Commonly performed pelvic binder modifications for femoral access may hinder binder efficacy.

BACKGROUND: Pelvic fractures are common and potentially life-threatening. Pelvic circumferential compression devices (PCCD) can temporize hemorrhage, but more invasive strategies that involve femoral access may be necessary for definitive treatment. The aim of our study was to evaluate the efficacy of PCCDs reducing open book pelvic fractures when utilizing commonly described modifications and placement adjustments that allow for access to the femoral vasculature. METHODS: Open book pelvic fractures were created in adult cadavers. Three commercially available PCCDs were used to reduce fractures. The binders were properly placed, moved caudally, or moved cranially and modified. Fracture reduction rates were then recorded. RESULTS: The pelvic fracture was completely reduced with every PCCD tested when properly placed. Reduction rates decreased with improper placement and modifications. CONCLUSION: Modifying PCCD placement to allow femoral access decreased the effectiveness of these devices Clinicians should be aware of this possibility when caring for critically injured trauma patients with pelvic fractures.

Length of stay and trauma center finances: A disparity of payer source at a Level I trauma center.

BACKGROUND: In an effort to reduce costs, hospitals focus efforts on reducing length of stay (LOS) and often benchmark LOS against the geometric LOS (GMLOS) as predicted by the assigned diagnosis-related group (DRG) used by the Centers for Medicare and Medicaid Services. The objective of this cross-sectional study was to evaluate the impact of exceeding GMLOS on hospital profit/loss with respect to payer source. METHODS: Contribution margin for each insured patient admitted to a Level I trauma center between July 1, 2016, and June 30, 2019, was determined. Age, ethnicity, race, DRG weight, DRG version, injury severity, intensive care unit admission status, mechanical ventilation, payer, exceeding GMLOS, and the interaction between payer and exceeding the GMLOS were regressed on contribution margin to determine significant predictors of positive contribution margin. RESULTS: Among 2,449 insured trauma patients, the distribution of payers was Medicaid (54.6%), Medicare (24.0%), and commercial (21.4%). Thirty-five percent (n = 867) of patient LOS exceeded GMLOS. Exceeding GMLOS by 10 or more days was significantly more likely for Medicaid and Medicare patients in stepwise fashion (commercial, 2.7%; Medicaid, 4.5%; Medicare, 6.0%; p = 0.030). Median contribution margin was positive for commercially insured patients ($16,913) and negative for Medicaid (-$8,979) and Medicare (-$2,145) patients. Adjusted multivariate modeling demonstrated that when exceeding GMLOS, Medicare and Medicaid cases were less likely than commercial payers to have a positive contribution margin (p < 0.001 and p < 0.001). CONCLUSION: Government-insured patients, despite having a payer source, are a financial burden to a trauma center. Excess LOS among government insured patients, but not the commercially insured, exacerbates financial loss. A shift toward a greater proportion of government insured patients may result in a significant fiscal liability for a trauma center. LEVEL OF EVIDENCE: Economic and Value-Based Evaluation, Level III.

Trauma patient transport times unchanged despite trauma center proliferation: A 10-year review.

INTRODUCTION: In certain regions of the United States, there has been a dramatic proliferation of trauma centers. The goal of our study was to evaluate transport times during this period of trauma center proliferation. METHODS: Aggregated data summarizing level I trauma center admissions in Arizona between 2009 and 2018 were provided to our institution by the Arizona Department of Health Services. We evaluated patient demographics, transport times, and injury severity for both rural and urban injuries. RESULTS: Data included statistics summarizing 266,605 level I trauma admissions in the state of Arizona. The number of state-designated trauma centers during this time increased from 14 to 47, with level I centers increasing from 8 to 13. Slight decreases in mean Injury Severity Score (rural, 9.4 vs. 8.4; urban, 7.9 vs. 7.0) were observed over this period. Median transport time for cases transported from the injury scene directly to a level I center remained stable in urban areas at 0.9 hours in both 2009 and 2018. In rural areas, transport times for these cases were approximately double but also stable, with median times of 1.8 and 1.9 hours. Transport times for cases requiring interfacility transfer before admission at a level I center increased by 0.3 hours for urban injuries (5.3-5.6 hours) and 0.9 hours for rural injuries (5.6-6.5 hours). CONCLUSION: Despite the threefold increase in the number of state-designated trauma centers, transport time has not decreased in urban or rural areas. This finding highlights the need for regulatory oversight regarding the number and geographic placement of state-designated trauma centers. LEVEL OF EVIDENCE: Care management, level IV, Epidemiological, level III.

