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.
 

17.18 What Happened Last Night?! – Variability in Night Shift ICU Care

Posted on December 22, 2014

J. Driver1, P. Y. Wai1, M. A. Zapf1, A. Kothari1, K. Y. Wolin1, P. C. Kuo1  1Loyola University Chicago Stritch School Of Medicine,Maywood, IL, USA

Introduction: ICU patients comprise the sickest patient population in the hospital. They are presumed to receive unwavering "around the clock" care. However, this assumption has not been previously investigated and anecdotal observations suggest that night time care is variable.  To determine potential differences in night time ICU care, patient care parameters were analyzed comparing hourly data from day, evening and night shifts. We hypothesized that variability in ICU care occurs during the night shift and impacts important patient outcomes. 

Methods: EPIC electronic medical record data from 15,493 patients in 5 ICUs from 2008-2013 at a major urban academic medical center were retrospectively analyzed for hourly urine output (U/O), mean arterial pressure (MAP), frequency of MD and RN EMR access and total fluid output during day, evening and night shifts. Variation in hourly U/O was selected as a surrogate marker for overall attention to care.  ICUs included: CCU, NeuroICU, CardiothoracicICU, MICU, and SICU. Mean night shift values were compared to the mean combined day and evening shift values. Statistical analysis was performed using paired t-tests or linear mixed effect modeling; p values < 0.05 were considered significant.

 

Results: There was reduced MAP (-0.75 mmHg/hr*) and reduced U/O (-18.9 mL/hr*) during the night shift. Paradoxically, frequency of care giver EMR access was significantly decreased at night (-33.4 times/hr*) and correlated with decreased U/O*, increased length of stay* and increased overall in-hospital mortality*. The model of resident and attending MD coverage and ICU specialty did not correlate with these parameters. (*p<0.0001) 

Conclusion: Our results demonstrate that attentiveness (measured by frequency of EMR access) correlated with surrogate care parameters (U/O) and outcome measures (length of stay and mortality). We conclude that variations in night shift ICU care may be due to caregiver inattention. Corrective strategies to increase patient monitoring, such as scheduled night shift ICU team rounding, should be identified.  

16.09 The “Halo Effect” in Trauma Centers: Does it Extend to Emergency General Surgery?

Posted on December 22, 2014

N. Nagarajan1, S. Selvarajah1, H. Alshaikh1, F. Gani1, H. Alturki1, A. Najafian1, C. K. Zogg1, D. T. Efron1, 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

Introduction:  Trauma Centers (TC) have been shown to have a “halo effect”, resulting in improved outcomes for non-trauma conditions. It remains unclear if these improvements extend to outcomes for emergency general surgery (EGS). Using emergent colectomy in patients with diverticulitis as an index condition, the objective of this study was to compare outcomes between TC and NTC.

Methods:  The Nationwide Emergency Department Sample (2006-2011) was queried for patients (≥16 years) who underwent an emergent colectomy (ICD9: 173*, 457*, 458*) with a primary diagnosis of diverticulitis (ICD9: 562.11, 562.13). Outcomes studied included mortality, total charges (in 2011 dollars) and length of stay (LOS). Mortality in TC and NTC was compared using logistic regression, controlling for age, sex, Charlson Comorbidity Index (CCI), type of insurance, income quartile, partial/total colectomy, presence of peritonitis, perforation, and hospital region, clustering by hospital. Unadjusted total charges and LOS were analyzed with non-parametric tests, then were adjusted for all of the above and mortality. Adjusted total charges and LOS were analyzed using generalized linear models with gamma and Poisson distributions, respectively.  

Results: A total of 25,396 patients were included; of whom 5,189 (20.4%) were treated at TC and 20,207 (79.6%) at NTC. Median age [60 years (IQR: 49-73), p = 0.959] and proportion of females (51.6% vs. 51.3%, p = 0.395) were similar between TC and NTC, but there were significant differences in insurance status (p = 0.027) and median household income (p <0.001) (Table I). Unadjusted mortality at TC did not significantly differ from NTC, median charges and were significantly different (Table I). After controlling for patient, procedure and hospital-level characteristics, the odds of mortality was significantly higher in TC (OR=1.24, 95% CI, 1.02-1.51). Estimated mean charges ($127,801 vs. $116,464, p = 0.004) and LOS (IRR=1.06, 95% CI, 1.05-1.11) were also significantly higher in TC after adjustment.

