18.18 Robotic Simulator Curriculum Validation Study

Posted on December 22, 2014

J. L. Miller1, S. M. Novak1, D. L. Bartlett1, A. H. Zureikat1, H. J. Zeh1, M. E. Hogg1  1University Of Pittsburgh,Surgical Oncology/Surgery/Medicine,Pittsburgh, PA, USA

Introduction:

Robotic surgery is becoming widely used by general surgery and its specialties such as surgical oncology. Our institution has performed over 1,000 robotic surgical oncology cases and has identified the learning curve for several complex robotic resections. Critical to successful dissemination of the platform is a better understanding of how new surgeons learn the technology. This study aims to evaluate content and predictive validity of robotic simulation in surgery.  We hypothesize mastery-based simulation is a valid tool to train residents and fellows toward operative proficiency.

Methods:

A mastery-based simulation curriculum was performed in a virtual reality environment. Mastery was defined as 90% proficiency on each module. A pretest/posttest experimental design utilized virtual reality M score tasks (Match Board 3, Ring & Rail 2, Tubes and Continuous Suture) and inanimate environments using video analysis (Ring Rollercoaster 4, Around the World and Interrupted Suture) to evaluate technical improvement. Prior robotic training experience and curriculum assessment was self-reported in a survey; fellows were asked to rate modules based on difficulty and utility using a Likert scale of 5 (5 being greatest).

Results:

11 fellows enrolled in the curriculum. Prior robotic simulator experience showed: min=0, max=31, median=0.375 and mode=0 hours. Prior robotic case experience demonstrated: min=0, max=50, median=12 and mode=4 cases. 9 fellows (82%) completed the mandatory curriculum. 7 fellows (77.8%) achieved mastery on all 24 modules (one deficient on 4, one deficient on 9). Individual test scores improved; overall time and errors decreased (Table). Of the 24 modules, frequency to mastery demonstrated: min=1, max=17, median=2. Simulator hours spent completing curriculum showed: min=1.1, max=6.6 and med=4.2. 9 (100%) fellows continued modules beyond mastery. Fellows rated modules between 1 and 5 for difficulty and 3 and 5 for utility. Needle driving and Endowrist 2 modules were perceived as most difficult; needle driving modules were most useful. 8 (89%) fellows perceived improvement in robotic skills after completing the curriculum.

Conclusion:

This pilot study is limited by sample size; however, these preliminary results show overall score improvement, decrease in errors and decrease in total time. Time to complete the curriculum is manageable.To increase power for statistical comparison, the study is ongoing to include incoming fellows, senior general surgery residents and other fellowship programs. Ultimately, the study will assess correlation between performance on simulator curriculum with inanimate biotissue curriculum and operative improvement to assess content and predictive validity.

18.19 Prehospital Trauma Care Education for First Responders in Western Rajasthan

Posted on December 22, 2014

A. Aekka2, M. V. Hollis2, E. M. Boudiab2, G. P. Laput2, H. Purohit3, A. K. Vyas2,4, D. Vyas1,2  1Michigan State University,Department Of Surgery,Lansing, MI, USA 2Michigan State University,College Of Human Medicine,Lansing, MI, USA 3Arogyaa.com,Meerut, UP, India 4Michigan State University,Department Of Pediatrics,Lansing, MI, USA

Introduction:

The burden of trauma and injury is particularly devastating for developing nations such as India. The crux of the problem lies in the astonishing lack of prehospital trauma services: 80% of trauma victims in India cannot access medical care within the first hour. Existing health education initiatives fail to engage first responders and neglect the local context. 

Methods:
A 2-day hands-on prehospital trauma management training program with video lectures was developed for first responders in the local language. The course consists of 10 interactive sessions dealing with essential prehospital trauma care concepts, such as airway establishment, hemorrhage control, CPR, fracture stabilization, triage, and communication. Extensive self-learning videos, which help to overcome the language barrier, and high-fidelity simulation, which presents the most realistic training experience, provide a level of engagement that traditional didactic methods cannot offer. Video-debriefing serves as a valuable evaluation method. First responders are further introduced to advanced tools, such as the King LT airway and pulse oximeter, but are instructed in improvised management as resources are limited on the field. A comprehensive, but concise manual and specialized tool kit were also developed for trainees.
 
48 participants from Jodhpur, Rajasthan, including police officers, firemen, ambulance and taxi drivers, EMTs, hospital staff, and nursing staff and students, attended the pilot course. 18 instructors were recruited from Jodhpur and included medical students/residents and faculty, private practice physicians, and police officials. These individuals were trained in a 4-hour session prior to the program regarding the course content, materials, expectations, methods of engagement, and principles, such as collaborative learning, positive reinforcement, and the use of native, lay-person language.
 

Results:
Pre- and post-training surveys were used to evaluate participants' competence in managing 10 prehospital trauma matters. Statistically significant increases in competence were demonstrated for all topics: Airway (35.0%), Hemorrhage (36.1%), Fractures (32.0%), Cervical Spine Injury (45.4%), Chest Injury (41.3%), IV Line Placement (29.9%), Extrication (18.6%), Scene Assessment (35.1%), Triage (26.5%), and Communication (25.4%). The greatest increases were observed in cervical spine and chest injury management. The lowest, but still significant, increases were observed in extrication and communication. A six-month post-training survey will be conducted.

Conclusion:
First responder training in the native language with simulation and video-debriefing improves understanding and skills in all essential aspects of prehospital care, however, results suggest that discussion of extrication and communication should be strengthened. The goal is to develop a program that engages and prepares first responders in the procedural, cognitive, and affective aspects of prehospital trauma management.

18.20 Novel Simulation Course for Application of Resuscitative Endovascular Balloon Occlusion of Aorta

Posted on December 22, 2014

R. A. Lawless1, J. D. Love1  1University Of Texas Health Science Center At Houston,Acute Care Surgery,Houston, TX, USA

Introduction:
Noncompressible truncal hemorrhage (NCTH) remains a major cause of death from traumatic injuries both in military and civilian populations.  Recent interest in resuscitative endovascular balloon occlusion of the aorta (REBOA) has shown promise as an alternative to resuscitative thoracotomy and adjunct to preperitoneal packing for NCTH.  General surgery residents and fellows are exposed to this technique in the elective and emergent setting during abdominal aortic aneurysm repair.  However, this skill is not always maintained in surgeons not planning on completing a vascular surgery fellowship.  The recent interest in REBOA has brought a need for training in this technique for both new trainees and current trauma attendings.

