Bridging the Gap: Comparison of Outpatient Clinic and Emergency Department Patients Undergoing Cholecystectomy.

INTRODUCTION: Literature shows failure of the outpatient clinic (OC) pathway after emergency department (ED) ultrasound diagnosis of symptomatic cholelithiasis (SC). We hypothesized SC to be more prevalent on final surgical pathology (FSP) in patients who successfully completed OC pathway. METHODS: This retrospective single-institution chart review compared OC and ED patients with right upper quadrant (RUQ) pain and cholelithiasis whom underwent cholecystectomy. Clinical evaluation was considered positive if RUQ pain >4 h, or + Murphy's sign. Ultrasound was positive if two of these three were present: sonographic Murphy's, wall thickness > 4 mm, or pericholecystic fluid. Results were compared with FSP. RESULTS: Six hundred-seven patients underwent cholecystectomy, 299 OC and 308 ED. OC was more likely to SC (23% versus 4.6%) (P < 0.0001) and ED acute cholecystitis (39.3% versus 4.7%). Chronic cholecystitis was the most common FSP in both OC (72%) and ED (56%) populations, of these, 73% of OC denied pain >4 h versus only 10% of ED (P < 0.001). Median time from evaluation to cholecystectomy was 14 d versus 14 h in the OC and ED respectively (P < 0.0001). CONCLUSIONS: While chronic cholecystitis was the most common FSP in both OC and ED, the majority of OC reported RUQ pain <4 h delineating these presentations. Duration of pain should be utilized as algorithm triage. We recommend patients with pain episode <4 h should complete OC algorithm with expedited cholecystectomy within 14 d.

Rectal Injury After Foreign Body Insertion: Secondary Analysis From the AAST Contemporary Management of Rectal Injuries Study Group.

BACKGROUND: Retained rectal foreign bodies are a common but incompletely studied problem. This study defined the epidemiology, injury severity, and outcomes after rectal injuries following foreign body insertion. METHODS: Twenty-two level I trauma centers retrospectively identified all patients sustaining a rectal injury in this AAST multi-institutional trial (2005-2014). Only patients injured by foreign body insertion were included in this secondary analysis. Exclusion criteria were death before rectal injury management or ≤48 h of admission. Demographics, clinical data, and outcomes were collected. Study groups were defined as partial thickness (AAST grade I) versus full thickness (AAST grades II-V) injuries. Subgroup analysis was performed by management strategy (nonoperative versus operative). RESULTS: After exclusions, 33 patients were identified. Mean age was 41 y (range 18-57), and 85% (n = 28) were male. Eleven (33%) had full thickness injuries and 22 (67%) had partial thickness injuries, of which 14 (64%) were managed nonoperatively and 8 (36%) operatively (proximal diversion alone [n = 3, 14%]; direct repair with proximal diversion [n = 2, 9%]; laparotomy without rectal intervention [n = 2, 9%]; and direct repair alone [n = 1, 5%]). Subgroup analysis of outcomes after partial thickness injury demonstrated significantly shorter hospital length of stay (2 ± 1; 2 [1-5] versus 5 ± 2; 4 [2-8] d, P = 0.0001) after nonoperative versus operative management. CONCLUSIONS: Although partial thickness rectal injuries do not require intervention, difficulty excluding full thickness injuries led some surgeons in this series to manage partial thickness injuries operatively. This was associated with significantly longer hospital length of stay. Therefore, we recommend nonoperative management after a retained rectal foreign body unless full thickness injury is conclusively identified.

American Association for the Surgery of Trauma/American College of Surgeons Committee on Trauma clinical protocol for postdischarge venous thromboembolism prophylaxis after trauma.

ABSTRACT: Trauma patients are at an elevated risk for developing venous thromboembolism (VTE), which includes pulmonary embolism and deep vein thrombosis. In the inpatient setting, prompt pharmacologic prophylaxis is utilized to prevent VTE. For patients with lower extremity fractures or limited mobility, VTE risk does not return to baseline levels postdischarge. Currently, there are limited data to guide postdischarge VTE prophylaxis in trauma patients. The goal of these postdischarge VTE prophylaxis guidelines are to identify patients at the highest risk of developing VTE after discharge and to offer pharmacologic prophylaxis strategies to limit this risk.

