Economic Analysis of AbClo, a Novel Abdominal Fascia Closure Device, for Patients With an Open Abdomen Following Trauma or Acute Abdominal Surgery.

BACKGROUND: Open Abdomen (OA) cases represent a significant surgical and resource challenge. AbClo is a novel non-invasive abdominal fascial closure device that engages lateral components of the abdominal wall muscles to support gradual approximation of the fascia and reduce the fascial gap. The study objective was to assess the economic implications of AbClo compared to negative pressure wound therapy (NPWT) alone on OA management. METHODS: We conducted a cost-minimization analysis using a decision tree comparing the use of the AbClo device to NPWT alone among patients with midline laparotomy for trauma or acute abdominal surgery who were ineligible for primary fascial closure. The time horizon was limited to the length of the inpatient hospital stay, and costs were considered from the perspective of the US Medicare payer. Clinical effectiveness data for AbClo was obtained from a randomized clinical trial. Cost data was obtained from the published literature. Probabilistic and deterministic sensitivity analyses were performed. The primary outcome was incremental cost. RESULTS: The mean cumulative costs per patient were $76 582 for those treated with NPWT alone and $70,582 for those in the group treated with the AbClo device. Compared to NPWT alone, AbClo was associated with lower incremental costs of -$6012 (95% CI -$19 449 to +$1996). The probability that AbClo was cost-savings compared to NPWT alone was 94%. CONCLUSIONS: The use of AbClo is an economically attractive strategy for management of OA in in patients with midline laparotomy for trauma or acute abdominal surgery who were ineligible for primary fascial closure.

Does Abdominal Seat Belt Sign Warrant Admission After a Negative CT Scan? A Cost-Utility Analysis.

BACKGROUND: Rapid deceleration against a seat belt during a motor vehicle collision (MVC) may result in an abdominal seat belt sign (ASBS), which is associated with a higher risk of hollow viscus injury (HVI). After a negative abdominal CT scan, management of patients with ASBS is variable, but recent evidence suggests emergency department (ED) discharge may be safe. Therefore, we hypothesized that discharge from the ED is cost-effective compared with 23-h observation or hospital admission for patients with ASBS and a negative CT. METHODS: A cost-utility model was developed for an evaluable patient with ASBS and negative CT scan using TreeAge software. ED discharge was compared with 23-h observation and admission. Analysis was from a health care-based third-party payer perspective. Quality-adjusted life years (QALYs) were based on 3-y expected outcomes. Probability and costs were estimated from published literature and the Healthcare Cost and Utilization Project. RESULTS: In our base case, ED discharge was the most cost-effective strategy, yielding a cost of $706 with 2.86 QALYs. The average costs of 23-h observation and hospital admission were $2600 and $8,827, respectively, with 2.87 QALYs gained each. The strategy of ED observation becomes cost-effective when the rate of HVI after ED discharge exceeds 2.3%. In a Monte Carlo simulation, ED discharge was the optimal strategy in 91% of 1000 trials of the model. CONCLUSIONS: ED discharge is a cost-effective strategy for evaluable patients with ASBS and a negative abdominal CT and remains so when the risk of HVI after ED discharge is higher than currently assumed.

The cost of gunshot abdominal vascular injuries. Its impact on patient, family and hospital.

BACKGROUND: Violent trauma with penetrating injuries is a relevant public health issue. Penetrating abdominal wounds cause 90-95% of vascular injuries, which not only have high associated morbidity and lethality, but also involve high attention costs. Cost analysis in hospitals has become a topic of great interest, as it justifies changes in hospital organization and management. OBJECTIVE: Determine the cost of gunshot abdominal vascular injuries for the patient, his family and the hospital. MATERIAL AND METHODS: We drove an observational, descriptive, prospective and longitudinal study of patients with of gunshot abdominal vascular injuries admitted in the Mexican Red Cross Trauma Center in the Federal District from January 1st to October 31st, 2018. RESULTS: 8149 patients were admitted in the emergency department, 149 with a diagnosis of gunshot injury, of which 6 (0.07%) had abdominal vascular injury. The total cost of medical care these patients was on average $174,770.79 (median $132,999.50) per capita, amount that surpasses their annual income and implies an institutional absorption of expenditure up to 95.5%. CONCLUSIONS: Institutional investment on the attention of high-impact pathologies and the development of strategies that facilitate access to health services are a real and priority necessity.