Methods:
Between the University of Texas Health Science Center and Texas Medical Center the Advanced Surgical Skills for Exposure in Trauma (ASSET) is held four times per year.  The curriculum is followed as determined by the ACS Committee on Trauma.  Following course completion, a didactic session, anatomic demonstration, and simulation session for the REBOA was introduced.

Results:
Participants included PGY-3, PGY-4, PGY-5, PGY-6, general surgery faculty, and trauma/critical care faculty.  From June 2012 to March 2014, 64 participants completed the simulation course.  Following the course a number of participants have utilized the technique learned from the course in the care of their trauma patients.  

Conclusion:
The REBOA technology can be taught to trainees and surgeons in practice and immediately applied in the trauma setting.  Course participants are confident in this technique of minimally invasive control of NCTH.  Future and ongoing plans for the course include a pre-test, post-test, self-assessment, and course survey.

16.17 30-day Unplanned Readmission After Lower Extremity Bypass: Is Diabetes An Independent Predictor?

Posted on December 22, 2014

A. Najafian1, S. Selvarajah1, E. B. Schneider1, M. B. Malas2, B. Ehlert3, K. C. Orion3, A. H. Haider1, C. J. Abularrage3  1Johns Hopkins University School Of Medicine,Center For Surgical Trials And Outcomes Research, Department Of Surgery,Baltimore, MD, USA 2Johns Hopkins University School Of Medicine,Department Of Surgery,Baltimore, MD, USA 3Johns Hopkins University School Of Medicine,Division Of Vascular Surgery And Endovascular Therapy, Department Of Surgery,Baltimore, MD, USA

Introduction:  Readmission negatively affects reimbursement and increases both morbidity and mortality. Lower extremity bypass (LEB) has been shown to be associated with readmission. This study aimed to compare 30-day unplanned readmission after LEB between diabetics and non-diabetics.

Methods:  Patients undergoing LEB in the 2011-12 ACS-NSQIP database were divided into 3 groups: non-diabetics (non-DM), non-insulin-dependent diabetics (NIDDM) and insulin dependent diabetics (IDDM). Unplanned readmission was compared and multivariate logistic regression was used to evaluate the influence of diabetes status on 30-day readmission. 

Results: A total of 9207 patients (5155 (56%) non-DM, 1690 (18%) NIDDM and 2362 (26%) IDDM) underwent LEB. Unplanned readmission was observed in 1448 (16%) patients. IDDM had significantly higher crude postoperative complication (30% non-DM, 36% NIDDM vs. 43%, P<0.001) and unplanned readmission rates (14% non-DM, 16% NIDDM vs. 20%, P<0.001). Concomitant cardiac disease significantly modified the association between diabetes and unplanned readmission. On multivariable analysis, IDDM was an independent predictor of unplanned readmission in the absence of cardiac disease (OR=1.21; 95% CI [1.01-1.44]; P=0.03). However, this association did not remain significant in the presence of cardiac disease (OR=1.16; 95% CI [0.88-1.53]; P=0.28). Subgroup analysis of IDDM patients revealed that regardless of cardiac status, postoperative complications were the strongest independent predictors of unplanned readmission. In IDDM without concomitant cardiac disease, the only preoperative independent predictors of unplanned readmission were dialysis (OR=1.57; 95% CI [1.08-2.28]; P=0.01) and anemia  (OR=1.51; 95% CI [1.09-2.08]; P=0.01). 

Conclusion: While unplanned readmission after LEB was more common among diabetics, only IDDM in the absence of cardiac disease was independently associated with unplanned readmission. In IDDM patients without cardiac disease, dialysis dependence and anemia significantly increased the likelihood of unplanned readmission. Regardless of cardiac status, postoperative complications were strongly associated with readmission.

 

16.18 Predictors of Surgical Site Infection after Discharge in Patients Undergoing Major Vascular Surgery

Posted on December 22, 2014

M. L. Barnes1, J. T. Wiseman1, S. Saha1, J. Havlena1, S. Fernandes-Taylor1, K. C. Kent1  1University Of Wisconsin School Of Medicine And Public Health,Wisconsin Surgical Outcomes Research Program,Madison, WI, USA

Introduction: Surgical site infection (SSI) after vascular surgery is one of the most common post-operative complications and is the leading cause of unplanned, potentially preventable hospital readmissions among surgical patients. Transitional care interventions to detect SSI after hospital discharge may help stem the burden of readmissions and morbidity associated with SSI; however little is known regarding the classification of patients at high-risk for development of SSI occurring after hospital discharge (postSSI).   

Methods: Patients who underwent major vascular surgery (abdominal aortic aneurysm, open aortoiliac, and lower extremity revascularization procedures) from 2005-2012 were identified from the American College of Surgeons National Surgical Quality Improvement Program Participant Use Files. Patients were categorized as having no SSI, SSI while in-hospital (preSSI), or postSSI. Multivariable logistic regression was performed using patient demographics, preoperative health characteristics and comorbidities, and operative variables to predict preSSI and postSSI.   