Not all cholecystitis is created equal: Disparities contributing to ED presentation and failure of the outpatient algorithm.

BACKGROUND: The majority of final surgical pathology (FSP) from both emergency department (ED) and outpatient clinic (OC) patients is chronic cholecystitis. We aimed to differentiate these presentations and identify disparities associated with ED utilization and OC failure. METHODS: Retrospective chart review of single institution ED and OC cholecystectomies for cholelithiasis. Clinical presentation, FSP, demographics, and zip code poverty (ZCP) levels were evaluated. Data analysis by summary statistics, bivariate comparisons, and logistic regression. RESULTS: Of 299 OC and 308 ED patients, OC was more likely to be Caucasian (78% vs 46%, p < 0.0001) and insured (89% vs. 32%, p < 0.0001). 71.8% of OC with ZCP <10% had insurance versus only 32.5% in ZCP >20%. Uninsured ED OR was 13.1 (95% CI 8.7-22.9). CONCLUSION: Uninsured ED patients are vulnerable to fail the outpatient algorithm, especially when misdiagnosed by US. Clinical diagnosis of cholecystitis in this population should warrant offering of urgent cholecystectomy.

Clinical diagnosis of cholecystitis in emergency department patients with cholelithiasis is indication for urgent cholecystectomy: A comparison of clinical, ultrasound, and pathologic diagnosis.

BACKGROUND: Biliary pathology is a common reason for emergency department visits with discharge and outpatient follow up if sonographic evaluation does not reveal evidence of cholecystitis. This retrospective review was conducted to assess the sensitivity of clinical versus sonographic evaluation for indication of urgent cholecystectomy. METHODS: Retrospective chart review of 308 patients who presented to the emergency department (ED) with right upper quadrant (RUQ) pain and cholelithiasis whom underwent cholecystectomy. The history and physical exam, laboratory values, ultrasound (US), and final surgical pathology were compared for accuracy of clinical to pathologic diagnosis. RESULTS: 95.5% of our patients that presented to the ED secondary to RUQ pain with cholelithiasis had pathologic cholecystitis. Sensitivity of clinical diagnosis was superior to US findings as compared to pathologic diagnosis of cholecystitis at 96% vs 44% and 87% vs 18% for acute (AC) and chronic cholecystitis (CC) respectively. CONCLUSION: RUQ pain with known cholelithiasis lasting longer than 4 hours is sensitive for pathologic cholecystitis. This finding, even with the absence of sonographic evidence of cholecystitis, is indication for index encounter urgent cholecystectomy.

Trauma transfers discharged from the emergency department-Is there a role for telemedicine?

BACKGROUND: As the only Level I trauma center in the state, our hospital has seen an increase in the number of traumas requiring transfer for a higher level of care, placing strain on an already strained health care system. Traumas that are transferred to our facility and subsequently discharged back home indicate a subset of patients who may not be appropriate to transfer. The aim of this study is to identify commonalities between patients who were transferred for a higher level of care but do not require inpatient status and to assess patients who may benefit from a telemedicine evaluation. METHODS: A 2-year retrospective review of a prospective collected database of patients who were discharged from the ED following transfer to a Level I trauma center was conducted. Data included demographics, injuries, transferring facility, method of transport, activation criteria and level, additional imaging, consulting services, procedures, and disposition. RESULTS: A total of 2,350 patients were transferred. Of those, 27% (632/2,350) were discharged home directly from the trauma bay. Of those patients, 36% (230/632) required complex bedside intervention or subspecialty consultation prior to discharge including complex laceration repairs 53%, ophthalmology examination 24%, splinting 18%, and joint reduction 5%. Sixty-four percent (402/632) of patients did not require complex bedside procedures prior to discharge. One hundred twenty hospitals transferred patients to our center during this period. The top 10 transferring facilities accounted for 40% (948/2,350) of our transfer volume. CONCLUSION: Our study demonstrates that patients who are transferred to our facility and subsequently discharged have a common pattern of injuries; typically, isolated hand and face/ophthalmology. This is likely attributed to the lack of resources in rural facilities to evaluate and develop treatment plans for these injuries; however, only 36% of discharged patients required a bedside procedure. Excluding Level I traumas, head and spine injuries, and patients requiring complex bedside procedures, there was a 13% inappropriate rate of transfer (310/2,350). Development and implementation of a telemedicine system could potentially reduce the transfer and ED discharge rate, thereby improving efficiency and allowing for reallocation of resources as appropriate. LEVEL OF EVIDENCE: Prognostic and Epidemiologic, Level III.