ANTECEDENTES: El trauma violento con lesiones penetrantes es un problema de salud pública relevante. Las heridas penetrantes abdominales causan el 90-95% de las lesiones vasculares, las cuales tienen elevada morbilidad asociada y letalidad, e implican elevados costos de atención. El análisis de costos en los hospitales es de gran interés, pues permite justificar cambios en la organización y la gestión hospitalaria. OBJETIVO: Determinar el costo de las lesiones vasculares abdominales por proyectil de arma de fuego para el paciente, su familia y el hospital. MATERIAL Y MÉTODOS: Se llevó a cabo un estudio observacional, descriptivo, prospectivo y longitudinal de pacientes con lesiones vasculares abdominales por proyectil de arma de fuego que ingresaron en el Centro de Trauma de Cruz Roja Mexicana en Ciudad de México entre enero y octubre de 2018. RESULTADOS: Ingresaron 8149 pacientes, 149 con diagnóstico de herida por proyectil de arma de fuego, de los cuales el 0.07% tuvieron lesión vascular abdominal. El costo total de la atención médica fue en promedio de $174,770.79 (mediana $132,999.50) por persona, el cual supera el ingreso anual de esos pacientes e implica una absorción institucional del gasto de hasta el 95.5%. CONCLUSIONES: La inversión institucional en la atención de patologías con alto impacto y el desarrollo de estrategias para facilitar el acceso a servicios de salud son una necesidad prioritaria real.

Advantages of early intervention with arterial embolization for intra-abdominal solid organ injuries in children.

PURPOSE: Active bleeding due to abdominal trauma is an important cause of mortality in childhood. The aim of this study is to demonstrate the advantages of early percutaneous transcatheter arterial embolization (PTAE) procedures in children with intra-abdominal hemorrhage due to blunt trauma. METHODS: Children with blunt abdominal trauma were retrospectively included. Two groups were identified for inclusion: patients with early embolization (EE group, n=10) and patients with late embolization (LE group, n=11). Both groups were investigated retrospectively and statistically analyzed with regard to lengths of stay in the intensive care unit and in the hospital, first enteral feeding after trauma, blood transfusion requirements, and cost. RESULTS: The duration of stay in the intensive care unit was greater in the LE group than in the EE group (4 days vs. 2 days, respectively). The duration of hospital stay was greater in the LE group than in the EE group (14 days vs. 6 days, respectively). Blood transfusion requirements (15 cc/kg of RBC packs) were greater in the LE group than in the EE group (3 vs. 1, respectively). The total hospital cost was higher in the LE group than in the EE group (4502 USD vs. 1371.5 USD, respectively). The time before starting enteral feeding after first admission was higher in the LE group than in the EE group (4 days vs. 1 day, respectively). CONCLUSION: Early embolization with PTAE results in shorter intensive care and hospitalization stays, earlier enteral feeding, and lower hospital costs for pediatric patients with intra-abdominal hemorrhage due to blunt trauma.

Hospital factors associated with higher costs in pediatric blunt abdominal trauma: A national study.

