52.09 Undertriage of Older Adult Trauma Patients: Is this a National Phenomenon?

Posted on December 22, 2014

L. M. Kodadek1, S. Selvarajah1, C. G. Velopulos1, A. H. Haider1  1Johns Hopkins University School Of Medicine,Department Of Surgery,Baltimore, MD, USA

Introduction:
Older age is associated with higher morbidity and mortality after injury.  National guidelines recommend that patients age ≥55 years be considered for triage to trauma centers (TCs) to ensure optimal care.  However, recent statewide studies suggest that significantly injured patients ≥55 years are actually more likely to be undertriaged to nontrauma centers (NTCs).  Our objective was to determine if older adult undertriage is a national phenomenon and to determine associated patient and injury factors. 

Methods:
The 2011 Nationwide Emergency Department Sample was used to perform a national analysis.  All adults age ≥55 years presenting to an emergency department (ED) with an injury diagnosis were identified using ICD-9 diagnosis codes (800.*-959.*).  Patients transferred to another short-term facility and patients with ICD-9 codes indicating superficial injury, foreign body injury and late effects were excluded.  To determine injury severity, Stata program for Injury Classification (ICDPIC) was used to assign a new injury severity score (NISS).  We performed weighted descriptive analysis comparing characteristics of patients by trauma center status.  As patients in rural areas may be transported to a NTC because of proximity, a subset analysis was performed examining patients in urban/suburban areas only where this would occur less commonly.  Logistic regression was performed to determine association between patient demographics and injury characteristics, controlling for hospital characteristics, injury severity and Charlson Comorbidity Index.

Results:
Of 4,135,782 ED visits meeting inclusion criteria, 74.0% were treated at NTCs, and 70.4% of all ED visits were in urban/suburban areas.  Although the majority of ED visits were associated with NISS<9 (85.1%), proportionally more ED visits at TCs had NISS≥9 compared to NTCs (22.2% vs. 12.3%, P<.001).  We found that 58.1% of patients with NISS≥9 were managed at a NTC.  On multivariate analysis it was noted that patients at NTCs were more likely to be ≥75 years, female, insured by the government and injured by falls.  Patients with moderate injuries (NISS 9 to 15) were more commonly treated at NTCs (62.7%) and patients with the most severe injuries (NISS > 25) were seen at similar rates in TCs and NTCs (49.1% vs. 50.9%).  

Conclusion:
There is substantial undertriage of patients age ≥55 years at the national level.  Nearly half of significantly injured older patients are being treated at NTCs.  The impact of undertriage needs to be determined and interventions are needed to ensure that older patients receive trauma care at the optimal site.  
 

52.10 Equal Access to Care Eliminates Racial/Ethnic Disparities in Patients with Operable Breast Cancer

Posted on December 22, 2014

A. C. DuBose1, Q. D. Chu1  1Louisiana State University Health Sciences Center,Division Of Surgical Oncology, Department Of Surgery,Shreveport, LA, USA

Introduction:  A recent study reported that racial/ethnic disparity in breast cancer mortality in the 50 largest cities in the U.S. has risen sharply, which can be attributed to a higher “amenability index”, a measure of accessibility to technologic advances. Our institution provides equal access and technologic advances to all women with breast cancer, irrespective of their socioeconomic status (SES). We determine whether such a practice can eliminate disparities in breast cancer outcome.

Methods: A prospective breast cancer database examined outcome for 977 patients with stage 0 to III breast cancer treated up to April 2013. The majority received standard definitive surgery as well as appropriate adjuvant treatment. Primary endpoint was overall-survival (OS). Statistical analysis performed included Kaplan-Meier survival analysis and independent-samples t test. P ≤ 0.05 was considered statistically significant.

Results: Sixty-one percent of patients were African-Americans (AA), and three-quarters were either free care or Medicaid.  Despite having a more aggressive tumor subtype (a lower percentage of ER/PR-positivity in AA as compared to Caucasian (C) patients; 38% vs. 52%, respectively), the 5-year overall survival (OS) for AA and C patients was similar (84% vs. 87%, respectively; P = 0.23). Multivariate analysis confirmed that race/ethnicity was not an independent predictor of OS (P=0.14);  OS for the entire cohort was comparable with that of the SEER database.

Conclusion: In a predominantly indigent population, equal access to care negates racial disparity in patients with breast cancer.

 

53.01 A Comparison of the Geographic Variation in Surgical Outcomes and Cost Between the US and Japan

Posted on December 22, 2014

M. Hurley4, L. Schoemaker2, J. Morton1, S. Wren1, S. Watanabe3, A. Yoshikawa3, J. Bhattacharya2  1Stanford University,Department Of Surgery,Palo Alto, CA, USA 2Stanford University,Center For Health Policy/Center For Primary Care And Outcomes Research,Palo Alto, CA, USA 3Global Health Consulting Japan,Tokyo, TOKYO, Japan 4Stanford University,Health Research And Policy,Palo Alto, CA, USA

Introduction:  Unwarranted geographic variation in spending has received intense scrutiny in the US. However, few studies have compared variation in spending and outcomes between different healthcare systems. In this study, we compare the geographic variation in post-surgical outcomes and cost of hospitalization between the United States and Japan.

Methods:  This retrospective study uses Medicare Part A data from the United States (2010-2011) and similar inpatient data from Japan (2012). Patients above the age of 65 undergoing one of five surgeries (CABG, AAA repair, colectomy, pancreatectomy, gastrectomy) were selected in the US and Japan. The weighted age- and sex-standardized coefficient of variation (COV) was calculated for post-operative mortality, the development of a complication, death after complication, length of stay, and the cost of the hospitalization. An adjusted COV was also calculated for each measure, additionally controlling for patient demographics, comorbidities, and urgency of admission.

