma patients. Hispanic and other race/ethnicity pediatric trauma patients have lower odds of treatment at HATHs. Further research is needed to study the root causes of these disparities to ensure that all children with injuries receive equitable and high-quality care.

Prehospital tourniquet application in extremity vascular trauma: Improved functional outcomes.

BACKGROUND: Support for prehospital tourniquet use has increased, with recent data suggesting that tourniquet usage decreases shock without increasing limb complications. We hypothesized that prehospital tourniquet application in extremity vascular trauma, compared with no prehospital tourniquet application, is associated with lower rates of delayed amputation and better functional mobility. METHODS: We retrospectively studied adult patients with extremity vascular trauma at an urban civilian Level 1 trauma center (June 2016-May 2021). Outcomes of interest included delayed amputation and mobility at hospital discharge, measured by the Activity Measure for Post-Acute Care "6 Clicks" Basic Mobility Score. The "6 Clicks" Basic Mobility Score was documented by physical therapy; higher scores indicate more independent mobility. Injury mechanism, initial lactate, 24-hour transfusions, mortality, and acute kidney injury were also collected. Comparisons were performed using χ2 analysis and Fisher Exact and Wilcoxon rank-sum tests. RESULTS: Of 232 patients, prehospital tourniquet application was not associated with mortality or lactate level (both P > .05). The prehospital tourniquet application group had more transfusions, lower rates of acute kidney injury, and fewer delayed amputations (all P < .05). Ninety-one patients (45 prehospital tourniquet application and 46 without prehospital tourniquet application) were evaluated for "Moving between Bed and Chair" in the "6 Clicks" Basic Mobility Score, with patients in the prehospital tourniquet application group demonstrating higher levels of independence (P = .034). CONCLUSION: Prehospital tourniquet application was associated with favorable outcomes, including higher functional mobility and decreased delayed amputation. This suggests that tourniquet use should be encouraged in the civilian setting to improve outcomes and reduce the risk of limb loss.

Feeling like an imposter: are surgeons holding themselves back?

Imposter syndrome is a psychological phenomenon where people doubt their achievements and have a persistent internalized fear of being exposed as a fraud, even when there is little evidence to support these thought processes. It typically occurs among high performers who are unable to internalize and accept their success. This phenomenon is not recognized as an official mental health diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; however, mental health professionals recognize it as a form of intellectual self-doubt. It has been reported that imposter syndrome is predominant in the high-stakes and evaluative culture of medicine, where healthcare workers are frequently agonized by feelings of worthlessness and incompetence. Imposter syndrome can lead to a variety of negative effects. These can include difficulty concentrating, decreased confidence, burnout, anxiety, stress, depression, and feelings of inadequacy. This article will discuss the prevalence of imposter syndrome among surgeons, its associated contributing factors, the effects it can have, and potential strategies for managing it. The recommended strategies to address imposter syndrome are based on the authors' opinions.

Burnout in Trauma Surgeons During the COVID-19 Pandemic: a Long-standing Problem Worsens.

Purpose of Review: Physician burnout is well-described in the literature. We analyze the effects of the COVID-19 pandemic on burnout in trauma and acute care surgeons (TACS). Recent Findings: Along with other healthcare workers and trainees, TACS faced unprecedented clinical, personal, and professional challenges in treating a novel pathogen and were uniquely affected due to their skillset as surgeons, intensivists, and leaders. The pandemic and its consequences have increased burnout and are suspected to have worsened PTSD and moral injury among TACS. The healthcare system is just beginning to grapple with these problems. Summary: COVID-19 significantly added to the pre-existing burden of burnout among TACS. We offer prevention and mitigation strategies. Furthermore, to build upon the work done by individuals and organizations, we urge that national institutions address burnout from a regulatory standpoint.

Home Medication Regimens Increase in Complexity After Admission for Fall in the Older Trauma Patient.

