15.01 Rigid Sigmoidoscopy is Diagnostically Superior to CT for Penetrating Rectal Injury

Posted on January 18, 2018

M. J. Chaudhary1, R. Smith2, G. Victorino1  1UCSF-East Bay,Surgery,Oakland, CA, USA 2Emory University,Surgery,Atlanta, GA, USA

Introduction:
Computed tomography (CT) is commonly used to evaluate penetrating pelvic organ injury. Rigid sigmoidoscopy may be used as an adjunct in identifying penetrating rectal injury but its sensitivity compared to CT remains unknown. The purposes of this study were: (1) to determine the clinical utility of pelvic computed tomography (CT) in identifying the need for operative intervention after penetrating pelvic trauma, and (2) to determine if rigid sigmoidoscopy, cystogram or retrograde urethrogram improve the diagnostic yield of penetrating pelvic organ injury.

Methods:
We conducted a retrospective review of the trauma registry at our university-affiliated trauma center between January 1999 and December 2016. All patients with penetrating pelvic trauma, who had a CT of the pelvis prior to any potential operative intervention, were included. Operative reports were used to calculate the sensitivity, specificity, negative predictive value (NPV), and positive predictive values (PPV) for CT and rigid sigmoidoscopy in identifying pelvic organ injury.

Results:
During the study period, 160 patients were treated for penetrating pelvic trauma. Overall mortality after penetrating pelvic injury (including combined body compartment trauma) was 16% (26/160). Bladder injuries comprised the majority of injuries (n=86, 54%), followed by injuries to the ureter, blood vessels, and rectum, respectively. Out of the 160 patients with penetrating pelvic trauma, 37% (59/160) underwent preoperative CT scans and 19% (31/160) underwent rigid sigmoidoscopy. A comparison of the sensitivity, specificity, PPV, and NPV of CT and rigid sigmoidoscopy for penetrating rectal injury is attached.

Rigid sigmoidoscopy identified 71% (5/7) of rectal injuries missed by CT. For the remaining two missed injuries, in one case rigid sigmoidoscopy failed to identify an injury and in the other rigid sigmoidoscopy was not performed. CT had a sensitivity of 66%, specificity of 98%, PPV of 67% and NPV of 95% for bladder injury. Cystogram or retrograde urethrogram (RUG) was performed in 3% (5/160) of patients. Cystogram and RUG used in isolation or combination had 100% sensitivity, specificity, NPV and PPV for bladder injury. However, these adjuncts did not identify any injuries missed on CT.

Conclusion:
CT of the pelvis in clinically suitable patients with penetrating pelvic trauma has a low sensitivity and NPV for diagnosing operatively significant rectal or bladder injury. Rigid sigmoidoscopy increases the diagnostic yield for penetrating rectal injury requiring operative intervention. When clinical concern for rectal injury exists following penetrating trauma in the absence of CT findings, rigid sigmoidoscopy is warranted. 

14.14 The Impact of Socieoeconomics in Firearm Related Injury

Posted on January 18, 2018

K. L. Haines1, C. Warner-Hillard1, S. Agarwal1, H. Jung1  1University Of Wisconsin,Surgery,Madison, WI, USA

Introduction:  We sought to evaluate the impact of socioeconomic status on mortality in firearm related mortality.

Methods: The National Trauma Databank was queried for all firearm related injury patients from 2010-2015. Pearson-Chi2 univariate regressions were run on patient comorbidities to determine what patient factors significantly contributed to mortality. Multivariate logistic regression models to stratify incidence and outcomes for all patients with firearm related injuries were created using significant covariates, age, gender, and injury severity. Subgroup logistic models were also created for self-inflicted, accidental, and assault injuries.

Results: There were 170,140 firearm related injuries in that time period. The firearm mortality rate was 2.17%. The incidence of firearm related injury was higher in younger patient (18-45 years, n=126,267, 74%). Younger patients had a higher had a significantly higher mortality rate than older patients on chi2analysis (p<0.001). However, when controlling for other risk factors, age was a significant, independent risk factor for mortality (p<0.001).

Uninsured patients who sustained a firearm related assault injury and self-inflicted injury were more likely to die than patients with any other form of insurance (OR 1.4, OR1.2, p < 0.001; respectively). Race did not impact mortality except in Black patients after firearm related assault injuries (OR 0.76 p<0.001). Patients with previously diagnosed psychiatric illnesses were less likely to die from self-inflicted GSW. Socioeconomic status, race and ethnicity did not affect mortality for accidental firearm related injuries.  Self-inflicted firearm related injury patients were eight times more likely to die as compared to accidental or assault injury patients (CI 3.3-19.7).