BACKGROUND/PURPOSE: Our objective was to evaluate hospital factors, including children's hospital status, associated with higher costs for blunt solid organ pediatric abdominal trauma. METHODS: We queried the 2012 Healthcare Cost and Utilization Project (HCUP) Kid's Inpatient Database (KID) for patients 18 years or younger with low-grade and high-grade blunt abdominal trauma. We calculated total hospital costs and adjusted cost ratios (CR) controlling for patient and hospital-level characteristics. RESULTS: The 2012 KID included 882 low-grade and 222 high-grade pediatric abdominal trauma patients. Median (interquartile range) per hospitalization costs were similar at children's and nonchildren's hospitals for both low-grade (children's = $6575 [$4333-$10,862], nonchildren's $7027 [$4230-$12,219] p = 0.47) and high-grade (children's = $10,984 [$6211- $20,007] nonchildren's $10,156 [$5439-$18,404] p = 0.55) groups. Adjusted cost ratios demonstrated higher costs in the West and among investor owned hospitals for low-grade and high-grade injuries, respectively. Costs at rural hospitals were higher in both groups (low-grade CR = 2.35 95% CI 2.02, 2.74, high-grade CR = 2.78 95% CI 2.13, 3.63) compared to urban teaching hospitals. Cost ratios did not differ based on children's hospital status. CONCLUSION: Hospital costs were similar for children's and nonchildren's hospitals caring for pediatric abdominal trauma. Costs at rural hospitals are higher and may suggest financial instability or nonstandardized care of pediatric trauma patients. LEVEL OF EVIDENCE: III.

Pediatric trauma center verification improves quality of care and reduces resource utilization in blunt splenic injury.

PURPOSE: We sought to evaluate value impact of transition from an adult trauma center treating children (ATC) to a verified pediatric trauma center (PTC) in children with blunt splenic injury (BSI). METHODS: Children with BSI from FY 2005 to FY 2017 were extracted from the hospital trauma registry. February 2009 distinguished "ATC" treated children from "PTC" treated children. Cohorts were subcategorized into "isolated injury" and "multisystem injury". Quality and financial characteristics were statistically compared. Analysis of covariance was used to evaluate changes in quality and financial trends over the transition period. A multiple linear regression was performed to identify variables independently predictive of hospital and professional charges. RESULTS: 126 children with BSI were identified (ATC, n = 56; PTC, n = 70). Splenic procedure rates and hospital charges decreased. Quality and cost metrics for isolated BSI remained unchanged while multisystem BSI children experienced improvements. PTC designation, ISS, splenic procedure, isolated BSI, average hospital LOS, and mortality were all independently predictive of hospital and professional charges. CONCLUSIONS: PTC verification improves the value of BSI management, but the associated decrease in operative rate is only partially responsible. Multisystem injury children experience the greatest value benefit from PTC verification. TYPE OF STUDY: Treatment and cost-effectiveness study. LEVEL OF EVIDENCE: Level III.

Effect of Abdominal Ultrasound on Clinical Care, Outcomes, and Resource Use Among Children With Blunt Torso Trauma: A Randomized Clinical Trial.

Importance: The utility of the focused assessment with sonography for trauma (FAST) examination in children is unknown. Objective: To determine if the FAST examination during initial evaluation of injured children improves clinical care. Design, Setting, and Participants: A randomized clinical trial (April 2012-May 2015) that involved 975 hemodynamically stable children and adolescents younger than 18 years treated for blunt torso trauma at the University of California, Davis Medical Center, a level I trauma center. Interventions: Patients were randomly assigned to a standard trauma evaluation with the FAST examination by the treating ED physician or a standard trauma evaluation alone. Main Outcomes and Measures: Coprimary outcomes were rate of abdominal computed tomographic (CT) scans in the ED, missed intra-abdominal injuries, ED length of stay, and hospital charges. Results: Among the 925 patients who were randomized (mean [SD] age, 9.7 [5.3] years; 575 males [62%]), all completed the study. A total of 50 patients (5.4%, 95% CI, 4.0% to 7.1%) were diagnosed with intra-abdominal injuries, including 40 (80%; 95% CI, 66% to 90%) who had intraperitoneal fluid found on an abdominal CT scan, and 9 patients (0.97%; 95% CI, 0.44% to 1.8%) underwent laparotomy. The proportion of patients with abdominal CT scans was 241 of 460 (52.4%) in the FAST group and 254 of 465 (54.6%) in the standard care-only group (difference, -2.2%; 95% CI, -8.7% to 4.2%). One case of missed intra-abdominal injury occurred in a patient in the FAST group and none in the control group (difference, 0.2%; 95% CI, -0.6% to 1.2%). The mean ED length of stay was 6.03 hours in the FAST group and 6.07 hours in the standard care-only group (difference, -0.04 hours; 95% CI, -0.47 to 0.40 hours). Median hospital charges were $46 415 in the FAST group and $47 759 in the standard care-only group (difference, -$1180; 95% CI, -$6651 to $4291). Conclusions and Relevance: Among hemodynamically stable children treated in an ED following blunt torso trauma, the use of FAST compared with standard care only did not improve clinical care, including use of resources; ED length of stay; missed intra-abdominal injuries; or hospital charges. These findings do not support the routine use of FAST in this setting. Trial Registration: clinicaltrials.gov Identifier: NCT01540318.