BACKGROUND: Hospitalization for the older trauma patient is an opportunity to assess polypharmacy. We hypothesized that medication regimen complexity (RxCS) and pain medication prescriptions (PRxs) would increase in older home-going patients admitted for a fall. METHODS: We retrospectively chart reviewed patients ≥45 years old admitted for a fall at a level 1 trauma center who were discharged home with full medication documentation. RxCS was compared pre-admission and post-discharge with Wilcoxon signed-rank tests; opioid and non-opioid PRxs were compared with Fisher's exact test, α = .05. RESULTS: 103 patients met inclusion criteria; 58% were ≥65 years old. RxCS (9 [.5-13] to 11 [4.5-15], P < .01) increased on discharge. Opioid PRx rates increased significantly in all age groups. Non-opioid PRx rates increased significantly for patients <65 but not for patients ≥65. CONCLUSIONS: Admission for a fall was associated with increases in RxCS, while PRx changes were age-dependent. Providers should recognize that admissions for older patients who fall after trauma are underutilized opportunities to address polypharmacy in high-risk patients.

And Miles to Go Before We Sleep: EAST Diversity and Inclusivity Progress and Remaining Challenges.

OBJECTIVE: The aim of this study was to examine the diversity, equity, and inclusion landscape in academic trauma surgery and the EAST organization. SUMMARY BACKGROUND DATA: In 2019, the Eastern Association for the Surgery of Trauma (EAST) surveyed its members on equity and inclusion in the #EAST4ALL survey and assessed leadership representation. We hypothesized that women and surgeons of color (SOC) are underrepresented as EAST members and leaders. METHODS: Survey responses were analyzed post-hoc for representation of females and SOC in academic appointments and leadership, EAST committees, and the EAST board, and compared to the overall respondent cohort. EAST membership and board demographics were compared to demographic data from the Association of American Medical Colleges. RESULTS: Of 306 respondents, 37.4% identified as female and 23.5% as SOC. There were no significant differences in female and SOC representation in academic appointments and EAST committees compared to their male and white counterparts. In academic leadership, females were underrepresented ( P < 0.0001), whereas SOC were not ( P = 0.08). Both females and SOC were underrepresented in EAST board membership ( P = 0.002 and P = 0.043, respectively). Of EAST's 33 presidents, 3 have been white women (9%), 2 have been Black, non-African American men (6%), and 28 (85%) have been white men. When compared to 2017 AAMC data, women are well-represented in EAST's 2020 membership ( P < 0.0001) and proportionally represented on EAST's 2019-2020 board ( P > 0.05). CONCLUSIONS: The #EAST4ALL survey suggests that women and SOC may be underrepresented as leaders in academic trauma surgery. However, lack of high-quality demographic data makes evaluating representation of structurally marginalized groups challenging. National trauma organizations should elicit data from their members to re-assess and promote the diversity landscape in trauma surgery.

History of Equity, Diversity, and Inclusion in Trauma Surgery: for Our Patients, for Our Profession, and for Ourselves.

Purpose of Review: Disparities exist in outcome after injury, particularly related to race, ethnicity, socioeconomics, geography, and age. The mechanisms for this outcome disparity continue to be investigated. As trauma care providers, we are challenged to be mindful of and mitigate the impact of these disparities so that all patients realize the same opportunities for recovery. As surgeons, we also have varied professional experiences and opportunities for achievement and advancement depending upon our gender, ethnicity, race, religion, and sexual orientation. Even within a profession associated with relative affluence, socioeconomic status conveys different professional opportunities for surgeons. Recent Findings: Fortunately, the profession of trauma surgery has undergone significant progress in raising awareness of patient and professional inequity among trauma patients and surgeons and has implemented systematic changes to diminish these inequities. Herein we will discuss the history of equity and inclusion in trauma surgery as it has affected our patients, our profession, and our individual selves. Summary: Our goal is to provide a historical context, a status report, and a list of key initiatives or objectives on which all of us must focus. In doing so, the best possible clinical outcomes can be achieved for patients and the best professional and personal "outcomes" can be achieved for practicing and future trauma surgeons.

Do new trauma centers provide needed or redundant access? A nationwide analysis.

