The Association of the Affordable Care Act With Medicaid Enrollment Status and Costs of Care at a Level I Trauma Center in a Medicaid Non-expansion State.

INTRODUCTION: The intended purpose of the Patient Protection and Affordable Care Act (ACA) was to expand access to health care insurance for all Americans. In our study, we examine the association of Medicaid enrollment status, health care outcomes, and financial outcomes for trauma patients at a level I urban trauma center in a state that did not expand Medicaid coverage under the ACA. METHODS: We retrospectively reviewed trauma admissions from 2011 to 2016, via the trauma registry (n = 36,250). A subgroup of Medicaid patients (n = 8840) was identified and compared for changes in selected variables and demographics following ACA implementation. The association of Medicaid payor status, by 3 year average pre-ACA (n = 3516) and post-ACA (n = 3324), on patient outcomes, payments collected, and accrued costs of care were analyzed. RESULTS: Three-year Medicaid median actual payments decreased 7.5% following implementation of the ACA ($4072 vs. $3767, P < .01). In contrast, the Medicaid median total cost of care increased 23% ($3964 vs. $4882, P < .01). The rate of patients insured by Medicaid decreased (24.0% vs. 16.2%, P<.001). Patients were admitted longer (1 d vs. 2 d, P < .01), and more injured (ISS 5 vs. 6, P < .01). DISCUSSION: Medicaid payor status under the ACA was associated with a decrease in actual payments and an increase in total cost of care. Moreover, the divergence in actual payments collected with the increased total cost of care warrants examination to ascertain the root cause in efforts to reduce this widening gap.

Prehospital End-Tidal CO2: A Superior Marker for Mortality Risk in the Acutely Injured Patient.

BACKGROUND: Emergency medical personnel must expeditiously triage acutely injured patients to the appropriate medical facility. Efficient and objective variables to facilitate this process and provide information to the receiving trauma center are needed. Currently, multiple variables are used to prognosticate injury severity and risk of mortality including vital signs, mental status, lactate, and base excess. We investigated the prehospital use of end-tidal carbon dioxide (ETCO2) as a noninvasive physiologic measure that can be obtained in the acutely injured patient. METHODS: We performed a retrospective analysis of 557 acutely injured patients over 2 years at a Level 1 trauma center. All patients arriving as trauma activations with ETCO2 measurements were included in analysis. End-tidal carbon dioxide measurements were categorized as low, normal, and high based on reference levels. Mortality was the primary outcome. Secondary receiver operator curves (ROC) for base excess, venous lactate, blood pressure, and venous pH were compared. We hypothesized ETCO2 levels would be able to predict mortality. RESULTS: End-tidal carbon dioxide levels conferred a mortality rate of 38%, 17.3%, and 2.9% for low, normal, and high, respectively (P < .001). Receiver operator curve analysis produced an area under the curve predictive value for ETCO2 (.748) which was superior to lactate (.660), SBP (.578), pH (.560), and base excess (.497). DISCUSSION: End-tidal carbon dioxide is a more sensitive and specific predictor of mortality in the acutely injured patient compared to venous lactate, base deficit, blood pressure, or venous pH. Additional studies are needed to determine if ETCO2 can be used as an effective prehospital adjunct to prevent mortality in acutely injured patients.

The trauma surgeon: A career of purpose and value.

ABSTRACT: Hereinafter is the article for the 2021 Eastern Association for the Surgery of Trauma presidential address, which was delivered in a virtual format. It is my hope that I have served Eastern Association for the Surgery of Trauma well through the years, and I have no doubt that this organization will continue its great path under the leadership of President Jeff Claridge, a true leader of character and value for whom I have great respect. It has truly been an honor and a privilege to serve this great beloved organization. Hopefully, this address brings word of inspiration, value, and encouragement to those who serve so selflessly every day as members of our respective trauma teams.

The Eastern Association for the Surgery of Trauma's Injury Control and Violence Prevention Committee's annual distracted driving outreach event: Evaluating attitude and behavior change in high school students.

