HIV Screening and Early Referral in the Trauma Population: The Experience of a Large Safety Net Hospital.

BACKGROUND: While the prevalence of HIV infection in the population is 0.5%, it is higher among trauma patients as are rates of unknown seropositivity. Routine HIV screening for all trauma evaluations was implemented at our urban level I center in 2009. We aimed to evaluate use and results of the program in our trauma population. METHODS: This was a retrospective analysis of all trauma evaluations between July 2015 and February 2018. After passage of legislation rescinding the requirement for consent to perform HIV testing, our trauma service instituted an order set which automatically tested for HIV unless the ordering physician opted out. Patients found to be infected with HIV were to be counseled and referred to specialty care. RESULTS: Of 6175 consecutive trauma evaluations during the study period, 449 (7.3%) patients had been screened within the prior year and were excluded. Of the remaining cohort, 2024 (35.3%) patients were screened with 27 (1.3%) testing positive. Among those testing positive for infection, 100% were male, 77% white, 63% non-Hispanic, and 70% lacked insurance. Twenty-five (92.6%) patients received counseling and 19 were referred to specialty care. Age, gender, race, ethnicity, Injury Severity Score, trauma activation level, and payor type were not significant predictors for positive HIV screen on logistic regression analysis. CONCLUSIONS: Despite a significantly higher rate of HIV in the trauma population, only a third of patients are screened. Such high infection rates justify the existence of this screening program but steps must be taken to increase screening rate. LEVEL OF EVIDENCE: Level 3.

Muscle Homeostasis Is Disrupted in Burned Adults.

Severe burn leads to substantial skeletal muscle wasting that is associated with adverse outcomes and protracted recovery. The purpose of our study was to investigate muscle tissue homeostasis in response to severe burn. Muscle biopsies from the right m. lateralis were obtained from 10 adult burn patients at the time of their first operation. Patients were grouped by burn size (total body surface area of <30% vs ≥30%). Muscle fiber size and factors of cell death and muscle regeneration were examined. Muscle cell cross-sectional area was significantly smaller in the large-burn group (2174.3 ± 183.8 µm2 vs 3687.0 ± 527.2 µm2, P = .04). The expression of ubiquitin E3 ligase MuRF1 and cell death downstream effector caspace 3 was increased in the large-burn group (P < .05). No significant difference was seen between groups in expression of the myogenic factors Pax7, MyoD, or myogenin. Interestingly, Pax7 and proliferating cell nuclear antigen (PCNA) expression in muscle tissue were significantly correlated to injury severity only in the smaller-burn group (P < .05). In conclusion, muscle atrophy after burn is driven by apoptotic activation without an equal response of satellite cell activation, differentiation, and fusion.

Administration of Tumescence in Pediatric Burn Patients Causes Significant Hypertension.

The effects of injecting tumescence containing phenylephrine in pediatric burn patients are unknown, but anecdotally our clinicians note a high incidence of hypertension requiring treatment. This study sought to determine whether tumescence with phenylephrine was associated with hypertension requiring treatment in our pediatric burn patients. This was a retrospective cohort study of pediatric burn patients who underwent tangential excision with split-thickness autografting, excision alone, or autografting alone from 2013 to 2017. Records were reviewed for hypertensive episodes, defined as ≥2 consecutive blood pressure readings that were >2 SD above normal. Published intraoperative age- and sex-adjusted standards were used to define reference values. Parametric and nonparametric tests were used when appropriate. In total, 258 operations were evaluated. Mean patient age was 7.6 ± 5.2 years, and 64.7% were male. Patients were predominately white (69.8%). Overall, there was a 62.8% incidence of hypertension. On univariate logistic regression analysis, duration of operation, estimated blood loss, treated TBSA, and weight-adjusted volume of tumescence were significant predictors of intraoperative hypertension (P < .01). On multivariate analysis, weight-adjusted volume of tumescence alone was significantly associated with the presence of hypertension with an odds ratio of 2.0 (95% confidence interval: 1.33-3.04). Of the 162 operations which exhibited at least one episode of significant hypertension, 128 cases (79%) were treated. Intraoperative administration of phenylephrine-containing tumescence in pediatric burn patients is associated with clinically significant hypertension requiring treatment. This practice should be conducted with caution in pediatric burn operations until its clinical implications are defined.