Conclusion: While firearm related injury is more prevalent in younger patients, age is an independent risk factor for mortality. Uninsured firearm related assault and self-inflicted injury patients are more likely to die than those patient with any form of insurance.
 

14.13 The Effect of Race and Insurance Status on Bicycle Trauma Outcomes in Adults

Posted on January 18, 2018

H. Chen2, K. Haines1, T. Zens1, B. Brummeyer2, S. Agarwal1, J. E. Scarborough1  1University Of Wisconsin School Of Medicine And Public Health,Department Of Surgery, Division Of Trauma And Acute Care Surgery,Madison, WI, USA 2University Of Wisconsin,School Of Medicine And Public Health,Madison, WI, USA

Introduction:
Race and insurance status have been shown to predict outcomes in pediatric bicycle traumas. It is unknown how these factors influence outcomes in adult bicycle traumas. This study aims to evaluate the association, if any, between race and insurance status with mortality in adults. 

Methods:
This retrospective cohort study used the National Trauma Data Bank (NTDB) Research Data Set for the years 2013-2015. Multivariate logistic regression models were used to determine the independent association between patient race and insurance status on helmet use and on outcomes after hospitalization for bicycle-related injury. These models adjusted for demographic factors and comorbid variables. When examining the association between race and insurance status with outcomes after hospitalization, injury characteristics were also included.

Results:
A study population of 45,063 met the inclusion and exclusion criteria. Multivariate regression demonstrated that black adults and Hispanic adults were significantly less likely to be helmeted at the time of injury than white adults [adjusted odds ratio of helmet use for blacks 0.25 (95% CI 0.22-0.28) and for Hispanics 0.33 (95% CI 0.30-0.36) versus whites]. Helmet usage was also independently associated with insurance status, with Medicare-insured patients [AOR 0.51 (95% CI 0.47-0.56) versus Private-insured patients], Medicaid-insured patients [AOR 0.18 (95% CI 0.17-0.20)], and Uninsured patients [AOR 0.29 (95% CI 0.27-0.32)] being significantly less likely to be wearing a helmet at the time of injury compared to Private-insured patients.  Although patient race was not independently associated with hospital mortality among adult bicyclists, we found that Uninsured patients had significantly higher odds of mortality [AOR 2.02 (AOR 1.31-3.12] compared to Private-insured patients.

Conclusion:
Minorities and under-insured patients are significantly less likely to be helmeted at the time of bicycle-related trauma when compared to white patients and those with private insurance.  Public health efforts to improve the utilization of helmets during bicycling should target these subpopulations.
 

14.10 A 5-Year Analysis of a Hospital-Based Violence Recovery Program

Posted on January 18, 2018

E. A. Bryant1, M. Castillo-Angeles1, D. Nehra1, M. Chadwick1, R. Ramsis1, L. A. Benedict2, R. Askari1, A. Salim1  1Brigham And Women’s Hospital,Division Of Trauma, Burn, And Surgical Critical Care, Department Of Surgery,Boston, MA, USA 2Children’s Mercy Hospital- University Of Missouri Kansas City,Kansas City, MO, USA

Introduction:  Hospital based violence intervention programs have been established in several major cities to address recurrent violence related trauma admissions. Our hospital established a violence recovery program (VRP) in 2012 to provide in hospital and community case management for victims of violence.  The aim of this study was to assess the short term performance of our program and to identify the characteristics of patients who actively utilized the resources that were offered. 

Methods:  This is a single-center retrospective study that includes patients admitted from 2012 to 2016. Data was obtained from the VRP's case management database and the trauma center's Trauma Registry. Participants who were initially approached by the VRP but refused further interventions were classified as "non-users," whereas those who had a minimum of 3 encounters with the VRP were classified as "high-users."  Demographics and injury characteristics were compared between non-users and high-users. Specific services utilized by high-users were examined.

Results: 447 patients met inclusion criteria, of whom 134 (30%) were high-users.  The high-users compared to non-users were younger (p=0.0005), more likely to be black (p<0.001), more likely to have sustained a gunshot wound (p<0.001) and had longer hospital lengths of stay (p<0.001). The service most commonly utilized by the high-users was housing assistance (63%), followed by employment assistance (59%), and safety planning (41%).

Conclusion: Over a five year period, our VRP provided extensive assistance to 30% of eligible patients.  We did not identify any modifiable factors differentiating high-users from non-users. Further work is ongoing to identify barriers to utilization of VRP services in an effort to improve utilization and also to evaluate longer-term outcomes.

