Vagueness in Goals-of-Care Conferences for Critically Ill Patients: Types of Hedge Language Used by Physicians.

OBJECTIVES: Hedge language is a category of language that refers to words or phrases that make statements "fuzzier." We sought to understand how physicians use hedge language during goals-of-care conferences in the ICU. DESIGN: Secondary analysis of transcripts of audio-recorded goals-of-care conferences in the ICU. SETTING: Thirteen ICUs at six academic and community medical centers in the United States. PATIENTS: Conferences were between clinicians and surrogates of incapacitated, critically ill adults. INTERVENTIONS: Four investigators performed a qualitative content analysis of transcripts using deductive followed by inductive methods to identify types of hedge language used by physicians, then coded all instances of hedge language across 40 transcripts to characterize general patterns in usage. MEASUREMENTS AND MAIN RESULTS: We identified 10 types of hedge language: numeric probabilistic statement ("there's an 80% chance"), qualitative probabilistic statement ("there's a good chance"), nonprobabilistic uncertainty statement ("hard to say for her"), plausibility shield ("we expect"), emotion-based statement ("we're concerned"), attribution shield ("according to Dr. X"), adaptor ("sort of"), metaphor ("the chips are stacking up against her"), time reference ("too soon to tell"), and contingency statement ("if we are lucky"). For most types of hedge language, we identified distinct subtypes. Physicians used hedge language frequently in every transcript (median: 74 hedges per transcript) to address diagnosis, prognosis, and treatment. We observed large variation in how frequently each type and subtype of hedge language was used. CONCLUSIONS: Hedge language is ubiquitous in physician-surrogate communication during goals-of-care conferences in the ICU and can be used to introduce vagueness to statements in ways beyond expressing uncertainty. It is not known how hedge language impacts decision-making or clinician-surrogate interactions. This study prioritizes specific types of hedge language for future research based on their frequency and novelty.

A National Evaluation of Emergency General Surgery Outcomes Among Hospitalized Cardiac Patients.

INTRODUCTION: Emergency general surgery among cardiac surgery patients is increasingly common and consequential. We sought to characterize the true burden of emergency general surgery among hospitalized complex cardiac patients. METHODS: We performed a retrospective analysis of the 2016-2017 National Inpatient Sample. We included adult patients with a primary diagnosis of complex cardiac disease. We then compared patients who underwent emergency general surgery (GS-OR) with those who did not (non-GS-OR). The primary outcome was mortality; secondary outcomes included length of stay and hospitalization costs. RESULTS: We identified 10.2 million patients with a primary diagnosis of complex cardiac disease, of which 148,309 (1.4%) underwent GS-OR. Mortality rates were significantly higher in the GS-OR group (11.0% versus 5.0%, P < 0.001). Among all cardiac patients, GS-OR was associated with 2.2 times increased odds of death (aOR: 2.2, P < 0.001). GS-OR patients also had longer length of stays (14.1 versus 5.8 d, P < 0.001). Among all cardiac patients, GS-OR was associated with an 8.1-day longer length of stay (P < 0.001). GS-OR patients were less often routinely discharged home (31.7% versus 45.3%, P < 0.001) and incurred higher inpatient costs ($46,136 versus $16,303, P < 0.001). Among all cardiac patients, GS-OR patients incurred $30,102 higher hospitalization costs (P < 0.001). CONCLUSIONS: Emergency general surgery among cardiac surgery patients is associated with a greater than two-fold increase in mortality, longer length of stays, higher rates of nonroutine discharge, and higher hospitalization costs. Emergency general surgery complications account for 4.0% of total inpatient costs of cardiac surgery patients and merit further study.

Building a Trainee-led Research Community to Propel Academic Productivity in Health Services Research.

Academic productivity is an increasingly important asset for trainees pursuing academic careers. Medical schools and graduate medical education programs offer structured research programs, but providing longitudinal and individualized health services research education remains challenging. Whereas in basic science research, members at multiple training levels support each other within a dedicated community (the laboratory), health services research projects frequently occur within individual faculty-trainee relationships. An optimal match of expertise, availability, and interest may be elusive for an individual mentor-mentee pair. We aimed to share our experience building Surgeons Writing about Trauma (SWAT), a trainee-led research community that propels academic productivity by facilitating peer collaboration and opportunities to transition into independent researchers. We highlight challenges of health services research for trainees, present how structured mentorship and a peer community can address this challenge, and detail SWAT's operational structure to guide replication at peer institutions.

Prospective study of long-term quality-of-life after rib fractures.