BACKGROUND: The National Center for Statistics and Analysis reports at least eight deaths and 1,160 daily injuries due to distracted driving (DD) in the United States. Drivers younger than 20 years are most likely to incur a distraction-related fatal crash. We aimed to determine short- and long-term impact of a multimodal educational program including student-developed interventions, simulated driving experiences, and presentations by law enforcement and medical personnel. METHODS: A single-day program aimed at teen DD prevention was conducted at a high school targeting students aged 15 years to 19 years old. Students were surveyed before, after, and at 6 weeks. We surveyed age, gender, knowledge, and experience regarding DD. Summary statistics were obtained at each survey time point. Bivariate and multivariable analysis were conducted to assess whether change in responses varied over time points. Multivariable models were adjusted for sex and urban and rural driving. RESULTS: Preintervention, postintervention, and 6-week follow-up surveys were completed by 359, 272 (76%), and 331 (92%) students, respectively. At baseline and 6-week follow-up, the most frequent passenger-reported DD behaviors were cell phone (63% [63% at follow-up) and radio use (61% [63%]). Similarly, the most frequent driver-reported DD behaviors were cell phone (68% [72%]) and radio use (79% [80%]). When students were asked, "How likely are you to use your cell phone while driving?" they answered "never" 35%, 70%, and 46% on the preintervention, postintervention, and 6-week surveys. They were less likely to report consequences to be worse or change in attitude to a great extent at 6 weeks (p < 0.01). Gender and urban or rural driving were not significantly associated with responses. CONCLUSIONS: While DD education may facilitate short-term knowledge and attitude changes, there appears to be no lasting effect. Research should be focused toward strategies for longer-term impact. LEVEL OF EVIDENCE: Therapeutic study, level II.

Prevention of firearm-related injuries with restrictive licensing and concealed carry laws: An Eastern Association for the Surgery of Trauma systematic review.

BACKGROUND: In the past decade, more than 300,000 people in the United States have died from firearm injuries. Our goal was to assess the effectiveness of two particular prevention strategies, restrictive licensing of firearms and concealed carry laws, on firearm-related injuries in the US Restrictive Licensing was defined to include denials of ownership for various offenses, such as performing background checks for domestic violence and felony convictions. Concealed carry laws allow licensed individuals to carry concealed weapons. METHODS: A comprehensive review of the literature was performed. We used Grading of Recommendations Assessment, Development, and Evaluation methodology to assess the breadth and quality of the data specific to our Population, Intervention, Comparator, Outcomes (PICO) questions. RESULTS: A total of 4673 studies were initially identified, then seven more added after two subsequent, additional literature reviews. Of these, 3,623 remained after removing duplicates; 225 case reports, case series, and reviews were excluded, and 3,379 studies were removed because they did not focus on prevention or did not address our comparators of interest. This left a total of 14 studies which merited inclusion for PICO 1 and 13 studies which merited inclusion for PICO 2. CONCLUSION: PICO 1: We recommend the use of restrictive licensing to reduce firearm-related injuries.PICO 2: We recommend against the use of concealed carry laws to reduce firearm-related injuries.This committee found an association between more restrictive licensing and lower firearm injury rates. All 14 studies were population-based, longitudinal, used modeling to control for covariates, and 11 of the 14 were multi-state. Twelve of the studies reported reductions in firearm injuries, from 7% to 40%. We found no consistent effect of concealed carry laws. Of note, the varied quality of the available data demonstrates a significant information gap, and this committee recommends that we as a society foster a nurturing and encouraging environment that can strengthen future evidence based guidelines. LEVEL OF EVIDENCE: Systematic review, level III.

Complications of bariatric surgery: the acute care surgeon's experience.