 

14.11 Do Racial Disparities Play a Role in Failure to Rescue in Emergency General Surgery?

Posted on January 18, 2018

M. Castillo-Angeles1, D. Metcalfe2, S. L. Nitzschke1, A. H. Haider1, A. Salim1, J. M. Havens1  1Brigham And Women’s Hospital,Surgery,Boston, MA, USA 2University Of Oxford John Radcliffe Hospital,Department Of Orthopaedics, Rheumatology And Musculoskeletal Sciences,Oxford, OXFORD, United Kingdom

Introduction: Failure to rescue (FTR) is an emerging quality metric that has been shown to be sensitive to differences in healthcare quality. Racial and socioeconomic disparities have been previously described in the surgical setting, but not in a particularly high-risk population such as Emergency general surgery (EGS) patients. This study sought to evaluate for disparities in FTR within the EGS population.

Methods: This is an observational study using the National Inpatient Sample (NIS) 2012-2013; the largest all-payer inpatient database in the United States. The inclusion criteria were all inpatients that underwent one of 7 EGS procedures shown to represent 80% of EGS volume, complications, and mortality nationally. Outcomes were Serious Adverse Events (SAE), in-hospital mortality, and FTR (in-hospital mortality in the population of patients that developed a SAE). Logistic multivariable regression models were used to adjust for patient- (age, sex, race, payer status, Charlson comorbidity index) and hospital-level (hospital size and location) characteristics. A subgroup analysis was performed comparing the outcomes between high-risk (partial excision of large intestine, excision of small intestine, control of hemorrhage and suture of ulcer of stomach or duodenum, lysis of peritoneal adhesions and laparotomy) and low-risk (appendectomy and cholecystectomy) procedures.

Results: A weighted total of 1.1 million EGS admissions were identified; 150,000 (13.8%) developed a SAE and 15,000 died, giving an overall FTR rate of 10%. Patients with public insurance (adjusted odds ratio 1.29, 95% CI 1.24 – 1.34) and uninsured patients (aOR 1.09, 1.02-1.16) were significantly more likely to die than those with private insurance. In both the unadjusted and adjusted analyses, Black patients had higher odds of a SAE (14.9% versus 17.3%, p<0.001; adjusted odds ratio 1.39, 95% CI 1.33-1.45) when compared to White patients. However, race was not a risk factor for FTR (aOR 0.87, 0.85-1.00). Publicly insured and uninsured patients had higher odds of SAE (aOR 1.29, 1.24-1.34 and aOR 1.09, 1.02-1.16, respectively). Publicly insured patients had increased adjusted odds of FTR when compared with privately insured patients (aOR 1.31, 1.13-1.52) (Table 1). Subgroup analysis between high- and low-risk procedures showed similar results.

Conclusion: Insurance status, but not race, is an independent risk factor for FTR in a representative population of patients undergoing EGS.  Race was determined a risk factor for developing SAEs. FTR partially explains worse outcomes for publicly insured and uninsured EGS patients. FTR is a complex problem and requires prospective studies for more in-depth analysis of this important quality measure.

 

14.12 Insurance Status and Race Affect Treatment and Outcome of Severity Stratified Traumatic Brain Injury

Posted on January 18, 2018

B. P. Nguyen1, K. Haines1, T. Zens1, C. Warner-Hillard1, S. K. Agarwal1  1University Of Wisconsin School Of Medicine And Public Health,Department Of Surgery, Division Of Trauma And Acute Care Surgery,Madison, WI, USA

Introduction:

Socioeconomic status and race has been shown to increase the chance of being afflicted by a Traumatic Brain Injury (TBI) and result in worse post-hospitalization outcomes. There is a paucity of data on how severity of TBI mediate these treatment and outcome factors. The goal of this study is to determine the effect disparities have on in-hospital mortality, discharge to inpatient rehabilitation, hospital length of stay (LOS), and TBI procedures performed based on insurance status and race/ethnicity throughout the range of TBI severity.

Methods:

This was a retrospective cohort study using the National Trauma Data Bank (2012-2015) analyzing patients with closed head injuries. Univariate and multivariate logistic/linear regression models were performed to determine the impact of race/ethnicity and insurance status on in-hospital mortality, discharge to inpatient rehabilitation, LOS, and TBI procedures performed in groups stratified by head Abbreviated Injury Scale (AIS).

