A Statewide Analysis of Pediatric Liver Injuries Treated at Adult Versus Pediatric Trauma Centers.

INTRODUCTION: Hemodynamically normal pediatric trauma patients with solid organ injury receive nonoperative management. Prior research supports that pediatric patients have higher rates of nonoperative management at pediatric trauma centers (PTCs). We sought to evaluate differences in outcomes of pediatric trauma patients with liver injuries. We hypothesized that the type of trauma center (PTC versus adult trauma center [ATC]) would not be associated with any difference in mortality. METHODS: The Pennsylvania Trauma Outcome Study database was retrospectively queried from 2003 to 2018 for all patients (<15 y) with liver injuries by International Classification of Disease 9 and 10 codes. Patients were categorized based on admission to the PTC or ATC. The primary endpoint was mortality with secondary endpoints being operative intervention and length of stay. Multivariate logistic regressions assessed the adjusted impact on mortality and surgical intervention. RESULTS: Of the 1600 patients with liver trauma, 607 met inclusion criteria. A total of 78.4% were treated at PTCs. Patients underwent hepatobiliary surgery more frequently at ATCs (11.5% [n = 15] versus 2.74% [n = 13], P < 0.001). Adjusted analysis showed lower odds of surgical intervention for hepatobiliary injuries at PTCs (adjusted odds ratio: 0.17, P = 0.001). There was a decrease in mortality at PTCs versus ATCs (adjusted odds ratio: 0.38, P = 0.032). CONCLUSIONS: Our statewide analysis showed that pediatric trauma patients with liver injuries treated at ATCs were associated with having higher odds of mortality and higher incidence of operative management for hepatobiliary injuries than those treated at PTCs. In addition, between centers, patients had similar functional status at discharge.

An Evaluation of Pediatric Secondary Overtriage in the Pennsylvania Trauma System.

BACKGROUND: We sought to determine the secondary overtriage rate of pediatric trauma patients admitted to pediatric trauma centers. We hypothesized that pediatric secondary overtriage (POT) would constitute a large percentage of admissions to PTC. MATERIALS AND METHODS: The Pennsylvania Trauma Outcome Study database was retrospectively queried from 2003 to 2017 for pediatric (age ≤ 18 y) trauma patients transferred to accredited pediatric trauma centers in Pennsylvania (n = 6). Patients were stratified based on discharge within (early) and beyond (late) 24 h following admission. POT was defined as patients transferred to a PTC with an early discharge. Multilevel mixed-effects logistic regression model controlling for demographic and injury severity covariates were utilized to determine the adjusted impact of injury patterns on early discharge. RESULTS: A total of 37,653 patients met inclusion criteria. For transfers, POT compromised 18,752 (49.8%) patients. Compared to POT, non-POT were more severely injured (ISS: 10 versus 6;P < 0.001) and spent less time in the ED (Min: 181 versus 207;P < 0.001). In adjusted analysis, concussion, closed skull vault fractures, supracondylar humerus fractures, and consults to neurosurgery were associated with increased odds of POT. Overall, femur fracture, child abuse evaluation, and consults to plastic surgery, orthopedics, and ophthalmology were all associated with a decreased risk of being POT. CONCLUSIONS: POT comprises 49.8% of PTC transfer admissions in Pennsylvania's trauma system. Improving community resources for management of pediatric concussion and mild TBI could result in decreased rates of POT to PTCs. Developing better inter-facility transfer guidelines and increased education of adult TC and nontrauma center hospitals is needed to decrease POT. LEVEL OF EVIDENCE: Epidemiologic study, level III.

A Comprehensive Review of the Outcome for Patients Readmitted to the ICU Following Trauma and Strategies to Decrease Readmission Rates.

In recent years, there has been an emphasis on evaluating the outcomes of patients who have experienced an intensive care unit (ICU) readmission. This may in part be due to the Patient Protection and Affordable Care Act's Hospital Readmission Reduction Program which imposes financial sanctions on hospitals who have excessive readmission rates, informally known as bounceback rates. The financial cost associated with avoidable bounceback combined with the potentially preventable expenses can result in unnecessary financial strain. Within the hospital readmissions, there is a subset pertaining to unplanned readmission to the ICU. Although there have been studies regarding ICU bounceback, there are limited studies regarding ICU bounceback of trauma patients and even fewer proven strategies. Although many studies have concluded that respiratory complications were the most common factor influencing ICU readmissions, there is inconclusive evidence in terms of a broadly applicable strategy that would facilitate management of these patients. The purpose of this review is to highlight the outcomes of patients readmitted to the ICU and to provide an overview of possible strategies to aid in decreasing ICU readmission rates.

