Multiple-Institution Comparison of Resident and Faculty Perceptions of Burnout and Depression During Surgical Training.

Importance: Prior studies demonstrate a high prevalence of burnout and depression among surgeons. Limited data exist regarding how these conditions are perceived by the surgical community. Objectives: To measure prevalence of burnout and depression among general surgery trainees and to characterize how residents and attendings perceive these conditions. Design, Setting, and Participants: This cross-sectional study used unique, anonymous surveys for residents and attendings that were administered via a web-based platform from November 1, 2016, through March 31, 2017. All residents and attendings in the 6 general surgery training programs in North Carolina were invited to participate. Main Outcomes and Measures: The prevalence of burnout and depression among residents was assessed using validated tools. Burnout was defined by high emotional exhaustion or depersonalization on the Maslach Burnout Inventory. Depression was defined by a score of 10 or greater on the Patient Health Questionnaire-9. Linear and logistic regression models were used to assess predictive factors for burnout and depression. Residents' and attendings' perceptions of these conditions were analyzed for significant similarities and differences. Results: In this study, a total of 92 residents and 55 attendings responded. Fifty-eight of 77 residents with complete responses (75%) met criteria for burnout, and 30 of 76 (39%) met criteria for depression. Of those with burnout, 28 of 58 (48%) were at elevated risk of depression (P = .03). Nine of 77 residents (12%) had suicidal ideation in the past 2 weeks. Most residents (40 of 76 [53%]) correctly estimated that more than 50% of residents had burnout, whereas only 13 of 56 attendings (23%) correctly estimated this prevalence (P < .001). Forty-two of 83 residents (51%) and 42 of 56 attendings (75%) underestimated the true prevalence of depression (P = .002). Sixty-six of 73 residents (90%) and 40 of 51 attendings (78%) identified the same top 3 barriers to seeking care for burnout: inability to take time off to seek treatment, avoidance or denial of the problem, and negative stigma toward those seeking care. Conclusions and Relevance: The prevalence of burnout and depression was high among general surgery residents in this study. Attendings and residents underestimated the prevalence of these conditions but acknowledged common barriers to seeking care. Discrepancies in actual and perceived levels of burnout and depression may hinder wellness interventions. Increasing understanding of these perceptions offers an opportunity to develop practical solutions.

Ventilator-Associated Pneumonia in Trauma Patients: Different Criteria, Different Rates.

BACKGROUND: No consensus exists regarding the definition of ventilator-associated pneumonia (VAP). Even within a single institution, inconsistent diagnostic criteria result in conflicting rates of VAP. As a Level 1 trauma center participating in the Trauma Quality Improvement Project (TQIP) and the National Healthcare Safety Network (NHSN), our institution showed inconsistencies in VAP rates depending on which criteria was applied. The purpose of this study was to compare VAP definitions, defined by culture-based criteria, National Trauma Data Bank (NTDB) and NHSN, using incidence in trauma patients. METHODS: A retrospective chart review of consecutive trauma patients who were diagnosed with VAP and met pre-determined inclusion and exclusion criteria admitted to our rural, 861-bed, Level 1 trauma and tertiary care center between January 2008 and December 2011 was performed. These patients were identified from the National Trauma Registry of the American College of Surgeons (NTRACS) database and an in-house infection control database. Ventilator-associated pneumonia diagnosis criteria defined by the U.S. Center for Disease Control and Prevention (used by the NHSN), the NTDB, and our institutional, culture-based criteria gold standard were compared among patients. RESULTS: Two hundred seventy-nine patients were diagnosed with VAP (25.4% met NHSN criteria, 88.2% met NTDB, and 76.3% met culture-based criteria). Only 58 (20.1%) patients met all three criteria. When NHSN criteria were compared with culture-based criteria, NHSN showed a high specificity (92.5%) and low sensitivity (28.2%). The positive predictive value (PPV) was 84.5%, but the negative predictive value (NPV) was 47.1%. The agreement between the NHSN and the culture-based criteria was poor (κ = 0.18). Conversely, the NTDB showed a lower specificity (57.8%), but greater sensitivity (86.4%) compared with culture-based criteria. The PPV and NPV were both 74% and the two criteria showed fair agreement (κ = 0.41). CONCLUSIONS: The lack of standard diagnostic criteria for VAP resulted in variable reporting to different agencies. Emphasis on establishing a consensus VAP definition should be undertaken.

