CHaMP: A Model for Building a Center to Support Health Care Worker Well-Being After Experiencing an Adverse Event.

BACKGROUND: With an already distressed health care workforce demonstrating high levels of burnout, depression, and suicide, access to behavioral health care, particularly after an adverse event, is critical. Unfortunately, clinicians identify multiple barriers to seeking behavioral support. In 2022 the National Academy of Medicine, in its National Plan for Health Workforce Well-Being, established "Support Mental Health and Reduce Stigma" as one of its seven priority areas. FRAMEWORK: The authors developed a program called CHaMP (Center for Healthy Minds and Practice) guided by a multidisciplinary task force that developed the vision, plan, and algorithms to improve crisis response; build a peer support program; and remove barriers to accessing mental health care by establishing an on-campus behavioral health support center. This program was implemented using Kotter's 8-step Model of Change. RESULTS: Within the first months of establishing this program, the support team responded to multiple activations of the crisis response plan, built a peer support program, and provided counseling services to 631 employees. During the COVID-19 pandemic, CHaMP played a central role in the support of all employees. CONCLUSION: This program and its implementation based on Kotter's 8-Step Model of Change was a powerful and practical methodology to design and implement interventions to address system and individual factors that affect clinician well-being and resilience after an adverse event.

Comparative Analysis of Radiology Trainee Burnout Using the Maslach Burnout Inventory and Oldenburg Burnout Inventory.

BACKGROUND: Burnout is an individualized response to imbalances between job demands and resources that has predominantly been evaluated with the Maslach Burnout Inventory (MBI). There are other instruments not validated among healthcare providers that may be comparable to the MBI. Utilizing alternative measurements can allow researchers to assess wellness with a larger array of questions. OBJECTIVE: We explored differences between the MBI- Human Services Survey for Medical Personnel (MBI-HSS [MP]) and Oldenburg Burnout Inventory (OLBI) in evaluating emotional exhaustion (EE)/exhaustion and depersonalization (DP)/disengagement. METHODS: We administered the MBI-HSS (MP) and OLBI to United States (US) radiology trainees during three,1-month intervals in April 2018, October 2018, and April 2019. Student's T-tests or ANOVA was used to evaluate differences between demographic groups and burnout scores in the MBI-HSS (MP) and OBLI. Non-inferiority analysis was completed to evaluate if the OBLI was not inferior to the MBI-HSS (MP) in how its subscales measure exhaustion and disengagement. The MBI-HSS (MP) subtotals for EE and DP were compared with the OLBI scores for exhaustion and disengagement using two-tailed paired T-tests for each trainee. RESULTS: Of 2823 trainees emailed, 770 (27.3%) responded. The mean EE Maslach score was 21/54, and the mean DP Maslach score was 8/30. The average OBLI exhaustion and disengagement score was 2.38 and 2.22, respectively. Comparative analysis of completed MBI-HSS (MP) and OLBI subscales yielded no significant difference between the EE/exhaustion (t(496)=1.038; p=0.30) or DP/disengagement (t(498)=0.084; p=0.933) subscales. CONCLUSIONS: Our national study of radiology trainees demonstrated that the OLBI was not inferior in assessing exhaustion and disengagement to the EE and DP subscales of the MBI-HSS (MP).

Dimensions of hospital workplace violence: Patient violence towards the healthcare team.

AIMS AND OBJECTIVES: To investigate the cognitive dimensions nurses use when perceiving patient-to-healthcare provider workplace violence. BACKGROUND: The concept of workplace violence, especially with respect to healthcare settings, has been well documented. Healthcare workers are at particular risk for experiencing violence from their patients, though these incidents often go unreported. Experiencing violence in the workplace has been associated with numerous negative outcomes, including absenteeism, burnout and diminished quality of care. However, little emphasis has been placed on understanding the concept of violence itself, or why one type of violence might go unreported whilst another is readily communicated to officials. DESIGN: A card-sorting, multidimensional scaling design. METHODS: Thirty two nurses completed the card-sorting task. Using multidimensional scaling (MDS), 75 reported incidents of violence were considered. SPIRIT research reporting checklist followed. RESULTS: Nurses categorise patient violence in three dimensions: physical versus verbal, active versus threatening and more versus less severe. Implications for further research and intervention are discussed. CONCLUSIONS: Violence in the hospital workplace is a complex perception by the healthcare worker that cannot be captured by a single dimension. RELEVANCE TO CLINICAL PRACTICE: This study provides a theoretical framework for understanding the complexity of patient-to-provider violence in a hospital setting. It sheds light on why only a minority of such events are reported. This model can serve as a foundation for future research exploring interventions for hospital violence.