An epidemiologic overview of 13 years of firearm hospitalizations in Pennsylvania.

BACKGROUND: Gun violence is a controversial public health issue plagued by a lack of recent research. We sought to provide a 13-y overview of firearm hospitalizations in Pennsylvania, analyzing trends in mode, intent, and outcome. We hypothesized that no adjusted change in mortality or functional status at discharge (FSD) would be observed for gunshot wound (GSW) victims over the study period. METHODS: All admissions to the Pennsylvania Trauma Outcome Study database from 2003 to 2015 were queried. GSWs were identified by external cause-of-injury codes. Collected variables included patient demographics, firearm type, intent (assault and attempted suicide), FSD, and mortality. Multilevel mixed-effects logistic regression models and ordinal regression analyses using generalized linear mixed models assessed the impact of admission year (continuous) on adjusted mortality and FSD score, respectively. Significance was set at P < 0.05. RESULTS: Of the 462,081 patients presenting to Pennsylvania trauma centers from 2003 to 2015, 19,342 were GSWs (4.2%). Handguns were the most common weapon of injury (n = 7007; 86.7%) among cases with specified firearm type. Most GSWs were coded as assaults (n = 15,415; 79.7%), with suicide attempts accounting 1866 hospitalizations (9.2%). Suicide attempts were most prevalent among young and middle-aged white males, whereas assaults were more common in young black males. Rates of firearm hospitalizations decreased over time (test of trend P = 0.001); however, admission year was not associated with improved adjusted survival (adjusted odds ratio: 0.99, 95% confidence interval: 0.97-1.01; P = 0.353) or FSD (adjusted odds ratio: 0.99, 95% confidence interval: 0.98-1.00; P = 0.089) while controlling for demographic and injury severity covariates. CONCLUSIONS: Temporal trends in outcomes suggest rates of firearm hospitalizations are declining in Pennsylvania; however, outcomes remain unchanged. To combat this epidemic, a multidisciplinary, demographic-specific approach to prevention should be the focus of future scientific pursuits.

Use of Six Sigma strategies to pull the line on central line-associated bloodstream infections in a neurotrauma intensive care unit.

The creation of a consistent culture of safety and quality in an intensive care unit is challenging. We applied the Six Sigma Define-Measure-Analyze-Improve-Control (DMAIC) model for quality improvement (QI) to develop a long-term solution to improve outcomes in a high-risk neurotrauma intensive care unit. We sought to reduce central line utilization as a cornerstone in preventing central line-associated bloodstream infections (CLABSIs). This study describes the successful application of the DMAIC model in the creation and implementation of evidence-based quality improvement designed to reduce CLABSIs to below national benchmarks.

Complex abdominal wall reconstruction: an outcomes review.

BACKGROUND: Complex abdominal wall reconstruction (AWR) remains challenging. Techniques for repair are numerous and include primary fascial approximation, separation of components (SOC), and use of various biologic and synthetic meshes. Given the vast expanse of available techniques and lack of consistent algorithms, an analysis of outcomes in AWR is presented. METHODS: A retrospective review was performed of complex AWRs performed by 2 surgeons at a single institution from July 2008 to October of 2011. Outcome differences for hernia repairs specifically addressing SOC with an acellular dermis inlay (retrorectus), underlay, or overlay mesh, as well as interposition biologic mesh placement were included. RESULTS: A total of 66 patients were identified. The average body mass index in this population was 35.5 kg/m. The average age was 53.7 years, with 62% females and 38% males. The overall rate of tobacco use history was 48%. Twenty-eight percent were diabetic. The overall hernia recurrence rate was 16%. Patients having SOC with inlay (retrorectus) mesh had a hernia recurrence rate of 9%. Hernia recurrence in those with SOC and biologic mesh reinforcement as an underlay or onlay was 12%; in those without mesh reinforcement, 22%; and for those with a biologic mesh interposition, 40%. CONCLUSIONS: The results of this review show that hernia recurrence rates are decreased with primary fascial repair. Further reduction occurs when biologic mesh reinforcement is used. The lowest recurrence rates were seen in the group with SOC and a porcine biologic mesh inlay. Abdominal wall reconstruction is challenging and with continued outcomes review a refined algorithm can be achieved. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic: III.