Milestones: The Road to Faculty Development.

PURPOSE: Milestones for the assessment of residents in graduate medical education mark a change in our evaluation paradigms. The Accreditation Council for Graduate Medical Education has created milestones and defined them as significant points in development of a resident based on the 6 competencies. We propose that a similar approach be taken for resident assessment of teaching faculty. We believe this will establish parity and objectivity for faculty evaluation, provide improved data about attending surgeons' teaching, and standardize faculty evaluations by residents. METHODS: A small group of advanced surgery educators determined appropriate educational characteristics, resulting in creation of 11 milestones (Fig. 2) that were reviewed by faculty and residents. The residents have historically answered 16 questions, developed by our surgical education committee (Fig. 3), on a 5-point Likert score (never to very often). Three weeks after completing this Likert-type evaluation, the residents were asked to again evaluate attending faculty using the Faculty Milestones evaluation. The residents then completed a survey of 7 questions (scale of 1-9-disagree to strongly agree, neutral = 5), assessing the new milestones and compared with the previous Likert evaluation system. RESULTS: Of 32 surgery residents, 13 completed the Likert evaluations (3760 data points) and 13 completed the milestones evaluations (1800 data points). The number completing both or neither is not known, as the responses are anonymous when used for faculty feedback. The Faculty Milestones attending physicians' scores have far fewer top of range scores (21% vs 42%) and have a wider spread of data giving better indication of areas for improvement in teaching skills. The residents completed 17 surveys (116 responses) to evaluate the new milestones system. Surveys indicated that milestones were easier to use (average rating 6.13 ± 0.42 Standard Error (SE)), effective (6.82 ± 0.39) and efficient (6.11 ± 0.53), and more objective (6.69 ± 0.39/6.75 ± 0.38) than the Likert evaluations are. Average response was 6.47 ± 0.46 for overall satisfaction with the Faculty Milestones evaluation. More surveys were completed than evaluations, as all residents had an opportunity to review both evaluation systems. CONCLUSIONS: Faculty Milestones are more objective in evaluating surgical faculty and mirror the new paradigm in resident evaluations. Residents found this was an easier, more effective, efficient, and objective evaluation of our faculty. Although our Faculty Milestones are designed for surgical educators, they are likely to be applicable with appropriate modifications to other medical educators as well.

When birds can't fly: an analysis of interfacility ground transport using advanced life support when helicopter emergency medical service is unavailable.

BACKGROUND: Helicopter emergency medical service (HEMS) transport of trauma patients is costly and of unproven benefit. Recent retrospective studies fail to control for crew expertise and therefore compare highly trained advance life support with less-trained basic life support crews. The purpose of our study was to compare HEMS with ground, interfacility transport while controlling for crew training. We hypothesized that patients transported by HEMS would experience shorter interhospital transport time and reduced mortality. METHODS: Our National Trauma Registry of the American College of Surgeons database was retrospectively queried to identify consecutive interfacility, hospital transfers (January 1, 2008, to November 1, 2012) to our Level I trauma center. Transfers were stratified by transportation vehicle (i.e., HEMS vs. ground transport). Cohorts were compared across standard demographic and clinical variables using univariate analysis. Multivariate logistic regression was performed to determine the association of these variables with mortality. RESULTS: The HEMS (n = 2,190) and ground (n = 223) cohorts were well matched overall, with no significant differences for demographics, injury severity, physiology, hospital length of stay, or complications. Median (interquartile range) time to definitive care was significantly lower for HEMS (150 [114] minutes vs. 255 [157] minutes, p < 0.001), without change in mortality (9.0% vs. 8.1%, p = 0.71). Multivariate logistic regression did not identify an association between transport mode and mortality. CONCLUSION: Despite faster interfacility transport times, HEMS offered no mortality benefit compared with ground when crew expertise was controlled for, contradicting recent large, retrospective National Trauma Data Bank studies. Our study may represent the best approximation of a prospective study by focusing on patients deemed worthy of HEMS by referring providers. Although HEMS may seem intuitively beneficial for time-dependent injuries, larger studies with a similar methodology are warranted to justify the cost and risk of HEMS and identify subsets of patients who may benefit. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III.