Exploration of the Relationship Between the Subcomponents of Burnout Throughout Radiology Training.

PURPOSE: The aim of this study was to investigate the relationship between the subcomponents of burnout and year of training among radiology residents. METHODS: In this cross-sectional analysis, the Maslach Burnout Inventory Human Services Survey for Medical Personnel (MBI-HSS [MP]) was distributed to eligible United States (US) radiology residents. Primary outcomes included the MBI-HSS (MP) subcomponents: emotional exhaustion (EE), depersonalization (DP), and personal accomplishment (PA). Multivariate analysis of variance, tests of between-subjects effects, and Tukey post hoc analysis with 95% confidence interval were conducted. RESULTS: A total of 770 of 2,823 residents (27.3%) responded, with 488 of 770 completing the MBI-HSS (MP). There was a statistically significant difference in subcomponent scores between cohorts based on year of training (P < .005) and a statistically significant effect between year of training and EE (P < .05) and DP (P < .005), but not PA. Third-year (R3) residents reported a higher frequency of EE than first-year (R1) residents and a higher frequency of DP than R1 and second-year (R2) residents. Fourth-year (R4) residents reported more DP than R1 residents. CONCLUSIONS: This analysis shows variation in burnout subcomponents during training, with the highest recorded EE and DP means and lowest recorded PA means among R3 residents. Although these findings demonstrate evidence of burnout among radiology residents, mean subcomponent scores for EE (21.3) and DP (8.4) were lower and for PA (35.1) was higher for all trainees than in previous studies assessing radiology residents, which correlates with less burnout. DP was the only subcomponent that remained statistically elevated between matriculating R1 and graduating R4 residents.

Predictors Between the Subcomponents of Burnout Among Radiology Trainees.

OBJECTIVE: The aim of this study was to investigate the effect of various predictors on burnout among radiology residents during their training. METHODS: In this cross-sectional analysis, we distributed the Maslach Burnout Index for Medical Personnel (MBI-HSS [MP]) to eligible United States (US) radiology residents. Covariates of interest included age, child status, debt burden, partner status, and self-identified gender. Primary outcomes include MBI-HSS (MP) subcomponent scores - emotional exhaustion (EE), depersonalization (DP), and personal accomplishment (PA). Mann-Whitney tests were used to compare averages between groups. RESULTS: Out of the 770 of 2823 residents (27.3%) who responded, 488 of 770 completed the MBI-HSS (MP). During the R1 year, male sex was associated with marginally higher PA scores (36.5 versus 33.5; P = .029). Having children or a partner was associated with lower EE scores (18.7 versus 26.8, P = .012; 22 versus 28.9, P = .022, respectively) and higher PA scores (37 vs 32.7, P = .024; 35 versus 31.3, P = .039, respectively) among the R3 cohort. Reporting debt < $200,000 was associated with lower EE scores among the R3 (21.2 versus 27.3, P = .028) and R4 (16.4 versus 21.9, P = .033) cohort. DISCUSSION: There are several predictors of burnout that transiently impact residents at different years of training and primarily impact EE or PA, but not DP scores. R3 residents' scores are most sensitive to these covariates.

Minimally Invasive Ivor Lewis Esophagectomy (MILE): technique and outcomes of 100 consecutive cases.