The Homeless Population: Medical Refugees in a Mature Trauma System.

INTRODUCTION: On any given day, there are >550,000 homeless persons in the United States. Little research has examined the relationship between the homeless population and traumatic injuries. We hypothesized that homeless trauma patients have a higher mortality compared to those who are not homeless. METHODS: The Pennsylvania Trauma Outcome Study database was retrospectively queried from 2003-2018 for all adult (age ≥15) patients admitted to trauma centers in Pennsylvania. Homelessness was defined as homeless on admission or homeless as their discharge status. Patient demographics, comorbidities, and clinical variables were compared between homeless and non-homeless patients. Logistic regression was used to control for age, gender, injury severity, injury type, admission Glasgow Coma Scale, and systolic blood pressure to assess morbidity and mortality. RESULTS: 773 patients were identified upon query. Homeless trauma patients were more likely to be male, younger, black, and of Hispanic ethnicity. Compared to non-homeless, they were more likely to have a positive drug screen or mental illness at the time of injury. They were not more significantly injured than their counterparts; however, in adjusted analysis, the homeless had significantly higher odds of both complications (Adjusted Odds Ratio [AOR]: 3.11; 95%CI: 2.64-3.66, P < .001) and mortality (AOR: 1.79; 95%CI: 1.29-2.50, P = .001). CONCLUSION: Although homeless patients were not more severely injured than the general trauma population, they had significantly higher odds of both complications and mortality. This population represents a very vulnerable community in need of medical intervention and injury prevention programs.

Trampoline Injuries in a Statewide Trauma System.

INTRODUCTION: It is well known that trampolines can be a particular source of danger, especially in children. We sought to examine the profile of those patients with trampoline injuries. We hypothesized there would be certain injury patterns predicative of trampoline injuries. METHODS: All patients submitted to Pennsylvania Trauma Outcome Study database from 2016 to 2018 were analyzed. Trampoline injury was determined by ICD-10 activity code. Injury patterns in the form of abbreviated injury scale body regions were examined. Patient demographics and clinical variables were compared between those with trampoline injury vs those without. RESULTS: There were 107 patients with a trampoline injury. All of these patients were discharged alive and had a blunt mechanism of injury. The most common injury type was injury to the extremities (n=90,[84.1%]) with 54(50.5%) upper extremity injuries and 36(33.6%) lower extremity injuries. Ten (9.35%) patients had injury to the spine and five (4.67%) had head injury. Those with trampoline injuries were significantly younger (13y vs. 48.6y) and more likely to be white or of Hispanic ethnicity. Almost half of the patients injured (49.5%) were under 10 years. Patients with trampoline injuries had significantly lower Injury Severity Scores and significantly higher shock index. DISCUSSION: The majority of patients with trampoline injuries had injury to an extremity. These results help better understand the demographic, physiologic, and anatomic patterns surrounding trampoline injuries. Current government standards recommend that no child under age six should use a full-sized trampoline; however, based of this study, we advise that this age be increased to ten.

Frailty Is Associated With Worse Outcomes In Geriatric Pelvic Fractures.

Frail, geriatric patients with pelvic fractures can present differently than non-frail patients. Using the Clinical Frailty Scale(CFS), a retrospective analysis was conducted to determine the relationship between patients' CFS and outcomes after pelvic fractures. We hypothesized that frail, geriatric trauma patients defined as a CFS>4 with pelvic fractures have worse outcomes than non-frail patients with a CFS≤4 despite similar injuries. All geriatric patients with pelvic fractures and documented CFS were included. Seventy patients were included, with 59% (n = 41) frail. The groups were compared with no difference in mortality. The frail group was older and were most likely discharged to a skilled nursing facility (65.8%). Non-frail were most likely discharged to acute rehab (52%). Frail had lower functional status at discharge (median: 14.5v.16, P = .015). Frail patients had worse overall outcomes in this analysis of geriatric pelvic fracture patients. Special attention should focus on this vulnerable population to ensure optimal treatment and outcomes.