Selective non-operative management of abdominal stab wounds is a safe and cost effective strategy: A South African experience.

INTRODUCTION Selective non-operative management (SNOM) of abdominal stab wounds is well established in South Africa. SNOM reduces the morbidity associated with negative laparotomies while being safe. Despite steady advances in technology (including laparoscopy, computed tomography [CT] and point-of-care sonography), our approach has remained clinically driven. Assessments of financial implications are limited in the literature. The aim of this study was to review isolated penetrating abdominal trauma and analyse associated incurred expenses. METHODS Patients data across the Pietermaritzburg Metropolitan Trauma Service (PMTS) are captured prospectively into the regional electronic trauma registry. A bottom-up microcosting technique produced estimated average costs for our defined clinical protocols. RESULTS Between January 2012 and April 2015, 501 patients were treated for an isolated abdominal stab wound. Over one third (38%) were managed successfully with SNOM, 5% underwent a negative laparotomy and over half (57%) required a therapeutic laparotomy. Over five years, the PMTS can expect to spend a minimum of ZAR 20,479,800 (GBP 1,246,840) for isolated penetrating abdominal stab wounds alone. CONCLUSIONS Provided a stringent policy is followed, in carefully selected patients, SNOM is effective in detecting those who require further intervention. It minimises the risks associated with unnecessary surgical interventions. SNOM will continue to be clinically driven and promulgated in our environment.

Outcomes of an accelerated care pathway for pediatric blunt solid organ injuries in a public healthcare system.

PURPOSE: An accelerated clinical care pathway for solid organ abdominal injuries was implemented at a level one pediatric trauma center. The impact on resource utilization and demonstration of protocol safety was assessed. METHODS: Data were collected retrospectively on patients admitted with blunt abdominal solid organ injuries from 2012 to 2015. Patients were subdivided into pre- and post-protocol groups. Length of hospital stay (LOS) and failure of non-operative treatment were the primary outcomes of interest. RESULTS: 138 patients with solid organ injury were studied: 73 pre- (2012-2014) and 65 post-protocol (2014-2015). There were no significant differences in age, gender, injury severity score (ISS), injury grade, or mechanism (p>0.05). LOS was shorter post-protocol (mean 5.6 vs. 3.4days; median 5 .0 vs. 3.0days; p=0.0002), resulting in average savings of $5966 per patient. Patients in the protocol group mobilized faster (p<0.0001) and experienced fewer blood draws (p=0.02). On multivariate analysis, protocol group (p<0.001) and ISS (p<0.001) were independently associated with LOS. There were no differences between groups in the need for operation, embolization, or transfusion. CONCLUSION: An accelerated care pathway is safe and effective in the management of pediatric solid organ injuries with early mobilization, less blood draws, and decreased LOS without significant morbidity and mortality. LEVEL OF EVIDENCE: Therapeutic, cost effectiveness, level III.

Feasibility of selective non-operative management for penetrating abdominal trauma in France.