Conclusion: The improved outcomes reported for other non-trauma conditions in TC were not observed for patients undergoing an emergent colectomy for diverticulitis after accounting for demographic and hospital-level characteristics.  Future research is needed to discern if differences in the clinical course of patients in TC compared to those in NTC are affecting our findings.

16.10 Benchmarking Statewide Trauma Mortality and Using AHRQ's Safety Indicators to Identify Intervention

Posted on December 22, 2014

D. Ang1, S. Kurek1, M. McKenney1, E. Barquist1, E. Barquist1, S. Norwood1, B. Kimbrell1, D. Villarreal1, H. Liu1, M. Ziglar2, J. Hurst1  1University Of South Florida College Of Medicine,Tampa, FL, USA 2Hospital Corporation Of America,Nashville, TENNESSEE, USA

Introduction:   Improving clinical outcomes of trauma patients is a challenging problem at a statewide level, particularly if data from the State’s registry is not publically available.  Promotion of optimal care throughout the State is not possible unless clinical benchmarks are available for comparison.  Using publically available administrative data from the State’s Department of Health and the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSI), we sought to create a statewide method for benchmarking trauma mortality while also identifying a pattern of unique complications that have an independent influence on mortality. 

Methods: Data for this study was obtained from State’s Agency for Health Care Administration (AHCA). Adult trauma patients were identified as having ICD-9 codes defined by the State. Stepwise logistic regression was used in order to create a parsimonious and predictive inpatient expected mortality model. The expected value of PSIs was created in a similar method using a multivariate model provided by the AHRQ.  Case mix adjusted mortality results were reported as observed to expected ratios (O/E).

Results:There were 37,793 trauma patients evaluated during the study period.  The overall fit of the expected mortality model was very strong at a c-statistic of 0.891.  Eleven out of 25 trauma centers had O/E ratios less than one, or better than expected.  Six statewide PSIs had O/E ratios higher than expected.  The PSI which had the strongest influence on trauma mortality for the State was PSI# 4 or death among surgical Inpatients with serious treatable complications.  Mortality could be further sub-stratified by complications at the hospital level.

Conclusion:This method offers an adjusted benchmarking method which screens at risk trauma centers in the State for higher than expected mortality.  Stratifying mortality based on Patient Safety Indicators may identify areas of needed improvement at a statewide level. 

 

16.11 Massive Transfusion Protocol: From Zero To Hero

Posted on December 22, 2014

I. A. Struve1, E. S. Salcedo1, C. S. Marshall1, J. M. Galante1  1University Of California – Davis,School Of Medicine,Sacramento, CA, USA

Introduction:  The Massive Transfusion Protocol (MTP) facilitates rapid transfusion of blood components for patients in hemorrhagic shock.  MTP implementation is highly resource intensive.  Rapid deployment of all available transfusion service personnel is necessary to prepare and issue blood products promptly.  This study explores factors contributing to appropriate blood product use with MTP activation in a Level 1 Trauma Center.  We aim to establish a quality benchmark for the use of a limited resource.  

Methods:  Records of patients, for whom MTP was activated, from 3-month intervals over three consecutive years, were reviewed.  Data collected includes: ordering specialty, patient location at the time of activation, and units transfused at 6 hours and at 24 hours.  The primary outcome assessed was zero-use rates, which were compared by ordering specialty and patient location at the time of MTP activation.  Zero-use was defined as zero PRBC units transfused at 24 hours following MTP activation. Secondary outcomes assessed were median PRBC units transfused and Crossed-To-Transfused (C:T) ratios, both compared by specialty and location. Categorical variables were compared with the chi-square test and continuous variables with confidence intervals using alpha=0.05.

Results:  MTP was activated for 183 patients. The predominant specialties that activated MTP were emergency medicine (43%), surgery (24%), and anesthesia (22%), The predominant patient locations at the time of MTP activation were the ER (50%) and the OR (43%). Zero-use rates compared between predominant ordering specialties were not significant (p=0.75). Zero-use rates compared between the ER and the OR were significant (p=0.008) (Table 1). When MTP did not result in zero use, only activations made with the patient in the OR results in massive transfusion (MT) (6 units) (Table 1). 

Conclusion:  Patient location at the time of MTP activation is a significant predictor of appropriate MTP use. The OR is superior likely because the source and extent of hemorrhage is directly visualized. In the OR, zero-use rates are lowest and the median number of transfused units are 6 within 6 hours, an accepted definition of massive transfusion.  Using the OR as a model for appropriate MTP activation, we propose a zero-use rate benchmark of 15%. 