Results: With the exception of length of stay after colectomy, the variability of the four post-surgical outcomes for all five surgeries was uniformly lower in the US compared to Japan. This pattern held even after adjusting for patient comorbidities. In contrast, cost variation was consistently higher in the US for all surgeries compared to Japan. The level of cost variation between surgeries was similar in the US (adjusted COV values of 17 to 22) and also in Japan (adjusted COV values of 5 to 11), indicating that within each country, the specific type of surgery had minimal influence on overall cost variability.

Conclusion: Though the US healthcare system has higher cost inefficiency, the presence of higher geographic variation in post-operative outcomes in Japan relative to the US suggests that the observed geographic variation in the US, both for health expenditures and outcomes, is not a unique manifestation of its structural shortcomings.

53.02 Quality of Emergency Department Care and Acute Care Surgery Outcomes

Posted on December 22, 2014

T. C. Tsai1,2, L. Burke2,3, M. J. Zinner1  1Brigham And Women’s Hospital,Surgery,Boston, MA, USA 2Harvard School Of Public Health,Health Policy And Management,Boston, MA, USA 3Beth Israel Deaconess Medical Center,Emergency Medicine,Boston, MA, USA

Introduction:
A significant proportion elderly patients undergoing emergency general surgery are admitted through emergency departments (ED).  However, quality efforts aimed at improving outcomes for these patients have focused primarily on intra-operative and post-operative processes of surgical care.  Little is known on whether the quality of emergency department care is related to postsurgical outcomes.  We therefore assessed whether low-quality EDs were associated with worse perioperative outcomes for elderly emergency general surgery patients. 

Methods:
We used the percentage of stroke patients receiving a head computed tomography (CT) scan within 45 minutes, a Centers for Medicare and Medicaid Services (CMS) publicly reported measure, as our measure of ED quality.  Using 2012 national Medicare inpatient claims, we calculated risk-adjusted 30-day mortality rates for elderly patients admitted through the ED and undergoing the following emergent operations: appendectomy, cholecystectomy, inguinal hernia, exploratory laparotomy, colectomy, and small bowel resection.  We then used a multivariate regression model adjusting for hospital features to assess the relationship between ED quality and acute care surgery outcomes. 

Results:
648 hospitals publicly reported their head CT process quality measure in 2012.  15.5% of patients received timely and appropriate imaging in low-quality EDs compared to 79.9% of patients in high-quality EDs (p<0.001). Compared to high-quality EDs, low-quality EDs were more likely to be small (32.1% vs. 18,7%, p<0.001), located in the South (47.3% vs. 30.7%, p<0.001), and publicly owned (24.2% vs. 10.0%, p<0.001).  Adjusting for hospital features, low-quality EDs were associated with higher 30-day surgical mortality (14.0% vs. 9.1%, p=0.019).

Conclusion:
Emergency care plays an important role in determining the outcomes of surgical patients. Hospitals with worse performance on publicly reported ED quality measures also have higher 30-day mortality for emergency surgical patients.  An emphasis on high-quality emergency care is critical for optimal outcomes of surgical patients.
 

53.03 Postoperative Health Services Use Before and After Implementation of a Provincial Bariatric Program

Posted on December 22, 2014

A. Elnahas1, T. Jackson1, A. Okrainec1, P. Austin2, C. Bell3, D. Urbach1,2  1University of Toronto,General Surgery,Toronto, Ontario, Canada 2Institute For Clinical Evaluative Sciences,Toronto, Ontario, Canada 3University of Toronto,General Internal Medicine,Toronto, Ontario, Canada

Introduction:  In 2009, the Ontario Ministry of Health and Long-term Care created the Ontario Bariatric Network (OBN)—a network of four interdisciplinary regional Bariatric Centers of Excellence—in an effort to address the exploding demand for bariatric surgery services funded outside Canada. The impact of outsourcing bariatric surgery to other jurisdictions, which can lack appropriate follow-up and supervision of patients, remains unexplored. The objective of this study is to compare postoperative hospital services use among Ontario residents who received bariatric surgery before and after implementation of the OBN.

Methods:  We conducted a retrospective, uncontrolled, before-and-after study using administrative data held at the Institute for Clinical Evaluate Sciences. All Ontario residents who underwent funded first-time bariatric surgery were included in the study. Use of hospital services within one year following surgery was compared between the 3-year periods before (2007-2009) and after (2010-2012) establishment of the OBN. Secondary outcomes included physician visits, re-operations and mortality.

Results: A total of 5,617 and 6,896 patients received bariatric surgery before and after implementation of the OBN, respectively. The two cohorts shared similar baseline characteristics. After adjustment for age, sex, neigborhood income quintile, rurality, procedure type and Adjusted Clinical Group comorbidity score, implementation of the OBN was associated with less days requiring postoperative hospital services (rate ratio [RR] 0.83, 95% CI 0.78 to 0.89, P<0.001), including less time in intensive care (RR 0.53, 95% CI 0.35 to 0.81, P=0.003) and a lower 1-year mortality (odds ratio [OR] 0.44, 95% CI 0.23 to 0.82, P=0.01). No statistically significant differences were found with respect to re-hospitalization or re-operation rates. Not surprisingly, the physician visit rate was significantly higher after the OBN (RR 3.50, 95% CI 3.19 to 3.84, P<0.001).

Conclusion: In our study of health services use among a large number of patients who received bariatric surgery before and after introduction of a comprehensive organized program, we found that a multidisciplinary bariatric program provided a safer model of care compared to outsourcing bariatric surgical services.

 

53.04 Achieving Better Elective Waiting Times: Remodelling the Colorectal Outpatient Clinic

Posted on December 22, 2014

B. Su’a1, A. Taneja1, A. G. Hill1  1The University Of Auckland,Department Of Surgery,Auckland, AUCKLAND, New Zealand

Introduction:
Outpatient specialist clinic appointments in the public health system face an increasing service demand.  There is an emerging need for more efficient resource utilisation to ensure that waiting time targets are met.  We present a novel remodelling of a rectal bleeding outpatient clinic aimed at improving efficiency by protocolising the management for patients with minor anorectal conditions.