Treating Hypertrophic Burn Scar With 2940-nm Er:YAG Laser Fractional Ablation Improves Scar Characteristics as Measured by Noninvasive Technology.

Their group previously demonstrated high-patient satisfaction for the treatment of hypertrophic burn scar (HBS) with the erbium: yttrium aluminum garnet (Er:YAG) laser, but this and other literature supporting the practice suffer from a common weakness of a reliance on subjective assessments by patients or providers. Herein, they sought to prospectively study the effects of Er:YAG fractional ablation on HBS using noninvasive, objective technologies to measure outcomes. Patients with HBS had identical regions of scar designated for treatment by the Er:YAG laser (TREAT) or to be left untreated (CONTROL). They prospectively collected scar measurements of TREAT and CONTROL regions preoperatively, 3 weeks, and 3 months after Er:YAG treatment. Scar measurements included viscoelastometry, transepidermal water loss, optical coherent tomography, and high-frequency ultrasound. Outcomes were measured for the aggregate difference between the TREAT group vs the CONTROL group, as well as within each group in isolation. Seventeen patients were seen preoperatively, followed by n = 15 at 3 weeks and n = 11 at 3 months. A mixed-model repeated measures analysis showed no significant effect of fractional ablation when comparing the overall TREAT group measurements with those of the CONTROL group. However, when considered as within-group measurements, TREAT scars showed significant improvement in viscoelastic deformity (P = .03), elastic deformity (P = .004), skin roughness (P = .05), and wrinkle depth (P = .04) after fractional ablation, whereas CONTROL scars showed no such within-group changes. HBS treated by the Er:YAG laser showed objective improvements, whereas no such changes were seen within the untreated scars over the same time frame.

Analysis of operating room efficiency between a hospital-owned ambulatory surgical center and hospital outpatient department.

BACKGROUND: Ambulatory surgery centers (ASCs) are frequently utilized; however some ambulatory procedures may be performed in hospital outpatient departments (HOPs). Our aim was to compare operating room efficiency between our ASC and HOP. METHODS: We reviewed outpatient general surgery procedures performed at our ASC and HOP. Total case time was divided into five components: ancillary time, procedure time, exit time, turnover time, and nonoperative time. RESULTS: Overall, 220 procedures were included (114 ASC, 106 HOP). Expressed in minutes, the mean turnover time (29.8 ±â€¯9.6 vs. 24.5 ±â€¯12.7; p < 0.01), ancillary time (32.2 ±â€¯7.0 vs. 22.2 ±â€¯4.5; p < 0.01), procedure time (77.4 ±â€¯44.9 vs. 56.2 ±â€¯23.0 p < 0.01), exit time (11.8 ±â€¯4.4 vs. 8.5 ±â€¯4.3; p < 0.01), and nonoperative time (62.9 ±â€¯21.9 vs. 48.7 ±â€¯15.0; p < 0.01) were longer at the HOP than at the ASC. CONCLUSION: ASC outpatient procedures are more efficient than those performed at our HOP. A system evaluation of our HOP operating room efficiency is necessary.

Assessment of general surgery resident study habits and use of the TrueLearn question bank for American Board of Surgery In-Training exam preparation.

BACKGROUND: Little information exists on the value of online question banks in preparing residents for the American Board of Surgery In-Training Examination (ABSITE). METHODS: We reviewed surgical residents' use of an online question bank (TrueLearn) and compared it to their ABSITE performance. RESULTS: The 2016-2017 records of 44 PGY 2-5 general surgery residents were examined. The total number of TrueLearn questions answered significantly correlated (p < 0.05) with correct answers and percentile rank on the 2017 ABSITE. If a resident was to complete the entire online TL question bank consisting of 1000 questions, the overall percentage correct and overall percentile on the ABSITE is estimated to increase by 3% and 20%, respectively. CONCLUSIONS: The use of the TrueLearn question bank is associated with an improved percentage of ABSITE questions answered correctly and improved PGY percentile scores.

