Outcomes of Traumatic Brain Injury Patients Managed in a Non-Intensive Care Unit Setting.

INTRODUCTION: The management of traumatic brain injury (TBI) requires significant health-care resources. The modified Brain Injury Guidelines (mBIG) stratifies TBI patients by severity to help guide disposition and management. We sought to analyze the outcomes of TBI patients managed in a non-intensive care unit (ICU) setting after stratifying them using the mBIG criteria. METHODS: A retrospective single-center study was performed on all adult patients who sustained blunt TBI from 2021 to 2022 and were managed in a non-ICU setting. Primary outcome was unplanned upgrade to the ICU. Secondary outcomes were need for neurosurgical intervention, unplanned intubation, mortality, and hospital length of stay. Patients were divided into cohorts of mBIG 1 & 2 versus mBIG 3. RESULTS: Of the 274 patients managed in a non-ICU setting, 119 (43.4%) met mBIG 3 criteria. The majority (76.5%) were managed in a step-down level of care. Nine patients required upgrade to the ICU, with only two upgraded for acute progression of their intracranial hemorrhage. Eight patients in mBIG 3 cohort required neurosurgical interventions, with only two related to progression of their intracranial hemorrhage and both over 24 h after admission. The remaining six patients had planned delayed neurosurgical intervention. Unplanned intubation occurred in three patients with only one related to a delayed progression of their TBI. Longer hospitalization and decreased survival were noted in mBIG 3 group. No differences in 30-d readmissions, stroke, venous thromboembolism events or seizures were found between the two groups. CONCLUSIONS: Select patients with severe TBI may be considered for admission to step-down units with frequent neurologic exams in lieu of ICU level of care.

Mental Health Care Resource Utilization of Victims of Interpersonal Violence in the Novel Coronavirus Era.

INTRODUCTION: Higher incidences of interpersonal violence were reported throughout the country during the coronavirus (COVID) time period. We aimed to compare health-care encounters and resource utilization related to interpersonal violence with mental health (MH) disorders before and during the pandemic within a year of the index visit for interpersonal violence. METHODS: A retrospective analysis of the Delaware Healthcare Claims data of all patients aged ≥16 y who suffered interpersonal violence was performed. Patients were followed up for 1 y pre and post their index visit of interpersonal violence episode during the pre-COVID (March 2018 through December 2018) and the COVID (March 2020 through December 2020) period. Census tract information was used to assess social determinants of health. RESULTS: There were 431 patients in the COVID period and 527 patients in the pre-COVID period with index violence claim encounters. African American patients were more likely to have a violence encounter during COVID (60.3% versus 47.2%, P < 0.001). Patients in the COVID period were more likely to live in a census tract with public assistance households (median 3.3% versus 2.2%, P = 0.005) and higher unemployment (7.5% versus 7.1%, P = 0.01). In the following year of index violence claim, the mean numbers of MH claim-days for COVID and pre-COVID patients were 19.5 (53.3) and 26.2 (66.2), (P = 0.51). The COVID group had fewer MH claim-days mostly in the second half of the year after the index encounter with an incidence rate ratio of 0.61, 95% CI (0.45-0.83). CONCLUSIONS: Racial and socioeconomic disparities were amplified and MH resource utilization was lower during COVID. Further injury prevention efforts should be focused on MH in future pandemics or disasters.

Safety and feasibility of destination care for bariatric surgery: a single institution retrospective study.