Results: Of the 50,091 patients who underwent major vascular surgery, 4,481 (9.0%) were diagnosed with SSI (2.1% preSSI; 6.8% postSSI). Multivariate predictors of both preSSI and postSSI include obesity vs. normal BMI (preSSI odds ratio [OR]:1.6; 95% confidence interval [CI]: 1.3-2.0) (postSSI OR: 2.2; 95% CI: 2.0-2.5) an existing open wound or wound infection (preSSI OR:1.2; 95% CI: 1.0-1.5) (postSSI OR:1.2; 95% CI: 1.1-1.3). Multivariate predictors unique to patients who experienced preSSI include totally dependent functional status (OR: 2.7; 95% CI: 1.8-4.0), emergency case (OR: 2.5, 95% CI: 1.9-3.1), chronic obstructive pulmonary disease (OR:1.4; 95% CI: 1.1-1.8) and prolonged operative time (OR:1.3; 95% CI: 1.0-1.7). Multivariate predictors unique to patients who experienced postSSI include female gender (OR:1.4; 95% CI 1.3-1.5), overweight vs. normal BMI (OR:1.3; 95% CI: 1.2-1.5), insulin dependent and non-dependent diabetes mellitus (OR:1.4; 95% CI: 1.2-1.5) (OR:1.3; 95% CI: 1.1-1.4), dyspnea with moderate exertion (OR:1.1; 95% CI: 1.0-1.3), rest pain/gangrene (OR:1.4; 95% CI: 1.3-1.5), coronary artery disease (OR:1.1; 95% CI: 1.0-1.2), hypertension requiring treatment (OR: 1.2; 95% CI: 1.1-1.4), peripheral vascular disease (OR:1.3; 95% CI: 1.2-1.4), smoking (OR:1.2; 95% CI: 1.1-1.3) and neurological disease (OR:1.1; 95% CI: 1.0-1.3).   

Conclusions: Predictors of preSSI after major vascular surgery are largely acute non-modifiable conditions whereas predictors of postSSI are primarily chronic comorbidities. Appropriate identification of these different sets of risk factors may improve both in-hospital wound surveillance and subsequent transitional care efforts to improve wound monitoring

16.19 Risk factors of Surgical Site Infection after Open Abdominal Aortic Aneurysm Repair

Posted on December 22, 2014

J. T. Wiseman1, S. Fernandes-Taylor1, K. C. Kent1  1University Of Wisconsin,Wisconsin Surgical Outcomes Research Program,Madison, WI, USA

Objective: Surgical site infection (SSI) is a major cause of morbidity after open abdominal aortic aneurysm repair (AAA). Incidence of SSI can lead to ventral hernia, graft infection, hospital readmission, increased costs, and in certain cases mortality. Identification of SSI risk factors at the time of open AAA repair may facilitate selection of patients at high-risk for SSI development, allowing for a higher level of in-hospital wound surveillance and subsequent implementation of appropriate transitional care interventions. The objective of this study is to describe the incidence and risk factors for SSI after open AAA repair using national data.

Methods: Patients who underwent open AAA repair from 2005-2012 were identified from the American College of Surgeons National Surgical Quality Improvement Program Participant Use Files. Multivariable logistic regression was performed using patient demographics, preoperative health characteristics and comorbidities, and operative variables to predict SSI.

Results: Of the 8,192 patients who underwent open AAA repair, 386 (4.3%) were diagnosed with SSI within 30 days of surgery. On multivariate analysis, patient preoperative health characteristics and comorbidities that predicted SSI included obesity vs. normal BMI (odds ratio [OR]: 2.1; 95% confidence interval [CI]: 1.6-2.7), overweight vs. normal BMI (OR: 1.4; 95% CI: 1.0-1.8), an existing open wound or wound infection (OR: 2.2; 95% CI: 1.2-3.9), dyspnea (OR: 1.5; 95% CI: 1.2-1.9), and smoking (OR: 1.3; 95% CI: 1.1-1.7). Operative factors that predicted SSI included emergency operation (OR: 1.8; 95% CI: 1.3-2.4) and operative time >5 hours vs. 3-5 hours (OR: 1.6; 95% CI: 1.3-2.1).

Conclusions: SSI after open AAA repair is a common post-operative complication. Our data suggest that there are readily identifiable patient and operative characteristics known prior to and at completion of open AAA repair that significantly predict increased risk of SSI, suggesting that targeted in-hospital wound surveillance and subsequent transitional care efforts may improve outcomes in this patient population.

 

16.20 Pancreatic lipoma: does it need treatment?

Posted on December 22, 2014

M. T. Fohtung1, K. Sandrasegaran1, N. Zyromski1  1Indiana University School Of Medicine,General Surgery,Indianapolis, IN, USA

Introduction:  Pancreatic lipomas are a rare and benign form of the mesenchymal neoplasms that make up 1%-2% of all pancreatic neoplasms. They are often diagnosed incidentally during radiographic imaging and treatment in the 69 reported cases in the literature has mostly been conservative although there is no consensus on the histopathologic significance of lipomas or whether surgical intervention is warranted. In this study, we describe 74 cases of intrapancreatic lipomas from a single institution over a 12-year period to elucidate the natural history including associated symptoms, the need for intervention and the potential for dedifferentiation to liposarcoma.

Methods:  In the period from January 2001 to December 2013, we selected patients over the age of 18 diagnosed with pancreatic lipoma based on Ultrasound, CT scan and MR imaging. Clinical data was coupled with radiographic images and reviewed. Age at the time of diagnosis, gender, presenting symptoms, location of lipoma in pancreas, size on imaging, surgical intervention and pathological findings were evaluated. 

Results: Pancreatic lipomas were identified in 74 patients including 41 women and 33 men aged 31-88 (median age 64). Most of the neoplasms were located in the head of the pancreas (n=32) followed by the body (n=16), tail (n=16), neck (n=6) and uncinate (n=6). The lipomas ranged in size from 0.1cm to 4.8cm. The majority of patients had no symptoms at presentation (n=36) while others had abdominal pain (n=26), dysphagia (n=1), jaundice (n=1), pelvic pain (n=1), chest pain (n=2), nausea/vomiting (n=2), dyspnea (n=1), constipation (n=1). One lipoma was pathologically confirmed and no patients underwent surgical resection.

Conclusion: Pancreatic lipomas are rare benign mesenchymal neoplasms with increasing incidence as the use of radiographic imaging continues to expand.  Most reported cases are managed conservatively with follow-up imaging especially when the lipoma has well defined margins and causes no obstruction to the pancreatic duct or common bile duct. Given the lack of consensus, questions remain about the histopathological significance concerning dedifferentiation to liposarcoma and whether surgical resection should then be considered as an intervention. This large single center study will help shed more light on these questions.