BACKGROUND: Complications of bariatric surgeries are common, can occur throughout the patient's lifetime, and can be life-threatening. We examined bariatric surgical complications presenting to our acute care surgery service. METHODS: Records were reviewed from January 2007 to June 2013 for patients presenting with a complication after bariatric surgery. RESULTS: Laparoscopic Roux-en-Y gastric bypass was the most common index operation (n = 20), followed by open Roux-en-Y gastric bypass (n = 6), laparoscopic gastric band (n = 4), and vertical banded gastroplasty (n = 3). Diagnoses included internal hernia (n = 10), small bowel obstruction (n = 5), lap band restriction (n = 4), biliary disease (n = 3), upper GI bleeding or ulcer (n = 3), ischemic bowel (n = 2), marginal ulcer (n = 2), gastric outlet obstruction (n = 2), perforated ulcer (n = 2), intussusception (n = 1), and incarcerated ventral hernia (n = 1). Operations were required in 91% of the patients. Laparoscopic outcomes were similar to open; however, open cases were more emergent (23.5% vs 69.2%) and had longer hospital length of stay (4.8 ± 3.5 vs 11.0 ± 10.3 days, P < .05). All patients survived. CONCLUSIONS: The acute care surgeon will encounter complications of bariatric surgery. Internal hernias or obstructive etiologies are the most common presentations and often require emergent or urgent surgery.

Comparison of procedural complications between resident physicians and advanced clinical providers.

BACKGROUND: In the era of resident work hour restrictions, many trauma centers across the country have incorporated advanced clinical providers (ACPs) as integral partners in the care of critically ill patients. In addition to providing daily care, ACPs have also begun performing invasive procedures. Few studies have addressed ACPs procedural complications. The purpose of this study was to compare the complication rates from surgical procedures performed by resident physicians (RPs) and ACPs in the critical care setting. METHODS: We conducted a retrospective review of all procedures performed from January to December of 2011 in our trauma and surgical intensive care units. Under attending supervision, ACPs performed procedures for surgical critical care patients and RPs for trauma patients. Procedures consisted of arterial lines, central venous lines, bronchoalveolar lavage, thoracostomy tubes, percutaneous endoscopic gastrostomy, and tracheostomies. Data included demographics, Acute Physiology and Chronic Health Evaluation III scores, complications, and outcomes and were divided into RP versus ACP groups. Complications were assessed by postprocedure radiography, operative notes, and postprocedure notes. Dichotomous data were compared using χ and continuous variables by Student's t tests. RESULTS: There were a total of 1,404 patients; the mean ± SE Acute Physiology and Chronic Health Evaluation III score for patients in the RP group was 40.8 ± 0.9 compared with ACP group at 47.7 ± 0.7 (p < 0.05). Our RPs performed 1,020 procedures, and 21 complications were noted (complication rate, 2%). The ACPs completed 555 procedures; 11 complications were incurred (complication rate, 2%). There were no difference in the mean ± SE intensive care unit (RP, 3.9 ± 0.2 days vs. ACP, 3.7± 0.1 days) and hospital (RP, 12.2 ± 0.4 days vs. ACP, 13.3 ± 0.3 days) length of stay. Mortality rates were also comparable between the two groups (RP, 11% vs. ACP, 9.7%). CONCLUSION: In critically ill patients, ACPs can competently perform invasive procedures safely. Our ACPs' responsibilities can be expanded to include invasive procedures in the critical care setting with appropriate supervision. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Arterial vs venous blood gas differences during hemorrhagic shock.

AIM: To characterize differences of arterial (ABG) and venous (VBG) blood gas analysis in a rabbit model of hemorrhagic shock. METHODS: Following baseline arterial and venous blood gas analysis, fifty anesthetized, ventilated New Zealand white rabbits were hemorrhaged to and maintained at a mean arterial pressure of 40 mmHg until a state of shock was obtained, as defined by arterial pH ≤ 7.2 and base deficit ≤ -15 mmol/L. Simultaneous ABG and VBG were obtained at 3 minute intervals. Comparisons of pH, base deficit, pCO2, and arteriovenous (a-v) differences were then made between ABG and VBG at baseline and shock states. Statistical analysis was applied where appropriate with a significance of P < 0.05. RESULTS: All 50 animals were hemorrhaged to shock status and euthanized; no unexpected loss occurred. Significant differences were noted between baseline and shock states in blood gases for the following parameters: pH was significantly decreased in both arterial (7.39 ± 0.12 to 7.14 ± 0.18) and venous blood gases (7.35 ± 0.15 to 6.98 ± 0.26, P < 0.05), base deficit was significantly increased for arterial (-0.9 ± 3.9 mEq/L vs -17.8 ± 2.2 mEq/L) and venous blood gasses (-0.8 ± 3.8 mEq/L vs -15.3 ± 4.1 mEq/L, P < 0.05). pCO2 trends (baseline to shock) demonstrated a decrease in arterial blood (40.0 ± 9.1 mmHg vs 28.9 ± 7.1 mmHg) but an increase in venous blood (46.0 ± 10.1 mmHg vs 62.8 ± 15.3 mmHg), although these trends were non-significant. For calculated arteriovenous differences between baseline and shock states, only the pCO2 difference was shown to be significant during shock. CONCLUSION: In this rabbit model, significant differences exist in blood gas measurements for arterial and venous blood after hemorrhagic shock. A widened pCO2 a-v difference during hemorrhage, reflective of poor tissue oxygenation, may be a better indicator of impending shock.