 

16.12 Reduced Mortality in Females After Traumatic Hemorrhage: Does It Extend to Non-Traumatic Hemorrhage?

Posted on December 22, 2014

H. Alshaikh1, S. Selvarajah1, N. Nagarajan1, F. Gani1, C. K. Zogg1, H. Alturki1, A. Najafian1, D. T. Efron2, C. G. Velopulos2, 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:  Multiple studies have demonstrated gender dimorphism in survival after trauma-induced hemorrhage. These findings have led to gender based therapeutics such as the administration of progesterone to males after injury. However, the potential survival benefit females may enjoy has not been well studied in non-traumatic emergency situations such as gastrointestinal (GI) hemorrhage. The objective of this study was to examine the association between gender and survival in patients presenting with acute non-traumatic GI hemorrhage using a nationally representative database. 

Methods:  Using Nationwide Inpatient Sample (NIS) data from 2007-2011, adults admitted through the emergency department with GI hemorrhage were identified using ICD-9 diagnosis code (578.*). Patients <18 years of age were excluded as were patients with missing demographic information and elective admissions. Weighted univariate and multivariable logistic regression was done to assess the relationship between gender and in-hospital mortality. The adjusted analysis controlled for demographic factors, hospital characteristics, patient transfer status and patient clinical severity. Severity was assessed using All-Patient Refined Diagnosis-Related Group (APR-DRG) severity scores. 

Results: A total of 809,798 weighted inpatient visits met the inclusion criteria, 51% of patient were female. Mean age was higher for women compared with men (72.1 vs. 65.8, p<0.001). Non-operative intervention was common among therapeutic options, including esophagogastroduodenoscopy (27.5%), small intestine endoscopy (26.5%) and colonoscopy (16.9%). About 43.9% of patients received blood transfusion, with higher proportion of women receiving them (51.7% vs. 48.3%, p<0.001). The proportion of patients with APR-DRG severity scores 1 and 2 (non-severe) was 52.9% for females (95%CI=52.3-53.6) and 52.4% for males (95%CI=51.7-53.1). Women demonstrated 14% lower unadjusted odds of death compared with men (OR 0.86, 95% CI 0.82-0.91). Moreover after adjustment, women demonstrated 22% lower odds of in-hospital mortality compared with men (OR 0.78, 95% CI 0.74-0.82). Alternative regression models were consistent with these results.

Conclusion: Females demonstrated significantly lower mortality after emergent GI hemorrhage despite controlling for severity and age. This evidence, in conjunction with other studies that demonstrate lower female mortality in traumatic hemorrhage, should prompt researchers to further investigate potential gender-related physiological pathways that could be altered by novel therapeutic options to improve patient outcomes.

16.13 Evaluation Of A Clinical Management Guideline For Tube Thoracostomy Removal In Trauma Patients

Posted on December 22, 2014

J. A. Marks1, G. Telford1, J. McMaster1, N. D. Martin1, P. Kim1  1University Of Pennsylvania,Division Of Traumatology, Surgical Critical Care And Emergency Surgery,Philadelphia, PA, USA

Introduction:
Recurrent pneumothorax after chest tube removal is a potential complication in trauma patients.  One potential mitigating maneuver is placement of a U-stitch at the skin incision during initial tube placement that is tied down during tube removal.  In this study, we evaluate this performance improvement initiative and its efficacy.

Methods:
At our urban, level one trauma center, we implemented a  Clinical Management Guideline (CMG) mandating U-stitch placement with all chest tubes in January 2012. The CMG further dictates that the procedure is performed by two providers. One provider secures the skin suture, and the second provider maintains an occlusive dressing with Vaseline and dry gauze. The tube is removed at end inspiration, or while patient performs Valsalva maneuver. A chest x ray is performed 4-6 hours after tube thoracostomy is removed.  Data was collected from our prospectively entered performance improvement database comparing pre and post CMG implementation.  

Results:
During the year preceding CMG implementation there were 9 recurrent pneumothoraces requiring reinsertion of a chest tube out of a total of 172 chest tube placements (5.2% recurrence rate).  In the two years after the CMG was instituted, recurrences were reduced to 1 out of 177 (0.6%) and 1 out of 139 (0.7%), respectively (p<0.002) (FIGURE).

Conclusion:
Recurrent pneumothorax after chest tube removal is a significant complication.  Placement of a U-stitch as part of a CMG can significantly reduce this complication.  This CMG should be considered broadly for all traumatic chest tube removals. 
 