Unplanned Readmissions to the Intensive Care Unit Among Geriatric Trauma Patients.

BACKGROUND: Unplanned readmission/bounceback to the intensive care unit (ICUBB) is a prevalent issue in the medical community. The geriatric population is incompletely studied in regard to ICUBB. We sought to determine if ICUBB in older patients was associated with higher risk of mortality. We hypothesized that, of those who were older, those with ICUBB would have higher mortality compared to those with no ICUBB. Further, we hypothesized that of those with ICUBB, older age would lead to higher mortality. METHODS: The Pennsylvania Trauma Outcome Study database was retrospectively queried from 2003 to 2018 for all trauma patients of age ≥40 years. Those with advance directives were excluded. Adjusted analysis in the form of logistic regressions controlling for demographic and injury covariates and clustering by facility were used to assess the adjusted impact of ICUBB and age on mortality. RESULTS: 363,778 patients were aged ≥40 years. When comparing mortalities between the age 40 and 49 years group and those in older groups, a dramatic increase in mortality was observed between those in each respective age category with ICUBB vs non-ICUBB. This trend was most prominent in those in the 90+ years age group (ICUBB: AOR: 34.78, P < .001; non-ICUBB: AOR: 9.08, P < .001). A second model only including patients who had ICUBB found that patients of age ≥65 years had significantly higher odds of mortality (AOR: 4.10, P < .001) when compared to their younger counterparts (age <65 years). DISCUSSION: An ICUBB seems to exacerbate mortality rates as age increases. This profound increase in mortality calls for strategies to be developed, especially in the older population, to attempt to mitigate the factors leading to ICUBB.

Radiographic Reread Protocols to Identify Clinically Relevant Errors in Initial Trauma Evaluations.

INTRODUCTION: Diagnostic radiology interpretive errors in trauma patients can lead to missed diagnoses, compromising patient care. Due to this, our level II trauma center implemented a reread protocol of all radiographic imaging within 24 hours on our highest trauma activation level (Code T). We sought to determine the efficacy of this reread protocol in identifying missed diagnoses in Code T patients. We hypothesized that a few, but clinically relevant errors, would be identified upon reread. METHODS: All radiographic study findings (initial read and reread) performed for Code T admissions from July 2015 to May 2016 were queried. The reviewed radiological imaging was given one of four designations: agree with interpretation, minor (non-life threatening) nonclinically relevant error(s)-addendum/correction required or clinically relevant error(s) (major [life threatening] and minor)-addendum/correction required, and trauma surgeon notified. The results were compiled, and the number of each type of error was calculated. RESULTS: Of the 752 radiological imaging studies reviewed on the 121 Code T patients during this period, 3 (0.40%) contained minor clinically relevant errors, 11 (1.46%) contained errors that were not clinically relevant, and 738 (98.1%) agreed with the original interpretation. The three clinically relevant errors included a right mandibular fracture found on X-ray and a temporal bone fracture that crossed the clivus and bilateral rib fractures found on computerized tomography. DISCUSSION: Clinically relevant errors, although minimal, were discovered during rereads for Code T patients. Although the clinical errors were significant, none affected patient outcomes. We propose that the implementation of reread protocols should be based upon institution-specific practices.

Admission ionized calcium levels predict the need for multiple transfusions: a prospective study of 591 critically ill trauma patients.