INTRODUCTION: In France, non-operative management (NOM) is not the widely accepted treatment for penetrating wounds. The aim of our study was to evaluate the feasibility of NOM for the treatment of penetrating abdominal traumas at 3 hospitals in the Southeast of France. METHODOLOGY: Our study was multicentric and retroprospective from January, 2010 to September, 2013. Patients presenting with a penetrating abdominal stab wound (SW) or gunshot wound (GSW) were included in the study. Those with signs of acute abdomen or hemodynamic instability had immediate surgery. Patients who were hemodynamically stable had a CT scan with contrast. If no intra-abdominal injury requiring surgery was evident, patients were observed. Criteria evaluated were failed NOM and its morbidity, rate of non-therapeutic procedures (NTP) and their morbidity, length of hospital stay and cost analysis. RESULTS: One hundred patients were included in the study. One patient died at admission. Twenty-seven were selected for NOM (20 SW and 7 GSW). Morbidity rate was 18%. Failure rate was 7.4% (2 patients) and there were no mortality. Seventy-two patients required operation of which 22 were NTP. In this sub-group, the morbidity rate was 9%. There were no mortality. Median length of hospital stay was 4 days for the NOM group and 5.5 days for group requiring surgery. Cost analysis showed an economic advantage to NOM. CONCLUSION: Implementation of NOM of penetrating trauma is feasible and safe in France. Indications may be extended even for some GSW. Clinical criteria are clearly defined but CT scan criteria should be better described to improve patient selection. NOM reduced costs and length of hospital stay.

Use of a Novel Accounting and Grouping Method for Major Trunk Injury-Analysis of Data from a Statewide Trauma Financial Survey.

Major trunk trauma is common and costly, but comparisons of costs between trauma centers (TCs) are rare. Understanding cost is essential to improve quality, manage trauma service lines, and to facilitate institutional commitment for trauma. We have used results of a statewide trauma financial survey of Levels I to IV TC to develop a useful grouping method for costs and clinical characteristics of major trunk trauma. The trauma financial survey collected billing and clinical data on 75 per cent of the state trauma registry patients for fiscal year 2012. Cost was calculated by separately accounting for embedded costs of trauma response and verification, and then adjusting reasonable costs from the Medicare cost report for each TC. The cost-to-charge ratios were then recalculated and used to determine uniform cost estimates for each patient. From the 13,215 patients submitted for the survey, we selected 1,094 patients with major trunk trauma: lengths of stay ≥ 48 hours and a maximum injury of AIS ≥3 for either thorax or abdominal trauma. These patients were then divided into three Injury Severity Score (ISS) groups of 9 to 15, 16 to 24, or 25+ to stratify patients into similar injury groups for analysis of cost and cost drivers. For abdominal injury, average total cost for patients with ISS 9 to 15 was $17,429. Total cost and cost per day increased with severity of injury, with $51,585 being the total cost for those with ISS 25. Similar trends existed for thoracic injury. Use of the Medicare cost report and cost-to-charge ratios to compute uniform costs with an innovative grouping method applied to data collected across a statewide trauma system provides unique information regarding cost and outcomes, which affects quality improvement, trauma service line management, and decisions on TC participation.

National variation in outcomes and costs for splenic injury and the impact of trauma systems: a population-based cohort study.

OBJECTIVE: To measure national variation in splenectomy rates, mortality, and costs for hospitalized patients with splenic injury and the impact of state trauma systems on these outcomes. METHODS: Using the HCUP State Inpatient Database for 2001, 2004, and 2007, all patients hospitalized with splenic injury were identified from 19 participating states. Multivariate regression was performed to compare splenectomy rates, inpatient mortality, and costs between states. Inclusiveness of statewide trauma systems was categorized based on the proportion of hospitals designated as a trauma center. RESULTS: Of 33,131 patients, 26.2% underwent splenectomy, 6.1% died, and median hospital costs were $14,317. After adjusting for patient, injury, and hospital characteristics, there was a 1.7-fold variation (RR 1.67; 95% CI, 1.39-2.01) among the 19 states in rates of splenectomy. Adjusted inpatient mortality varied more than 2-fold between the highest and lowest states (RR 2.43; 95% CI, 1.76-3.37). Adjusted hospital costs varied over 60% between the highest and lowest states (cost ratio 1.61; 95% CI, 1.41-1.83). States with the most inclusive trauma systems had significantly lower splenectomy rate (RR 0.79; 95% CI, 0.68-0.92) and lower mortality (RR 0.71; 95% CI, 0.58-0.87), but similar hospital costs (CR 1.05; 95% CI, 0.95-1.16) compared to states with exclusive or no trauma systems. CONCLUSIONS: Significant geographic variation in the management, outcome, and costs for splenic injury exists in the United States, and may reflect differences in quality of care. Inclusive trauma systems seem to improve outcomes without increasing hospital costs.