16.14 Airway Management of Trauma Patients as an Indicator of Quality in a Pre-Hospital Flight Program

Posted on December 22, 2014

R. Weston1, D. Chesire1, D. Meysenburg1, J. Fortner1, R. Houghton1, K. Solomon1, B. Burns1  1University Of Florida,College Of Medicine,Jacksonville, FL, USA

Introduction:  Airway compromise has been identified as a preventable cause of poor outcomes and death in trauma patients. Given its importance, pre-hospital airway management is vital and can be used as a valuable indicator of critical care quality.  The purpose of this study was to analyze successful pre-hospital airway management performed by helicopter flight staff.    

Methods:  This retrospective chart review evaluated all flight crew airway interventions involving trauma patients between January 1, 2008 through December 31, 2013. Descriptive statistics were used on the number of successful intubations as well as alternative airways.

Results: Of a total of 191 trauma patients requiring airway intervention,  167 were endotracheal intubations (87.4%), 24 were alternative airway intervention such as laryngeal mask airway, combitube or bag valve mask (12.5%). Of the endotracheal intubations, 80.1% were successfully placed by flight crew on their first attempt and the overall success rate was 94.2%. Of the intubations attempted by the flight crew, 43 patients had unsuccessful attempted endotracheal intubation by ground crew.  Of these, the flight crew was ultimately successful at placing an endotracheal tube in  41/43 (95.3%) trauma patients.

Conclusion: High endotracheal success rate by flight personnel suggests that medical air transport is more than just an expedited transport mode to the hospital; it can be considered a mobile critical care unit. The fact that 95.3% of previously attempted airways were “rescued” by the flight crew further demonstrates a higher level of care administered in the field
 

16.15 Missed Tetanus Prophylaxis in Severe Trauma Patients at a Level One Academic Trauma Center

Posted on December 22, 2014

E. O. Pierce1, J. B. Brock1, A. V. Dukes1, C. Stevens1, T. E. Robertson1  1University Of Mississippi,Surgery,Jackson, MS, USA

Introduction:
Tetanus has become an uncommon disease in developed countries due to vaccinations. Appropriate tetanus prophylaxis continues to be a problem, allowing for tetanus cases to still occur in the United States. The Advisory Committee on Immunization Practices (ACIP) recommends that tetanus-prone wounds be given prophylaxis.  Tetanus-prone wounds are contaminated wounds, including abrasions, as well as puncture wounds, avulsions, missiles, crushes, burns or frostbite. The purpose of this study was to determine if there are missed tetanus vaccination opportunities at a level one academic trauma center.

Methods:
A retrospective chart review was performed on severe trauma patients between July 2012 and June 2014. All leveled trauma patients ages 18 and older who met the Trauma Quality Improvement Program (TQIP) inclusion criteria were reviewed. These patients were compared to patients given tetanus prophylaxis in our institution. The results were further evaluated by age of patient, type of trauma (blunt, penetrating, burns), and type of presentation (transfer from outside hospital, direct presentation from the scene).

Results:
4,319 patients ages 18 and over presented as leveled traumas during the given time period. Of these, 30.2% received the recommended tetanus prophylaxis. 571 of these leveled trauma patients (13%) were greater than 65 years of age and 19.6% of these patients received tetanus prophylaxis. There were 3,314 blunt traumas and 27.8% of these received prophylaxes. There were 945 penetrating traumas and 37.7% of these received prophylaxes. There were 36 burns and 58.3% of these received prophylaxes. 1,586 patients were transferred from outside hospitals and 2,667 were brought in directly from the trauma scene. 13.4% of transfers received prophylaxis and 39.9% of direct responses received prophylaxis

Conclusion:
A large number of trauma patients are not receiving tetanus prophylaxis despite presenting with tetanus-prone wounds. Immunization status could not be gleaned from this retrospective chart review, but most adults after major trauma are unable to recall their immunization status. Patients who were transferred from another center may have received immunization there, but even primary response teams from the scene had only a 40% immunization rate. All penetrating wounds meet vaccination criteria and blunt may or may not include a tetanus prone wound, but considering the risks and benefits of vaccination, it would be reasonable to have all traumas receive tetanus prophylaxis. Major blunt trauma rarely presents without an abrasion. Further research will include provider education and systems improvements to determine the best mechanism to increase vaccination rates. There are missed tetanus vaccination opportunities at this level one academic trauma center.
 