Prospective Analysis of Operating Room and Discharge Delays in a Burn Center.

Delays to the operating room (OR) or discharge (DC) lead to longer lengths of stay and increased costs. Surprisingly, little work has been done to quantify the number and cost of delays for inpatients to the OR, and to DC to outpatient status. They reviewed their burn admissions to determine how often a patient experiences delays in healthcare delivery. Data for all burn admissions were prospectively collected from 2014 to 2016. A quality improvement filter was created to define acceptable parameters for patient throughput. Every hospital day was labeled as 1) No delay, 2) Operation, 3) Delay to the OR, or 4) Delay to DC. They had 1633 admissions: 432 ICU admissions (26%) and 1201 floor admissions (74%). Six hundred fifteen patients (37.7%) received an operation. Patients with delays included 331 with OR delays (20.3%) and 503 with DC delays (30.8%). Average delay days included (Mean ± SD): OR delay days = 4.7 ± 6.2 and DC delay days = 4.1 ± 4.4. Total number of hospital days was 13,009, divided into 1616 OR delay days (12%) and 2096 DC delay days (16%). Significant OR delays were due to patient unstable for OR (n = 387 [24%]), OR space availability (n = 662 [41%]), indeterminate wound depth (n = 437 [27%]), and donor site availability (n = 83 [5%]). Significant DC delays were due to medical goals not reached (n = 388 [19%]), pain control and wound care (n = 694 [33%]), PT/OT clearance (n = 168 [8.0%]), and DC placement delays (n = 754 [36%]). Costs for OR and DC delays ranged between US$1,000,000 and US$5,000,000. Costs of increasing OR capacity and/or additional social work ancillary staff can be justified through millions of dollars of savings annually.

Trauma Surgeon and Palliative Care Physician Attitudes Regarding Goals-of-Care Delineation for Injured Geriatric Patients.

BACKGROUND: The value of defining goals of care (GoC) for geriatric patients is well known to the palliative care community but is a newer concept for many trauma surgeons. Palliative care specialists and trauma surgeons were surveyed to elicit the specialties' attitudes regarding (1) importance of GoC conversations for injured seniors; (2) confidence in their own specialty's ability to conduct these conversations; and (3) confidence in the ability of the other specialty to do so. METHODS: A 13-item survey was developed by the steering committee of a multicenter, palliative care-focused consortium and beta-tested by trauma surgeons and palliative care specialists unaffiliated with the consortium. The finalized instrument was electronically circulated to active physician members of the American Association for the Surgery of Trauma and American Academy for Hospice and Palliative Medicine. RESULTS: Respondents included 118 trauma surgeons (8.8%) and 244 palliative care specialists (5.7%). Palliative physicians rated being more familiar with GoC, were more likely to report high-quality training in performing conversations, believed more palliative specialists were needed in intensive care units, and had more interest in conducting conversations relative to trauma surgeons. Both groups believed themselves to perform GoC discussions better than the other specialty perceived them to do so and favored their own specialty leading team discussions. CONCLUSIONS: Both groups believe themselves to conduct GoC discussions for injured seniors better than the other specialty perceived them to do so, which led to disparate views on the optimal leadership of these discussions.

Acute Kidney Injury After Burn: A Cohort Study From the Parkland Burn Intensive Care Unit.