BACKGROUND: Esophagectomy is the mainstay of therapy for esophageal cancer but is a complex operation that is associated with significantly high morbidity and mortality rates. The primary aim of this study is to report our perioperative outcomes, and long-term survival of Minimally Invasive Ivor Lewis Esophagectomy (MILE). METHODS: IRB approved retrospective study of 100 consecutive patients who underwent elective MILE from September 2013 to November 2017 at University of Florida, Jacksonville. RESULTS: Primary diagnosis was esophageal cancer (n = 96) and benign esophageal disease (n = 4). Anastomotic leak rate was observed in 6%; 30- and 90-day mortality rates were 2% and 3%, respectively. The mean length of hospital stay was 10.3 days; 87 patients were discharged to home, while 12 patients were discharged to rehabilitation facility, and there was one in-hospital mortality secondary to graft necrosis. At a mean follow-up was 37 months (2-74), the 3- and 5-year overall survivals are 63.9 ± 5.0% (95% CI 53.3-72.7%) and 60.5 ± 5.3% (95% CI 49.4-69.9%), respectively. The 3- and 5-year disease-free survival is 75.0 ± 4.8% (95% CI 64.2-83.0%) and 70.4 ± 5.5% (95% CI 58.0-80.0%). CONCLUSION: MILE can be performed with low perioperative mortality, and favorable long-term overall and disease-free survival.

Psychological Prophylaxis: An Integrated Psychological Services Program in Trauma Care.

The primary medical goals of acute care are restoration of physical health and return to physical function. However, in response to traumatic events and injuries, psychological factors are critical to one's overall recovery. Both pre-morbid psychiatric comorbidities and post-injury psychological compromise affect physical and psychological recovery in inpatient trauma populations. The Psychological Services Program (PSP), a model trauma/acute care program, addresses these critical factors in a Level 1 Trauma Center. The program routinely treats over one-quarter of the trauma patients at any given time. The incorporation of the PSP into treatment team care ensures that patients in need of mental health support can be identified and treated during their recovery. This unique model is recommended as a potential injury prevention and recovery intervention strategy for the myriad mental health comorbidities that may function as risk factors for poor post-injury adaptation and also as risk factors for possible future traumatic injury.

Nursing Professional Development Anti-Bullying Project.

This article describes a nursing professional development, evidence-based intervention project addressing the significant problem of bullying in the nursing workplace. The project entailed a 9-week, multitiered approach to teach behaviors to combat bullying and create the self-efficacy to do so. Results demonstrated statistically significant t-test comparisons of pre- and postsurvey measures, supporting the clinical question that empowerment and perceptual change drove individual and group behavior to confront bullying and create a positive culture shift.

Comparative Analysis of State Trauma Triage Criteria vs. Paramedic Discretion.

OBJECTIVE: The Florida Adult Trauma Triage Criteria (FATTC) define specific parameters concerning injury mechanism and physiologic data that prompt paramedics to initiate a trauma alert and necessitate transport to a trauma center. In the state of Florida, paramedics are also given discretion to bring patients to the trauma center who do not meet those criteria. Our aim was to compare the injury characteristics and outcomes of adult patients who were evaluated in our trauma center after activation due to FATTC criteria vs. paramedic discretion (PD) and to identify predictors of PD. METHODS: This retrospective study included all patients 18 years and older evaluated in our trauma center from January 1, 2007, to December 31, 2014. Descriptive statistics were computed for all variables. Bivariate and multivariate analyses were performed to compare demographic, injury severity, and outcome differences between groups. RESULTS: A total of 13,963 patients met FATTC during the study period, and 1,811 were brought in by PD. PD patients had lower injury severity and crude mortality. Regression modeling of demographic and injury variables found that only the combination of older age and higher heart rate predicted PD when both were lower than FATTC alone. CONCLUSIONS: While PD patients were less seriously injured and had lower mortality, they experienced similar lengths of stay and resource utilization after presentation. Paramedics may be able to identify patients at risk for poor outcomes who would otherwise not be captured by FATTC.

How Safe Is the Safety Net? Comparison of Ivor-Lewis Esophagectomy at a Safety-Net Hospital Using the NSQIP Database.