16.16 Structured Interdisciplinary Rounds (SIR) on a Trauma Ward

Posted on December 22, 2014

A. E. Liepert1, D. Segersten1, H. Jung1, A. O’Rourke1, S. Agarwal1  1University Of Wisconsin,Department Of Surgery,Madison, WI, USA

Introduction: Patient satisfaction is becoming an important factor in healthcare reimbursement. Structured interdisciplinary rounding (SIR) has been shown to be effective in improving patient care and satisfaction, but trauma has often been excluded as this population is associated with uncertainty in presentation, hospital course, and outcome. We examined the impact of non-ICU interdisciplinary rounding upon trauma patient satisfaction.

Methods: Over a nine-month period, patient satisfaction scores were reported in the trauma inpatient population before and after intervention of SIR at our ACS verified Level One trauma center. Pre-intervention rounding consisted of separate physician (resident and attending) examination and discussion with patients, whereas the intervention group consisted of bedside rounds with physicians (resident and attending), nursing, pharmacy, nutrition, physical therapy, occupational therapy, and social work. Scripted and practiced communication between team members, patients and families was instituted. Patient satisfaction surveys were mailed to patients at time of discharge, collected, and reported in rolling three month reports. As this was a quality improvement initiative, with aggregate data devoid of patient identifiers, the study is exempt from Institutional Review Board review.

Results: 2339 trauma patients were admitted to the hospital, of which 829 patients were admitted to the trauma care ward, making up 67% of the floor’s total population. From patient satisfaction surveys, patient perception of satisfaction in nursing communication revealed an overall downward trend (83.3% to 76.9%); however, patient perception of physician communication improved (nadir 69.6% to 76.9%).

Conclusion: The implementation of SIR can have an impact upon patient satisfaction in the trauma population. Future studies examining team communication and patient outcome need to be performed to fully evaluate the impact of this intervention.

 

14.15 Prevalence of injuries due to falls in Nepal: A countrywide population based survey

Posted on December 22, 2014

S. Devkota1, S. Gupta2,3, S. Ghimire1, A. Ranjit4, M. Swaroop5, A. L. Kushner3,6, B. C. Nwomeh3,7  1Chitwan Alpine Polyclinic And Diagnostic Center,Chitwan, , Nepal 2University Of California – San Francisco , East Bay,Surgery,Oakland, CA, USA 3Surgeons OverSeas,New York, NY, USA 4Johns Hopkins – Center For Surgical Trials And Outcomes Research,Baltimore, MD, USA 5Northwestern University Feinberg School Of Medicine,Surgery – Trauma/Critical Care And Center For Global Health,Chicago, IL, USA 6Johns Hopkins Bloomberg School Of Public Health,International Health,Baltimore, MD, USA 7Nationwide Children’s Hospital,Pediatric Surgery,Columbus, OH, USA

Introduction:  An estimated 424 000 fatal falls occur globally each year, making it the second leading cause of unintentional injury-related deaths after road traffic injuries. Over 80% of fall-related fatalities occur in low- and middle-income countries, with regions of the Western Pacific and South East Asia accounting for more than two thirds of deaths.  Data from low-income South Asian countries like Nepal are lacking, particularly at the population level. 

Methods:  A nationally representative cross-sectional study was performed in 15 of the 75 districts in Nepal, randomly selected proportional to population, using the Surgeons OverSeas Assessment of Surgical Needs (SOSAS) survey tool. Three villages were randomly selected within each district, one urban and two rural. The SOSAS survey is divided into two portions: (1) demographic data including the household’s access to healthcare and recent deaths in the household and (2) assessment of a representative spectrum of surgical conditions, including injuries.  Data was collected regarding an individuals’ experience of injury including road traffic injuries, falls, penetrating trauma and burns.  Data included anatomic location, timing of injury and whether or not healthcare was sought, and if not, the reason for barrier to care.  Descriptive statistics was used to analyse the data.

Results:  Of the 2695 individuals from 1,350 households interviewed, 141 individuals reported injuries secondary to falls (5.2%, 95% CI 4.4% to 6.1%), with a mean age of 30.7 (SD 20.0); 58% were male.  Falls represented 44.3% of total injuries (n=320) reported (95%CI 38.8% to 50.0%).    The most common locations of injuries due to falls were in the extremity, 73.2% (SD 3.7%, 95% CI 65.7% to 80.8%, Table 1); the upper extremities were the most common site in the extremities that were involved (52.1%). Twelve individuals had an unmet surgical need (8.5%, 95% CI 4.5% to 14.4%).  Reasons for barrier to care included:  no money for healthcare (n=3), facility/personnel not available (n=7) and fear/no trust (n=2).  Of the 80 recent deaths, 7 were due to injuries from falls (8.8%, 95% CI 3.6% to 17.2%), with a mean age of 46 years (SD 22.8).  Surgical care was not delivered to those who died; reasons included no time (n=4), facility/personnel not available (n=1), fear/no trust (n=1) and no need (n=1). 