17.01 Mortality and Discharge Outcomes For Higher vs. Lower Level Trauma Centers in Isolated Hip Fracture Patients

Posted on December 22, 2014

H. Nelson-Williams1, J. Canner1, E. Schneider1, D. T. Efron1, E. R. Haut1, B. Shafiq1, A. H. Haider1, C. G. Velopulos1  1Johns Hopkins University School Of Medicine,Surgery,Baltimore, MD, USA

Introduction:
Younger, multi-trauma patients have improved survival when treated at a trauma center (TC). Many regions are now proposing that patients over age 65 be triaged to a higher level TC (HLTC) vs. lower level TC (LLTC), even for isolated injury, despite the absence of an established benefit in this elderly cohort. We therefore sought to determine if isolated hip fracture patients have improved survival outcomes based on trauma center level.

Methods:
A retrospective cohort of 1.07 million patients in The Nationwide Emergency Department Sample (NEDS) from 2006 to 2010 was used to identify 239,288 isolated hip fracture patients aged 65 to 105 years. Patients were stratified by AIS score. Multivariable logistic regression was performed controlling for age, sex, Charlson index, payor, zip code, teaching status, location, and region. The main outcome measures were in-hospital mortality and discharge disposition among patients admitted to a HLTC (Level I or II) vs. a LLTC center (Level III or non-designated TC).

Results:
Nearly all patients had an extremity AIS 3 (99.9%). Unadjusted logistic regression analyses revealed 8% higher odds of mortality (OR 1.08; 95% CI 1.00-1.16) and 10% lower odds of being discharged home (OR 0.90; 95% CI 0.80-1.00) among patients admitted to a HLTC versus LLTC. After controlling for patient and hospital-level factors, neither the odds of mortality (OR 1.06; 95% CI 0.97-1.15) nor the odds of discharge to home (OR 0.98; 95% CI 0.85-1.12) differed significantly between patients treated at a HLTC vs. LLTC. There were differences across payer (Table 1) and region for discharge home, with patients in the South and West more likely to be discharged home than to rehab.
 

Conclusion:
Among patients with isolated hip fractures, those admitted to a HLTC do not differ in mortality or discharge disposition from similar patients admitted to a LLTC. These findings may have important implications for trauma systems and triage protocols.
 

17.02 Trauma System Regionalization across State Borders

Posted on December 22, 2014

J. J. Sumislawski1, S. A. Savage1, B. L. Zarzaur2  1University Of Tennessee Health Science Center,Memphis, TN, USA 2Indiana University School Of Medicine,Indianapolis, IN, USA

Introduction: Organization of trauma centers into a state trauma system is associated with reduced mortality. Development of a trauma system could affect a neighboring state’s trauma center. In 2010, an inclusive trauma system was implemented that allowed centers in bordering states to participate. This study was designed to examine the effect of the development of this new trauma system on a participating out-of-state Level 1 trauma center.

Methods: Patients referred to a participating out-of-state trauma center were included. Using a difference-in-differences approach, residents of the state with the new trauma system (TSystem patients) were compared with residents of the state with the trauma center (TCenter patients) PRE (2008-2009) and POST (2011-2012) implementation of the trauma system.

Results: TCenter patients decreased 3% PRE versus POST while TSystem patients increased 39% (Table 1). Injury severity did not change for TCenter patients but decreased for TSystem patients PRE (mean Injury Severity Score 15) versus POST (12, p<0.05). Transfers from referring hospitals increased from both states. For TSystem patients, air arrivals decreased and payer status did not change. Compared with TCenter patients, odds of mortality for TSystem patients decreased PRE (OR 0.97; 95% CI 0.72, 1.31) versus POST (OR 0.73; 95% CI 0.53, 0.99). When only those with ISS >10 were analyzed, mortality did not change PRE (OR 0.85; 95% CI 0.60, 1.20) versus POST (OR 0.96; 95% CI 0.67, 1.37). Secondary overtriage increased PRE (OR 0.67; 95% CI 0.54, 0.83) versus POST (OR 1.53; 95% CI 1.32, 1.78) for TSystem patients.

Conclusion: Development of a state trauma system resulted in an increase in less severely injured patients referred to an out-of-state trauma center without change in payer status. For patients of higher injury severity, there was no change in odds of mortality PRE versus POST for either state. Trauma-system implementation promoted overtriage of in-state patients to the out-of-state trauma center. Despite increases in volume and overtriage, allowing participation of a neighboring state’s trauma center did not result in increased mortality for either state’s residents.

 

17.03 Break a Leg Not the Bank: Should We Treat Simple Fractures in Trauma Centers?

Posted on December 22, 2014

F. Gani1, N. Nagarajan1, H. Alshaikh1, C. K. Zogg1, H. Alturki1, S. Selvarajah1, A. Najafian1, L. Kodadeck1, C. G. Velopulos2, D. T. Efron2, E. B. Schneider1, A. H. Haider1  1Johns Hopkins University School Of Medicine,Center For Surgical Trials And Outcomes Research, Department Of Surgery,Baltimore, MD, USA 2Johns Hopkins University School Of Medicine,Department Of Surgery,Baltimore, MD, USA

Introduction:  Healthcare policy efforts are increasingly geared toward providing higher quality care at lower costs. For fractures alone, healthcare spending in the United States is estimated to be >$20 billion per year. Previous data for severely injured patients suggest an improvement in survival at trauma centers. Little is known about possible differences in patient charges for the management of non-life threatening conditions at trauma centers vs. non-trauma center hospitals. Using uncomplicated, closed tibial fractures as an index condition, this study examined possible differences in patient charges at level 1 trauma centers (TC) compared with non-trauma centers (NTC).