Maggot Therapy for Elephantiasis Nostras Verrucosa Reveals New Applications and New Complications: A Case Report.

Elephantiasis nostras verrucosa (ENV) is a rare dermatologic condition caused by chronic nonfilarial lymphedema. The treatment for ENV is challenging and based solely on case reports. We report novel therapy for ENV with maggot debridement therapy (MDT), an effective wound therapy that has gained popularity with the rise of antimicrobial resistance. MDT, in combination with tangential surgical debridement, was effective in the treatment of ENV. In nature, sheep infested with more than 16 000 blow fly larvae exhibit ammonia toxicity. Although hyperammonemia as a side effect of maggot therapy has been theorized, its existence has not been described in human studies until this case. This patient exhibited hyperammonemia during maggot therapy; with alterations in serum ammonia reflecting changes in larval population. Maggot therapy should be considered for the treatment of ENV. Hyperammonemia with maggot therapy exists, and clinicians who employ this treatment should be aware of this potential adverse effect.

An objective study of the impact of the electronic medical record on outcomes in trauma patients.

It is commonly believed that the electronic medical record (EMR) will improve patient outcomes. However, there is scant published literature to support this claim and no studies in any surgical population. Our hypothesis was that the EMR would not improve objective outcome measures in patients with traumatic injury. Prospectively collected data from our university-based Level I trauma center was retrospectively reviewed. Demographic, injury severity as well as outcomes and complications data were compared for all patients admitted over a 20-month period before introduction of the EMR and a 20-month period after full, hospital-wide use of the EMR. Implementation of the EMR was associated with a decreased hospital length of stay, P = 0.02; intensive care unit length of stay, P = 0.001; ventilator days, P = 0.002; acute respiratory distress syndrome, P = 0.006, pneumonia, P = 0.008; myocardial infarction, P = 0.001; line infection, P = 0.03; septicemia, P = 0.000; renal failure, P = 0.000; drug complication, P = 0.001; and delay in diagnosis, P = 0.04. There was no difference in mortality, unexpected cardiac arrest, missed injury, pulmonary embolism/deep vein thrombosis, or late urinary tract infection. This is the first study to investigate the impact of the EMR in surgical patients. Although there was an improvement in some complications, the overall impact was inconsistent.

Open fractures: it doesn't come out in the wash.

BACKGROUND: Six hours from injury to washout is considered the gold standard in the treatment of open traumatic fractures. Despite this being our hospital policy, the rural nature of our Level I trauma center causes delays in discovery and transport, creating a unique randomization of time to washout. We hypothesized that orthopedic complications after open fractures are related to the severity of the fractures, not the timing of the washout. METHODS: Patients and fractures were reviewed retrospectively over 6.3 years, evaluating for demographics, injury severity, location of fracture, mechanism of injury, Gustilo fracture grade, and time from injury to initial washout. Orthopedic wound complication rates were compared using logistic regression. RESULTS: A total of 1,487 open fractures in 1,278 patients were reviewed. Time from injury to washout was 26 to 4,749 min (mean, 510 min), with 48 patients having no washout. Overall, 8.2% of fractures (n=122) had an orthopedic complication, rates of which increased with severity (Injury Severity Score, Abbreviated Injury Score [AIS], and Gustilo class) and blunt injuries but were not related to time to washout. Penetrating injuries showed no difference in complication rates according to time to washout. Lower extremity fractures had a higher rate of complications than those of the upper extremity (odds ratio 2.2), likely because of differences in fracture grade. By multivariable logistic regression, only fracture grade, Revised Trauma Score (RTS), and male gender were independent predictors of wound complications; penetrating trauma was predictive of low risk. Time to washout was not an independent predictor of wound complications. CONCLUSIONS: Although grossly contaminated fractures should not be left unattended, the degree of initial injury, as judged by fracture grade and physiology (RTS), was predictive of orthopedic wound complications, whereas time to washout was not. Hence, there is little benefit of washout in Gustilo grade 1/AIS 1 fractures or penetrating injuries, regardless of grade, and adherence to a specific time to washout is not beneficial.