BACKGROUND: Deaths from uncontrolled exsanguinating hemorrhage occur rapidly postinjury. Any successful resuscitation strategy must also occur early, underscoring the importance of rapid identification of patients at risk for multiple transfusions. Previous studies have shown low ionized calcium (iCa) levels to be associated with hypotension and function as a predictor of mortality. We hypothesized that admission iCa levels could potentially predict the need for multiple transfusions in critically ill trauma patients. METHODS: Admission iCa was collected prospectively on all trauma activations during a 9-month period. Youden's index was used to determine the appropriate cutpoint for iCa. Outcomes (mortality, multiple transfusions [≥5 units packed red blood cells in 24 hours] and massive transfusion [≥10 units packed red blood cells in 24 hours]) were compared using Wilcoxon rank-sum and χ tests where appropriate. Multivariable logistic regression was performed to determine whether iCa was an independent predictor of multiple transfusions. RESULTS: A total of 591 patients were identified: 461 (78%) men and 130 (22%) women. Cutpoint was identified as 1.00. iCa was <1.00 (lo-Cal) in 332 patients and≥1.00 (hi-Cal) in 259 patients. Mortality was significantly increased in the lo-Cal group (15.5% vs. 8.7%, p=0.036). In addition, both multiple transfusions (17.1% vs. 7.1%, p=0.005) and massive transfusion (8.2% vs. 2.2%, p=0.017) were significantly increased in the lo-Cal group. Multivariable logistic regression analysis identified iCa<1 as an independent predictor of the need for multiple transfusions after adjusting for age and injury severity (odds ratio=2.294, 95% confidence interval=1.053-4.996). CONCLUSIONS: Low iCa levels at admission were associated with increased mortality as well as an increased need for both multiple transfusions and massive transfusion. In fact, multivariable logistic regression analysis identified low iCa levels as an independent predictor of multiple transfusions. Admission iCa levels may facilitate the rapid identification of patients requiring massive transfusion, allowing for earlier preparation and administration of appropriate blood products.

Improved survival after hemostatic resuscitation: does the emperor have no clothes?

BACKGROUND: In light of recent data, controversy surrounds the apparent 30-day survival benefit of patients achieving a fresh frozen plasma (FFP) to packed red blood cell (PRBC) ratio of at least 1:2 in the face of massive transfusions (MT) (≥10 units of PRBC within 24 hours of admission). We hypothesized that initial studies suffer from survival bias because they do not consider early deaths secondary to uncontrolled exsanguinating hemorrhage. To help resolve this controversy, we evaluated the temporal relationship between blood product administration and mortality in civilian trauma patients receiving MT. METHODS: Patients requiring MT over a 22-month period were identified from the resuscitation registry of a Level I trauma center. Shock severity at admission and timing of shock-trauma admission, blood product administration, and death were determined. Patients were divided into high- and low-ratio groups (≥1:2 and<1:2 FFP:PRBC, respectively) and compared. Kaplan-Meier analysis and log-rank test was used to examine 24-hour survival. RESULTS: One hundred three patients (63% blunt) were identified (66 high-ratio and 37 low-ratio). Those patients who achieved a high-ratio in 24 hours had improved survival. However, severity of shock was less in the high-group (base excess: -8.0 vs. -11.2, p=0.028; lactate: 6.3 vs. 8.4, p=0.03). Seventy-five patients received MT within 6 hours. Of these, 29 received a high-ratio in 6 hours. Again, severity of shock was less in the high-ratio group (base excess: -7.6 vs. -12.7, p=0.008; lactate: 6.7 vs. 9.4, p=0.02). For these patients, 6-hour mortality was less in the high-group (10% vs. 48%, p<0.002). After accounting for early deaths, groups were similar from 6 hours to 24 hours. CONCLUSIONS: Improved survival was observed in patients receiving a higher plasma ratio over the first 24 hours. However, temporal analysis of mortality using shorter time periods revealed those who achieve early high-ratio are in less shock and less likely to die early from uncontrolled hemorrhage compared with those who never achieve a high-ratio. Thus, the proposed survival advantage of a high-ratio may be because of selection of those not likely to die in the first place; that is, patients die with a low-ratio not because of a low-ratio.

Benzodiazepines increase the likelihood of both infectious and thrombotic complications.