Methods:  Data from the 2006-2011 HCUP Nationwide Emergency Department Sample (NEDS) were queried and patients with a primary diagnosis of closed tibial fracture who underwent routine same-day discharge from the emergency department (ED) were identified using ICD-9-CM diagnosis codes. Patients with an Abbreviated Injury Scale (AIS) extremity score of ≤2 were included in the study cohort. Patients with other major concomitant injuries listed in diagnosis positions 2-15 were excluded as were individuals who had a calculated  AIS >0 in any region except “extremity.” Patient demographics, injury and hospital characteristics were compared between TC and NTC using χ² and t-tests. Wilcoxon rank-sum tests examined TC vs. NTC difference in median patient charges. A generalized linear model with a gamma distribution and robust error variances (adjusted for age, sex, insurance status, Charlson comorbidity index, income quartile, mechanism of injury and hospital region) examined differences in mean total charges between patients treated at TC and NTC.

Results: A total of 15,773 patients met inclusion criteria. 1,845 patients were treated at TC and 13,361 patients at NTC. Patients at TC were younger compared to those at NTC, median age 44 (IQR = 32-56) and 48 years (IQR = 38-60) respectively. Proportionally fewer female patients were treated at TC vs. NTC (44.77% vs. 51.21%, p<0.001). Median total charges were higher at TC vs. NTC [$2,278, (IQR $1,259-$4074) vs. $1,351, (IQR $848-$2,313), p<0.001]. Adjusted charges for management in the ED were 94% higher at TC vs. NTC [$3,781 (95%CI $3,548-$4,013) vs. $1,951 (95% CI $1,902-$2,000) p<0.001].

Conclusion: Patients undergoing routine same-day discharge after ED treatment of an uncomplicated tibial fracture at TC incur substantially higher charges than otherwise similar patients treated at NTC. Better understanding the factors underlying the differences in charges observed between TC vs. NTC facilities may enable substantial savings to the healthcare system.

 

17.04 The Relationship Between Blood Alcohol Level and Injury Severity: Is the Floppy Patient Myth True?

Posted on December 22, 2014

C. Valdez1, C. Renne1, M. Radomski1, R. Amdur1, J. Dunne1, B. Sarani1  1George Washington University School Of Medicine And Health Sciences,General Surgery,Washington, DC, USA

Introduction:
The impact of inebriation on severity of injury is unclear.  Conventional teaching suggests increasing blood alcohol level (BAL) may be associated with fewer injuries because the patient is limp due to intoxication at the time of injury. The few studies to date on this topic are limited to a particular mechanism of injury (MOI), injury pattern, or BAL. Therefore we sought to determine the impact of BAL on injury pattern and severity across all MOI. We hypothesize that there is no relationship between BAL and injury severity when controlling for MOI. 

Methods:
Following IRB approval, a retrospective study was performed at an adult trauma center from January 1, 2011 to December 31, 2012. All MOI were included. Injury severity was assessed using the injury severity score (ISS). Chi square and ANOVA were used to examine the relationship between BAC, injury pattern, and ISS within each MOI. Multivariate regression model (MVR) examined the BAC-ISS association adjusting for MOI, gender, and age. 

Results:
Of 1397 patients, the mean age was 44±19, mean ISS was 7.5±6.8, mean BAL was 92±130 mg/dL and 70% were male. Overall mortality rate was 1.3%. Rib fracture (p=0.002) and hemo/pneumothorax (p=0.0009) were negatively associated with BAL, while concussion and laceration had a positive association with BAL (p<0.0001). An increasing BAL had a negative correlation with ISS following fall from standing (p<0.001).  Across all MOI combinde, there was no significant association between BAL and ISS. 

Conclusion:
Inebriated patients have a decreased risk of rib fractures and hemo/pneumothoax, and an increased risk of concussion or laceration.  Increased BAL is associated with a lower ISS in the specific MOI of fall from standing. However, across all MOI, there was no significant association between BAL and ISS when controlling for MOI.  Inebriated patients should be triaged and approached with the same clinical index of suspicion for injury as sober patients. 

17.05 Trends in the treatment of pelvic fractures 2008-2010: Where do we stand?

Posted on December 22, 2014

C. Chu2, L. Tennakoon1, D. Spain1, K. Staudenmayer1  1Stanford University,Surgery,Palo Alto, CA, USA 2University Of South Carolina School Of Medicine,Columbia, SC, USA

Introduction: Bleeding from pelvic fractures can be life-threatening. Treatment for bleeding pelvic fractures involves noninvasive means (pelvic binders) and invasive procedures such as angioembolization (AE) and external fixation (EXFIX).  It is not known how frequently these modalities are used in U.S. trauma centers or whether there have been trends over time.  We hypothesized that there would be an increase in the use of AE and a decrease in the use of EXFIX over time. We also sought to determine if the procedures were associated with a reduction in mortality.

Methods: We used the National Trauma Databank (NTDB) from 2008-2010.   Patients were included in the study if they had the International Classification of Diseases, 9th edition and Clinical Modification (ICD-9-CM) codes for pelvic fractures.  Patients were excluded if they were <18 years, had an isolated acetabular fracture, were not admitted to the hospital, or had an ISS<15.  Only centers that had demonstrated an ability to perform AE or EXFIX were included in the analysis.  The primary outcomes were whether the patient had an AE or EXFIX within the first 24 hours after admission. The secondary outcome was mortality. Univariate analyses and multi-level logistic regression (to control for center effects) were used.

Results: A total of 22,568 met inclusion and exclusion criteria.  Patients were predominantly male (59.6%), white (70.3%), and between the ages of 18 and 44 (50.7%).   Overall, AE and EXFIX were performed in 746 (3.3%) and 663 (2.9%) of patients, respectively.  Patients who received AE and EXFIX were different across all measures in unadjusted analyses, but after adjusting for known confounders, only age, injury severity, physiologic instability, and diagnosis of shock were associated with receiving a procedure.    Over the study period, there was an increase in the use of AE (2.5% in 2007 to 3.7% in 2010, p<0.001), which remained significant in adjusted analysis (OR per year 1.15, p=0.008).  There was no significant trend for EXFIX.  AE and EXFIX were associated with a higher mortality in unadjusted analyses compared to those who did not receive a procedure (11.0% for no procedure vs. 20.5% and 13.4% for AE and EXFIX, respectively; p<0.001).  In adjusted analyses, AE remained associated with higher mortality (OR 1.63, p<0.001), whereas EXFIX was associated with a slightly lower risk (OR 0.95, p<0.01).