Examining the myth of the "July Phenomenon" in surgical patients.

BACKGROUND: The objective of this study is to evaluate morbidity and mortality rates in surgical patients at the beginning of the academic year. METHODS: The National Surgical Quality Improvement Program database was utilized to gather data on the 10 most common inpatient operative procedures from 2005-2007. Study end points included mortality, serious adverse events (SAE), and all morbidities. Statistical analysis of outcomes was conducted examining the total population, and then stratified by operation to assess for significant differences in end points (P < .05). RESULTS: A total of 89,473 patients were identified. During the first academic quarter, the mortality rate was no different in the study group than the control group (2.0% vs 2.2%, P = .793). Overall SAE and morbidity rates were similar between populations (11.5% vs 11.4%, P = .697 and 18.3% vs 17.8%, P = .076, respectively). When stratified by operation, "artery bypass graft" (3.7% vs 2.9%, P = .039) and "repair bowel opening" (1.1% vs 0.6%, P = .033) subsets had increases in mortality rate. Multivariate analysis confirmed the deleterious effect of first quarter admission in only the "artery bypass graft" subset (OR = 1.35, CI 1 = .023-1.774). CONCLUSION: By in large, these data refute the "July Phenomenon." Multivariate analysis revealed patient disease to have a greater impact than timing of operation in the "repair bowel opening" subset. The "artery bypass graft" population was affected by timing of operation and the very small effect on mortality (<1%) may reflect new surgery residents being unfamiliar with the management of complex cardiovascular disease.

Importance of methicillin-resistant Staphylococcus aureus eradication in carriers to prevent postoperative methicillin-resistant Staphylococcus aureus surgical site infection.

Although infrequent, postoperative methicillin-resistant Staphylococcus aureus (MRSA) surgical site infection (SSI) is associated with significant morbidity and cost. Previous studies have identified the importance of MRSA screening to diminish the risk of postoperative MRSA SSI. The current study quantifies the importance of eradication of the MRSA carrier state to prevent MRSA SSI. Beginning February 2007, all admissions to an 800-bed tertiary care hospital were screened for MRSA by nasal swab using rapid polymerase chain reaction-based testing. Patients found to be nasal carriers of MRSA were treated with 2 per cent mupirocin nasal ointment and 4 per cent chlorhexidine soap before surgery. The subset of patients undergoing procedures that are part of the Surgical Care Improvement Project (SCIP) were followed for MRSA SSI (n = 8980). The results of preoperative MRSA screening and eradication of the carrier state were analyzed. Since the initiation of universal MRSA screening, 11 patients undergoing SCIP procedures have developed MRSA SSI (0.12%). Of these, six patients (55%) had negative preoperative screens. Of the five patients with positive preoperative screens, only one received treatment to eradicate the carrier state. In patients who develop MRSA SSI, failure to treat the carrier state before surgery results in MRSA SSI.

Physician behavior: not ready for 'Never'land.