Methods:
An evidence based protocol for the management of patients with minor anorectal conditions and outlet rectal bleeding was devised by the colorectal department at CMDHB in November 2013.  A key feature was to utilise a Patient Initiated Follow Up system (PIFU) where patients are given a ‘card to call’ instead of being provided with routine follow up appointments.  Patients were allocated to a new, once monthly ‘PR bleeding clinic.’  The control group was a historical cohort of sequential patients with minor anorectal conditions who had been seen by the colorectal unit prior to 2013.

Results:
68 patients were prospectively analysed in the new clinic from November 2013 to May 2014 and 80 patients were included in the historical group from December 2012 to February 2012.  Baseline characteristics were similar.  Whilst there was no significant difference in the overall rate of colonic investigations, CT colonography was more frequently utilised in the new clinic (26.5% vs. 8.8%, p=0.007).  Patients in the new clinic were also more likely to receive haemorrhoid banding (39.7% vs. 13.8%, p=0.001), whilst elective surgery rates remained similar (11.8% vs. 15.0%, p=0.635).  Routine follow up appointments were significantly less in the new clinic (4.4% vs. 48.8%, p<0.001).  A PIFU card was given to 56 out of 68 patients in the new clinic.  Nine patients called back, of which only 2 patients required further follow up appointments.  The median duration of the follow up period was 176 days.  Mean waiting time from time of original referral was 45 ± 20 days in the new clinic group vs. 99 ± 25 days in the control group (p<0.001).

Conclusion:
Protocolised management of patients with minor anorectal conditions reduces follow up of patients with minor anorectal conditions.  This releases capacity to see new patients in a pressured public hospital outpatient clinic and can improve elective waiting times.
 

50.05 Efficacy of Gastrografin Challenge in Comparison to Standard Management of Small Bowel Obstruction

Posted on December 22, 2014

Y. M. Baghdadi1, M. Amr1, M. A. Khasawneh1, S. Polites1, M. Zielinski1  1Mayo Clinic,Rochester, MN, USA

Introduction: The Gastrografin® Challenge is a diagnostic and therapeutic tool to treat patients with small bowel obstruction (SBO), however, long-term data on SBO recurrence after the Gastrografin® Challenge is limited. We hypothesized that patients treated with Gastrografin® would have the same long-term recurrence as those treated prior to the implementation of the Gastrografin® Challenge protocol.

Methods: Institutional review board approval was obtained to review medical records of patients 18 years or older admitted for acute SBO between 7/2009-9/2011. Patients with contraindications to the Gastrografin® Challenge (i.e. signs of strangulation) were excluded. Kaplan-Meier method was used to describe the time-dependent outcomes. Data is presented as mean ± standard deviation, or percentage, as appropriate.

Results: A total of 191 patients were identified of whom 52 received the Gastrografin® Challenge (27%). The mean age was 65 ± 17 years with 103 women (54%). Operative exploration and complications during the initial hospitalization were less common in patients who underwent the Gastrografin® Challenge (27% vs 42%, p=0.045, and 10% vs 39%, p<0.0001, respectively). The duration of index hospitalization was comparable (9 vs 9 days, p= 0.87). Overall survival from recurrence was 91% (95%CI: 76.5%-96.7%) over 12 months (Figure 1). There were no recurrences among patients who received the Gastrografin® Challenge at one year follow-up (survival rates; 0% vs 86.9%, p=0.04). 

Conclusion: The Gastrografin ® challenge is safe and promising tool in managing patients with SBO with fewer explorations at the index of admission and subsequent lower recurrence rates during follow-up. 

 

50.06 Effect Of Alcohol And Illict Drug Use In Pediatric Trauma Patients: An Analysis Of The NTDB

Posted on December 22, 2014

H. Aziz1, P. Rhee1, V. Pandit1, M. Khalil1, R. S. Friese1, B. Joseph1  1University Of Arizona,Trauma/Surgery/Medicine,Tucson, AZ, USA

Introduction:

Alcohol misuse is an important source of preventable injuries in the adolescent population. While alcohol screening and brief interventions are required at American College of Surgeons-accredited trauma centers, there is no standard screening method. The aim of our study was assess the effect of alcohol and illicit drugs in pediatric trauma outcomes. 

Methods:

We performed a retrospective analysis of the NTDB. Pediatric patients (≤ 20) who were tested for alcohol and/ or illicit drugs were included in the analysis. Outcome measures were difference in complications and mortality between the two groups. 

Results:

A total of 31,923 pediatric trauma patients were tested for alcohol; 21% of whom tested positive for alcohol. Of the 17,053 patients tested for illicit drugs; 14 % were tested positive for illicit drug use. Propensity matched analysis revealed that pediatric patient with alcohol/illicit drugs use were more likely to have in hospital complications (21% vs. 16%; p-0.01) and a higher mortality rates (7% vs 3%; p-0.001) as compared to their counterparts. 

Conclusion:

Alcohol and illicit drugs use and abuse are associated significant consequences in pediatric population. Our study highlights the increasing use of alcohol and illicit drugs in pediatric trauma patients. Strict screening criteria in pediatric trauma patients are warranted. 

 

50.07 Injury Severity Score (ISS) as a Predictor of Perioperative Complications in Open Humerus Fractures

Posted on December 22, 2014

N. N. Branch1,2, A. Obirieze2, R. H. Wilson1,2  1Howard University College Of Medicine,Washington, DC, USA 2Howard University Hospital,Surgery,Washington, DC, USA

Introduction: Patients with open humerus fractures are often subjected to high velocity forces.  Consequently, they may present with an isolated injury or polytrauma, requiring prioritization of fracture management with the need to stabilize more immediate life threatening injuries.  The extent of these injuries may intuitively correlate with outcomes, however, not all patients will undergo definitive fixation during their hospitalization.  As such we sought to determine the relationship between Injury Severity Score (ISS) and perioperative complications after open reduction and internal fixation (ORIF) of traumatic open humerus fractures.