BACKGROUND: Recent data suggest that surgical outcomes at hospitals caring for low-income, vulnerable populations are suboptimal compared with outcomes from nonsafety-net hospitals. Therefore, the purpose of our study was to compare outcomes for patients who underwent an Ivor-Lewis esophagectomy at a safety-net hospital with the National Surgical Quality Improvement Program (NSQIP) database. STUDY DESIGN: We retrospectively reviewed the medical records of consecutive patients who underwent an Ivor-Lewis esophagectomy, between September 2013 and January 2017, at a single safety-net hospital. Patient characteristics and outcomes were compared with the 2013 to 2015 NSQIP database. Continuous variables were compared using Student's t-test, and categorical variables were analyzed using chi-square tests. Values of p < 0.05 were considered significant. RESULTS: We identified 78 patients from the safety-net hospital and 1,825 patients in the NSQIP database who underwent an Ivor-Lewis esophagectomy. Baseline characteristics were similar, except the safety-net hospital patients were more likely to have COPD (19.2% vs 8.1%; p = 0.001) and be current smokers (42.3% vs 26.0%; p = 0.001); patients in the NSQIP group had a higher BMI (28 kg/m2 vs 26 kg/m2; p = 0.001). There were no differences between groups for mortality, readmission, discharge destination, or mean operative time. Safety-net hospital patients had significantly fewer complications (16.7% vs 33.3%; p = 0.003), fewer reoperations (6.4% vs 14.5%; p = 0.046), and shorter hospital length of stay (10.3 vs 13.1 days; p = 0.001). CONCLUSIONS: Patients who underwent an Ivor-Lewis esophagectomy at a safety-net hospital had fewer complications and reoperations, and a shorter hospital length of stay compared with a national cohort. These findings illustrate the value of clinical pathways in optimizing the patient outcomes at safety-net hospitals and providing excellent care to their vulnerable patient population.

Superomedial pedicle reduction mammaplasty: increased resection weight does not increase nipple necrosis.

BACKGROUND: The superomedial pedicle (SMP) reduction mammaplasty offers several advantages over more traditional operative techniques, such as retained sensation to the nipple areola complex (NAC) and improved preservation of long-term breast shape. However, many surgeons believe that using the SMP can cause an increase in NAC necrosis rates up to 13.1%, especially in large volume reductions. The aims of this paper are to determine the rate of nipple necrosis when performing an SMP reduction mammaplasty at our institution and establish if there is a difference in those rates based on the weight of tissue removed. We then compared our overall rate of nipple necrosis to those found using a systematic review of literature involving other pedicles to determine if this technique is equivalent to more commonly used methods. METHODS: We performed a retrospective chart review of patients who underwent breast reduction surgery using SMP at a single institution between May 1, 2013, and May 1, 2015. Each breast was counted separately, and the weight of the tissue removed was recorded. Six-mo follow-up data were analyzed using the chi-square analysis to compare rates of NAC necrosis among our patients and historical cohorts. RESULTS: One hundred thirty-five breasts (70 patients) met inclusion criteria. Patients had a mean resection weight per breast of 1016.7 g (±478.3). There was an NAC necrosis rate of 0% in the groups where 1200 g or less of tissue were removed and 2.3% (n = 1) in the group where greater than 1200 g of tissue were removed. We found no statistically significant difference in the rate of NAC necrosis with increased resection weights, (P = 0.32). The overall rate of NAC necrosis for this study was 0.7% per breast, which is equivalent to the rates found during the systematic review of literature. CONCLUSIONS: In this study, the SMP breast reduction technique shows a low rate of NAC. We found no statistically significant increase in NAC necrosis rates as the volume of tissue removed increases, and the SMP appears to have an overall rate of NAC necrosis similar to more commonly used pedicles. Although the results of this study may be related to patient selection or surgical technique, we believe that this pedicle preserves the breast's main blood supply so that less tissue ischemia occurs.

Analysis of Mortality in Traumatically Injured Patients Based on Body Mass Index and Mechanism Reveals Highest Mortality among the Underweight in Comparison with the Ideal Weight Patients.