American Association for the Surgery of Trauma/American College of Surgeons-Committee on Trauma Clinical Protocol for inpatient venous thromboembolism prophylaxis after trauma.

ABSTRACT: Trauma patients are at increased risk of venous thromboembolism (VTE), which includes both deep vein thrombosis and pulmonary embolism. Pharmacologic VTE prophylaxis is a critical component of optimal trauma care that significantly decreases VTE risk. Optimal VTE prophylaxis protocols must manage the risk of VTE with the competing risk of hemorrhage in patients following significant trauma. Currently, there is variability in VTE prophylaxis protocols across trauma centers. In an attempt to optimize VTE prophylaxis for the injured patient, stakeholders from the American Association for the Surgery of Trauma and the American College of Surgeons-Committee on Trauma collaborated to develop a group of consensus recommendations as a resource for trauma centers. The primary goal of these recommendations is to help standardize VTE prophylaxis strategies for adult trauma patients (age ≥15 years) across all trauma centers. This clinical protocol has been developed to (1) provide standardized medication dosing for VTE prophylaxis in the injured patient; and (2) promote evidence-based, prompt VTE prophylaxis in common, high-risk traumatic injuries. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level V.

Effect of Post-splenectomy Booster Vaccine Program on Vaccination Compliance in Trauma Patients.

OBJECTIVE: In 2012, the Centers for Disease Control and Prevention (CDC) Advisory Council on Immunization Practice recommended an additional post-splenectomy booster vaccine at 8 weeks following the initial vaccine. The objective of this study was to evaluate our vaccination compliance rate and what sociodemographic factors were associated with noncompliance following this recommendation. MATERIALS AND METHODS: A retrospective review of a performance improvement database of trauma patients eligible for post-splenectomy vaccination (PSV) at a level I trauma center was carried out between 2009 and 2018. Overall and institutional compliance with PSV was compared before and after the addition of booster vaccine recommendation. Factors associated with booster noncompliance were also identified. RESULTS: A total of 257 patients were identified. PSV compliance rate in the pre-booster was 98.4%, while overall and institutional post-booster compliance rate were significantly lower at 66.9% (P ≤ .001) and 50.0% (P ≤ .001), respectively. Compared to booster institutional compliers, institutional noncompliers lived farther from the trauma center (48 vs. 86 miles, P = .02), and though not statistically significant, these patients were generally older (34.9 vs. 40.5, P = .05). DISCUSSION: PSV booster compliance is low even with the current educational materials and recommendations. Additional approaches to improve compliance rates need to be implemented, such as sending letters to the patient and their primary care providers (PCPs), collaborating with rehab/long-term acute care centers, communicating with city and county health departments and city pharmacies, or mirroring other countries and creating a national database for asplenic patients to provide complete information.

Trainee Utilization of the SCORE Curriculum is Associated With Improved ABSITE Performance: A Multi-institutional Study.

BACKGROUND: The Surgical Council on Resident Education's (SCORE) structured educational curriculum for general surgery residents uses a 2-year repeating cycle of modules and quizzes called "This Week in SCORE" (TWIS) to organize and sequence the curricular content on the SCORE portal. The purpose of this study was to evaluate the impact of using the SCORE content and TWIS curriculum on American Board of Surgery In-Training Examination (ABSITE) performance. To date, no multi-institutional studies have examined this effect. METHODS: Eight residency programs participated, including university and community-based programs. SCORE usage overall, TWIS usage, and ABSITE percentile scores (adjusted for post-graduate year [PGY]) were analyzed for the academic years 2017 to 2020. SCORE usage was defined as number of SCORE logins annually per resident with "low usage" ≤10 times and "high usage" >10 times. TWIS usage was defined as "low usage" (no TWIS quizzes done) or "high usage" (≥1 TWIS quiz per year). RESULTS: Four hundred and twenty-eight trainees were evaluated. Trainees with high SCORE and TWIS usage consistently achieved a higher ABSITE percentile score. This difference was maintained in subgroup analysis by PGY with the greatest impact in PGY-1 and PGY-2 levels. CONCLUSIONS: Utilization of multiple aspects of SCORE content appears to have a significant positive impact on ABSITE performance across all levels of postgraduate training. This multi-institutional study of a large number of users is the first to demonstrate that increased usage of SCORE content appears to be a predictor of ABSITE performance success.