Conclusion:  This study provides population-based data on injury prevalence in Nepal, identifying injuries due to falls as a major public health problem.  While health education to reduce the risk of falls remains essential, these data highlight persistent barriers to access to care for the injured and the need to improve trauma care systems in Nepal.

 

14.17 Impacting the Global Trauma Burden — Training First Responders in Mozambique

Posted on December 22, 2014

A. Merchant1, K. Mcqueen1, O. Gunter1  1Vanderbilt University Medical Center,Trauma And Critical Care,Nashville, TN, USA

Introduction: Over half of prehospital deaths in low-income countries are the result of airway compromise, respiratory failure or uncontrolled hemorrhage; all three of these conditions can be addressed using basic first aid measures. For both hospital personnel and laypersons, a  basic trauma resuscitation training in modified ABC techniques can be easily learned and applied to increase the number of first responders in Mozambique, a resource-challenged country. This approach supports WHO guidelines to reduce the impact of an injury once it occurs and optimize its outcome.

Methods: In March 2014, a trauma training session was administered to 100 people in Mozambique: half were hospital personnel from 7 district medical centers and the other half were selected laypersons. Five of the hospitals advertised surgical capability; two other medical centers were chosen based on long transport times to main hospitals and need for patient stabilization. This training session included a pre-test, intervention, and post-test to evaluate and demonstrate first response skills of airway management, hemorrhage control, and cervical spine precautions using resources available in hospital and street settings. Paired t-tests and linear regression curves were used to analyze the data.

Results: Laypersons answered 26.9% of the pre-test questions correctly and showed 86.9% improvement in their scores after the intervention; hospital personnel initially answered 41.7% correctly and improved their scores by 44%. All participants were able to open an airway, externally control hemorrhage, and transport a patient with appropriate precautions. In addition, hospital personnel were able to verbalize intravenous fluid resuscitation and oxygen application during assessment.

Conclusion: The trauma training session served as new information that improved knowledge and skills for both groups, as well as increased the number of first responders in Mozambique. This knowledge can minimize secondary and tertiary injuries by providing effective prehospital care in developing nations with limited trauma resources. Thus, this study supports WHO recommendations to utilize the strengths of a developing nation – population – as the first step in establishing an organized trauma triage system.

 

14.18 Geriatric Emergency General Surgery – Survival and Outcomes in a Low-Middle Income Country

Posted on December 22, 2014

A. A. Shah1,2, H. Zafar2, R. Riviello1, C. K. Zogg1, S. Zafar4, A. Latif5, Z. Rehman2, A. H. Haider1  1Johns Hopkins University School Of Medicine,Center For Surgical Trials And Outcomes Research, Department Of Surgery,Baltimore, MD, USA 2Aga Khan University Medical College,Department Of Surgery,Karachi, Sindh, Pakistan 3Harvard School Of Medicine,Center For Surgery And Public Health, Brigham And Women’s Hospital,Brookline, MA, USA 4Howard University College Of Medicine,Department Of Surgery,Washington, DC, USA 5Johns Hopkins University School Of Medicine,Department Of Anesthesia,Baltimore, MD, USA

Introduction:  Geriatric surgical outcomes remain grossly understudied in low-middle income healthcare settings. The purpose of this study was to compare epidemiology and outcomes between old and young adults presenting to a tertiary care facility in South Asia for emergency general surgical (EGS) conditions.

Methods:  Discharge data from a university hospital were obtained for all adult patients (≥16 years) presenting between March 2009 and April 2014 with ICD-9-CM diagnosis codes consistent with an EGS condition, as described by the American Association for the Surgery of Trauma (AAST). The patient population was dichotomized into old (>65 years) and young (≤65 years) adults. Multivariate analyses, accounting for age, gender, year of admission, type of admission, admitting specialty, length of stay (LOS), major complications and Charlson Comorbidity Index, were used to compare the two populations. Outcomes of interest included all-cause mortality, major complications and LOS.

Results: A total of 13,893 patients were included. Patients >65 years constituted 15.3% (n=2,123) of the patient population. Old adults were more likely to be male (OR[95%CI]:1.14 [1.02-1.27]) and present through the ED (OR[95%CI]: 1.22[1.09-1.38]). They more commonly presented with gastrointestinal bleeding (OR[95%CI]: 2.63[1.99-3.46]) and for resuscitation (OR[95%CI]: 2.17 [1.67-2.80]). After multivariate adjustment, age >65 years independently accounted for a 60% increase in mortality (OR[95%CI]: 1.60[1.18-2.16]). Elderly patients also had a higher likelihood of developing major complications (OR[95%CI]: 2.09[1.67-2.61]). There were no significant differences in lengths of hospital stay between elderly and young-adult patients (4.3 vs. 4.5 days, respectively).