Disruptive physician behavior, particularly by surgeons, is a common perception. Increasing awareness and regulatory oversight is being felt in medical practice; however, little data exist regarding the frequency of these behaviors. This study was undertaken to determine the prevalence and type of reported behavioral issues. Blinded data for 2 years of physician behavior reports were reviewed for department, gender, event summary, and peer review conclusions. Chi-square analysis was used with statistical significance at P < 0.05. One hundred ninety-one behavior issues were reported in our 751-bed hospital, which employs 640 active physicians. One hundred fourteen (18%) physicians were reported. Forty-four (7%) physicians had multiple reports, accounting for 121 (63%) reports. Twenty-seven physicians were reported twice, eight 3 times, four 4 times, three 5 times, and one 6 times. Multiple-report physicians compared with single-report physicians showed no difference in distribution of outcomes, but more communication issues and fewer unacceptable behaviors. Specialty groups with a higher incidence of reported behaviors included anesthesia, cardiology, hospitalists, orthopedics, trauma, and obstetrics/gynecology. Female physicians were less likely to be reported. Staff reports were mainly against physicians within their hospital practice area (75 of 94 [80%]), whereas physician reports were mainly against physicians outside their practice area (18 of 25 [72%]). Disruptive physician behavior is variable and culturally defined. Although all reports should be taken seriously, fewer than 1 per cent of reported incidents were found to be definably disruptive and valid. As quality and oversight groups consider making disruptive physician behavior a "never" event, firm definitions and full peer review are mandatory.

A contemporary rural trauma center experience in blunt traumatic aortic injury.

INTRODUCTION: Traumatic aortic injury (TAI) is a rare yet highly lethal injury associated with blunt force deceleration injury. The adoption of thoracic endovascular aortic repair (TEVAR) has become a safer option than traditional open repair. The purpose of this study is to review a rural trauma center experience with TAI. METHODS: A retrospective analysis was performed, reviewing all patients who presented with TAI between 2000 and 2009. Clinical, anatomical, and procedural variables of all cases were systematically reviewed. Clinical endpoints included mortality, and aortic-related mortality, and hospital length of stay. The study population was stratified by those that underwent surgical repair (SR) and those managed medically (MM). RESULTS: Fifty-six patients presented with blunt TAI; 35 patients (62.5%) were surgically repaired (22 open, 13 TEVAR), while 21 (37.5%) were MM. The only difference in comorbidities was a higher rate of coronary artery disease in MM. Mean hospital arrival time (SR, 188.6 ± 30.3 minutes, MM, 253 ± 65.3 minutes), aortic injury grade (SR, 2.7 ± 0.1; MM, 2.3 ± 0.2), and injury severity score were not significantly different between the groups. Head Abbreviated Injury Score (AIS) was worse in the MM group, while chest AIS was worse in the SR group (P < .05). There were nine (42.9%) deaths in the MM group, while there were only two (5.7%) in the SR group (P < .001). There was no significant difference in aortic-related mortality. Mean follow-up time was not statistically different. CONCLUSION: These data provide a group of stable patients to examine the management of TAI in the endovascular era. The low aortic-related mortality in the MM group demonstrates that there is time for a thorough evaluation in patients sustaining TAI who arrive without hemodynamic instability.

Trauma intensive care unit survival: how good is an educated guess?