Conclusion: The use of AE in severely injured pelvic fracture patients is increasing.  However, this procedure is associated with a higher mortality.  It is possible that AE is used more often in patients at high risk of death, but that its use does not reduce this risk.  We should carefully examine the use of this expensive resource in future studies.

 

17.06 Trauma System Funding is Associated WIth Increased Numbers of Level 3 Trauma Centers

Posted on December 22, 2014

E. Kelly1, E. R. Kiemele2, G. Reznor1, J. M. Havens1, Z. Cooper1, A. Salim1  1Brigham And Women’s Hospital,Boston, MA, USA 2Harvard School Of Medicine,Brookline, MA, USA

Introduction:
Taken as a group, state trauma systems are associated with beneficial effects, such as reduction in mortality, but not all trauma systems are the same. Some states allocate a yearly budget in support of its system's activities, some states do not. It has not been shown that the benefits of a trauma system accrue equally to all states, or if the prescence of  funding leads to beneficial effects not seen in states without a budget. It is also not known whether funding for a trauma system is associated with financial benefits that produce a return on the investment of budgetary funds. The objective of this study was to determine if f states with funded trauma systems are associated with an increase in access to trauma care (as defined as numbers of trauma centers per capita), or cost effectiveness of trauma care (as defined by numbers of trauma centers per Gross Domestic Product) compared to states without trauma system funding in place.

Methods:
A retrospective population based study was performed.  Data for the number of verified trauma centers in 2010 were obtained from the American College of Surgeons (ACS) and for state-designated trauma centers from official reports from state departments of health. Only adult centers were examined. Populations and Gross Domestic Product (GDP) were obtained from the US Census. The main outcome measure was the number of trauma centers per state per population and per GDP. Statistical analysis was carried out using the Chi Square Test and Poisson Regression; p values <.05 were reported as significant.

Results:
There was no statistically significant correlation between the presence of a funded system and the numbers of Level 1 or Level 2 trauma centers. However, there was a statistically significance increase in the number of Level 3 centers in states with funded trauma systems per state GDP and population.  In funded states, the number of Level 3 trauma centers per GDP and state population were 72.5±14.2/$100 Billion and 65.2±13.2/Million people compared to 4.31±1.7/$100 Billion and 1.60±0.60/Million people for non-funded states (p < 0.05). Poisson multivariate regression identified system funding as an independent predictor of number of Level 3 centers.  Data expressed as mean ± SEM.

Conclusion:
Our study shows that the number of Level 3 trauma centers significantly and independently correlated with the presence of a funded trauma system. The number of Level 1 and 2 centers showed no such correlation. As Level 3 trauma centers are a key point of entry for trauma care, further study is warranted to determine if increased Level 3 access leads to improved time to definitive care or other clinical outcomes.  Furthermore, our study shows that states that allocate funds for trauma systems operation have a greater number of Level 3 centers per dollar of GDP, even in states with lower tax bases, resulting in more cost efficient access.
 

17.07 Morbidity and Mortality from Traumatic Brain Injury in Older Adults, 2000-2011

Posted on December 22, 2014

R. Haring1,2,3, K. Narang1, J. K. Canner1, A. O. Asemota1,4, B. P. George1,5, S. Selvarajah1, A. H. Haider1,3, E. B. Schneider1  1Johns Hopkins University School Of Medicine,Department Of Surgery,Baltimore, MD, USA 2Lake Erie College Of Osteopathic Medicine,Bradenton, FL, USA 3Johns Hopkins University Bloomberg School Of Public Health,Health Policy And Management,Baltimore, MD, USA 4Johns Hopkins University School Of Medicine,Department Of Neurology And Neurosurgery,Baltimore, MD, USA 5University Of Rochester School Of Medicine And Dentistry,Rochester, NY, USA

Introduction:  The increase in TBI-related morbidity and mortality have led the CDC to call it “the silent epidemic.” Adults age 65+ are more prone to falls and other mechanisms of injury, and may thus be at a higher risk of TBI-related morbidity and mortality. This study seeks to identify factors contributing to TBI and related mortality among the elderly.

Methods:  We analyzed data from the Nationwide Inpatient Sample, and included records that described hospitalizations occurring among individuals age 65 and older from 2000-2010 and contained data on patient age, sex, mechanism of injury, payer status, as well as descriptive data relating to the hospital involved.  A subset of patients was compiled whose records also contained race information. Logistic regression analyses were conducted to produce both crude and adjusted odds ratios (OR) of death. Population-based TBI incidence and mortality rates were calculated.

Results: A total of 950,132 hospitalizations were identified that met inclusion criteria. TBI incidence increased both with time and patient age. Falls were by far the most common mechanism of injury, leading to 65.3% of hospitalizations. Multivariable logistic regression models showed that female sex and younger age, as well as having Medicare or Medicaid vs. private insurance/HMO, self-pay, or no-charge designations as primary payer, were all associated with lower odds of death. Self-pay status was associated with 91% greater odds of in-hospital mortality; however, female sex was associated with 33% lower odds of mortality compared with males. Population-based rates of admission increased 105.8% from 2000-2010; the TBI-associated population-level mortality rate, however, increased by only 33.7% over the same period, while injury severity remained stable.

Conclusion: The trends in TBI-related hospitalization from 2000-2010 suggest that while TBI incidence is climbing, the odds of death after admission for TBI are falling. Further interventions, possibly to include government and institutional policy aimed at fall prevention and insurance coverage, may further reduce morbidity and mortality associated with TBI among older adults.

 

17.08 National Trends in the Elderly (65-84) and the Supra-Elderly (>85) Trauma: 1997-2012

Posted on December 22, 2014

L. Podolsky2, V. Polcz1,2, O. Sizar1, A. Farooq1,2, M. Bukur1, I. Puente1, R. Farrington1, M. Polcz2, C. Orbay2, F. Habib1  1Broward Health Medical Center,Trauma,Ft Lauderdale, FL, USA 2Florida International University,Surgery,Miami, FL, USA

Introduction:
Trends in incidence and outcomes of traumatic injury among the elderly (age 65-84) and the supra-elderly (age > 85) are unknown. This information has the potential to offer insight into informed trauma system planning and improve outcomes in this highly vulnerable population. 