[Costs and role of ultrasound follow-up of polytrauma patients after initial computed tomography]. / Kosten und Stellenwert von Ultraschallverlaufskontrollen bei polytraumatisierten Patienten nach initialer Computertomografie.

PURPOSE: To assess the costs and diagnostic gain of abdominal ultrasound follow-up of polytrauma patients initially examined by whole-body computed tomography (CT). MATERIALS AND METHODS: A total of 176 patients with suspected multiple trauma (126 men, 50 women; age 43.5 ± 17.4 years) were retrospectively analyzed with regard to supplementary and new findings obtained by ultrasound follow-up compared with the results of exploratory FAST (focused assessment with sonography for trauma) at admission and the findings of whole-body CT. A process model was used to document the staff, materials, and total costs of the ultrasound follow-up examinations. RESULTS: FAST yielded 26 abdominal findings (organ injury and/or free intra-abdominal fluid) in 19 patients, while the abdominal scan of whole-body CT revealed 32 findings in 25 patients. FAST had 81 % sensitivity and 100 % specificity. Follow-up ultrasound examinations revealed new findings in 2 of the 25 patients with abdominal injuries detected with initial CT. In the 151 patients without abdominal injuries in the initial CT scan, ultrasound follow-up did not yield any supplementary or new findings. The total costs of an ultrasound follow-up examination were EUR 28.93. The total costs of all follow-up ultrasound examinations performed in the study population were EUR 5658.23. CONCLUSION: Follow-up abdominal ultrasound yields only a low overall diagnostic gain in polytrauma patients in whom initial CT fails to detect any abdominal injuries but incurs high personnel expenses for radiological departments.

Incidental findings in focused assessment with sonography for trauma in hemodynamically stable blunt trauma patients: speaking about cost to benefit.

BACKGROUND: The purpose of this study was to identify which age-related groups of hemodynamically stable blunt trauma patients will present a positive cost-to-benefit ratio, in regard to the screening of incidental findings on Focused Assessment with Sonography for Trauma (FAST). METHODS: We conducted a prospective study using retrospective data taken from the trauma registry of 6,041 consecutive hemodynamically stable blunt trauma patients who underwent FAST at our Level I urban trauma hospital during the year 2009. A receiver operating characteristic curve was used to determine whether age level is useful in detecting organ-/system-specific incidental findings in trauma patients undergoing FAST and to establish the required diagnostic cutoff value of this selected test. A cost-benefit analysis was then performed for the age-specific cutoff values of each organ/system evaluated by FAST. RESULTS: We found 522 incidental findings in 468 patients (7.8%). Further diagnostic workup was instructed in 35% (168 of 468) of patients with incidental findings. The cost-benefit analysis for the age-specific cutoff values found in the receiver operating characteristic curve analysis showed that the project of screening for incidental findings on FAST was viable only when the ultrasound operator additionally searches the liver/biliary tree (≥43 years) and the kidneys (≥56 years). CONCLUSIONS: A systematic examination of the liver and biliary tree and both kidneys of specific age groups during FAST screening of hemodynamically stable blunt trauma patients may disclose a potentially unknown pathology with a positive cost-to-benefit ratio.

Nonsurgical management of blunt splenic injury: is it cost effective?