Methods: A retrospective analysis of the National Trauma Data Bank from 2007-2010 utilizing ICD-9 codes was conducted.  Patients >18 years old, who underwent open reduction and internal fixation (ORIF) of the humerus at a level I or level II trauma center were included.  Using multivariate analyses covariates were controlled for including but not limited to obesity, congestive heart failure, diabetes, bleeding disorders, age, steroid use, and smoking status.  Univariate and bivariate analyses were also performed.  ISS was stratified into four groups, 1: <16, 2: 16-24, 3: 25-75, and 4: unknown with ISS <16 serving as the reference group.

Results:A total of 5,663 patients met the inclusion criteria.  The majority of whom were white (65%) males (71%) ages 25-44 (39%) with private insurance (26%) whose fracture resulted from blunt trauma secondary a motor vehicle collision (26%).  The average hospital length of stay was 11.8 days with a mean of 3.5 days in the intensive care unit.  59% of patients had an ISS of <16.  On multivariate analysis with increasing ISS (group 2 and 3) increased the odds of developing an organ/space surgical site infection (SSI), sepsis, or any infection (Table 1).  Further, the odds of having any perioperative complication in addition to death within 30 days of admission increased with increasing ISS (Table 1).  Superficial SSI was increased by almost five times for ISS group 3 (OR: 4.73 CI: 2.3-9.2 p<0.001), and deep SSI were increased more than seven times for ISS group 2 (OR: 7.68 CI: 1.31-45.14 p=0.024) compared to an ISS of <16.

Conclusion: Injury Severity Score is an accurate predictor of perioperative complications associated with ORIF of traumatic open fractures of the humerus.  This is particularly true of infectious complications and mortality.  In general with increasing ISS there is an increase in the odds of developing a perioperative complication. 

 

50.08 Under Fire: Gun Violence is not just an Urban Problem

Posted on December 22, 2014

C. Morrison1, K. Bupp1, B. Gross1, K. Rittenhouse1, F. Rogers1  1Lancaster General Hospital,Trauma,Lancaster, PA, USA

Introduction: Gun violence continues to be a source of trauma patient morbidity and mortality annually in U.S. communities. Recent research suggests increasing gunshot violence severity in urban centers. We sought to characterize gun violence in the combined suburban and rural county of Lancaster, PA, to compare it to gun violence results obtained in urban areas.

Methods:  In a Pennsylvania-verified, level II trauma center, treated gunshot wounds (GSW) from January 2000 to December 2013 were queried from the trauma registry. BB/pellet GSWs were excluded. Data collected included mortality, ISS, and number of GSW per patient. Cost data was obtained for patients from 2004-2013, and costs were calculated using cost-charge modifiers. A binary logistic regression was performed to assess mortality over time. Linear trend tests assessed the change in percent of patients with 3 or more GSWs, with ISS≥15 and ISS≥25 over the 14-year study period. Significance was defined as p<0.05.

Results: A total of 478 patients met inclusion criteria. Of these patients, 83.3% sustained interpersonally-inflicted GSWs, while the remaining 16.7% sustained self-inflicted GSWs. The population was 62% white, 35% black, and 3% other.  Risk-adjusted mortality (for age, ISS) showed no significant change in mortality over time (p=0.999). Linear trend tests revealed no significant changes in percent of patients with 3 or more GSWs (p=0.693), with ISS≥15 (p=0.546), or with ISS≥25 (p=0.342) over time. No significant change in cost per case was found (p=0.380), however percent reimbursement significantly increased (p=0.009).

Conclusion: Even the fairly suburban and rural communities of Lancaster County, PA are not sheltered from the problem of gun violence, although the rate seems to be stable in a non-urban environment. Despite advances in pre-hospital and hospital care, including damage control techniques, the mortality from GSW has not changed. Future efforts to improve the outcome for GSW should focus more on preventative efforts.
 

50.09 Percutaneous versus Surgical Tracheostomy: a meta-analysis.

Posted on December 22, 2014

C. J. Lee1, R. S. Chamberlain1,2,3  1Saint Barnabas Medical Center,Surgery,Livingston, NJ, USA 2New Jersey Medical School,Newark, NJ, USA 3Saint George’s University,Grenada, Grenada, Grenada

Introduction:  Percutaneous tracheostomy (PT) was first described by Toye and Weinstein in 1969, and has gained wide acceptance.  Despite being the procedure of choice in many ICUs, ongoing controversy over complication rates has led many surgeons to prefer standard open tracheostomy (ST) versus PT.   This meta-analysis assesses all randomized controlled trials (RCTs) comparing PT to ST evaluating operative time and postoperative outcomes to develop evidence based recommendations on tracheostomy method. 

Methods:  A comprehensive literature search of PubMed, the Cochrane Central Register of Controlled Trials, and Medline was performed. 21 prospective, RCTs were identified comparing PT with ST in adult, intensive care unit patients requiring tracheostomy (1991-2014). Data were extracted on study design, study size, rate of tracheostomy site infection, rate of intraoperative and postoperative hemorrhage, rate of pneumothorax, rate of subcutaneous emphysema, and recorded operative time.

Results: 21 trials involving 2,074 subjects were included in the meta-analysis. Among these 2,074 adult ICU patients, 996 involved PT, and 1,078 were ST. PT techniques included Cook Blue Rhino, Ciaglia and Griggs’ techniques. PT was associated with a 65% decrease in the likelihood of wound infection (risk ratio (RR) 0.35; 95% CI, 0.22 to 0.54, p<0.001) and significantly shorter operative time (Standard difference in means -1.67; 95% CI, -2.25 to -0.99, p<0.001) compared to ST. No significant differences in intraoperative hemorrhage (p=0.675), postoperative hemorrhage (p=0.287), pneumothorax (p=0.528) or subcutaneous emphysema rates were observed (p=0.484). 