Methods:
The Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP-NIS) database was queried to identify patients with ICD codes for a traumatic injury. Data, stratified by age group was then abstracted for incidence, lengths of stay, charges, mortality and discharge status for patients for the period 1997-2012. The study period was divided into four periods of 4-years each. Statistical analysis was performed using the ANOVA, t test, and chi square test as appropriate. A p value of <0.05 was used to determine significance. 

Results:

Over the 16-year study period, traumatic events in the elderly have increased by 6.8% (p=0.0005) and by 29% in the supra elderly (p<0.001). In contrast, admissions for injury decreased in both adults and children (6%, and 29.5% respectively, p=0.0005). A decrease in length of stay was seen with decrease from 6.0 to 5.2 days (p<0.0001) in the elderly and 6.2 to 5.0 days (p<0.0001) in the supra-elderly. Length of stay for adults on the other hand has increased from 4.83 to 5.1 (p=0.06). Pediatric patient in-hospital mortality has decreased significantly (p=0.001) with concurrent increases in discharge to home (p=0.003). Adult in-hospital mortality rates and discharges home have remained stable (p=0.83, p=0.24 respectively). Elderly patients have shown stable in-hospital mortality rates (p=0.149) with decreased discharges home (p=0.0003). The supra-elderly have shown the worst trend in outcomes, with significant increases in in-hospital mortality (p=0.0003) and significantly fewer patients being discharged home (p=0.0004). Costs have risen for patients of all age groups over the study period (p<0.0001). 

Conclusion:

Geriatric trauma is rising at an exponential rate, with the elderly and supra-elderly patients forming an increasing proportion of the trauma population. These elderly and supra-elderly patients have been shown to have poorer outcomes, as demonstrated by in-hospital mortality and discharge status. Geriatric specific trauma programs are urgently needed to address this evolving epidemic. 

17.09 Towards a Single-Payer System in Trauma: More Than Halfway There Already.

Posted on December 22, 2014

V. Polcz1, L. Podolsky1,2, m. bukur1, M. Polcz2, c. orbay2, I. Puente1, r. Farrington1, o. sizar1, a. Farooq1, F. Habib1,2  1Broward Health Medical Center,Trauma,Ft Lauderdale, FL, USA 2Florida International University,Surgery,Miami, FL, USA

Introduction:
Delivery of trauma care is financially challenging. Financial viability is largely dependent on the payer mix, which changes over time. We therefore sought to determine the changing payer mix for the period of 1997-2012. This information has the potential to offer insight into informed trauma system planning, and may improve outcomes and quality of care for patients regardless of payer status.

Methods:
The Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP-NIS) database was queried to identify payer status for total trauma admissions from 1997-2012. Data, stratified by payer status, was then abstracted for incidence, lengths of stay, charges, mortality and discharge status for patients within this period. The study period was divided into quartiles of 4 years each. Statistical analysis was performed using the ANOVA, and a p value of <0.05 was used to determine significance. 

Results:
Over the 16-year study period, trauma admissions for patients with government-funded payer status have increased significantly over the time period assessed, with both Medicare (p<0.0001) and Medicaid (p<0.0001) showing a significant increase as a proportion of the total patient population. Admissions of patients to trauma with private insurance status, in contrast, have shown a significant decrease in proportion of the total patient population over the time period studied (p=0.002). Patients with no insurance (p=0.921) or other payer status (p=0.406) were observed to have no significant change in proportion of trauma patient population from 1997-2012. The results of this analysis are summarized in Table 1.

Conclusion:
Government-funded trauma care is rising at a significant rate, with Medicare and Medicaid-funded patients forming an increasing proportion of the trauma population. Funding from private insurers continues to decline, and the uninsured continue to impose a constant financial burden on trauma centers nationwide. 

17.10 Uncompensated “Charity” Care in the Context of Trauma Center Designation

Posted on December 22, 2014

O. Mansuri1, C. Steffen1, L. Nelson1, C. Gonzalez2, B. England1, C. Boje1, K. Fenn1, E. Myers1, J. Stothert1  1University Of Nebraska Medical Center,Trauma & Surgical Critical Care / Department Of Surgery,Omaha, NE, USA 2Boston Medical Center,Boston, MA, USA

Introduction:
This study investigates in a hybrid qualitative/quantiative approach how state designation of trauma centers impacts general finances, uncompensated “charity” care and community investment. This is significant given many states are reassessing the definition of charity care in the context of how not-for-profit hospitals are evaluated, and the financial implications thereof.

Methods:
The Return of Organization Exempt From Income Tax (IRS Form 990) for state designated level 2 and level 3 trauma centers in Nebraska were reviewed for a three year period. Number of state licensed hospital beds was also gathered for each trauma center. IRS 990 forms were reviewed for number of employees, volunteers, revenue, assets, charity care, community benefits, bad debt, and Medicare surplus and shortfall. This data was then first analyzed in a descriptive fashion, followed by regression analysis. The relative financial metrics were controlled by hospital bed size.

Results:
When comparing level 2 and level 3 general financial variables, total revenue variance was 7.8%, salaries 2.9%, total expenses 6.0%, total assets 3.9%, total liabilities 17.2%, and net assets 3.4%.  These variances were nominal when compared to the variances seen in level 2 and level 3 charity care variables: charity care cost 43.3%, un-reimbursed Medicaid 37.9%, community health improvement 36.6%, health professions education 64.7%, cash-in-kind 82.6%, bad debt expense 6.2%, and Medicare shortfall 28%.  Level 2 centers reported higher amounts spent on charity care, un-reimbursed Medicaid, health professions education, cash-in-kind contributions, and had larger Medicare shortfalls.