BACKGROUND: Our prior research has demonstrated that increasing the number of trauma centers (TCs) in a state does not reliably improve state-level injury-related mortality. We hypothesized that many new TCs would serve populations already served by existing TCs, rather than in areas without ready TC access. We also hypothesized that new TCs would also be less likely to serve economically disadvantaged populations. METHODS: All state-designated adult TCs registered with the American Trauma Society in 2014 and 2019 were mapped using ArcGIS Pro (ESRI Inc., Redlands, CA). Trauma centers were grouped as Level 1 or 2 (Lev12) or Level 3, 4 or 5 (Lev345). We also obtained census tract-level data (73,666 tracts), including population counts and percentage of population below the federal poverty threshold. Thirty-minute drive-time areas were created around each TC. Census tracts were considered "served" if their geographic centers were located within a 30-minute drive-time area to any TC. Data were analyzed at the census tract level. RESULTS: A total of 2,140 TCs were identified in 2019, with 256 new TCs and 151 TC closures. Eighty-two percent of new TCs were Levels 3 to 5. Nationwide, coverage increased from 75.3% of tracts served in 2014 to 78.1% in 2019, representing an increased coverage from 76.0% to 79.4% of the population. New TC served 17,532 tracts, of which 87.3% were already served. New Lev12 TCs served 9,100 tracts, of which 91.2% were already served; new Lev345 TCs served 15,728 tracts, of which 85.9% were already served. Of 2,204 newly served tracts, those served by Lev345 TCs had higher mean percentage poverty compared with those served by Lev12 TCs (15.7% vs. 13.2% poverty, p < 0.05). DISCUSSION: Overall, access to trauma care has been improving in the United States. However, the majority of new TCs opened in locations with preexisting access to trauma care. Nationwide, Levels 3, 4, and 5 TCs have been responsible for expanding access to underserved populations. LEVEL OF EVIDENCE: Prognostic and Epidemiologic; Level IV.

Race and trauma mortality: The effect of hospital-level Black-White patient race distribution.

BACKGROUND: Race-related health disparities have been well documented in the United States. In some settings, Black patients have better outcomes in hospitals that serve high proportions of Black patients. We hypothesized that Black trauma patients would have lower mortality in high Black-serving (H-BS) hospitals. METHODS: We identified all adult patients with Black or White race and with an Injury Severity Score of ≥4 from the 2017 National Inpatient Sample. We collected hospital identifier, mechanism, age, sex, comorbidities, urban-rural location, insurance, zip code income quartile, and injury severity calculated from International Classification of Diseases, Tenth Revision, codes. We used a previously published method to group hospitals by proportion of Black patients served: HB-S (top 5%), medium Black serving (5-25%), and low Black serving (L-BS; bottom 75%). Adjusted logistic regression using an interaction variable between race and hospital service rank (reference: White patients in H-BS) was used to identify factors associated with mortality. RESULTS: We analyzed 184,080 trauma patients (median age, 72 years [interquartile range, 55-84 years]; Injury Severity Score, 9 [4-10]), of whom 11.7% were Black. Overall mortality was 4%. Of 2,376 hospitals, 126 (5.3%) were H-BS and 469 (19.7%) were medium Black serving. Furthermore, 29.8% of Black and 3.6% of White patients were treated at H-BS hospitals, while 71.7% of White and 23.6% of Black patients were treated at L-BS hospitals (p < 0.001). Black patients had the lowest mortality at H-BS hospitals (odds ratio [OR], 0.76 [0.64-0.92]) and the highest mortality (OR, 1.43 [1.13-1.80]) at L-BS hospitals. White patients had the lowest mortality at L-BS hospitals (OR, 0.76 [0.64-0.92]). CONCLUSION: After adjusting for patient and hospital factors, disparities exist such that Black and White patients have the best outcomes in hospitals that treat those patients most frequently, suggesting potential for racial bias at the institutional level. Further efforts must be made to promote equitable treatment at all hospitals and reduce these disparities. LEVEL OF EVIDENCE: Prognostic and Epidemiologic; Level IV.

Variations in Discharge Destination Following Severe Traumatic Brain Injury across the United States.