Conclusion: PT is associated with a significant decrease (65%) in the incidence of wound infection when compared to ST, and is comparable regarding other major operative complications such as hemorrhage, pneumothorax, and subcutaneous emphysema. PT can be performed in a significantly shorter amount of time compared to ST. In the critically ill patient in an intensive care setting, PT can be recommended as the procedure of choice and a safe alternative when an elective tracheostomy is required.

 

50.10 Paravertebral Blocks Significantly Reduce the Risk of Death in Patients with Mulitple Rib Fractures

Posted on December 22, 2014

K. Basiouny1, N. Gamsky1, B. Sarani1, P. Dangerfield1, R. L. Amdur1, M. Rose2, J. Dunne1  2George Washington University School Of Medicine And Health Sciences,Department Of Anesthesia,Washington, DC, USA 1George Washington University School Of Medicine And Health Sciences,Division Of Trauma, Department Of Surgery,Washington, DC, USA

Introduction

Multiple rib fractures are associated with significant morbidity and mortality. Attempting to find a way to mitigate theses complications, we began placing paravertebral blocks (PVB) in such patients.  The goal of this study is to assess the efficacy of PVB in patients with multiple rib fractures compared to the national trauma data bank (NTDB).  We hypothesize that PVB significantly improve survivability.

Methods

The 2008 NTDB was to develop expected death rates based on patient characteristics and compared against a consecutive cohort of patients in a single level I trauma center from 2011 to 2014. Patients 18 years or older with ≥ 3 rib fractures or a sternal fracture and hospital length of stay > 3 days were included. Variables abstracted include: demographics; rib fracture variables (number of ribs fractured, sternum fracture, flail-chest); injury type (blunt, penetrating, burn); Glasgow coma score (GCS), and injury severity score (ISS).  A logistic regression model using gender, age, GCS, ISS, and number of ribs fractured was developed from the NTDB and then used in our sample to predict death. The PVB x risk interaction was added to this model to determine if the association between risk and outcome varies significantly based on whether or not PVB was present. Probability of death was grouped into 6 risk strata: 10th, 25th, 50th, 75th, and 90th percentile and examined with chi-square grouped by the presence or absence of PVB.

Results [BS1] 

The NTDB cohort consists of 35058 patients. The lowest 10% had a death rate of 0.3%, while the highest 10% had a death rate of 32.6. The association between the risk category and death was strong (phi=.40, p<.0001).  There were 318 GW patients with 3 or more rib fractures with 81 that received PVB, all trauma patients cared for from 2011 to 2014. We collected age, ISS, GCS, gender, and total fracture numbers.  There appeared to be difference between the GW cohort and the NTDB.  Patients with the highest two risk stratified death rates who received a PVB had a much lower than the expected death rate. In the model using Risk score and PVB as predictors, the prediction model for death was very accurate (c=.95) with sensitivity and specificity of .89 & .90 respectively.   The OR for Risk was 7.86 [3.80-16.26], p<.0001. This indicates that for every 1-step increase in the risk score (from 1 to 6), the odds of death increases almost 8 times. The OR for PVB was 0.14 [0.02-1.22], p=.075.  The length of stay in the hospital was significantly higher in the highest risk stratified group who received PVBs with an R2 of .41.    

Conclusion

Patients in the highest risk stratified groups with ≥ 3 rib or sternal fractures have improved survival with use of paravertebral blocks.

51.07 Endoscopic Removal of Esophageal Foreign Bodies is Associated with Increased Resource Utilization.

Posted on December 22, 2014

J. Tashiro1, R. S. Kennedy1, E. A. Perez1, F. Mendoza2, J. E. Sola1  1University Of Miami,Division Of Pediatric Surgery, DeWitt Daughtry Family Department Of Surgery,Miami, FL, USA 2Baptist Children’s Hospital,Children’s Emergency Center,Miami, FL, USA

Introduction: Ingested foreign bodies are a frequent presentation in pediatric emergency departments. Although most will pass spontaneously through the gastrointestinal tract, the majority of esophageal foreign bodies (EFB) require removal. We analyzed hospital admissions for EFB to identify significant indicators for resource utilization in the U.S.

Methods: Kids’ Inpatient Database (1997-2009) was used to identify patients <20 yrs of age with EFB (ICD-9-CM 935.1). Multivariate logistic regression analyses (MVA) were constructed to identify predictors of resource utilization. Cases were weighted to project national estimates.

Results: Overall, 14,767 EFB cases were identified. Most patients were <5 years of age (72%), male (57%), and non-Caucasian (55%), with a median (IQR) length of stay of 1 (1) day, and total charges of 11,003 (8,505) USD. A total of 11,180 procedures were performed, most commonly esophagoscopy (77%), followed by bronchoscopy (20%), gastroscopy (2%), and rarely surgery (0.8%). A total of 5,826 patients (39% of the cohort) did not have an endoscopic procedure and were not transferred. Esophageal ulceration was the most common diagnosis, although caustic injury or esophageal perforation occurred infrequently (0.5% and 0.4%, respectively). By MVA, increased TC were associated with a diagnosis of esophageal ulceration (OR=1.72), esophagoscopy (OR=1.68), and bronchoscopy (OR=1.51), all p<0.001. TC also increased with admission to urban non-teaching hospitals (OR=1.45) vs. urban teaching hospitals, p<0.001. Large bedsize hospitals and facilities located in the Western U.S. had the highest TC vs. all others, p<0.001. Prolonged LOS (≥1 day) was associated with admission to non-children’s hospitals (OR=1.25) and children’s general hospitals (OR=1.22), as well as with esophageal ulceration (OR=2.19) and esophagoscopy (OR=1.11), p<0.05. Girls had higher odds of longer hospitalization (OR=1.19), p<0.001. Meanwhile, admission to small bedsize hospitals (OR=0.77) or facilities in the Western U.S. tended to decrease admission LOS, p<0.05. Overall hospital mortality was 0.1% (n=16).