Are all trauma centers created equal? Level 1 to level 1 trauma center patient transfers in the setting of rapid trauma center proliferation.

BACKGROUND: Level 1 trauma centers should provide definitive care for every aspect of injury. However, in environments that have experienced trauma center proliferation, not all level 1 centers may have the resources or expertise needed for every patient, necessitating transfer to another trauma center. The purpose of this study was to assess the incidence of such transfers and associated impact on patient outcome and burden on the receiving level 1 center. METHODS: In a metropolitan area experiencing trauma center proliferation, we performed a 5.5-year review of patient transfers to an established level 1 (index center) from other state designated level 1 centers. American College of Surgeons verification level was identified for each facility. Comparisons were performed between the cohort of transferred patients and patients with similar demographics, injury patterns, and severity managed at the index center using propensity score matching. RESULTS: A total of 104 patients were received from other state level 1 centers (39% American College of Surgeons level 2, 61% American College of Surgeons level 1). Nearly 70% of patients were transferred for definitive evaluation and/or management of brain, spine, or cerebrovascular injury. For 76% of this subgroup, specialty consultation was available, but the injury was deemed beyond their capability. Comparison of the transfer cohort propensity score matched to the control cohort (93 vs. 558 patients) demonstrated increased length of stay (6.5 days vs. 4.6 days, p = 0.001) and cost (US $36,027 vs. US $30,654, p = 0.033) associated with the transfer cohort, with similar mortality (12.1% vs. 9.7%, p = 0.492). CONCLUSION: The number of level 1 to level 1 transfers observed imply a disparity in resources and capability among level 1 trauma centers in the region. The majority of transfers were for neurosurgical care, suggestive of a deficit of adequate neurosurgical coverage in the setting of trauma center proliferation. Both patients and established trauma centers bear the burden for these transfers with respect to increased cost and length of stay. LEVEL OF EVIDENCE: Care management, level IV.

The health literacy of hospitalized trauma patients: We should be screening for deficiencies.

BACKGROUND: Although the impact of health literacy (HL) on trauma patient outcomes remains unclear, recent studies have demonstrated that trauma patients with deficient HL have poor understanding of their injuries, are less likely to comply with follow-up, and are relatively less satisfied with physician communication. In this study, we sought to determine if HL deficiency was associated with comprehension of discharge instructions. METHODS: In this prospective study, hospitalized trauma patients underwent evaluation of HL prior to discharge. Newest Vital Sign (NVS) instrument was used to score HL as deficient, marginal, or proficient. Three days postdischarge, patients were telephonically administered a six-point scored questionnaire regarding comprehension of discharge instructions. A general linear model was used to determine the association between HL and comprehension of discharge instructions. RESULTS: Sixty-three patients were administered both NVS and discharge instruction questionnaire. Ten (15.9%) patients scored as deficient in HL on the NVS screen, 16 (25.4%) as marginally proficient, and 37 (58.7%) as proficient. The HL proficiency significantly predicted follow-up score with increasing proficiency associated with higher scores on the discharge comprehension assessment (p < 0.001). Adjusted mean scores (± SE) for deficient, marginal, and proficient patients were 2.8 ± 0.5, 3.2 ± 0.4, and 4.7 ± 0.2. Post hoc comparisons demonstrated significant differences between proficient with marginal proficiency (p = 0.002) and deficient proficiency (p = 0.001). CONCLUSION: Performance on bedside test of HL among trauma inpatients predicted ability to comprehend instructions following hospital discharge. This study supports the value of HL screening prior to discharge. The HL-deficient patients may benefit from a transitional care program to improve comprehension of discharge instructions after leaving the hospital. LEVEL OF EVIDENCE: Therapeutic/Care Management, level III.