Acute kidney injury (AKI) is a common and morbid complication in patients with severe burn. The reported incidence of AKI and mortality in this population varies widely due to inconsistent and changing definitions. They aimed to examine the incidence, severity, and hospital mortality of patients with AKI after burn using consensus criteria. This is a retrospective cohort study of adults with thermal injury admitted to the Parkland burn intensive care unit (ICU) from 2008 to 2015. One thousand forty adult patients with burn were admitted to the burn ICU. AKI was defined by KDIGO serum creatinine criteria. Primary outcome includes hospital death and secondary outcome includes length of mechanical ventilation, ICU, and hospital stay. All available serum creatinine measurements were used to determine the occurrence of AKI during the hospitalization. All relevant clinical data were collected. The median total body surface area (TBSA) of burn was 16% (IQR: 6%-29%). AKI occurred in 601 patients (58%; AKI stage 1, 60%; stage 2, 19.8%; stage 3, 10.5%; and stage 3 requiring renal replacement therapy [3-RRT], 9.7%). Patients with AKI had larger TBSA burn (median 20.5% vs 11.0%; P < .001) and more mechanical ventilation and hospitalization days than patients without AKI. The hospital death rate was higher in those with AKI vs those without AKI (19.7% vs 3.9%; P < .001) and increased by each AKI severity stage (P trend < .001). AKI severity was independently associated with hospital mortality in the small burn group (for TBSA ≤ 10%: stage 1 adjusted OR 9.3; 95% CI, 2.6-33.0; stage 2-3 OR, 35.0; 95% CI, 9.0-136.8; stage 3-RRT OR, 30.7; 95% CI, 4.2-226.4) and medium burn group (TBSA 10%-40%: stage 2-3 OR, 6.5; 95% CI, 1.9-22.1; stage 3-RRT OR, 35.1; 95% CI, 8.2-150.3). AKI was not independently associated with hospital death in the large burn group (TBSA > 40%). Urine output data were unavailable. AKI occurs frequently in patients after burn. Presence of and increasing severity of AKI are associated with increased hospital mortality. AKI appears to be independently and strongly associated with mortality in patients with TBSA ≤ 40%. Further investigation to develop risk-stratification tools tailoring this susceptible population is direly needed.

A comparison of cholecystitis grading scales.

BACKGROUND: Previously, our group developed the Parkland grading scale for cholecystitis (PGS) to stratify gallbladder (GB) disease severity that can be determined immediately when performing laparoscopic cholecystectomy (LC). In prior studies, PGS demonstrated excellent interrater reliability and was internally validated as an accurate measure of LC outcomes. Here, we compare PGS against a more complex cholecystitis severity score developed by the national trauma society, American Association for the Surgery of Trauma (AAST), which requires clinical, operative, imaging, and pathologic inputs, as a predictor of LC outcomes. METHODS: Eleven acute care surgeons prospectively graded 179 GBs using PGS and filled out a postoperative questionnaire regarding the difficulty of the surgery. Three independent raters retrospectively graded these GBs using PGS from images stored in the electronic medical record. Three additional surgeons then assigned separate AAST scores to each GB. The intraclass correlation coefficient statistic assessed rater reliability for both PGS and AAST. The PGS score and the median AAST score became predictors in separate linear, logistic, and negative binomial regression models to estimate perioperative outcomes. RESULTS: The average intraclass correlation coefficient of PGS and AAST was 0.8647 and 0.8341, respectively. Parkland grading scale for cholecystitis was found to be a superior predictor of increasing operative difficulty (R, 0.566 vs. 0.202), case length (R, 0.217 vs. 0.037), open conversion rates (area under the curve, 0.904 vs. 0.757), and complication rates (area under the curve, 0.7039 vs. 0.6474) defined as retained stone, small-bowel obstruction, wound infection, or postoperative biliary leak. Parkland grading scale for cholecystitis performed similar to AAST in predicting partial cholecystectomy, readmission, bile leak rates, and length of stay. CONCLUSION: Both PGS and AAST are accurate predictors of LC outcomes. Parkland grading scale for cholecystitis was found to be a superior predictor of subjective operative difficulty, case length, open conversion rates, and complication rates. Parkland grading scale for cholecystitis has the advantage of being a simpler, operative-based scale which can be scored at a single point in time. LEVEL OF EVIDENCE: Single institution, retrospective review, level IV.

Prospective validation of the safety of a laparoscopic cholecystectomy training paradigm featuring incremental autonomy.