Conclusion: Most EFB occur in children <5 years of age. Although surgery is rarely required, endoscopic removal of EFB is associated with increased TC and LOS. Surgeons should consider non-endoscopic removal techniques in witnessed and recent ingestions of blunt EFB such as coins. Hospital mortality is extremely rare in children with esophageal foreign bodies.

52.01 Patient-Centered Costs Disproportionately Impact Low Income Patients

Posted on December 22, 2014

A. R. Scott1,3, A. J. Rush1, C. J. Balentine2, D. H. Berger1,3, A. D. Naik1,3, J. W. Suliburk1  1Baylor College Of Medicine,Houston, TX, USA 2University Of Wisconsin,Madison, WI, USA 3VA Center For Innovations In Quality, Effectiveness And Safety,Houston, TX, USA

Introduction:

Surgical diseases and their treatment have a significant economic impact. Costs associated with surgery are frequently studied at the system level, but reports of the costs for individual patients are less common. The price a patient pays for a surgical intervention and the surrounding care includes not only fees recognized by the healthcare system, but also patient-centered costs including travel, childcare, and lost wages. We hypothesized that the patient-centered costs of routine postoperative clinic visits disproportionately impact patients with low incomes.

Methods:

This was a cross-sectional study performed in the acute care surgical follow-up clinic at an urban level 1 trauma center which serves as the county safety net hospital. In January and February 2014, a survey covering social, demographic, and financial topics was collected from patients undergoing follow up for appendectomy, cholecystectomy, and surgical treatment of soft tissue infections, which represent approximately 30% of the patients seen in our facility. The patient-centered cost was calculated from these surveys as the sum of the costs of transportation, childcare, and lost wages. Costs were compared between patients whose annual income was less than 50% of the Federal Poverty Level (FPL), 50-100% FPL, 100-200% FPL, and more than 200% FPL. The Kruskal-Wallis test was used to compare groups and then post-hoc analysis performed using the Wilcoxon rank-sum with Bonferroni correction.

Results:

Surveys response rate was >90% with a total of 97 surveys collected; 59 contained all data needed for cost calculations. The median patient-centered cost of a clinic visit was $27 (IQR $20-$62). Components of this cost were $16 ($14-$20) for travel, $22 ($20-$50) for childcare in patients requiring childcare, and $0 ($0-$30) in lost wages. No significant differences (p = 0.95) in cost were seen between patients in the four income groups (Table 1). When the patient-centered costs as a percentage of monthly income were compared, however, significant differences (p < 0.001) were seen (Table 1). No significant differences were present between the three higher income groups.

Conclusion:

The patient-centered cost of a routine postoperative clinic visit can be a significant burden. Consistent with our hypothesis, the lowest income patients are disproportionately impacted, spending more than 6% of their monthly income on costs associated with the clinic visit. Efforts of cost containment should focus not just on system costs, but also patient-centered costs. Future studies should examine alternative, lower cost methods of follow up for low-risk surgeries in an effort to reduce their financial burden.

 

50.01 Transport Time as a Factor in the Survival Benefit of Trauma Patients Transported by Helicopter

Posted on December 22, 2014

J. B. Brown1, M. L. Gestring2, M. R. Rosengart1, A. B. Peitzman1, T. R. Billiar1, J. L. Sperry1  1University Of Pittsburgh,Department Of Surgery,Pittsburgh, PA, USA 2University Of Rochester,Department Of Surgery,Rochester, NY, USA

Introduction:
Helicopter transport (HT) following traumatic injury has been shown to improve survival; however the contibution of factors such as speed and crew resources are not clear. The study objective was to examine the impact of HT vs ground transport (GT) on survival across similar prehospital transport times (PHTT).

Methods:
Subjects >15 years undergoing HT or GT from the scene of injury in the National Trauma Databank (2007-2012) were included. Subjects were excluded if dead on arrival or missing PHTT. PHTT was stratified by 5min increments between 0 and 60mins. To account for differences between HT and GT groups, propensity score matching was used to estimate the probability of HT. Variables in the propensity-score included age, sex, prehospital vital signs, prehospital response and scene time, injury severity score, and mechanism of injury. 1:1 nearest neighbor matching was used to match HT and GT subjects on the probability of undergoing HT. Standardized differences were used to assess balance after matching. Conditional logistic regression was used to determine the association of HT vs GT with in-hospital survival across PHTT strata, controlling for ICU admission, emergent surgery, mechanical ventilation, and insurance status. False discovery rate correction was used for multiple comparisons. Transport distance was estimated from PHTT using national average HT and GT transport speeds.

Results: 
156,010 pairs were matched, giving 312,020 subjects for analysis. The propensity score model had good discrimination (AUC=0.91).  After matching, no variable in the propensity score had a standardized difference >0.2 with a 77% reduction in overall bias. HT subjects required ICU admission, emergent surgery, and mechanical ventilation more often than GT subjects (p<0.01). HT vs GT median prehospital response time (19min vs 19min) and scene time (14min vs 15min) were similar.  Median PHTT in the HT group was 21min (IQR 16, 30) compared to 23min (IQR 15, 36) in the GT group (p<0.01). HT vs GT was independently associated with an increased odds of survival in a time window between 6 and 25mins (Fig). This corresponds to an estimated transport distance between 14.3 and 59.4mi for HT, and 3.3 and 13.8mi for GT. The survival benefit of HT peaked at a PHTT of 11-15min (OR 2.02; 95%CI 1.70-2.41, p<0.01).