INTRODUCTION: Increasing emphasis on value-based healthcare has prompted both employers and healthcare organizations to develop innovative strategies to supply high quality care to patients. One such strategy is through the bundled care payment model (BCPM). Through this model, our institution partnered with employers from across the country to provide quality care for their members. Patients traveling greater than 2 h driving time from the bariatric center were considered "destination" patients. To properly care for our destination patients, our institution created a "destination bariatric program." We sought to investigate comparative outcomes for the first 100 patients who completed the program. We hypothesized that there would be no difference in patient outcomes or complications between destination and local patient groups undergoing sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB). METHODS AND PROCEDURES: A retrospective cohort analysis of patients undergoing bariatric surgery at a MBSAQIP-accredited bariatric surgery center between May 2019 and October 2021 was conducted. Patients were divided into destination or local patient groups based on participation in the established destination surgery program. Patient demographics, perioperative clinical outcomes, and complications were compared and statistically analyzed using two-sample t-tests, Chi-square tests, Fisher's exact tests, and univariate logistic regressions. RESULTS: This study identified 296 patients, which consisted of destination (n = 110) and local (n = 186) patient cohorts. Patients in the destination group had higher rates of diabetes mellitus (29.1% vs 24.2%, p = 0.029), but otherwise cohorts had similar basic demographics and comorbidities. Outcomes revealed no statistically significant associations between patient cohort (destination versus local) and ED admission (p = 0.305), hospital readmission (p = 0.893), surgical reintervention (p = 0.974), endoscopic-reintervention (p = 0.714), and patient complications in the postoperative period (30 days). CONCLUSION: Participation in destination care programs for bariatric surgery was found to be both safe and feasible. These destination programs represent an opportunity to provide a broader patient population access to complex surgical care.

A Pilot Study Using a Collagen/Oxidized Regenerative Cellulose Dressing for Split- Thickness Skin Graft Donor Sites to Reduce Pain and Bleeding Complications.

BACKGROUND: Standardized treatment of split-thickness skin graft (STSG) donor sites is not established. Bleeding can necessitate premature dressing changes, interrupting the healing process and increasing pain. PURPOSE: A collagen/oxidized regenerated cellulose (C/ORC) dressing was used on the donor site. The authors hypothesized that the collagen matrix could decrease bleeding-related complications, reduce pain, and foster epithelialization. METHODS: The C/ORC matrix was applied to the donor site after hemostasis was achieved. Dressings were removed between postoperative days 4 and 7, and the patients' pain levels, bleeding complications, and percentage healed were recorded. RESULTS: Thirty-nine patients were treated with the C/ORC donor site dressing. Of these, 35 patients (89.7%) were receiving at least prophylactic anticoagulation, and no bleeding complications were recorded. The average area of donor sites was 123.8 cm2 (range, 20-528 cm2). Utilizing the Numerical Rating Scale, 25 patients (64.1%) reported no pain with dressing removal while 5 (12.8%) reported a decrease in pain. The percentage of epithelialization as assessed by treating clinician was at least equivalent to other modalities. CONCLUSIONS: The application of a C/ORC matrix to STSG donor wound sites resulted in no bleeding complications and excellent pain control while promoting epithelialization in the patients studied. Following this study, the C/ORC dressing has been incorporated into the authors' standard protocol.

Outcomes with advanced versus basic life support in blunt trauma.

INTRODUCTION: The role of advanced life support (ALS) versus basic life support (BLS) in blunt trauma is controversial. Previous studies have shown no mortality benefit with ALS for penetrating trauma but the blunt population has mostly remained unaddressed. METHODS: A retrospective cohort study was conducted at a Level 1 trauma center comparing outcomes in blunt trauma patients managed by ALS versus BLS from July 1, 2014 to December 31, 2014. Both Injury Severity Score (ISS) and select Abbreviated Injury Score (AIS) were used to determine differences in mortality, length of stay (LOS) and complications based on mode of transportation, prehospital time, and number of prehospital interventions. RESULTS: 698 total patients were identified. Mortality and complications were grossly higher in ALS patients (p = 0.01 and < 0.001, respectively). When accounting for ISS and AIS there was no difference in mortality (p=<0.001-0.003). Prehospital interventions did not increase prehospital time (p = 0.7) but did correlate with increased mortality (p < 0.001). CONCLUSION: There is no mortality advantage for blunt trauma patients managed by ALS versus BLS.

The "Death Diamond": Death Beyond Trauma.