BACKGROUND: Surgical training is under scrutiny for the effect increased resident autonomy may have on patient outcomes. We hypothesize that as laparoscopic cholecystectomy (LC) difficulty increases, there will be increased involvement by senior residents and attending physicians with no differences in complications. METHODS: Ten acute care surgeons were asked to fill out a postoperative questionnaire regarding surgical difficulty after every LC between 11/9/2016 and 3/30/2017. Either the Jonckheere-Terpstra test, Mantel-Haenzel chi square test, or ANOVA was used to test for the association between perioperative data and surgical difficulty. RESULTS: A total of 190 LCs were analyzed. PGY level, percent of surgery time with attending surgeon involvement, partial cholecystectomy rate, and length of operation all significantly rose with increasing level of difficulty (p < 0.001) with no significant differences in 60-day emergency room bounce-backs, readmission, or complication rates. CONCLUSIONS: We found that as LC difficulty increases, so does attending surgeon and/or senior resident involvement, without increased morbidity.

Prospective validation of the Parkland Grading Scale for Cholecystitis.

BACKGROUND: The Parkland Grading Scale for Cholecystitis (PGS) was developed as an intraoperative grading scale to stratify gallbladder (GB) disease severity during laparoscopic cholecystectomy (LC). We aimed to prospectively validate this scale as a measure of LC outcomes. METHODS: Eleven surgeons took pictures of and prospectively graded the initial view of 317 GBs using PGS while performing LC (LIVE) between 9/2016 and 3/2017. Three independent surgeon raters retrospectively graded these saved GB images (STORED). The Intraclass Correlation Coefficient (ICC) statistic assessed rater reliability. Fisher's Exact, Jonckheere-Terpstra, or ANOVA tested association between peri-operative data and gallbladder grade. RESULTS: ICC between LIVE and STORED PGS grades demonstrated excellent reliability (ICC = 0.8210). Diagnosis of acute cholecystitis, difficulty of surgery, incidence of partial and open cholecystectomy rates, pre-op WBC, length of operation, and bile leak rates all significantly increased with increasing grade. CONCLUSIONS: PGS is a highly reliable, simple, operative based scale that can accurately predict outcomes after LC. TABLE OF CONTENTS SUMMARY: The Parkland Grading Scale for Cholecystitis was found to be a reliable and accurate predictor of laparoscopic cholecystectomy outcomes. Diagnosis of acute cholecystitis, surgical difficulty, incidence of partial and open cholecystectomy rates, pre-op WBC, operation length, and bile leak rates all significantly increased with increasing grade.

Trauma and emergency general surgery patients should be extubated with an open abdomen.

BACKGROUND: Open abdomen (OA) and temporary abdominal closure (TAC) are common techniques to manage several surgical problems in trauma and emergency general surgery (EGS). Patients with an OA are subjected to prolonged mechanical ventilation. This can lead to increased rates of ventilator-associated pneumonia (VAP). We hypothesized that patients who were extubated with an OA would have a decrease in ventilator hours and as a result would have a lower rate of VAP without an increase in extubation failures. METHODS: A retrospective review was performed of all trauma and EGS patients managed at our institution with OA and TAC from January 2014 to February 2016. Patients were divided into cohorts consisting of those who were successfully extubated with an OA and those who were not. The number of extubation events and ventilator-free hours were calculated for each patient. Adverse events such as the need for reintubation with an OA and VAP were collected. RESULTS: Fifty-two patients (20 trauma, 32 EGS) were managed with an OA and TAC during the study period. Twenty-five patients (6 trauma, 19 EGS) had at least one extubation event with an OA. Median extubation events per patient was 3 (interquartile range, 1-5). The median ventilator-free hours for patients who were extubated was 101 hours (interquartile range, 39.42-260.46). Patients that were never extubated with an OA had higher rates of VAP (30.8% vs. 3.8%, p = 0.01). CONCLUSION: This study provides much needed data regarding the feasibility of extubation in trauma and EGS patients managed with an OA and TAC. Benefits of early extubation may include lower VAP rates in this population. Plans for reexploration hinder the decision to extubate in these patients. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Inability to predict subprophylactic anti-factor Xa levels in trauma patients receiving early low-molecular-weight heparin.