BACKGROUND: Discharge destination after traumatic brain injury (TBI) may be influenced by non-patient factors such as regional or institutional practice patterns. We hypothesized that non-patient factors would be associated with discharge destination in severe TBI patients. METHODS: All patients in the ACS Trauma Quality Improvement Program 2016 data set with severe TBI, defined as head Abbreviated Injury Scale ≥3, were categorized by discharge destination. Logistic regression was used to assess factors associated with each destination; odds ratios and 95% confidence level are reported. Regressions were adjusted for age, gender, race, insurance, GCS, ISS, polytrauma, mechanism, neurosurgical procedure, geographic region, teaching status, trauma center level, hospital size, and neurosurgeon group size. RESULTS: 75,690 patients met inclusion criteria. 51% were discharged to home, 16% to rehab, 14% to SNF, and 11% deceased. Mortality was similar across geographic region, teaching status, and hospital size. Southern patients were more likely to be discharged to home while Northeastern patients were more likely to be discharged to rehab. Treatment by groups of 3 or more neurosurgeons was associated with SNF discharge as was treatment at community or non-teaching hospitals. Patients treated at larger hospitals were less likely to be discharged to rehab and more likely to go to SNF. CONCLUSIONS: Geographic region, neurosurgeon group size, teaching status, and hospital size are significantly associated with variation in discharge destination following severe TBI. Regional and institutional variation in practice patterns may play important roles in recovery for some patients with severe TBI.

"What Are My Injuries?" Health Literacy and Patient Comprehension of Trauma Care and Injuries.

BACKGROUND: Trauma patients often have complex injuries treated by multidisciplinary providers with wide-ranging expertise. We hypothesized that trauma patients would frequently incorrectly identify both their injuries and care teams. We also hypothesized that low health literacy level would be correlated with low levels of comprehension about injuries or care teams. MATERIALS AND METHODS: We performed a prospective study of adult trauma inpatients >18 years. Participants were surveyed to report on 1) injured body regions 2) their care teams, and 3) health literacy via a validated survey. Self-reported injuries and care teams were compared to the patient's medical record. We also studied whether health literacy was associated with patient knowledge of injuries and care teams. RESULTS: Fifty participants were surveyed; thirty-two percent could not identify ≥50% of their injuries. Patients reliably identified injuries to the head, but injuries to other body areas were often misidentified. Forty-two percent of patients were not able to identify ≥50% of their medical teams, and 28% could not identify ≥75% of their medical teams. Patients often did not recognize teams such as nutrition, physical/occupationalt, or social work as part of their care. Thirteen participants reported adequate health literacy. Health literacy was not related to participant knowledge of injuries or care teams (both P = 0.9). CONCLUSION: Many trauma inpatients were unable to correctly identify their injuries and care teams despite a range of self-reported health literacy scores.

Is more better? Do statewide increases in trauma centers reduce injury-related mortality?

OBJECTIVES: Trauma centers are inconsistently distributed throughout the United States. It is unclear if new trauma centers improve care and decrease mortality. We tested the hypothesis that increases in trauma centers are associated with decreases in injury-related mortality (IRM) at the state level. METHODS: We used data from the American Trauma Society to geolocate every state-designated or American College of Surgeons-verified trauma center in all 50 states and the District of Columbia from 2014 to 2018. These data were merged with publicly available IRM data from the Centers for Disease Control and Prevention. We used geographic information systems methods to map and study the relationships between trauma center locations and state-level IRM over time. Regression analysis, accounting for state-level fixed effects, was used to calculate the effect of total statewide number of trauma center on IRM and year-to-year changes in statewide trauma center with the IRM (shown as deaths per additional trauma center per 100,000 population, p value). RESULTS: Nationwide between 2014 and 2018, the number of trauma center increased from 2,039 to 2,153. Injury-related mortality also increased over time. There was notable interstate variation, from 1 to 284 trauma centers. Four patterns in statewide trauma center changes emerged: static (12), increased (29), decreased (5), or variable (4). Of states with trauma center increases, 26 (90%) had increased IRM between 2014 and 2017, while the remaining 3 saw a decline. Regression analysis demonstrated that having more trauma centers in a state was associated with a significantly higher IRM rate (0.38, p = 0.03); adding new trauma centers was not associated with changes in IRM (0.02, p = 0.8). CONCLUSION: Having more trauma centers and increasing the number of trauma center within a state are not associated with decreases in state-level IRM. In this case, more is not better. However, more work is needed to identify the optimal number and location of trauma centers to improve IRM. LEVEL OF EVIDENCE: Epidemiologic, level III; Care management, level III.