Conclusion:
The survival benefit for HT in trauma at the population level is concentrated in a PHTT window between 6 and 25mins. These results highlight the importance of logistical considerations and the potential influence of crew resources on outcome for HT in trauma, with implications for trauma system design and planning. Further study of the interplay between transport time, distance, and survival for HT in trauma is warranted.

50.02 Does Decade of Life Matter: An Age Related Analysis of SICU Patients

Posted on December 22, 2014

N. Melo1, J. Chan1, J. Mirocha1, M. Bloom1, E. Ley1, R. Chung1, D. Margulies1  1Cedars-Sinai Medical Center,Los Angeles, CA, USA

Introduction: With the increasing aging population in the Intensive Care Unit (ICU), we analyzed patients admitted to our Surgical ICU to determine if age had an effect on mortality and complications.

Methods: A retrospective chart review was conducted between February 2011 and January 2014 on all patients admitted to the Surgical ICU at our institution.   Patient demographics and complications were analyzed using decade of life (< 50, 50-60, 60-70, 70-80, ≥ 80) to determine whether this influenced outcomes and rate of complications.  ANOVA and Chi-Squared tests were used as appropriate for analysis.

Results:  2,272 patients were included in the study.  Patients were 55.3% male, average age was 59.7 years, and average APACHE score of 26.68.  We found that mortality increases with increasing age (p<0.05).  There was no difference in ICU length of stay (LOS), or Ventilator Days.  With increasing age, there were increases in rates of Deep Vein Thrombosis (DVT), Sepsis, Urinary Tract Infection (UTI), Arrhythmias, Shock, and Pulmonary Embolism (PE) (p< 0.05).    We saw an increase in renal failure for ages 50-70.   There were no differences in GI bleeds.   Rates of SIRS declined with increasing age.

Conclusion:  Although ICU mortality is known to increase with age, we demonstrate that patients as young as 50 start to have an increase risk of complications.    Interestingly, LOS and Ventilator Days were not affected by age.   SIRS was decrease as patients aged, which may be related to the inability to mount an early physiologic response.   This study will help to increase vigilance in the ICU and help with utilization of resources.

50.03 Trajectory Subtypes After Injury: Implications In The Era Of Patient Centered Outcomes

Posted on December 22, 2014

B. L. Zarzaur1, T. M. Bell1, B. L. Zarzaur1  1Indiana University School Of Medicine,Surgery,Indianapolis, IN, USA

Introduction:  The recent focus on patient centered outcomes highlights the need to better describe recovery trajectories in terms of patient quality of life for surgical disease.  Most clinicians and patients expect an initial large decrease in physical and mental functioning after injury followed by a gradual increase in both during recovery. However there is little data regarding the existence of subtypes of recovery trajectories following non-neurologic injury. The purpose of this study was to characterize the types of recovery trajectories that exist after non-neurologic moderate to severe injury.    

Methods:  Adults admitted towith an injury severity score > 10 but without traumatic brain injury or spinal cord injury were eligible. A baseline quality of life survey (SF-36) was administered at the time of admission and repeated at 1, 2, 4 and 12 months after injury. To determine if distinct trajectories existed for the physical component score (PCS) and the mental component score (MCS) of the SF-36, group based trajectory modeling was used (GBTM). GBTM is a semi-parametric statistical technique that identifies homogeneous subpopulations within a heterogeneous population. 

Results: 500 patients were enrolled. Follow-up was 93% at 1 month, 82% at 2 months, 70% at 4 months and 58% at 12 months. After GBTM, PCS had 3 distinct trajectories. Trajectory 1 (10.3%) is characterized by a lower baseline PCS, followed by no improvement over time. Trajectory 2 (65.6%) has a drastic decline in PCS 1 month after injury, but shows, slow consistent improvement over time. Trajectory 3 (24.1%) also has a sharp decline in PCS but has a rapid recovery and reaches near-baseline levels of health by month 12.  For the MCS, 5 trajectories were identified. Trajectory 1 (9.5%), has a low MCS at baseline and continues to have low scores throughout the rest of the study. Trajectory 2 (14.4%) has a large decrease in MCS post-injury and does not recover over the next twelve months. Trajectory 3 (22.7%) has an initial decrease in MCS early after injury, followed by continuous recovery. Trajectory 4 (19.1%) has a steady decline in MCS across most of the study. Lastly, trajectory 5 (34.3%) has consistently high MCS across all phases of recovery.

Conclusion: Both physical and mental recovery trajectories are more complex than is typically realized. There is greater variation in mental health outcomes among non-neurologically injured patients compared to physical health outcomes. The existence of multiple recovery trajectories for patients has significant implications on patient centered clinical trial design and in the distribution of limited resources devoted to recovery.

 

50.04 In Their Own Words: Improving Trauma Services For Young Men of Color

Posted on December 22, 2014

V. E. Chong1, R. N. Smith1, L. Ashley4, A. C. Marks4, T. Corbin2, J. Rich3, G. P. Victorino1  1UCSF-East Bay,Surgery,Oakland, CALIFORNIA, USA 2Drexel University College Of Medicine,Philadelphia, PA, USA 3Drexel University School Of Public Health,Philadelphia, PA, USA 4Youth ALIVE!,Oakland, CALIFORNIA, USA

Introduction:  Young men of color are disproportionately affected by interpersonal violence, which has lasting effects in the form of post-traumatic stress disorder (PTSD) and other pre-clinical symptoms of behavioral health issues. In developing services that address young men of color and their post-injury needs, their voices are often overlooked. As such, we conducted an exploratory research study using qualitative methods to investigate young men of color’s experiences with health care after suffering injury due to interpersonal violence. We aimed to identify portals of care through which young men of color seek help and to understand their relationships with these portals of care. 