INTRODUCTION: Benzodiazepines (BZDs) modulate peripheral γ-amino-butyric acid type A on macrophages causing immunomodulation. They inhibit proinflammatory cytokines increasing infections. Prior studies have also shown that infections can increase thrombotic complications. We sought to examine this relationship in trauma patients. We hypothesized that the presence of BZDs on admission urine drug screen (UDS) would increase rates of both complications. METHODS: All patients submitted to the Pennsylvania Trauma Outcome Study database from 2003 to 2018 were queried. Those with a positive UDS for BZDs were analyzed. Infectious complications were defined as pneumonia, urinary tract infection, sepsis, wound, and soft tissue infection, and thrombotic complications were defined as presence of pulmonary embolism or deep vein thrombosis. Logistic regressions controlling for demographic and injury covariates assessed the adjusted impact of BZDs on infectious and thrombotic complications. RESULTS: A total of 3,393 patients (2.08%) had infectious complications, and 3,048 (1.87%) had thrombotic complications. Furthermore, 33,260 patients (20.4%) had a positive UDS for BZDs on admission. Univariate analysis showed that those positive for BZDs had higher rates of infectious (3.33% vs. 1.76%, p < 0.001) and thrombotic (2.84% vs. 1.62%, p < 0.001) complications. Multivariate analysis revealed that BZDs significantly increased the odds of infectious and thrombotic complications. Patients who tested positive for BZDs and subsequently developed infection had increased odds (adjusted odds ratio, 1.65; p < 0.001) of developing thrombotic complications. CONCLUSION: Trauma patients with a positive UDS for BZDs had higher odds of both infectious and thrombotic complications. Moreover, odds of thrombotic complications were higher in those with infections. LEVEL OF EVIDENCE: Epidemiological, level III.

The effect of the Affordable Care Act on rates on inpatient rehabilitation hospital admission in a mature trauma system.

BACKGROUND: The beneficial effects of acute rehabilitation for trauma patients are well documented but can be limited because of insurance coverage. The Patient Protection and Affordable Care Act (ACA) went into effect on March 23, 2010. The ACA allowed patients who previously did not have insurance to be fully incorporated into the health system. We sought to analyze the likelihood of discharge to rehab for trauma patients before and after the implementation of the ACA. We hypothesized that there would be a higher rate of inpatient rehabilitation hospital (IRH) admission after the ACA was put into effect. METHODS: The Pennsylvania Trauma Outcome Study (PTOS) database was retrospectively queried from 2003 to 2017 for all trauma patients admitted to accredited trauma centers in Pennsylvania, who also had a functional status at discharge (FSD). Admission to an IRH was determined using discharge destination. Two categories were created to represent periods before and after ACA was implemented, 2003 to 2009 (pre-ACA) and 2010-2017 (post-ACA). A multilevel mixed-effects logistic regression model controlling for demographics, injury severity, and FSD assessed the adjusted impact of ACA implementation on IRH admissions. RESULTS: From the Pennsylvania Trauma Outcome Study query, 341,252 patients had FSD scores and of these patients, 47,522 (13.9%) were admitted to IRH. Patients who were severely injured were more likely to be admitted to IRH. Compared with FSD scores signifying complete independence at discharge, those with lower FSD had significantly increased odds of IRH admission. The odds of IRH admission post-ACA implementation significantly increased when compared with pre-ACA years (adjusted odds ratio, 1.14; 95% confidence interval, 1.12-1.17; p < 0.001; area under the receiver operating curve, 0.818). CONCLUSION: The implementation of the ACA significantly increased the likelihood of discharge to IRH for trauma patients. LEVEL OF EVIDENCE: Care management, level III.

Massive Transfusion Protocol and Subsequent Development of Venous Thromboembolism: Statewide Analysis.

BACKGROUND: Massive transfusion protocols (MTP) are a routine component of any major trauma center's armamentarium in the management of exsanguinating hemorrhages. Little is known about the potential complications of those that survive a MTP. We sought to determine the incidence of venous thromboembolism (VTE) following MTP. We hypothesized that MTP would be associated with a higher risk of VTE when compared with a risk-adjusted control population without MTP. METHODS: The Pennsylvania Trauma Outcome Study database was retrospectively queried from 2015 to 2018 for trauma patients who developed VTE and survived until discharge at accredited trauma centers in Pennsylvania. Patient demographics, injury severity, and clinical outcomes were compared to assess differences in VTE development between MTP and non-MTP patients. A multivariate logistic regression model assessed the adjusted impact of MTP on VTE development. RESULTS: 176 010 patients survived until discharge, meeting inclusion criteria. Of those, 1667 developed a VTE (pulmonary embolism [PE]: 662 [0.4%]; deep vein thrombosis [DVT]: 1142 [0.6%]; PE and DVT: 137 [0.1%]). 1268 patients (0.7%) received MTP and, of this subset of patients, 171 (13.5%) developed a VTE during admission. In adjusted analysis, patients who had a MTP and survived until discharge had a higher odds of developing a VTE (adjusted odds ratio: 2.62; 95% CI: 2.13-3.24; P < .001). DISCUSSION: MTP is a harbinger for higher risk of VTE in those patients who survive. This may, in part, be related to the overcorrection of coagulation deficits encountered in the hemorrhagic event. A high index of suspicion for the development of VTE as well as aggressive VTE prophylaxis is warranted in those patients who survive MTP.