Opioids and Injury Deaths: A population-based analysis of the United States from 2006 to 2017.

INTRODUCTION: In the United States, the opioid epidemic claims over 130 lives per day due to overdoses. While the use of opioids in trauma patients has been well-described in the literature, it is unknown whether prescription opioid use is associated with mortality after trauma. We hypothesized that legally obtained prescription opioid consumption would be positively associated with injury-related deaths in the United States. METHODS: Cross-sectional time-series data was compiled using state-level mortality data from the Centers for Disease Control and Prevention Multiple Causes of Death database and prescription opioid shipping data to each state using the US Department of Justice Automated Reports and Consolidated Ordering System Retail Drug Summary reports from 2006 to 2017, with opioids shipped used as a proxy for local opioid consumption. Oxycodone and hydrocodone amounts were converted to morphine equivalent doses (MEDs). Our primary outcome was an association between MEDs and injury mortality rates at the state-level. We analyzed total injury-related deaths and subgroups of unintentional deaths, suicides, and homicides. We modeled the data using fixed effects regression to reduce bias from unmeasured differences between states. RESULTS: Data were available for all states and the District of Columbia. Opioid deliveries increased through 2012 and then declined. Total injury-related mortalities have been increasing steadily since 2012. Opioid MEDs did not show a consistent or statistically significant relationship with injury-related mortality, including with any subgroups of unintentional deaths, suicides, and homicides. CONCLUSION: In every state examined, there was no consistent relationship between the amount of prescription opioids delivered and total injury-related mortality or any subgroups, suggesting that there is not a direct association between prescription opioids and injury-related mortality. This is the first study to combine national mortality and opioid data to investigate the relationship between legally obtained opioids and injury-related mortality. The US opioid epidemic remains a significant challenge that requires ongoing attention from all stakeholders in our medical and public health systems.

Can educational videos reduce opioid consumption in trauma inpatients? A cluster-randomized pilot study.

BACKGROUND: Opioids are often used to treat pain after traumatic injury, but patient education on safe use of opioids is not standard. To address this gap, we created a video-based opioid education program for patients. We hypothesized that video viewing would lead to a decrease in overall opioid use and morphine equivalent doses (MEDs) on their penultimate hospital day. Our secondary aim was to study barriers to video implementation. METHODS: We performed a prospective pragmatic cluster-randomized pilot study of video education for trauma floor patients. One of two equivalent trauma floors was selected as the intervention group; patients were equally likely to be admitted to either floor. Nursing staff were to show videos to English-speaking or Spanish-literate patients within 1 day of floor arrival, excluding patients with Glasgow Coma Scale score less than 15. Opioid use and MEDs taken on the day before discharge were compared. Intention to treat (ITT) (intervention vs. control) and per-protocol groups (video viewers vs. nonviewers) were compared (α = 0.05). Protocol compliance was also assessed. RESULTS: In intention to treat analysis, there was no difference in percent of patients using opioids or MEDs on the day before discharge. In per-protocol analysis, there was no different in percent of patients using opioids on the day before discharge. However, video viewers still on opioids took significantly fewer MEDs than patients who did not see the video (26 vs. 38, p < 0.05). Protocol compliance was poor; only 46% of the intervention group saw the videos. CONCLUSION: Video-based education did not reduce inpatient opioid consumption, although there may be benefits in specific subgroups. Implementation was hindered by staffing and workflow limitations, and staff bias may have limited the effect of randomization. We must continue to establish effective methods to educate patients about safe pain management and translate these into standard practices. LEVEL OF EVIDENCE: Therapeutic, Level IV.

Variation in neurosurgical intervention for severe traumatic brain injury: The challenge of measuring quality in trauma center verification.