BACKGROUND: Standard low-molecular-weight heparin dosing may be suboptimal for venous thromboembolism prophylaxis. We aimed to identify independent predictors of subprophylactic Xa (subXa) levels in trauma patients treated under a novel early chemoprophylaxis algorithm. METHODS: A retrospective analysis of trauma patients from July 2016 to June 2017 who received enoxaparin 40 mg twice daily and had peak Xa levels drawn was performed. Patients were divided into cohorts based on having a subXa (<0.2 IU/mL) or prophylactic (≥0.2 IU/mL) Xa level. RESULTS: In all, 124 patients were included, of which 38 (31%) had subXa levels, and 17 (14%) had Xa levels greater than 0.4 IU/mL. Of the subXa cohort, 35 (92%) had their dosage increased, and the repeat Xa testing that was done in 32 revealed that only 75% reached prophylactic levels. The median time to the initiation of chemoprophylaxis was 21.9 hours (interquartile range [IQR], 11.45-35.07 hours). Patients who were defined as having lower risk of having a complication as a result of bleeding had a shorter time to starting prophylaxis than those at higher risk (18.39 hours [IQR 5.76-26.51 hours] vs. 29.5 hours [IQR 16.23-63.07 hours], p < 0.01).There was no difference in demographics, weight, body mass index, creatinine, creatinine clearance, injury severity score, type of injury, weight-based dose, time to chemoprophylaxis, or bleeding complications between the cohorts. No independent predictors of subXa level were identified on multivariable logistic regression. CONCLUSIONS: A significant number of trauma patients fail to achieve prophylactic Xa levels. Intrinsic factors may prevent adequate prophylaxis even with earlier administration and higher dosing of low-molecular-weight heparin. LEVEL OF EVIDENCE: Therapeutic, level IV.

Impact of a Laser Service Line for Burn Scar on a Dedicated Burn OR's Flow and Productivity.

Our group began performing erbium-YAG 2940 wavelength fractional resurfacing of burn scar in our burn center's dedicated burn operating room (OR) in January 2016. The impact of these procedures on the performance of a mature, dedicated burn OR is unknown. All burn OR cases performed between January 1, 2015 and December 31, 2015 served as a pre-laser (PRE-LSR) historical control. A postintervention cohort of laser-only cases (LSR) performed between January 1, 2016 and August 17, 2016 was then identified. PRE-LSR and LSR cases were retrospectively reviewed for OR component times, and work relative value units (wRVU) billed. A total of 628 burn OR cases were done in 2015 (PRE-LSR), while 488 burn OR cases were done between January 1 and August 17, 2016. Of these 488, 59 cases were LSR (12.1%). Calculated on a monthly basis, significantly more cases were done per day in the LSR era (2.2 ± 0.4 cases/d) than PRE-LSR (1.6 ± 2.0 cases/d; P < .0001). The LSR group was significantly shorter than the PRE-LSR group for all OR component times (induction, prep, and procedure all P < .0001; transport out, P = .01; room turnover, P = .004). Aggregate OR component time was 79.2 ± 33.4 minutes for LSR and 157.5 ± 65.0 minutes for PRE-LSR (P < .0001). LSR yielded 6.9 ± 3.2 wRVU/h, while PRE-LSR generated 12.2 ± 8.9 wRVU/h (P < .0001). Despite significantly shorter OR component times and more cases being done per day, laser treatment of burn scar using a single 17108 Current Procedural Terminology code cuts wRVUs generated per hour in a mature burn OR roughly in half.

Burn Surgeon and Palliative Care Physician Attitudes Regarding Goals of Care Delineation for Burned Geriatric Patients.