A comprehensive analysis of undertriage in a mature trauma system using geospatial mapping.

INTRODUCTION: The correct triage of trauma patients to trauma centers (TCs) is essential. We sought to determine the percentage of patients who were undertriaged within the Pennsylvania (PA) trauma system and spatially analyze areas of undertriage (UTR) in PA for all age groups: pediatric, adult, and geriatric. We hypothesized that there would be certain areas that had high UTR for all age groups. METHODS: From 2003 to 2015, all admissions from the Pennsylvania Trauma Systems Foundation registry and those meeting trauma criteria (International Classification of Diseases, Ninth Diseases: 800-959) from the Pennsylvania Health Care Cost Containment Council (PHC4) database were included. Admissions were divided into age groups: pediatric (<15 years), adult (15-64 years), and geriatric (≥65 years). All pediatric trauma cases were included from the Pennsylvania Trauma Systems Foundation and PHC4 registry, while only cases with Injury Severity Score of >9 were included in adult and geriatric age groups. Undertriage was defined as patients not admitted to level I/II adult TCs (n = 24), pediatric (n = 3), or adult and pediatric combined facility (n = 3) divided by the total number of patients from the PHC4 database. ArcGIS Desktop (version 10.7; ESRI, Redlands, CA) and GeoDa (version 1.14.0; CSDS, Chicago, IL) open source license were used for geospatial mapping of UTR with a spatial empirical Bayesian smoothed UTR by zip code tabulation area (ZCTA) and Stata (version 16.1; Stata Corp., College Station, TX) for statistical analyses. RESULTS: There were significant percentages of UTR for all age groups. One area of high UTR for all age groups had TCs and large nontrauma centers in close proximity. There were high rates of UTR for all ages in rural areas, specifically in the upper central regions of PA, with limited access to TCs. CONCLUSION: It appears there are two patterns leading to UTR. The first is in areas where TCs are in close proximity to large competing nontrauma centers, which may lead to inappropriate triage. The second has to do with lack of access to TCs. Geospatial mapping is a valuable tool that can be used to ascertain where trauma systems should focus scarce resources to decrease UTR. LEVEL OF EVIDENCE: Epidemiological, level III; Care management, level III.

Geriatric Trauma Mortality: Does Trauma Center Level Matter?

BACKGROUND: Given their mostly rural/suburban locations, level II trauma centers (TCs) may offer greater exposure to and experience in managing geriatric trauma patients. We hypothesized that geriatric patients would have improved outcomes at level II TCs compared to level I TCs. METHODS: The Pennsylvania Trauma Outcome Study (PTOS) database was retrospectively queried from 2003 to 2017 for geriatric (age ≥65 years) trauma patients admitted to level I and II TCs in Pennsylvania. Patient demographics, injury severity, and clinical outcomes were compared to assess differences in care between level I and II TCs. A multivariate logistic regression model assessed the adjusted impact of care at level I vs II TCs on mortality, complications, and functional status at discharge (FSD). The National Trauma Data Bank (NTDB) was retrospectively queried for geriatric (age ≥65 years) trauma admissions to state-accredited level I or level II TCs in 2013. RESULTS: 112 648 patients met inclusion criteria. The proportion of geriatric trauma patients across level I and level II TCs were determined to be 29.1% and 36.2% (P <.001), respectively. In adjusted analysis, there was no difference in mortality (adjusted odds ratio [AOR]: 1.13; P = .375), complications (AOR: 1.25; P = .080) or FSD (AOR: 1.09; P = .493) when comparing level I to level II TCs. Adjusted analysis from the NTDB (n = 144 622) also found that mortality was not associated with TC level (AOR: 1.04; P = .182). DISCUSSION: Level I and level II TCs had similar rates of mortality, complications, and functional outcomes despite a higher proportion (but lower absolute number) of geriatric patients being admitted to level II TCs. Future consideration for location of centers of excellence in geriatric trauma should include both level I and II TCs.