Improving overtriage of aeromedical transport in trauma: a regional process improvement initiative.

BACKGROUND: Aeromedical transport (AMT) is an effective but costly means of rescuing critically injured patients. Although studies have shown that it improves survival to hospital discharge compared with ground transportation, an efficient threshold or universal criteria for this mode of transport remains to be established. Herein, we examined the effect of implementing a Trauma Advisory Committee (TAC) initiative focused on reducing AMT overtriage (OT) rates. METHODS: TAC outreach coordinators implemented a process improvement (PI) initiative and collected data prospectively from January 2007 to December 2011. OT was defined as patients who were airlifted from scene and later discharged from the emergency department. Serving as liaisons to surrounding counties, TAC outreach coordinators conducted quarterly PI meetings with local emergency medical service agencies. Patients were grouped into those who were airlifted from TAC counties versus counties outside TAC's jurisdiction (non-TAC). Standard statistical methods were used. RESULTS: From 2007 to 2011, 3,349 patients were airlifted from 30 counties, 1,427 (43%) from TAC counties and 1,922 (57%) from non-TAC counties. The OT rates from TAC counties declined compared with non-TAC counties each year and reached statistical significance in 2008 (17% vs. 23%, p < 0.05), 2009 (11% vs. 17%m p < 0.05), and 2011 (6% vs. 12%, p < 0.05). The reduction in OT continued over the study duration, with improvement in TAC counties compared with previous years. CONCLUSION: Implementation of a regional TAC PI initiative focused on OT issues led to a more efficient use of AMT. LEVEL OF EVIDENCE: Prognostic study, level III; therapeutic study, level IV.

Colonoscopy is superior to neostigmine in the treatment of Ogilvie's syndrome.

BACKGROUND: Colonic pseudo-obstruction in critically ill patients may lead to devastating colonic perforation. Neostigmine is often the first-line intervention, because colonoscopy is more invasive and labor intensive. METHODS: A retrospective 10-year review at a tertiary medical center identified 100 patients with Ogilvie's syndrome, in whom treatment course and clinical and radiographic response were evaluated. RESULTS: Colonoscopy was significantly more successful than neostigmine (defined as no further therapy) after 1 or 2 interventions (75.0% vs 35.5%, P = .0002, and 84.6% vs 55.6%, P = .0031, respectively). One colonoscopy was more effective than 2 neostigmine administrations (75.0% vs 55.6%, P = .044). Clinical response (poor, fair, or good) was significantly better after colonoscopy than neostigmine after 1 or 2 interventions (P = .0028 and P = .00079). Cecal diameters decreased significantly more after colonoscopy than neostigmine (from 10.2 ± .5 cm to 7.1 ± .4 cm vs from 10.5 ± .5 cm to 8.8 ± .5 cm, P = .026). Neostigmine administration before colonoscopy did not affect outcomes. There were 3 perforations (3.7%): 1 each after colonoscopy, neostigmine, and no intervention. Neostigmine dose or repetition did not affect radiographic (P = .41) or clinical (P = .31) response. CONCLUSIONS: Colonoscopy is superior to neostigmine for Ogilvie's syndrome and should be considered first-line therapy, although neostigmine is useful in select patients and repeat interventions.

A paradigm shift in the approach to families for organ donation: honoring patients' wishes versus request for permission in patients with Department of Motor Vehicles donor designations.