BACKGROUND: Resource utilization in medicine is becoming a more and more urgent issue with ongoing national discussions on healthcare coverage. In the management of a trauma system, large amounts of resources and money are expended on individual patients in hope of a "great save." In addition, those of us caring for these patients are required to estimate outcomes daily to the family in an effort to choose the best course of care for an individual patient. Hence, we undertook a study to analyze the accuracy of outcomes predictions of various members of the healthcare team. METHODS: During a period of 38 months (July 2005 to August 2008), an observational study of patients admitted to a Level I Trauma Center Intensive Care Unit (ICU) was undertaken. Institutional Review Board permission was obtained before starting the study. Only patients older than 18 years were included. Patients who were moribund or expected discharge within 72 hours were excluded.Our traumatized ICU patients are cared for by a multidisciplinary team consisting of a trauma/ICU attending, all of whom have additional certification in surgical critical care and who rotate through the ICU on a weekly basis, a surgical ICU fellow, residents and medical students of several levels of training who rotate on a monthly basis, trauma advanced-level practitioners who rotate weekly, and bedside ICU nurses who work routine shifts. Respiratory therapists, nutritionists, ICU pharmacists, and other members of the rounding team were not included in the study because they do not provide global patient care. Regardless of admitting physician, the patients are managed by the team, and our practice of care is similar across the group, based on protocols and consensus.For each of the study patients, a survey tool was filled out by the ICU rounding team on hospital day 1 and hospital day 3. The tool was completed by members of the team providing global care to the patient and varied depending on the members of the group at each day's rounds. All current and admission data on injuries, study and laboratory results, and current patient status were available to all members of the team. Each member was expected to fill out the survey tool independently, and the results of the tool were not discussed during rounds.Concurrently, data were collected by the ICU fellow and research nurse. These data and the results of the survey tools were entered in a database for analysis after patient discharge. A retrospective analysis was undertaken to analyze the relative accuracy of the care, team members' assessment, and actual survival. Statistical analysis was done using by-chance accuracy comparisons. RESULTS: Two hundred twenty-three patients had 326 observations performed. Day 3 accuracy improved for most groups. In all groups, accuracy was found to be statistically significantly better than by-chance accuracy. Given that the majority of patients in the trauma population are survivors, sensitivity and positive predictive value of the observer's ability to predict death were also evaluated. CONCLUSIONS: Although significantly better than chance prediction, the ability of members of the ICU team to predict survival of trauma patients remains poor, particularly on initial evaluation. A period of clinical observation improves the accuracy. Unfortunately, experience of the observer does not seem to improve accuracy of survival prediction. This data indicate that care must be taken when describing likely outcomes to patient family members.

Running out of gas but not trauma patients: the effect of the price of gas on trauma admissions.

As fuel costs steadily rise and motor vehicle collisions continue to be a leading cause of morbidity and mortality, we examined the relationship between the price of gasoline and the rate of trauma admissions related to gasoline consumption (GRT). The National Trauma Registry of the American College of Surgeons data of a rural Level I trauma center were queried over 27 consecutive months to identify the rate of trauma admissions/month related to gas utilization compared with the number of nongasoline related trauma admissions, based on season and day of the week. The average price/gallon of regular gas in our region was obtained from the NorthCarolinaGasPrices. com database. A log linear model with a Poisson distribution was created. No significant association exists between the average price/gallon of gasoline and the GRT rate across the months, seasons, and weekday and weekend periods. As the price of gas continues to rise, the rate of rural GRT does not decrease. Over a longer period of time and with skyrocketing prices, this relationship may not hold true. These findings may also be explained by the rural area where limited alternative transportation opportunities exist and a trauma patient population participating in high risk behavior regardless of cost.

What price commitment: what benefit? The cost of a saved life in a developing level I trauma center.

BACKGROUND: In 1999, a Level I Trauma Center committed significant resources for development, recruitment of trauma surgeons, and call pay for subspecialists. Although this approach has sparked a national ethical debate, little has been published investigating efficacy. This study examines the price of commitment and outcomes at a Level I Trauma Center. METHODS: Direct personnel costs including salary, call pay, and personnel expenses were analyzed against outcomes for two periods defined as PRE (1994-1999) and POST (2000-2005). Patient care costs and 1999 to 2000 transition data were excluded. Demographics, outcomes, and direct personnel costs were compared. Significant mortality reductions stratified by age and injury severity score (ISS) were used to calculate lives saved in relation to direct personnel costs. Student's t test and chi were used (significance *p < 0.05). RESULTS: In the PRE period, there were 7,587 admissions compared with 11,057 POST. There were no significant differences PRE versus POST for age (41.4 +/- 24.4 years vs. 41.3 +/- 24.9 years), gender (62.4% vs. 63.7% male), mechanism of injury (11.5% vs. 11.8% penetrating), and percent intensive care unit admissions (30.1 vs. 29.9). Significant differences were noted for ISS (10.5 +/- 9.7 vs. 11.6 +/- 10.1*), percent admissions with ISS >or=16 (18.5 vs. 27.3*), and revised trauma score (10.8 +/- 2.8 vs. 10.7 +/- 2.8*). Both the average length of stay (6.8 +/- 8.8 vs. 6.5 +/- 9.8*) and percent mortality for ISS >or=16 (23 vs. 17*) were reduced. When mortality was stratified by both age and ISS, significant reductions were noted and a total of 173 lives were saved as a result. However, direct personnel costs increased from $7.6 million to $22.7 million. When cost is allocated to lives saved; the cost of a saved life was more than $87,000. CONCLUSIONS: Resources for program development, including salary and call pay, significantly reduced mortality. Price of commitment: $3 million per year. The cost of a saved life: $87,000. The benefit: 173 surviving patients who would otherwise be dead.