BACKGROUND: Long-term quality-of-life after rib fractures remains understudied. We aimed to evaluate quality-of-life of patients who had rib fractures 1 year after discharge. We hypothesized that patients with rib fractures, even as an isolated injury, have suboptimal long-term quality-of-life. METHODS: We prospectively enrolled adults admitted to our level 1 trauma center with acute rib fractures. Primary outcome was quality-of-life at 1 year after discharge, characterized using the revised trauma-specific quality-of-life questionnaire and a supplemental survey. Secondary analysis evaluated association between baseline frailty (measured using the Rib Fracture Frailty Index) and quality-of-life. Patients with low versus moderate frailty risk underwent full matching and linear mixed model analysis. RESULTS: We enrolled 139 patients, among whom 72 (52%) completed 1-year surveys. Patients reported excellent emotional well-being (median [interquartile range]: 4.8 [3.7-5.0]) and functional engagement (median [interquartile range]: 5.0 [4.3-5.0]) but poor physical well-being and recovery (median [interquartile range]: 3.2 [2.8-3.6]). Nearly 40% of patients reported some degree of rib pain, and 29% had not returned to preinjury working capacity. Patients with and without isolated rib fractures reported similar median revised trauma-specific quality-of-life scores. We did not find statistically significant association between low versus moderate frailty and any quality-of-life domain, but no patients in our cohort had high frailty risk and our study was underpowered to detect this association. CONCLUSION: Rib fractures are associated with suboptimal quality-of-life 1 year after discharge, even after isolated injury. Our sample size was limited, but our findings highlight persistent long-term consequences of rib fractures despite advances in inpatient management. Patients should be counseled on the potential for prolonged convalescence.

Prospective study of short-term quality-of-life after traumatic rib fractures.

BACKGROUND: Postdischarge convalescence after traumatic rib fractures remains unclear. We hypothesized that patients with rib fractures, even as an isolated injury, have associated poor quality of life (QoL) after discharge. METHODS: We prospectively enrolled adult patients at our level I trauma center with rib fractures between July 2019 and January 2020. We assessed QoL at 1 and 3 months after discharge using the Trauma-specific Quality-of-Life (T-QoL; 43-question survey evaluating five QoL domains on a 4-point Likert scale, where 4 indicates optimal and 1, worst QoL) and supplementary questionnaires. We used generalized estimating equations to assess T-QoL score trends over time and effect of age, sex, injury pattern, self-perceived injury severity, and Injury Severity Score. RESULTS: We enrolled 139 patients (108 completed the first and 93 completed both surveys). Three months after discharge, 33% of patients were not working at preinjury capacity, and 7% were still using opioid analgesia. Suffering rib fractures mostly impacted recovery and resilience (T-QoL score, mean [robust standard error] at 1 month, 2.7 [0.1]; 3 months, 3.0[0.1]) and physical well-being domains (1 month, 2.5 [0.1]; 3 months, 2.9[0.1]). Quality of life improved over time across all domains. Compared with patients who perceived their injuries as mild/moderate, patients who perceived their injuries as severe/very severe reported worse T-QoL scores across all domains. In contrast, Injury Severity Score did not affect QoL. Patients 65 years or older (-0.6 [0.1]) and women (-0.6 [0.2]) reported worse functional engagement compared with those 65 years or older and men, respectively. CONCLUSION: We found that patients with traumatic rib fractures experience suboptimal QoL after discharge. Quality of life improved over time, but even 3 months after discharge, patients reported challenges performing activities of daily living, slower-than-expected recovery, and not returning to work at preinjury capacity. Perception of injury severity had a large effect on QoL. Patients with rib fractures may benefit from close short-term follow-up. LEVEL OF EVIDENCE: Prognostic and epidemiological, level III.

Mobile application-based guidelines to enhance patient care and provider education in trauma and acute care surgery.