Conclusion: Older adults seem to suffer from a different set of EGS conditions compared to their younger counterparts. The results of this study will assist in formulating specialized management guidelines and help prioritize care for geriatric patients with EGS conditions in low-middle income healthcare settings.

14.19 An Estimation of Cost Arising From Motorcycles Injuries in Kigali, Rwanda

Posted on December 22, 2014

J. Allen Ingabire1, J. Byiringiro1, F. J. Calland2, J. Okiria1  1National University Of Rwanda,College Of Health Sciences And Medicine,School Of Medicine,Department Of Surgery,Butare, SOUTH, Rwanda 2University Of Virginia,Surgery Depatment,Charlottesville, VA, Virgin Islands, U.S.

Introduction: Motorcycles has become a popular mean of transport in Kigali, Rwanda and their injuries are associated with a high number of admissions in the main referral hospital of Kigali. These accidents are associated with a high financial burden to the country. This study aimed at evaluates the total cost arising from motorcycles injuries of patients admitted at University Teaching Hospital of Kigali.

Methods: Retrospective cross-sectional cost study of motorcycles injured patients admitted in University Teaching Hospital of Kigali from January-December, 2011. Data were collected from patient medical, police, insurance and financial records as well as patient interviews. Cost analysis was based upon the standard road accident cost conceptual framework.

Results:A total of 1232 road traffic injuries were reported during the study period and Motorcycle injuries accounted for 73.05% (900 cases) of all injuries. Youths were more involved in motorcycle accident (53.2%) than other age group (16-30 years) .The majority of Motorcycles victims were motorcyclists, (30.86%) and Motorcycle-vehicle (41.61%) was the first cause of motorcycle injuries then motorcycle-pedestrian (30.86%). Head injuries and fractures were the predominant diagnoses (82.15%).The mean hospital stay was 15.43 days, permanent disability was confirmed in 11.5% (n=104), and mortality rate was 10.4% (n=94). The total economic cost of motorcycle injuries was US$ 4,141,300. This is made up of about 28.28% accident-related costs and 71.72% casualty-related costs. The accident-related costs totaling US$892,775 was made up of property damaged costs of 21.56% and administration costs of 6.72%. Whilst the casualty-related cost of US$886.665.50 was made up of labor output costs estimated at US$ 1,631550 (39.4%) was  the highest cost, followed by medical cost estimated atUS$901,150(21.76%),out-of-pocket expenditure (5.9%), intangible costs (4.35%) and the lowest cost was funeral costs totaling US$24,007 (0.58%). The average cost per patient was estimated at US$4,601. There was significant association between category of injured patients and total cost/patient (p>0.05).

 

 

Conclusion:Motorcycle injuries create a substantial disability and cost burden in Kigali, Rwanda. Prevention and early treatment should be promoted to decrease the morbidity and financial burden.
 

14.20 Improving Trauma and Emergency Care in China: Results from an International Training Collaborative

Posted on December 22, 2014

A. Chaturvedi1, Y. V. Pei2, A. Mohammed3, D. Clapp1, D. M. Allin4, C. Orner5, M. Narayan1  1University Of Maryland,R Adams Cowley Shock Trauma Center,Baltimore, MD, USA 2University Of Maryland,Department Of Emergency Medicine,Baltimore, MD, USA 3Calderdale Royal Hospital,Department Of Emergency Medicine,Halifax, WEST YORKSHIRE, United Kingdom 4University Of Kansas,Department Of Medicine,Lawrence, KS, USA 5Heart To Heart International,Olathe, KS, USA 6China 120,Trauma And Emergency Responce Center,Chengdu, SICHUAN, China

Introduction:
The practice of emergency medicine in China officially began only 28 years ago. However, due to a lack of standardized formal training for emergency medical practitioners, the practice of trauma and emergency care in China is still in early development. Pre-hospital providers in China are typically physicians and nurses who undergo fragmented training at sites that hold variable certification requirements. International speakers are often invited to participate in the instruction of medical professionals. The purpose of this study is to evaluate the impact of an English-based trauma and emergency medicine training module on participants’ confidence in knowledge and skills.