Letting the Numbers Speak for Themselves: A Simple Approach to Cost Reduction for Laparoscopic Appendectomy.

Instrument choices are influenced primarily by a surgeon's training and individual preference. Cost is often of secondary interest, particularly in the absence of any contracted fiscal obligation to the hospital. The purpose of this study was to evaluate how a simple intervention involving dissemination of cost data among a surgeon peer group influenced behavior with respect to surgical instrument choice. Cost data for laparoscopic appendectomies between July-December 2016 were disseminated to surgeons belonging to the same department of a teaching hospital. Each surgeon was provided his or her own cost data along with blinded data for his or her peers for comparison. Cost for each disposable instrument used among the group was provided for reference. Costs of laparoscopic appendectomy performed after the intervention (June-December 2017) were compared with costs before the intervention, for both individual surgeons and the group as a whole. A random effects linear regression model clustered on surgeon was then used to assess the average cost saving of the intervention while accounting for the intracorrelation of surgeon costs. One outlier was removed from the analysis, resulting in a cohort of 89 cases before the intervention and 74 postintervention. After outlier removal, data were normally distributed. The mean cost per case decreased for 10 of the 11 surgeons analyzed (minimum decrease of $7 to maximum decrease of $725). The remaining surgeon increased from an average of $985 ± 235 pre-intervention to $1003 ± 227 postintervention. The average cost saving for the group was $238 ± 226 and was associated with an average reduction in cost of 21 per cent. A linear regression analysis clustered on surgeon suggested the intervention was associated with an average saving of $260 (ß = -260, SE = 39, P < 0.001). After dissemination of cost data among surgeon peers, a reduction in costs was observed. Most notably, significant savings occurred in the absence of any mandate or incentive to reduce costs. Providing cost data to surgeons to facilitate natural competition among peers is a simple and effective tool for reducing operating room costs.

Health literacy and quality of physician-trauma patient communication: Opportunity for improvement.

BACKGROUND: Although physician-patient communication and health literacy (HL) have been studied in diverse patient groups, there has been little focus on trauma patients. A quality improvement project was undertaken at our Level I trauma center to improve patient perception of physician-patient communication, with consideration of the effect of HL. We report the first phase of this project, namely the reference level of satisfaction with physician-patient communication as measured by levels of interpersonal care among patients at an urban Level I trauma center. METHODS: Level I trauma center patients were interviewed during hospitalization (August 2016 to January 2017). Short Assessment of Health Literacy tool was used to stratify subjects by deficient versus adequate HL. Interpersonal Processes of Care survey was administered to assess perception of physician-patient communication. This survey allowed patients to rate physician-patient interaction across six domains: "clarity," "elicited concerns," "explained results," "worked together (on decision making)," "compassion and respect," and "lack of discrimination by race/ethnicity." Each is scored on a five-point scale. Frequencies of "top-box" (5/5) scores were compared for significance (p < 0.05) between HL-deficient and HL-adequate patients. RESULTS: One hundred ninety-nine patients participated. Average age was 42 years, 33% female. Forty-nine (25%) patients had deficient HL. The majority of patients in both groups rated communication below 5/5 across all domains except "compassion and respect" and "lack of discrimination by race/ethnicity." Health literacy-deficient patients were consistently less likely to give physicians top-box scores, most notably in the "elicited concerns" domain (35% vs. 54%, p = 0.012). CONCLUSION: Health literacy-deficient patients appear relatively less satisfied with physician communication, particularly with respect to perceiving that their concerns are being heard. Overall, however, the majority of patients in both groups were unlikely to score physician communication in the "top box." Efforts to improve physician-trauma patient communication are warranted, with attention directed toward meeting the needs of HL-deficient patients. LEVEL OF EVIDENCE: Prognostic/Epidemiologic, level I.

The use of extracorporeal membrane oxygenation in blunt thoracic trauma: A study of the Extracorporeal Life Support Organization database.