BACKGROUND: This study analyzed outcomes and cost of splenic embolization compared with surgery for the management of blunt splenic injury. METHODS: We performed a retrospective chart review of all patients admitted with isolated, blunt splenic injury. An intent-to-treat analysis was initially conducted. Outcomes and cost/charges were compared in patients treated with embolization and surgical treatment. RESULTS: Of 236 patients admitted with isolated, blunt splenic injury, 190 patients were ultimately managed by observation, 31 by splenic embolization, and 15 by surgical management. Comparing outcomes and cost data for splenic embolization versus surgical management, there was no significant difference in intensive care unit use, hospital stay, complications, or re-admission. Surgical management patients required more blood transfusions and incurred higher procedure charges. Conversely, splenic embolization patients underwent more radiologic evaluations and charges. Total procedure-related charges were higher for surgical management when compared with splenic embolization ($28,709 vs $19,062; P = .016), but total hospital cost and total hospital charges were not significantly different. CONCLUSIONS: Nonsurgical treatment of blunt splenic injury is safe and cost effective. Angioembolization was statistically similar to surgical therapy regarding cost.

Enterocutaneous fistula complicating trauma laparotomy: a major resource burden.

Enterocutaneous fistula (ECF) is an uncommon and poorly studied postoperative complication. The objective of this study was to analyze the incidence and resource utilization of patients who developed an ECF after trauma laparotomy. All patients with an ECF occurring after trauma laparotomy at a Level I trauma center were identified through a review of both the Trauma Registry and the Morbidity and Mortality reports for a 9-year period ending in December 2006. Each ECF case was matched with a control (non-ECF) that did not develop this complication after laparotomy. The matching criteria were: age, gender, mechanism of injury, Injury Severity Score, Abbreviated Injury Score, and damage control laparotomy requiring an open abdomen. Outcomes analyzed were intensive care unit (ICU) and hospital length of stay, mortality, and total hospital charges. During the 9-year period, of 2373 acute trauma laparotomies performed, 36 (1.5%) patients developed an enterocutaneous fistula, and were matched to 36 controls. Patients with an ECF were 31 +/- 12 years of age, were 97 per cent male, had a mean Injury Severity Score of 21 +/- 10, and 75 per cent were penetrating. Eighty-nine per cent of the ECF patients had a hollow viscus injury. The most common was colon (69%), followed by small bowel (53%), duodenum (36%), and stomach (19%). Fifty-six per cent of the ECF patients had multiple hollow viscus injuries. The development of an ECF was associated with significantly increased ICU length of stay (28.5 +/- 30.5 vs 7.6 +/- 9.3 days, P = 0.004), hospital length of stay (82.1 +/- 100.8 vs 16.2 +/- 17.3 days, P < 0.001), and hospital charges ($539,309 vs $126,996, P < 0.001). In conclusion, the development of an enterocutaneous fistula after laparotomy for trauma resulted in a significant impact on resource utilization including longer ICU and hospital length of stay and higher hospital charges. Further investigation into the prevention and treatment of this costly complication is warranted.

"Awake" laparoscopy for the evaluation of equivocal penetrating abdominal wounds.

BACKGROUND: Diagnostic laparoscopy is useful for the assessment of equivocal penetrating abdominal wounds, and has become the modality of choice for the evaluation of such wounds at our institution. We hypothesised that, in appropriate patients, diagnostic "awake" laparoscopy (AL) could be performed under local anaesthesia in the emergency department (ED), allowing for expedited discharge and potential cost savings. METHODS: Selected haemodynamically stable patients with penetrating abdominal injury underwent AL. Suitability for AL was at the discretion of the attending surgeon. Identification of peritoneal penetration by AL led to exploratory laparotomy in the operating room. Patients with no evidence of peritoneal penetration were discharged from the ED (ALneg). These patients were matched to a cohort of 24 patients who underwent diagnostic laparoscopy in the OR which was negative for peritoneal penetration (DLneg). Length of stay and hospital charges were compared. RESULTS: Over a 30-month period, 15 patients underwent AL without complication. No peritoneal penetration was found in 11 patients. The remaining four patients underwent exploratory laparotomy, of which two were positive for intra-abdominal injury. Mean time to discharge was 7h in the ALneg group versus 18 h in the DLneg group (p=0.0003). Cost savings on hospital charges averaged 2227 US dollars per patient in the ALneg group compared with the DLneg group. CONCLUSIONS: AL may be safely performed in the ED, allowing for expedited patient discharge. Cost savings are achieved by the avoidance of charges inherent to diagnostic laparoscopy performed in the operating room.