Thromboelastography (TEG) has become a critical tool for the diagnosis, assessment, and management of hyperfibrinolysis and coagulopathy in trauma. In 2015, Chapman et al. of the Denver group coined the term "Death Diamond" (DD) to describe a TEG tracing identified in a unique trauma population. The DD was associated with a 100 per cent positive predictive value for mortality. Given the potential prognostic implications and resource savings associated with validating the DD as a marker of futile care, we sought to further evaluate DD outcomes. A retrospective review of 6850 TEGs, 34 patients (24 trauma and 10 nontrauma), displayed a DD tracing. Through invasive procedures and transfusions, nine DD tracing "normalized," but, ultimately, this did not impact the outcome because the DD had a positive predictive value of 100 per cent for mortality in both populations. The median survival time in trauma patients was two hours compared with seven hours in nontrauma patients. Overall, this study further validates the predictive value of the DD in a trauma population while also serving as an assessment of the DD in a nontrauma population. Given these findings, a DD may prove to be an indicator of futile care. Further multicenter studies should be conducted to confirm these results.

Improving Tracheostomy Decannulation Rate In Trauma Patients.

OBJECTIVE: Identify the effect of a multidisciplinary tracheostomy decannulation protocol (TDP) in the trauma population. DESIGN: Single center retrospective review. SETTING: American College of Surgeons Level 1 Trauma Center; large academic associated community hospital. PATIENTS: Adult trauma patients who required a tracheostomy. INTERVENTIONS: A TDP empowering respiratory therapists to move patients towards tracheostomy decannulation (TD). MEASUREMENTS: TD rate, time to TD, length of stay, reintubation and recannulation rates. MAIN RESULTS: A total of 252 patients met inclusion criteria during the study period with 134 presenting after the TDP was available. Since the TDP was implemented, patients managed by the TDP had a 50% higher chance of TD during the hospital stay (p<0.001). The time to TD was 1 day shorter with the TDP (p=0.54). There was no difference in time to discharge after ventilator liberation (p=0.91) or in discharge disposition (p=0.66). When comparing all patients, the development of a TDP, regardless if a patient was managed by the TDP, resulted in an 18% higher chance of TD (p=0.003). Time to TD was 5 days shorter in the post intervention period (p=0.07). There was no difference in discharge disposition (p=0.88) but the time to discharge after ventilator liberation was shorter post protocol initiation (p=0.04). CONCLUSIONS: In a trauma population, implementation of a TDP significantly improves TD rates during the same hospital stay. A larger population will be required to identify patient predictive factors for earlier successful TD.

Long-term outcome in elderly patients after operation for traumatic intracranial hemorrhage.

OBJECTIVE: This study examined outcomes in elderly TBI patients who underwent a cranial operation. METHODS: We identified TBI patients > or = 65 who underwent a cranial operation from January 1, 2004 to December 31, 2008. Data collected included: age, admission GCS, mechanism of injury, ISS, Head AIS, type of operation, hemorrhage acuity, time to operation, pre-hospital warfarin or clopidogrel, and in-hospital death. Survivors were contacted by phone to determine an Extended Glasgow Outcome Score (GOSE). A favorable outcome was defined as having a GOSE of > or = 5 at follow-up, an unfavorable outcome was defined as: in-hospital death, death within one year of injury, and a GOSE < 5 at follow-up. Chi-square and student's t-test were used. RESULTS: One hundred sixty-four elderly TBI patients underwent cranial surgery. Mean age was 79.2 +/- 7.6 years. Most patients: had a ground level fall (86.0%), suffered a subdural hematoma (95.1%), and underwent craniotomy (89.0%). Twenty-eight percent died in the hospital and another 20.1% died within one year. Fifty-six patients were eligible for a GOSE interview of these: 17 were lost to follow-up, seven refused the GOSE interview, 22 had a GOSE > or = 5, and ten had a GOSE < 5. Mean follow-up was 42.6 +/- 14.9 months. Of all the factors analyzed, only older age was associated with an unfavorable outcome. CONCLUSIONS: While age was associated with outcome, we were unable to demonstrate any other early factors that were associated with long-term functional outcome in elderly patients that underwent a cranial operation for TBI.