BACKGROUND: Reports documenting the use of extracorporeal membrane oxygenation (ECMO) after blunt thoracic trauma are scarce. We used a large, multicenter database to examine outcomes when ECMO was used in treating patients with blunt thoracic trauma. METHODS: We performed a retrospective analysis of ECMO patients in the Extracorporeal Life Support Organization database between 1998 and 2014. The diagnostic code for blunt pulmonary contusion (861.21, DRG International Classification of Diseases-9th Rev.) was used to identify patients treated with ECMO after blunt thoracic trauma. Variations of pre-ECMO respiratory support were also evaluated. The primary outcome was survival to discharge; the secondary outcome was hemorrhagic complication associated with ECMO. RESULTS: Eighty-five patients met inclusion criteria. The mean ± SEM age of the cohort was 28.9 ± 1.1 years; 71 (83.5%) were male. The mean ± SEM pre-ECMO PaO2/FIO2 ratio was 59.7 ± 3.5, and the mean ± SEM pre-ECMO length of ventilation was 94.7 ± 13.2 hours. Pre-ECMO support included inhaled nitric oxide (15 patients, 17.6%), high-frequency oscillation (10, 11.8%), and vasopressor agents (57, 67.1%). The mean ± SEM duration of ECMO was 207.4 ± 23.8 hours, and 63 patients (74.1%) were treated with venovenous ECMO. Thirty-two patients (37.6%) underwent invasive procedures before ECMO, and 12 patients (14.1%) underwent invasive procedures while on ECMO. Hemorrhagic complications occurred in 25 cases (29.4%), including 12 patients (14.1%) with surgical site bleeding and 16 (18.8%) with cannula site bleeding (6 patients had both). The rate of survival to discharge was 74.1%. Multivariate analysis showed that shorter duration of ECMO and the use of venovenous ECMO predicted survival. CONCLUSION: Outcomes after the use of ECMO in blunt thoracic trauma can be favorable. Some trauma patients are appropriate candidates for this therapy. Further study may discern which subpopulations of trauma patients will benefit most from ECMO. LEVEL OF EVIDENCE: Therapeutic/care management study, level V.

"Corkscrew stenosis": defining and preventing a complication of percutaneous dilatational tracheostomy.

OBJECTIVE: The short-term safety of percutaneous dilatational tracheostomy has been widely demonstrated. However, less is known about their long-term complications. Through an illustrative case series, we present and define "corkscrew stenosis," a type of tracheal stenosis uniquely associated with percutaneous dilatational tracheostomy. METHODS: Patients treated at our institution for tracheal stenosis after percutaneous dilatational tracheostomy were reviewed. Demographic data including gender, age, history of presentation, lesion morphology, imaging, and management was collected and evaluated. The pathology of the stenosis and the strategies for prevention are presented. RESULTS: From January, 2008 through December 2011, 11 patients had tracheal stenosis after percutaneous dilatational tracheostomy. The mean age was 54 ± 17 years and 55% were male. The stenotic lesions were characterized by a corkscrew morphology at the stoma site with a mean distance of 2.3 ± 0.8 cm from the vocal cords. Images of these lesions demonstrated disruption and fracture of the proximal tracheal cartilages and displacement of the anterior tracheal wall into the tracheal lumen. The majority of our patients required tracheal resection for definitive repair. CONCLUSIONS: We suggest that a unique form of tracheal stenosis can result from percutaneous dilatational tracheostomy. We observed corkscrew stenosis to be located proximally, associated with fractured tracheal rings, and morphologically appearing as interdigitation of these fractured rings. Recognizing corkscrew stenosis, its unique mechanism of formation, and technical means of prevention may be important in advancing the long-term safety of this procedure for critically ill patients who require prolonged ventilatory support.

Hardware preservation after sternal wound infection in a lung transplant recipient.

Sternal wound infections can result in significant morbidity and mortality. Managing these complications is particularly challenging when infected hardware is involved. Traditional thinking mandates removal of infected hardware, yet this hardware is often essential to chest wall stability in the early postoperative period. Here, we present a case of an infected transverse sternotomy wound involving hardware in a lung transplant patient whose treatment included successful hardware preservation. Our experience and other experiences reported in the literature highlight the alternatives in the management of this complication.