BACKGROUND: Intracranial pressure monitor (ICPm) procedure rates are a quality metric for American College of Surgeons trauma center verification. However, ICPm procedure rates may not accurately reflect the quality of care in TBI. We hypothesized that ICPm and craniotomy/craniectomy procedure rates for severe TBI vary across the United States by geography and institution. METHODS: We identified all patients with a severe traumatic brain injury (head Abbreviated Injury Scale, ≥3) from the 2016 Trauma Quality Improvement Program data set. Patients who received surgical decompression or ICPm were identified via International Classification of Diseases codes. Hospital factors included neurosurgeon group size, geographic region, teaching status, and trauma center level. Two multiple logistic regression models were performed identifying factors associated with (1) craniotomy with or without ICPm or (2) ICPm alone. Data are presented as medians (interquartile range) and odds ratios (ORs) (95% confidence interval). RESULTS: We identified 75,690 patients (66.4% male; age, 59 [36-77] years) with a median Injury Severity Score of 17 (11-25). Overall, 6.1% had surgical decompression, and 4.8% had ICPm placement. Logistic regression analysis showed that region of the country was significantly associated with procedure type: hospitals in the West were more likely to use ICPm (OR, 1.34 [1.20-1.50]), while Northeastern (OR, 0.80 [0.72-0.89]), Southern (OR, 0.84 [0.78-0.92]), and Western (OR, 0.88 [0.80-0.96]) hospitals were less likely to perform surgical decompression. Hospitals with small neurosurgeon groups (<3) were more likely to perform surgical intervention. Community hospitals are associated with higher odds of surgical decompression but lower odds of ICPm placement. CONCLUSION: Both geographic differences and hospital characteristics are independent predictors for surgical intervention in severe traumatic brain injury. This suggests that nonpatient factors drive procedural decisions, indicating that ICPm rate is not an ideal quality metric for American College of Surgeons trauma center verification. LEVEL OF EVIDENCE: Epidemiological, level III; Care management/Therapeutic level III.

Equity on the frontlines of trauma surgery: An #EAST4ALL roundtable.

BACKGROUND: Inequity exists in surgical training and the workplace. The Eastern Association for the Surgery of Trauma (EAST) Equity, Quality, and Inclusion in Trauma Surgery Ad Hoc Task Force (EAST4ALL) sought to raise awareness and provide resources to combat these inequities. METHODS: A study was conducted of EAST members to ascertain areas of inequity and lack of inclusion. Specific problems and barriers were identified that hindered inclusion. Toolkits were developed as resources for individuals and institutions to address and overcome these barriers. RESULTS: Four key areas were identified: (1) harassment and discrimination, (2) gender pay gap or parity, (3) implicit bias and microaggressions, and (4) call-out culture. A diverse panel of seven surgeons with experience in overcoming these barriers either on a personal level or as a chief or chair of surgery was formed. Four scenarios based on these key areas were proposed to the panelists, who then modeled responses as allies. CONCLUSION: Despite perceived progress in addressing discrimination and inequity, residents and faculty continue to encounter barriers at the workplace at levels today similar to those decades ago. Action is needed to address inequities and lack of inclusion in acute care surgery. The EAST is working on fostering a culture that minimizes bias and recognizes and addresses systemic inequities, and has provided toolkits to support these goals. Together, we can create a better future for all of us.

Downstream hospital system effects of a comprehensive trauma recovery services program.

BACKGROUND: Trauma patients are often noted to have poor compliance but high recidivism and readmission rates. Participation in a trauma recovery services (TRS) program, which provides peer support and other psychosocial resources, may impact the trajectory of patient recovery by decreasing barriers to follow-up. We hypothesized that TRS participants would have greater downstream nonemergent use of our hospital system over the year following trauma, manifested by more positive encounters, fewer negative encounters, and lower emergency department (ED) charges. METHODS: We studied trauma survivors (March 2017 to March 2018) offered TRS. Hospital encounters and charges 1 year from index admission were compared between patients who accepted and declined TRS. Positive encounters were defined as outpatient visits and planned admissions; negative encounters were defined as no shows, ED visits, and unplanned admissions. Charges were grouped as cumulative ED and non-ED charges (including outpatient and subsequent admission charges). Adjusted logistic and linear regression analyses were used to identify factors associated with positive/negative encounters and ED charges. RESULTS: Of 511 identified patients (68% male; injury severity score, 14 [9-19]), 362 (71%) accepted TRS. Trauma recovery services patients were older, had higher injury severity, and longer index admission length of stay (all p < 0.05). After adjusting for confounders, TRS patients were more likely to have at least one positive encounter and were similarly likely to have negative encounters as patients who declined services. Total aggregate charges for this group was US $74 million, of which US $30 million occurred downstream of the index admission. Accepting TRS was associated with lower ED charges. CONCLUSION: A comprehensive TRS program including education, peer mentors, and a support network may provide value to the patient and the health care system by reducing subsequent care provided by the ED in the year after a trauma without affecting nonemergent care. LEVEL OF EVIDENCE: Therapeutic/care management, level IV.