The purpose of this study was to evaluate the effect of body mass index (BMI) on mortality after traumatic injury. The records of patients from 2012 to 2015 were retrospectively reviewed. The patients were stratified into the following groups based on admission BMI (kg/m2): underweight (UW) (BMI <19), ideal weight (IW) (BMI = 19-24.9), overweight (OW) (BMI = 25-29.9), obese (OB) (BMI = 30-39.9), and morbid obese (MO) (BMI >40). The groups were well matched with no significant differences in demographics and Injury Severity Score. Morality for the IW group was compared with the remaining BMI groups. A total of 6049 patients were identified. In comparison with IW group, the UW mortality was significantly higher (IW vs UW, 4.1% vs 8.8%, P = 0.001); however, the there was no significant difference with remaining groups. There was also no significant difference in mortality between IW and the remaining groups for patients that went directly to the operating room or for patients that had penetrating trauma (stab wounds and gunshot wounds). However, for blunt trauma, the mortality was significantly higher for UW (IW vs UW, 4.3% vs 9.4%, P = 0.001), no different for IW vs OW (4.3% vs 3.7%, P = 0.3), and significantly lower for IW vs OB (4.3% vs 2.8%, P = 0.04) and for IW vs MO (4.3% vs 1.0%, P = 0.03). After traumatic injuries, it is the underweight patients (BMI <19) and not the obese, that are at a significantly higher risk for overall mortality; this difference is especially evident after blunt trauma where obesity may actually confer a protective role.

An evaluation of trauma outcomes related to insurance status in patients requiring prehospital helicopter transport.

INTRODUCTION: Disparities in access to medical care and outcomes of medical treatment related to insurance status are documented. However, little attention has been given to the effect of health care funding status on outcomes in trauma patients. Hypothesis/Problem This study evaluated if adult trauma patients who arrived by air transport to a trauma center had different clinical outcomes based on their health insurance status. METHODS: A retrospective analysis was performed of all adult trauma patients arriving by prehospital flight services to a Level I Trauma Center over a 5-year period. Patients were classified as unfunded or funded based on health insurance status. Injury severity scores (ISS) were compared, while the end points evaluated in the study included duration of stay in the intensive care unit (ICU), duration of hospitalization, and mortality. RESULTS: A total of 1,877 adult patients met inclusion criteria for the study, with 14% (n = 259) classified as unfunded and 86% (n = 1,618) classified as funded. Unfunded patients compared to funded patients had a significantly lower average ISS (12.82 vs 15.56; P < .001) but a significantly higher mortality rate (16.6% vs 10.7%; P < .01) and a 1.54 relative risk of death (95% CI, 1.136-2.098). Neither mean ICU stay (3.44 days vs 4.98 days; P = .264) nor duration of hospitalization (11.18 days vs 13.34 days; P = .382) was significantly different when controlling for ISS. CONCLUSION: Unfunded health insurance status is associated with worse outcomes following less significant injury. Further investigation of baseline health disparities for identification and early intervention may improve outcomes. Additionally, these findings may have implications for the health systems of other countries that lack universal health care coverage.

An analysis of shock index as a correlate for outcomes in trauma by age group.

BACKGROUND: Shock index as the ratio of heart rate to systolic blood pressure is a simple triage tool that correlates well with various outcomes in trauma patients. Concern has been raised regarding the accuracy of shock index in older patients. We sought to investigate the effects of age on the accuracy of shock index. METHODS: This is a retrospective review of data from a level I trauma center. Shock index was calculated for 16,269 patients, and they were stratified into age groups by decade. The correlation between prehospital shock index for each of the age groups and for several outcome variables were evaluated by Pearson correlation coefficients. Logistic regression was used to evaluate an increase in shock index during transit and its relationship with mortality. RESULTS: All correlation values for patients between 16 and 60 years of age were positive (P < .05). In patients who are older than 80 years, none of the correlations with the outcome variables were statistically significant. In patients older than 60 years, an increased shock index during transit correlated with an increase in mortality rates. CONCLUSION: As expected, prehospital shock index alone has diminishing accuracy for patients older than 60 years of age and should be interpreted cautiously by trauma triage personnel. Shock index alone in patients younger than 60, and its increase during transit in patients older than 60, can be used as a valuable tool for the prehospital triage of trauma patients when determining the need for transport to a trauma center, preparation of resources, or activation of the trauma team.

Pediatric trauma patients are more likely to be discharged from the emergency department after arrival by helicopter emergency medical services.