BACKGROUND: Recently, we reported a donation consent rate of only 80% for patients designated as donors with the Department of Motor Vehicles (DMV), which equaled missed opportunities for 17 potential transplant recipients during 3 months. We undertook the current study to increase our donation consent rate in patients with prior DMV donor designations. METHODS: In October 2006, we modified our approach for donor consent by asking to honor the patient's wishes rather than asking for permission. The consent rates from January through September 2006 (preinitiative) were compared with rates from October through April 2007 (postinitiative). RESULTS: During the preinitiative period, 66 approaches were made; 24 patients were registered as donors with the DMV (36%). In total, consent for donation was obtained from 43 families (65%). Only 20 of 24 (83%) families of patients with prior DMV designation donated, and 23 of 42 families of patients with no DMV designation donated (55%). One hundred forty-one organs were successfully transplanted (average 3.3 organs per procurement). Of 71 postinitiative approaches, 42 families donated (59%) and 125 organs were transplanted (average 3.0 organs per procurement). Consent for donation was obtained in 23 of 52 non-DMV-designated donors (44%). The families of all 19 DMV-designated donors consented for donation (100%). CONCLUSION: Modifying our approach to consent for organ donation to honor the patient's wishes based on DMV donor designation rather than ask for permission increased organ procurement in this population to 100%. However, further efforts are needed at the state and national levels regarding the recognition of first-person consent for organ donation.

Organ donation: family members NOT honoring patient wishes.

BACKGROUND: Each year, many organ donation opportunities are missed because of the lack of familial consent. Occasionally, patients' consents for organ donation through the Department of Motor Vehicles (DMV) are posthumously overruled by their families. We assessed the number of potential opportunities for organ donation that are missed because of lack of familial consent despite previously expressed wishes for donation as registered with the state DMV. METHODS: The medical records of potential donors were reviewed to ascertain appropriateness for donation, familial consent or denial for donation, and number of organs transplanted from each eligible donor. These data were then compared with DMV data regarding prior patient designations either for or against organ donation. RESULTS: One hundred four approaches for donation were made to families during a 3-month period. The DMV donor status was available for 84 patients; 25 were designated as organ donors. Five families refused consent for organ donation despite the patient's documented wishes to donate (80% organ recovery). Twenty-two consents were obtained from the remaining 59 patients not listed as donors by the DMV (37% organ recovery). An average of 3.4 organs were transplanted from eligible donors. CONCLUSION: DMV designation for organ donation increases the yield of consent for organ donation. However, despite prior DMV designations for donation, 20% of families ultimately denied consent for donation. This translated into 17 missed opportunities for potential transplant recipients during the 3-month study period.

Selective management of blunt hepatic injuries including nonoperative management is a safe and effective strategy.

BACKGROUND: The justification and preference for operative versus nonoperative management of hepatic injuries caused by blunt trauma remains ambiguous. This review assesses the outcome of operative and nonoperative management of liver injury after blunt trauma. METHODS: We retrospectively reviewed the demographics, severity of injury, severity of liver injury, associated concomitant injuries, management scheme, and outcome of patients with documented hepatic injury from 1993 to 2003. RESULTS: The overall mortality rate was 9.4%, with 3.7% caused by the liver injury itself. Fifty-nine percent (330 of 561) of liver injuries were of low severity (grades I and II), with an overall mortality rate of 6.6% caused by concomitant injuries and liver-related mortality of 0%. Forty-one percent (231 of 561) of liver injuries were high-severity injuries (grades III, IV, and V). Mortality for nonoperative management of high-severity liver injuries was 2.2%. If operative intervention was required because of hemodynamic instability or concomitant injuries then the mortality rate was significantly higher at 30%. Forty-two of the 378 (11%) liver injuries treated nonoperatively required an adjunctive procedure for successful management. CONCLUSIONS: Selective management of liver injuries presented a low liver-related mortality rate. Low-grade injuries can be managed nonoperatively with excellent results. High-grade injuries can be managed nonoperatively, if operative intervention is not required for hemodynamic instability or associated injuries, with a low mortality. In these patients, adjunctive procedures will be required selectively for successful nonoperative management of high-grade liver injuries. High-grade injuries requiring operative management because of hemodynamic instability or concomitant injuries continue to have significantly higher mortality.