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

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

Factors Influencing Nonadherence to Recommended Postdischarge Follow-Up After Trauma.

INTRODUCTION: Historically, trauma patients have low adherence to recommended outpatient follow-up plans, which is crucial for improved long-term clinical outcomes. We sought to identify characteristics associated with nonadherence to recommended outpatient follow-up visits. METHODS: This is a single-center retrospective examination of inpatient trauma survivors admitted to a level 1 trauma center (March 2017-March 2018). Patients with known alternative follow-up were excluded. All outpatient visits within 1 y from the index admission were identified. The primary outcome was nonadherence, which was noted if a patient failed to follow-up for any specialty recommended in the discharge instructions. Factors for nonadherence studied included age, injury severity score, mechanism, length of stay, number of referrals made, and involvement with a Trauma Recovery Services program. Bivariate and logistic regression analyses were performed. RESULTS: A total of498 patients were identified (69% men, median age 43 y [range, 26-58 y], median injury severity score 14 [range, 9-19]). Among them, 240 (47%) were nonadherent. The most common specialties recommended were orthopedic surgery (56% referred, 19% nonadherent), trauma (54% referred, 35% nonadherent), and neurosurgery (127 referred, 35% nonadherent). Lowest levels of follow-up were seen for nonsurgical referrals. In adjusted analysis, a higher number of referrals made (odds ratio [OR], 2.45; 95% confidence interval [CI], 1.95-3.05) and older age (OR, 1.01; 95% CI, 1.00-1.02) were associated with nonadherence. Trauma Recovery Service participants and penetrating trauma patients were more likely to be adherent (OR, 0.60; 95% CI, 0.37-0.97). CONCLUSIONS: The largest contributor to nonadherence was the number of referrals made; patients who were referred to multiple specialists were more likely to be nonadherent. Peer support services may lower barriers to follow-up.

Grade of injury, not initial management, is associated with unplanned interventions in liver injury.

INTRODUCTION: Risk factors for complications after liver injury do not distinguish between patients undergoing selective non-operative management (sNOM) vs operative management (OM) as the initial treatment strategy. Our objective was to identify risk factors for complications requiring an unplanned intervention following sNOM or OM. We hypothesized that patient undergoing sNOM will have fewer unplanned interventions. METHODS: Adults presenting to a level I trauma center with grade III or higher liver injury over a period of 6 years were reviewed. Patient and injury factors, initial management strategy, subsequent complications and interventions were obtained. Bivariate analysis was performed between patients undergoing sNOM vs OM to determine factors associated with unplanned interventions, defined as intervention >48 h after injury. Logistic regression was performed to identify independent risk factors for unplanned interventions. RESULTS: 191 patients were identified: 105 (55%) grade III, 64 (34%) grade IV, and 22 (12%) grade V injury; 136 (71%) underwent sNOM and 55 (29%) underwent OM. 21 (15%) patients required an unplanned intervention: 26 percutaneous drainage, 10 ERCP, and 3 angiography; 12 had multiple procedures. Male gender, younger age, higher ISS, higher grade of injury, firearm mechanism, and initial OM (all p < 0.05) were associated with unplanned interventions. Firearm mechanism and injury grade IV and V, but not initial OM, were independent risk factors for an unplanned intervention. CONCLUSIONS: Grade of liver injury, not the initial mode of treatment, was significantly associated with requiring an unplanned intervention for liver-related complications. Surveillance at 7-10 days, or prior to discharge, in the high-risk group may be able to capture those requiring unplanned intervention and readmission.