BACKGROUND: Despite faster transport times, concern about the safety of medical helicopters has led to scrutiny in the national media. Few criteria exist for the use of helicopter emergency medical services (HEMS). This study evaluated if pediatric trauma patients transported by HEMS from the injury scene were more likely to be discharged from the emergency department and more likely to be less severely injured based on Injury Severity Score (ISS) compared with adult patients. METHODS: Retrospective data were obtained from the trauma registry at our Level I trauma center between July 1, 2005, and June 30, 2009. Trauma patients arriving by HEMS from the injury scene were included. χ(2) was used to compare the discharge rate and the ISS (divided into 0-15 and 16-75) of the adult and pediatric populations. Pediatric patients were those younger than 16 years. RESULTS: A total of 2,897 trauma patients were transported by HEMS. A total of 247 (9%) were pediatric patients, and 2,650 (91%) were adults. Among the pediatric patients, 23% were discharged, and 77% were admitted. Of the adult patients, discharge occurred in 16%, and 84% were admitted. Comparison of the discharge rate between pediatric and adult patients revealed a significantly higher proportion of discharge among the pediatric patients (p < 0.01). Among the pediatric patients, 72% had an ISS of 0 to 15, and 28% had an ISS of 16 to 75. Among the adult patients, 55% had an ISS of 0 to 15, and 45% had an ISS of 16 to 75. Comparison of these groups revealed a statistically significantly lower ISS in the pediatric group (p < 0.01). CONCLUSION: Consistent with a lower severity of injury, pediatric trauma patients transported by HEMS were more likely to be discharged directly from the emergency department when compared with adult patients. LEVEL OF EVIDENCE: Epidemiologic study, level III.

Proficiency of surgical faculty and residents with ethical dilemmas: is modeling enough?

OBJECTIVE: Professionalism, an Accreditation Commission for Graduate Medical Education (ACGME) competency, embraces the concept of adherence to ethical principles. Despite this, most surgical residencies do not currently include ethics as part of their core curriculum. Further, expertise in effectively managing ethical dilemmas is frequently obtained via modeling after the attending physician. This study evaluated surgical faculty (SF) and residents (SR) on their understanding of basic ethical principles and their overall confidence in translation of these principles into clinical practice. The objective was to determine if there are any differences in the overall levels of knowledge and confidence in ethics between SR and SF. DESIGN AND SETTING: Immediately before the first session of a Kamangar Grant supported monthly Ethics Forum, all SF and SR completed a Pre-Curriculum Questionnaire (PCQ) on their knowledge about ethical principles and their confidence in dealing with ethical issues. PQC contained 13 multiple-choice and true/false knowledge questions and 8 questions evaluating confidence rated on a 5-point Likert scale. PARTICIPANTS: Surgical faculty (SF) (n = 16) and SR (n = 36). Knowledge and confidence scores were compared between SR and SF, using Student t-test analysis to evaluate differences between groups. RESULTS: No significant differences were found in ethical knowledge scores between faculty and residents. Faculty confidence is higher than resident (p < 0.05). Further, female faculty confidence is higher than that of their male counterparts (p < 0.05). CONCLUSIONS: While SF are more confident in their ethical decision-making, their fundamental knowledge base in ethics is not different from that of SR. Female SF report greater self-confidence over their male counterparts. In total, SF may not possess the foundation to effectively mentor residents in appropriate ethical principles and their translation to clinical practice. This study supports the need for both SR and SF to engage in an integrated education program in ethics to promote on-going dialogue in this complex topic.

A prehospital shock index for trauma correlates with measures of hospital resource use and mortality.

BACKGROUND: The assessment and treatment of trauma patients begins in the prehospital environment. Studies have validated the shock index as a correlate for mortality and the identification of shock in trauma patients. We investigated the use of the first shock index obtained in the prehospital environment and the first shock index obtained upon arrival in the trauma center as correlates for other outcomes to evaluate its usefulness as a triage tool. METHODS: This is a retrospective review of data from a level I trauma center. Prehospital and trauma center shock indices for 16,269 patients were evaluated as correlates for duration of hospital stay, duration of stay in the intensive care unit, the number of ventilator days, blood product use, and destination of transfer from the trauma center. RESULTS: Pearson correlation coefficients revealed that the relationship of prehospital and trauma center shock indices were correlates for duration of hospital stay, duration of stay in the intensive care unit, the number of ventilator days, and blood product use. A chi-square analysis found that shock indices ≥0.9 indicate a higher likelihood of disposition to the intensive care unit, operating room, or death. CONCLUSION: A prehospital shock index for trauma correlates with measures of hospital resource use and mortality. A prospective study is needed to determine the use of this measure as a triage tool.