The Effects of Fasting Status on the Relative Risk of Pulmonary Aspiration in Acute Care Surgery Patients.

BACKGROUND: Acute care surgery patients are often unfasted at the time of surgery, presenting a unique opportunity to study the effects of fasting on the risk of pulmonary aspiration. We aimed to determine the relative risk of aspiration in patients who were fasted at the time of surgery according to guidelines versus those in an unfasted state. METHODS: A retrospective chart review of 100 patients who underwent appendectomy (n = 76) or exploratory laparotomy (n = 24) was conducted at a single institution in 2016-2017. Using the American Society of Anesthesiologists (ASA) Practice Guidelines for Preoperative Fasting, patients were stratified into study and control groups according to whether they were unfasted (nothing by mouth for <8 hours prior to surgery) or fasted (nothing by mouth for >8 hours prior to surgery). Data controlled for patients' age, sex, body mass index (BMI), most recent hemoglobin A1c, presence of gastroesophageal reflux disease (GERD), and presence of hiatal hernia. RESULTS: Of the 76 patients who underwent appendectomy, 15% were unfasted with a total of 0 aspiration events (P < .001). Of the 24 patients who underwent exploratory laparotomy, 42% were unfasted with a total of 0 aspiration events (P < .001). This yields a relative risk of pulmonary aspiration of 1.0 (absolute risk of 0) in both the study and control groups. DISCUSSION: In an acute care surgery population including patients who were not fasted according to guidelines, there was no increase in the risk of pulmonary aspiration. LEVEL OF EVIDENCE: Epidemiological study; Level III.

An analysis of pediatric social vulnerability in the Pennsylvania trauma system.

BACKGROUND: The social vulnerability index (SVI) is used to assess resilience to external influences that may affect human health. Social vulnerability has been noted to be a barrier to healthcare access for pediatric patients. We hypothesized that Pennsylvania (PA) pediatric trauma patients high on the social vulnerability index would have significantly lower rates of rehab admission following admission to a hospital for traumatic injury. METHODS: The SVI was determined for each PA zip code area utilizing the census tract based 2014 SVI provided by the CDC along with a weighted crosswalk between census tracts and zip code areas using the Housing and Urban Development zip code crosswalk files. The rate of the uninsured population was extracted from the CDC SVI files in addition to other US Census variables based upon estimates from the 2014 American Community Survey (ACS). We also included the individual primary payer status of each subject. Pediatric (age <15 years) trauma admissions with in-hospital mortality excluded, were extracted from the PA Healthcare Cost Containment Council (PHC4) for all hospital admissions for the period of 2003-2015 (n = 63,545). Complete case analysis was conducted based upon the final model providing a sample of 52,794. Cases were coded as rehab patients based upon discharge status (n = 603; 1.1%). A multi-level logistic model was used to determine if subjects had a higher odds of being discharged to rehab based on SVI, undertriage rates of their zip code area of residence and their own primary payer status; this was adjusted for age, multi-system injury and a head, chest or abdomen injury with abbreviate injury scale (AIS) severity > = 3. RESULTS: SVI and undertriage rates of the zip code areas of residence were not significantly associated with admission to rehab. The individual primary payer status of the subject was significantly associated with admission to rehab (OR 95%CI vs. self/uninsured; Medicaid 3.65 1.84-7.24; Commercial = 3.09 1.56-6.11; other/unknown = 2.85 1.02-7.93). Admission to rehab was also significantly associated with age, injury severity (ISS), head or chest injury with AIS scores > = 3, year of admission and hospital type. CONCLUSION: Individual patient level factors (primary payer of patient) may be associated with the odds of rehab admission rather than neighborhood factors. LEVEL OF EVIDENCE: Epidemiologic: Level III.