Methods:

An English-based training module was established in conjunction with several international institutions and the Chengdu 120 Center, Chengdu, China. 4 days of structured training in English with consecutive Chinese translation consisted of didactic presentations and practical skills stations targeting nurses and physicians. Participants completed surveys assessing pre and post confidence in knowledge and skills using a semantic differential scale.

Results:
A total of 101 surveys were collected from 63 doctors and 38 nurses from Chengdu. 48% of participants were male. 71% of all participants were between the ages of 20 and 39. Education ranged from high school to master’s level of training. 66% of participants reported having received formal training in trauma within the last 2 years and 56% reported having received formal training in disaster management. Of the 101 surveys, 86 (55 doctors and 31 nurses) were complete for statistical analysis. Student’s t test revealed a statistically significant increase in perceived confidence level in all of the 14 topics of instruction (p<.0001). An increase in confidence was reported in both physicians and nurses, regardless of the participant’s years of experience in his or her respective occupation. Improvement was also significant irrespective of the participant’s previous training experience within the last 2 years.

Conclusion:
Trauma and emergency medical services have limited capacity in most areas of China. Foreign instructors are often invited to participate in health provider instruction.  Potential barriers to the success of such a program include language and teaching style.  A structured educational program based in English with consecutive Chinese translation positively impacted confidence levels of first responders in Chengdu, China. Participants felt more competent in all areas of topics and skills of instruction, which may ultimately improve provider skills in pre-hospital management of trauma and emergencies. These responses were seen in physicians and nurses across all experience levels. The collaboration between local Chinese and international medical professionals may help improve current Chinese emergency medical practices.
 

13.12 Financial Implications of Managing Penetrating Trauma Patients to an Acute Care Surgery Service

Posted on December 22, 2014

B. C. Branco1, P. Rhee1, B. Joseph1, A. L. Tang1, G. Vercruysse1, T. O’Keeffe1  1University Of Arizona,Trauma,Tucson, AZ, USA

Introduction:  Trauma centers often report unfavorable financial performance by caring for injured patients Penetrating trauma in particular has a significant impact on health care systems, with up to one third of these patients reported as uninsured. The financial impact on trauma surgery practice is unknown. The purpose of this study was to evaluate the financial implications of managing penetrating trauma patients in a level I trauma center.

Methods: All trauma patients admitted to a level I trauma center over a fiscal year (July 2011 to June 2012) were retrospectively identified. Demographics, clinical data and outcomes were extracted. Hospital and trauma surgeon financial data were also extracted. Outcomes were total charges, costs, net margin and reimbursements. Patients were compared according to injury mechanism. What stats did you use?

Results: 3,343 trauma patients were admitted of which 513 (15.3%) sustained penetrating trauma (51.3% GSW and 48.7% SW) and 2,830 (84.7%) blunt. Penetrating trauma patients had lower overall ISS (8.4 ± 11.3 vs. 9.2 ± 9.4, p<0.001) but were more likely to undergo an intra-cavitary procedure (39.3% vs. 26.7%, p<0.001). Patients who sustained penetrating trauma were more often uninsured (19.4% vs. 9.1%, p<0.001) and had Medicaid (55.8% vs. 36.9%, p<0.001). There were no significant differences in hospital LOS (penetrating: 4.2 ± 6.5 days vs. blunt: 4.7 ± 6.8 days, p=0.271). Overall, hospital net margin was $1.2 ± 1.3 k per trauma patient (1.9 ± 1.3 k for blunt vs. -2.4 ± 1.3 for penetrating, p<0.001). The average % hospital reimbursement was 25 ± 23% for blunt and 15 ± 18% for penetrating trauma (p<0.001). There were no differences in total hospital costs (10.4  ± 2.9 k vs. 10.1  ± 1.9 k, p=0.841) or patient charges (40.8 ± 8.1 k vs. 44.9 ± 7.4 k, p=0.302). Nevertheless, trauma surgeon professional charges were significantly higher for penetrating trauma (3.9 ± 7.3 k vs. 1.6 ± 3.2 k, p<0.001), in particular after GSWs (4.7 ± 8.9 k vs. 1.7 ± 3.4 k, p<0.001), as were surgeon’s reimbursement (1.4 ± 1.9 k vs. 0.6 ± 1.0 k, p<0.001.

Conclusions: Penetrating trauma was found to be a significant source of revenue loss for hospitals. This data may help inform mission support efforts in critical access hospitals that have high rates of penetrating trauma. Trauma surgeon reimbursement were however significantly higher after penetrating trauma, in particular after gunshot wounds, due to the associated operative interventions.

 

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