Selective angiographic embolization of blunt splenic traumatic injuries in adults decreases failure rate of nonoperative management.

BACKGROUND: To determine whether angioembolization (AE) in hemodynamically stable adult patients with blunt splenic trauma (BST) at high risk for failure of nonoperative management (NOM) (contrast blush [CB] on computed tomography, high-grade IV-V injuries, or decreasing hemoglobin) results in lower failure rates than reported. METHODS: The records of patients with BST from July 2000 to December 2010 at a Level I trauma center were retrospectively reviewed using National Trauma Registry of the American College of Surgeons. Failure of NOM (FNOM) occurred if splenic surgery was required after attempted NOM. Logistic regression analysis was used to identify factors associated with FNOM. RESULTS: A total of 1,039 patients with BST were found. Pediatric patients (age <17 years), those who died in the emergency department, and those requiring immediate surgery for hemodynamic instability were excluded. Of the 539 (64% of all BST) hemodynamically stable patients who underwent NOM, 104 (19%) underwent AE and 435 (81%) were observed without AE (NO-AE). FNOM for the various groups were as follows: overall NOM (4%), NO-AE (4%), and AE (4%). There was no significant difference in FNOM for NO-AE versus AE for grades I to III: grade I (1% vs. 0%, p = 1), grade II (2% vs. 0%, p = 0.318), and grade III (5% vs. 0%, p = 0.562); however, a significant decrease in FNOM was noted with the addition of AE for grades IV to V: grade IV (23% vs. 3%, p = 0.04) and grade V (63% vs. 9%, p = 0.03). Statistically significant independent risk factors for FNOM were grade IV to V injuries and CB. CONCLUSION: Application of strictly defined selection criteria for NOM and AE in patients with BST resulted in one of the lowest overall FNOM rates (4%). Hemodynamically stable BST patients are candidates for NOM with selective AE for high-risk patients with grade IV to V injuries, CB on initial computed tomography, and/or decreasing hemoglobin levels. LEVEL OF EVIDENCE: III, therapeutic study.

Age does not affect outcomes of nonoperative management of blunt splenic trauma.

BACKGROUND: The purpose of this study was to examine the effect of age on the outcomes of nonoperative management (NOM) of blunt splenic trauma (BST). STUDY DESIGN: The records of patients with BST, from July 2000 to December 2010 at a level I trauma center, were retrospectively reviewed using NTRACS (National Trauma Registry of the American College of Surgeons). Patients were divided into 2 age groups: 17 to 55 years and greater than 55 years. Stepwise logistic regression analysis was used to identify risk factors associated with failure of nonoperative management (FNOM). RESULTS: There were 539 hemodynamically stable patients with BST who underwent NOM. Of these, 459 were age 55 or less, and 80 were greater than 55. Overall, there was no significant difference in FNOM rate for patients age 55 or less vs greater than 55 (4% vs 5%, p = 0.73). This also held true when FNOM was analyzed by each grade: I (1% vs 3%, p = 0.38), II (2% vs 0%, p = 1.0), III (4% vs 0%, p = 1.0), IV (8% vs 20%, p = 0.33), and V (21% vs 50%, p = 0.47). The addition of angioembolization (AE) to high grade IV to V injuries significantly lowered the FNOM rate: age 55 or less (6% AE vs 28% NO-AE, p = 0.02); with a trend toward significance for age greater than 55 (0% AE vs 60% NO-AE, p = 0.2). Age was not a statistically significant independent risk factor for FNOM (p = 0.37). CONCLUSIONS: Age does not affect outcomes of NOM of BST. High grade (IV to V) injuries are not a contraindication to NOM for patients older than 55. As experience with AE grows in patients with high grade injury and age greater than 55, it may prove to be a valuable adjunct to NOM in this group of patients.