The elderly trauma patient: an investment for the future?

BACKGROUND: The cost of care in elderly (ELD) trauma patients is high compared with younger patients, but the association between age and reimbursement relative to cost is less clear. The purpose of this study was to explore the relationship between total costs (TC) and reimbursement in young (YNG) and ELD trauma patients. METHODS: The National Trauma Registry of the American College of Surgeons was queried for patients admitted to a level I trauma center between January 2002 and December 2004. YNG patients (18-64 years) were compared with ELD patients (> or =65 years) for mechanism of injury, Injury Severity Score, and outcome variables. Data obtained from the hospital cost accounting system included TC, total payment, and net margin (P-L). Virtually, all patients were reimbursed based on the fixed diagnostic-related group payment. RESULTS: There were 641 ELD and 3,470 YNG patients included in the study. ELD patients were more commonly injured via a blunt mechanism than the YNG patients (97% vs. 83%; p < 0.001). The ELD were more severely injured (Injury Severity Score 14.9 +/- 10.8 vs. 13.3 +/- 10.9), developed more complications (54% vs. 34%), and died more frequently (17% vs. 4.7%; all p < 0.05). TC for the ELD were significantly higher than the YNG ($20,788.92 +/- $28,305.54 vs. $19,161.11 +/- $30,441.56; p = 0.02). Total payment ($20,049.75 +/- $29,754.52 vs. $16,766.14 +/- $31,169.15) and P-L (-$739.18 +/- $17,207.84 vs. -$2,294.98 +/- $22,309.51; both p < 0.05) were significantly better for the ELD cohort. However, a financial loss was realized for all patients with trauma. CONCLUSION: When compared with YNG trauma patients, reimbursement in the ELD appears favorable. However, compensation via diagnostic-related group payment fails to cover costs even in the ELD. Reimbursement for all patients with trauma is suboptimal and needs to be improved.

Active surveillance screening of MRSA and eradication of the carrier state decreases surgical-site infections caused by MRSA.

BACKGROUND: Surgical-site infections (SSI), because of MRSA, are a challenge for acute care hospitals. The current study examines the impact of best practices and active surveillance screening for MRSA on reduction of MRSA SSIs. STUDY DESIGN: Beginning February 2007, all admissions to a 761-bed tertiary care hospital were screened for MRSA by nasal swab using polymerase chain reaction-based testing. Positive nasal carriers of MRSA were treated before operation. The subset of patients undergoing procedures that are part of the Surgical Infection Prevention Project were followed for MRSA SSIs. SSI rates (per 100 procedures) were determined using the National Nosocomial Infection Surveillance definitions. MRSA SSI rates were compared before and after the MRSA screening intervention. Differences were analyzed using Fisher's exact test and chi-square with Yate's continuity correction. Where specimens were available, genotyping of MRSA was performed using a commercially available assay. RESULTS: After universal MRSA surveillance, 5,094 patients underwent Surgical Infection Prevention Project procedures. The rate of MRSA SSI decreased from 0.23% to 0.09%. The reduction was most pronounced in joint-replacement procedures (0.30% to 0%; p = 0.04). No other differences were statistically significant. Of the seven patients in whom MRSA SSI developed after universal screening, four had positive MRSA screens; none had received preoperative eradication of MRSA. In two of these patients, the genotype of MRSA detected on screening and in SSI was genetically indistinguishable. CONCLUSIONS: Surveillance for MRSA and eradication of the carrier state reduces the rate of MRSA SSI.