Methods:  We conducted three focus group interviews with young men of color ages 18-30 using semi-structured interview guides we developed based on pertinent issues from the literature on trauma and PTSD. Focus group audiotapes were transcribed and the text was transformed to lines and stanzas. Analysis was performed via NVivo qualitative research software. The interview text was coded for recurring themes and reviewed by three study personnel. We subsequently administered a trauma symptoms screening to 69 young men of color. The screening tool was self-developed based on feedback from the focus groups and included 3 of the 4 variables in the validated Primary Care PTSD (PC-PTSD) screen. 

Results: Our focus group participants sought health care from a variety of sources. They distinguish between institutions that provide “life-saving” treatment, like trauma centers, and those that provide post-injury services, such as pain management and prescriptions. After injury, these young men often turned to “folk medicine” to treat their maladies, repeatedly describing their use of marijuana, alcohol, and cough syrup with codeine. They preferred obtaining these post-injury services through non-traditional providers, such as cannabis clubs and family members, as they described attempts to access these services at “life-saving” institutions as “a waste of time” and fraught with experiences of patient-provider misalignment. Lastly, among the young men we interviewed in the trauma symptom screening portion, 90% reported at least two symptoms of trauma, including sleep disruption, re-experiencing, focus problems, hyperarousal, and dissociation. Further, 16% of participants had screens suggestive for PTSD.  

Conclusion: Focus groups and interviews with young men of color who have been victims of violence reveal their views of the problems in their health care, their need for alternative systems of care, the disconnect between their expressed needs and the perceptions of providers, and the powerful impact of stress on their well-being. To better align our services with the expectations and needs of our patients, their concerns should be addressed and solutions integrated into quality improvement efforts.  

 

48.05 Trauma Crude Mortality is Misleading

Posted on December 22, 2014

A. J. Kerwin1, J. B. Burns1, J. H. Ra1, D. Ebler1, D. J. Skarupa1, N. Krumrei1, J. J. Tepas1  1University Of Florida,Acute Care Surgery,Jacksonville, FL, USA

Introduction: Today there is greater scrutiny of healthcare outcomes. Mortality is one quality indicator that has been used for benchmarking but there is more to mortality than meets the eye. Terminal care, percentage of penetrating trauma, patients presenting without vital signs (DOAs) and hospice discharges to can all impact a program’s mortality. Our objective was to examine the effect of this on trauma mortality.

Methods: Deidentified data from our quality management program for the years 2009- 2013 was reviewed to examine mortality as a quality indicator. We examined all deaths, death by injury type, hospice discharges, and DOAs. Chi-square analysis was performed for statistical analysis.

Results: For the period 2009- 2013 there were a total of 10,762 trauma service admits. There were 9,223 blunt trauma admits and 1,539 for penetrating trauma. There were 670 deaths during that time for an overall mortality rate of 6.2%. 480 (71.6%) deaths occurred following blunt trauma and 190 (28.4%) following penetrating trauma. Overall mortality following penetrating trauma was statistically significantly higher than after blunt trauma (11.9% vs. 5.2%; p<0.0001). During the study period there were 255 DOAs. Adding these to the overall mortality analysis increased the number of deaths by 38% and significantly increased the overall mortality rate to 8.5% (p= 0.001). During the study period there were 81 hospice discharges. Counting these patients in the mortality group gives a total of 751 deaths and significantly increases the mortality rate to 7.1% (p=0.0280).

Conclusion: Mortality is an important quality indicator for trauma programs but simply reporting crude mortality is misleading. Penetrating trauma, hospice discharges and DOAs can be important drivers of higher mortality that can reflect negatively upon a program. Hospice discharges should be included when reporting mortality. Trauma surgeons should work together to define uniform reporting of mortality as a quality indicator.

 

48.06 Prospective Evaluation of Bradycardia and Hypotension after Early Propranolol for Traumatic Brain Injury

Posted on December 22, 2014

J. Murry1, D. Hoang1, G. Barmparas1, D. Lee1, M. Bukur1, M. Bloom1, K. Inaba1, D. Margulies1, A. Salim1, E. J. Ley1  1Cedars-Sinai Medical Center,Los Angeles, CA, USA

Introduction:   Beta adrenergic receptor blockade may improve outcomes after traumatic brain injury (TBI) by modulating the subsequent cascade of immune and inflammatory changes, but its early use is not routine in part due to concern for bradycardia and hypotension. We hypothesize that judicious early propranolol after TBI (EPAT) does not alter bradycardia and hypotensive events.

Methods:   We conducted a prospective, observational study on all patients who presented with moderate to severe TBI from March 2010 to August 2013.  The first 10 patients enrolled did not receive propranolol at SICU admission (CONTROL).  Subsequent patients received propranolol at 1mg IV every 6 hours starting within 12 hours of SICU admission (EPAT) for a minimum of 48 hours.  Propranolol was held for heart rate <60bpm (bradycardia), blood pressure <90mmHg (hypotension), SICU transfer, or patient deterioration. Bradycardia and hypotensive events were recorded hourly for the first 72 hours after SICU admission.

Results:  Thirty-eight patients met enrollment criteria; 10 CONTROL and 28 EPAT.  EPAT patients received 6.6±3.9 (mean±sd) doses of propranolol.  The two cohorts were similar when compared by age>65 years, male gender, ED SBP< 90mmhg, head AIS≥4, ISS≥16 and hospital mortality (table).  ED GCS≤8 was higher in CONTROL (100% v. 35.7%, p<0.01).  Mean number of hypotensive events per patient, mean heart rate per bradycardia event, and mean blood pressure per hypotensive event were similar. The mean number of bradycardia events per patient was higher in CONTROL (mean 5.8 v. 1.6, p = 0.047).

Conclusion:  While bradycardia and hypotensive events occur early after TBI, low dose intravenous propranolol does not increase their number or severity.  Early use of propranolol after TBI appears to be safe.  Additional enrollment continues to determine if EPAT improves outcomes.

 

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