The open abdomen in trauma: do infectious complications affect primary abdominal closure?

OBJECTIVE: One of the primary goals of damage control surgery in the trauma patient is primary closure of the abdomen. We hypothesized that extra-abdominal infections, such as those complicating injuries to the thorax, diaphragm, long bones, or musculoskeletal system, would decrease the likelihood of primary abdominal closure and increase hospital resource utilization in patients requiring open abdominal management. METHODS: The trauma registry of the American College of Surgeons (TRACS) was reviewed retrospectively from 1995-2002 for open abdomen technique and damage control surgery. The outcome was primary fascial closure or delayed closure. Patients who died prior to closure were excluded. We evaluated infectious complications, including ventilator-associated pneumonia (VAP), blood stream infection (BSI), and surgical site infection (SSI). Other parameters studied were multiple rib fractures, long bone fractures, chest injuries, diaphragm injuries, empyema, and transfusion requirements. Hospital charges were obtained from the hospital administrative database. Univariate, multivariate, and regression analyses were performed to identify the effects of infectious complications on primary abdominal closure, length of stay, total hospital charges, and disposition. RESULTS: Three hundred forty-four patients required the open abdomen technique: 67% received damage control laparotomy and 33% decompression of abdominal compartment syndrome. Two hundred seventy-six patients (80%) went on to abdominal closure of some form and constituted the primary study group. Primary abdominal closure was achieved in 180 (65%) with a mean time to closure of 3.5 days. Ventilator-associated pneumonia, BSI, and SSI were associated with lack of primary closure (p < 0.05). Increased blood transfusions also were associated with failure of primary closure (p < 0.05). Ventilator-associated pneumonia and BSI were associated with significantly greater lengths of stay in the intensive care unit (ICU) (24.2 days vs. 12.6 days and 30.5 days vs. 17.9 days; both p < 0.0001) and significantly greater total hospital charges (232,080 US dollar vs. 142,893 US dollar; 247,440 US dollar vs. 160,940 US dollar; and 264,778 US dollar vs. 170,447 US dollar; all p < 0.001). CONCLUSION: Inability to achieve primary abdominal closure was associated with infectious complications (VAP, BSI, and SSI) and large transfusion requirements. Infectious complications also significantly increased ICU utilization and hospital charges. Death was associated with BSI, femur fractures, and large transfusion requirements, whereas infectious complications did not have a significant impact on discharge disposition.

The cost of treating serious abdominal firearm-related injuries in South Africa.

INTRODUCTION: Firearms, the leading external cause of non-natural deaths in South Africa, claim approximately 15,000 lives annually. Up to 127,000 firearm-injured victims seek state health care assistance per annum. The fiscal burden of treating these injuries is not known. METHODS: All serious abdominal firearm-related injuries (requiring admission to hospital and emergency surgery) presenting to a state hospital over a 6-month period were reviewed. A cost analysis using five variables was performed: operating theatre time, duration of hospital and high-care unit stay, pharmaceutical and blood products used, laboratory services used and diagnostic imaging studies performed. RESULTS: Twenty-three patients with serious abdominal gunshot injuries were admitted, of whom 21 (91%) were treated at the hospital from admission until discharge. Each admission cost approximately US dollars 1,467. Hospital stay (47%) and operating theatre (30%) costs accounted for most of the total cost. Pharmaceuticals and blood products (20%), laboratory services (2%) and imaging studies (1%) contributed less than 25% to the total cost. CONCLUSION: Serious abdominal gunshot injuries cost at least 13-fold more than the annual per capita South African government expenditure on health. This fiscal burden of approximately US dollars 2.9 million, almost 4% of the annual health budget, does not include the cost of treating other serious gunshot injuries. These findings highlight the need for successful violence prevention strategies in South African.