Vancomycin dosing in critically ill trauma patients: The VANCTIC Study.

BACKGROUND: Current guidelines from the Infectious Diseases Society of America and the American Society of Health-System Pharmacists recommend vancomycin troughs of 15 mg/L to 20 mg/L for serious methicillin-resistant Staphylococcus aureus infections. The pharmacokinetics of vancomycin are altered in critically ill patients, leading to inadequate serum levels. Rates of initial therapeutic vancomycin troughs have ranged from 17.6% to 33% using intermittent infusions (i.e., 15-20 mg/L) and approximately 60% using continuous infusions (i.e., 15-25 mg/L) in critically ill trauma patients (1-4). We hypothesized that our dosing protocol would achieve higher rates of initial therapeutic troughs compared with previously published reports due to more aggressive loading doses than those seen in previously published reports. METHODS: This was a retrospective study of all critically ill trauma patients admitted to a Level I trauma intensive care unit over a 39-month period who had a suspected serious infection, who were treated with empiric vancomycin per the "pharmacy to dose" protocol, and who had an appropriately drawn steady state trough level. The primary outcome was the rate of initial therapeutic troughs, which was defined as 14.5 mg/L to 20.5 mg/L. RESULTS: One hundred ninety-seven patients were screened. Seventy patients met inclusion criteria. The study cohort had a median age of 47.5 years and a median Injury Severity Score of 28. Augmented renal clearances were observed, with a median creatinine clearance of 159.1 mL/min and a median Augmented Renal Clearance in Trauma Intensive Care (ARCTIC) score of 7. The median vancomycin loading dose was 24.6 mg/kg with an initial maintenance dose of 17.71 mg/kg. An every eight hour dosing interval was initiated on 47.14% of the patients, and 45.71% of the patients were initially started on an every 12 hour dosing interval. Only 15.71% of the study patients achieved an initial therapeutic trough; 42.86% were less than 10 mg/L, and 8.57% were greater than 20.5 mg/L. Acute kidney injury occurred in 10% based on the Infectious Diseases Society of America/American Society of Health-System Pharmacists vancomycin guidelines and in 11.4% based on the Acute Kidney Injury Network criteria. CONCLUSION: Our incidence of initial therapeutic troughs was slightly below previously reported studies. Based on our results, which are consistent with previous literature, it would appear that our guideline-adherent protocol of intermittent vancomycin is insufficient to achieve troughs of 15 mg/L to 20 mg/L. LEVEL OF EVIDENCE: Therapeutic, level III.

The paralyzing effect of insurance status on throughput of acute spinal cord patients.

OBJECTIVE: To determine whether lack of insurance is a predictor of poor outcomes and increased healthcare expenditure for SCI patients. METHODS: Retrospective cohort study of trauma patients admitted with an acute, severe (AIS ≥ 3) SCI and admission score of ASIA-A to a Level 1 trauma center (2012-2016). Patient characteristics and outcomes (LOS, complications) were compared between insured and uninsured patients. Multivariable adjustment was performed using linear regression. RESULTS: Of 76 patients who met eligibility, 44 had insurance and 32 were uninsured (NOINSUR). Despite having similar ventilator days (13 vs. 12.1) and ICU LOS (20.1 vs. 16.8), the NOINSUR group had more ventilator-free days (22.3 vs 6.6; p < 0.0001), longer Stepdown Unit length of stay (10.2 vs 2.3; p = 0.0036), and a longer hospital length of stay (35.3 vs 18.7; p = 0.0062). CONCLUSION: Uninsured SCI patients face longer hospital LOS due to their insurance status and lack of funding for timely rehabilitation placement. This utilizes valuable hospital resources and puts them at risk for hospital related complications and further increased healthcare expenditures.