Conclusion:
This preliminary hybrid qualitative/quantitative pilot study into the charity care of trauma centers demonstrates that level of trauma center influences uncompensated “charity” care financial variables when taking into account size and general financial variables.  This raises important considerations for level 1 trauma center funding mechanisms.  A broader study of national trauma centers with increased focus on uncompensated care financial variables is in planning to better understand the role and impact of trauma centers on charity care.
 

17.11 Using Research Electronic Data Capture to Simplify Institutional Research Efforts

Posted on December 22, 2014

A. H. Healy1, K. A. Frappier1, J. L. Madden1, A. Elmer1, S. H. McKellar1, C. H. Selzman1  1University Of Utah,Salt Lake City, UT, USA

Introduction:  Many institutions submit patient data to national registries while simultaneously maintaining their own institutional databases, creating substantial duplication of effort. Research Electronic Data Capture (REDCap) is a free technology available to academic centers in the United States to help in the storage and management of research data sets. REDCap can be customized to facilitate importation of data from various sources. We report the use of REDCap to create a comprehensive institutional data set created from submissions to a national registry.

Methods:  Institutional data for patients with left ventricular assist devices (LVADs) was regularly submitted to the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) beginning in 2006. Using INTERMACS entry forms as a template, corresponding REDCap forms were created. Care was taken to match REDCap variable names to those used in INTERMACs. An institutional request for INTERMACs data was then made. This data was then uploaded to REDCap, populating the previously created forms with retrospective data. 

Results: The data upload from INTERMACS to REDCap was successful in 90 LVAD patients comprising data from an eight-year period, creating a data set that was identical to the data in the national database without duplication of effort. With the REDCap forms created and populated, it was also confirmed that this information could be regularly updated through serial data requests. This data could then be combined with other patient-based REDCap forms that store data not collected by INTERMACS, such as the results of tissue-based biologic studies performed at an institutional level. REDCap data exports, which can be easily deidentified to maintain patient confidentiality, can be customized depending on the topic of interest.

Conclusion: REDCap is a user-friendly research data management tool that can be used to store data submitted to national registries through data importation to forms identical to those used in the national registry. Periodic updates to the REDCap database can be easily made by requesting institutional data from the national registry, eliminating duplication of effort in maintaining institutional databases and data transcription errors, such as keystroke errors. Though this method is vulnerable to changes in forms at the national registry level, it makes large sets of institutional data quickly available to facilitate institutional research projects.

 

17.12 Surgeons’ Perspective of a Newly Implemented Electronic Medical Record

Posted on December 22, 2014

R. C. Frazee1, H. T. Papaconstaninou1, R. C. Frazee1  1Baylor Scott & White Healthcare,Department Of Surgery,Temple, TEXAS, USA

Introduction:   The American Recovery and Reinvestment Act mandates “meaningful use” of an electronic medical record (EMR) to receive current financial incentives and to avoid future financial penalties.  Surgeons’ ongoing adoption of an EMR nationally will be influenced by the early experiences of institutions that have made the transition from paper to electronic records.  In February 2014, our institution adopted EPIC™ as our primary mode of patient documentation and order entry.  We queried surgeons at our institution regarding their perception of the EMR at 3 months after institutional implementation.

 

Methods:   A written survey was obtained from senior staff and residents of a multispecialty department of surgery.  Surgeons were asked to respond on a Likert Scale ranging from 1-strongly disagree to 5-strongly agree.

 

Results:  Fifty-nine surveys were obtained from 24 senior staff and 35 residents with average scores to each inquiry below:

 

 

 

Conclusion:  Surgeons’ perspective of the EMR in their early experience is that it is more effective providing billing documentation than clinical documentation.  There is concern regarding the impact of the EMR on patient satisfaction.  In spite of these drawbacks, the surgeons were satisfied with EPIC™ as the choice of EMR.

 

17.13 LACE Index Fails to Predict Readmissions in General Surgery

Posted on December 22, 2014

A. Gbegnon1, J. G. Armstrong1, J. Monestina1, J. W. Cromwell1  1University Of Iowa,General Surgery,Iowa City, IA, USA

Introduction: Hospital readmissions are costly and rates of these are increasingly being used as measures of quality.  Several predictive models have been developed to aid in the identification of patients at high risk of readmission so that valuable readmission-prevention resources may be appropriately assigned.  The LACE index (LI) has become the most widely used of these tools because of its ease-of-implementation using electronic health record data, even being embedded into some EHR systems.  A LI of 10 or higher is frequently used to identify patients at high risk of readmission.  The LI was developed primarily on non-surgical patients and has not been validated in the surgical populations to which it is now being applied.  Poor discrimination of readmission risk in this population would likely result in under-resourcing of this group of patients.  Our goal is to evaluate the performance of the LI on encounters of general surgery patients in our hospital.

Methods: We performed a retrospective analysis of patients who underwent a general surgery operation between January 2011 and March 2014, and whose readmission data was submitted to the National Surgical Quality Improvement Program (NSQIP).  The primary outcome measure was unplanned, related readmissions within 30 days of operation. Exclusion criteria included patients who did not have a LI, who died within 30 days of their operation, and patients who had not been discharged within 30 days of their operation.  To examine LI discrimination we generated a receiver operative characteristic (ROC) curve, and calculated the area under the curve (AUC). The LI was calculated by the method of van Walraven et al. from discrete elements within the EHR.

Results: There were 219 patient encounters that met inclusion criteria.  The overall readmission rate in the study population was 12.8%.  The readmission rate for encounters with a LI=<9 was 13.6%, while the readmission rate for LI >=10 was 9.5%. The positive predictive value using this threshold was 0.14.  The AUC (c-statistic) for the LI was 0.51, indicative of poor discrimination.

Conclusion: This study is the first to attempt to validate the LI for identifying patients at high risk of readmission in a general surgery population.  The LI exhibited poor positive predictive value and discrimination approaching that of random guesses in this population.  With the LI being widely applied to hospital populations for the purpose of identifying patients in need of readmission prevention resources, general surgery patients may be under-resourced where this index is being used.  Surgeons and hospitals should be aware of the limitations of the LI and seek other strategies for identifying surgical patients at high risk of readmission.

 

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