INTRODUCTION: Providing up-to-date, universally accessible care guidelines and education within a quaternary care center is challenging. At our institution, trauma and acute care surgery guidelines have historically been published using a paper-based format. Mobile application-based guidelines were developed to address the shortcomings of paper-based guidelines. METHODS: We assessed the utility, usability, and satisfaction of healthcare providers towards paper-based versus mobile application-based guidelines. A survey was administered to providers within the emergency department and intensive care unit. RESULTS: Fifty of 137 providers responded (36.5% response rate). Nearly half (47.4%, 9 of 19) of those who received a copy of the paper-based guidelines lost the guidelines at least once. Regarding usage of the mobile application-based guidelines, 92.6% (25 of 27) were aware of the application; 92.6% (25 of 27) considered the application comprehensive, 85.2% (23 of 27) thought the application was organized, and 66.7% (18 of 27) thought the application was easy to use. Additionally, 88.9% (24 of 27) found the application moderately, very, or extremely helpful and 85.2% (23 of 27) judged the application moderately, very, or extremely necessary. Overall, 88.9% (24 of 27) were satisfied with the application and indicated likeliness to recommend to a colleague. Seventeen of 27 (63.0%) agreed or strongly agreed that the application improved their provision of trauma and acute care. CONCLUSION: This survey demonstrates positive usability, utility, and satisfaction among trauma healthcare providers with the mobile application-based guidelines. Additionally, this quality improvement initiative highlights the importance of having comprehensive, organized, and easy-to-use trauma and acute care surgery guidelines and targeted educational materials available on demand. The successful transition from paper to mobile application-based guidelines serves as a model for other institutions to modernize and improve patient care and provider education. LEVEL OF EVIDENCE: IV.

Traumatic Injuries Due to Interpersonal and Domestic Violence in the United States.

BACKGROUND: Domestic and intimate partner violence (DV) are under-reported causes of injury. We describe the health care utilization of DV patients, hypothesizing they are at increased risk of mortality. METHODS: We queried the 2014 Nationwide Emergency Department Sample for adult patients (18 y and older) with a primary diagnosis of trauma. DV was abstracted using International Statistical Classification of Diseases, ninth Revision codes for partner or spouse intimate violence, abuse, or neglect. The primary outcome was mortality; secondary outcomes included admission rates and charges. RESULTS: Among 14 million trauma patients, 654,356 (5.0%) had a diagnosis of DV. Compared with other trauma patients, DV patients were younger (34.6 versus 46.8 y, P < 0.001), more often male (69.5% versus 50.1%, P < 0.001), and more likely to be uninsured (31.5% versus 15.6%, P < 0.001). 9154 (1.4%) were injured because of intimate partner violence, of which 90.2% were female. Drug and alcohol abuse (22.2%), anxiety (1.8%), and depression (1.3%) were high among all DV trauma patients. DV emergency department charges were higher ($4462 versus $2,871, P < 0.001). In adjusted analyses, DV trauma patients had 2.1 higher odds of mortality (aOR: 2.31, P < 0.001). DV trauma patients were also associated with a $1516 increase in emergency department charges compared with non-DV trauma patients (95% CI: $1489-$1,542, P < 0.001). CONCLUSIONS: Injuries related to all types of DV are emerging as a public health crisis among both genders. To mitigate under-reporting, it is important to identify at-risk patients and provide them with appropriate resources.

The "T's" of snakebite injury in the USA: fact or fiction?

BACKGROUND: Venomous snakebites can result in serious morbidity and mortality. In the USA, the "T's of snakebites" (testosterone, teasing, touching, trucks, tattoos & toothless (poverTy), Texas, tequila, teenagers, and tanks) originate from anecdotes used to colloquially highlight venomous snakebite risk factors. We performed an epidemiologic assessment of venomous snakebites in the USA with the objective of evaluating the validity of the "T's of snakebites" at a national level. METHODS: We performed a retrospective analysis of the National Emergency Department Sample. Data from January 1, 2016 to December 31, 2016 were obtained. All emergency department (ED) encounters corresponding to a venomous snakebite injury were identified using the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes. Primary outcomes were mortality and inpatient admission. Demographic, injury, and hospital characteristics were assessed. Data were analyzed according to survey methodology. Weighted values are reported. RESULTS: In 2016, 11 138 patients presented to an ED with a venomous snakebite. There were 4173 (37%) persons aged 18 to 44, and 7213 (65%) were male. Most snakebites were reported from the South (n=9079; 82%), although snakebites were reported from every region in the USA. Only 3792 (34%) snakebites occurred in rural counties. Persons in the lowest income quartile by zip code were the most heavily represented (n=4337; 39%). The most common site of injury was the distal upper extremity (n=4884; 44%). Multivariate analysis revealed that species of snake (OR=0.81; 95% CI 0.73 to 0.88) and older age (OR=1.42; 95% CI 1.08 to 1.87) were associated with hospital admission. There were <10 inpatient deaths identified, and no variables were predictive of death. DISCUSSION: Some of the "T's of snakebites" may be valid colloquial predictors of the risk for venomous snakebites. Based on national data, common demographics of venomous snakebite victims include lower income, Caucasian, and adult men in the South who are bit on the upper extremity. Understanding common demographics of venomous snakebite victims can effectuate targeted public health prevention messaging. LEVEL OF EVIDENCE: IV.