Palliative care specialists (PCS) and burn surgeons (BS) were surveyed regarding: 1) importance of goals of care (GoC) conversations for burned seniors; 2) confidence in their own specialty's ability to conduct these conversations; and 3) confidence in the ability of the other specialty to do so. A 13-item survey was developed by the steering committee of a multicenter consortium dedicated to palliative care in the injured geriatric patient and beta-tested by BS and PCS unaffiliated with the consortium. The finalized instrument was electronically circulated to active physician members of the American Burn Association and American Academy for Hospice and Palliative Medicine. Forty-five BS (7.3%) and 244 PCS (5.7%) responded. Palliative physicians rated being more familiar with GoC, were more comfortable having a discussion with laypeople, were more likely to have reported high-quality training in performing conversations, believed more palliative specialists were needed in intensive care units, and had more interest in conducting conversations relative to BS. Both groups believed themselves to perform GoC discussions better than the other specialty perceived them to do so. BS favored leading team discussions, whereas palliative specialists preferred jointly led discussions. Both groups agreed that discussions should occur within 72 hours of admission. Both groups believe themselves to conduct GoC discussions for burned seniors better than the other specialty perceived them to do so, which led to disparate views on perceptions for the optimal leadership of these discussions.

Prospective Evaluation of Operating Room Inefficiency.

Previously, they identified that 60 per cent of their facility's total operative time is nonoperative. They performed a review of their operating room to determine where inefficiencies exist in nonoperative time. Live video of operations performed in a burn operating room from June 23, 2017 to August 16, 2017 was prospectively reviewed. Preparation (end of induction to procedure start) and turnover (patient out of room to next patient in room) were divided into the following activities: 1) Preparation: remove dressing, position patient, clean patient, drape patient, and 2) Turnover: clean operating room, scrub tray setup, anesthesia setup. Ideal preparation time was calculated as the sum of time needed to perform preparation activities consecutively. Ideal turnover time was calculated as the sum of time needed to clean the operating room and to set up either the scrub tray or anesthesia (the larger of the two times as these can be done in parallel). They reviewed 101 consecutive operations. An average of 2.4 ± 0.8 cases per day were performed. Ideal preparation and turnover time were 16.6 and 30.1 minutes, a 38.3 and 32.5 per cent reduction compared with actual times. Attending surgeon presence in the operating room within 10 minutes of a patient's arrival was found to significantly decrease time to incision by 33 per cent (52.7 ± 14.3 minutes down to 35.7 ± 20.4, P < .0001). A reduction in preparation and turnover time could save $1.02 million and generate $1.76 million in additional revenue annually. Reducing preparation and turnover to ideal times could increase caseload to 4 per day, leading to millions of dollars of savings annually.

Patient satisfaction after fractional ablation of burn scar with 2940nm wavelength Erbium-Yag laser.

OBJECTIVE: Fractional laser therapy is a new treatment with potential benefit in the treatment of burn scars. We sought to determine patient satisfaction after burn scar treatment with the Erbium-Yag laser. METHODS: We performed a telephone survey of all patients who underwent fractional resurfacing of burn scars with the Erbium-Yag 2940 wavelength laser at Parkland Hospital from 01/01/2016 to 05/01/2017. Subjects were asked to rate their satisfaction with their scars' after treatment characteristics on a scale from 1 (completely unsatisfied) to 10 (completely satisfied). Subjects were also asked to assess their treatment response using the UNC 4P Scar Scale before and after treatment. RESULTS: Sixty-four patients underwent 156 treatments. A survey response rate of 77% (49/64) was seen (age: 36.8+21 years; surface area treated=435+326cm2; 35% of burn scars were >2 years old; mean scar age of 1.02+0.4 years). Overall, 46/49 (94%) of patients reported some degree of scar improvement after treatment. Patient satisfaction scores were 8.3+2.3. Number of laser treatments included: 1 (31%), 2 (33%), 3 (18%), 4(10%), >5 (8%). Treatment depth, scar age, and number of laser procedures were not significant predictors of satisfaction or UNC 4P Scar scores. The paired t-test showed a significant reduction on each of the UNC 4P Scar scale items (pain, pruritus, pliability, paresthesia). One subject reported that she felt that the laser treatment made her scar worse (2%). CONCLUSION: Burn patients treated with the Erbium-Yag laser are highly satisfied with changes in their burn scars.