Results:

We analyzed 708,261 TBI patients 76.6% white, 30% private insurance, 13% uninsured, the distribution of severity was 1.3% AIS of 1, 28.3% of AIS of 2, 30.1% of AIS of 3, 30.4% of AIS of 4, 9.9% of AIS of 5. As compared to privately insured patients, uninsured patients experienced greater mortality with increasing AIS, which began from an AIS of 3 (OR = 1.01, p < 0.001) and was the highest at an AIS of 5 (OR = 1.11, p < 0.001). As compared to privately insured patients, uninsured patients were less likely to be discharged to inpatient rehabilitation with increasing AIS as seen beginning from an AIS of 2 (OR = 0.98, p < 0.001) to an AIS of 5 (OR = 0.84, p < 0.001). As compared with white patients, black patients had a longer LOS as their AIS increased, this disparity started at an AIS of 2 (0.16 days, p < 0.001) and increasing to the longest LOS at an AIS of 5 (2.44 days, p < 0.001). As compared with non-Hispanic patients, Hispanic patients had a longer LOS with increasing AIS starting with an AIS of 2 (0.11 days, p < 0.001) increasing to the longest LOS at an AIS of 5 (1.124 days, p < 0.001). Compared with privately insured patients, Medicaid patients had a longer LOS in all AIS stratifications starting from an AIS of 1 (0.55 days, p < 0.001) increasing to the longest LOS at an AIS of 5 (5.52 days, p < 0.001).

Conclusion:

Disparities lead to differences in mortality, procedures performed, and discharge to inpatient rehabilitation for uninsured patients in higher ranges of TBI severity. Also, disparities lead to differences to LOS for black, Hispanic and Medicaid patients throughout the entire spectrum of TBI severity. The most vulnerable populations and minorities with the highest TBI severity seem to have the greatest disparities in treatment and outcome factors.

14.07 Impact of Race and Socioeconomic Status on Treatment and Outcomes of Blunt Splenic Injuries

Posted on January 18, 2018

L. M. Woldanski1, K. Haines1, T. Zens1, S. Agarwal1  1University Of Wisconsin School Of Medicine And Public Health,Department Of Surgery,Madison, WI, USA

Introduction: Racial, ethnic, and socioeconomic disparities exist in trauma patients. Management of blunt splenic injuries (BSI) can vary from splenectomy, embolization, or non-operative management. This study assessed the effect of race and insurance status on treatment plans and outcomes in blunt splenic trauma.  

Methods:  The National Trauma Data Bank was used to study on patients aged 15-89 with BSI from 2013-2015. Patients with abbreviated injury scores greater than 2 in non-abdominal areas were eliminated, as were patients with other concomitant abdominal injuries requiring repair. Variables of interest were compared across groups using Chi-Square tests, and those with significant associations were used in multivariate regression models for each outcome of interest to control for confounding variables.

Results:We analyzed 13,537 BSI patients. Uninsured patients had increased odds of mortality (OR 1.6, p>0.001), more splenic operations (OR 1.6, p<0.001), and were less likely to have non-operative management (OR 0.63, p<0.001). Uninsured patients were also twice as likely to be discharged home and three times as likely to leave AMA. (OR 0.35, OR 0.33; p<0.001). Blacks and Hispanics had higher mortality (OR 1.5; p=0.035, p=0.029 respectively). Blacks had more splenic operations (OR 1.23, p=0.03) and were 0.5 times less likely to receive angioembolization (p<0.001), while Hispanics had less splenic operations (OR 0.81, p=0.032).

Conclusion:Noteworthy differences exist in the management of splenic trauma patients based on race/ethnicity and socioeconomic status, despite controlling for demographics and injury characteristics. Insurance status and race affect surgical treatment plans and mortality, particularly for uninsured, Black and Hispanic patients. 

 

14.08 Risk Factors for Trauma Readmissions: Everything Matters

Posted on January 18, 2018

S. O. Dennis1, J. K. Canner2, D. T. Efron2, E. R. Haut2, J. V. Sakran2, K. A. Stevens2, C. Jones2  1East Carolina University Brody School Of Medicine,Greenville, NC, USA 2Johns Hopkins University School Of Medicine,Department Of Surgery,Baltimore, MD, USA

Introduction:  Trauma readmission rates are used to assess quality of care, hence identifying risk factors for readmission has become a priority. Prior studies have had disparate results and result in few predictors of readmission. We sought to examine a large data set to determine risk factors increasing odds of readmission after trauma.

Methods:  We used Maryland’s Health Services Cost Review Commission (HSCRC) Inpatient Data Set to identify injured patients admitted to acute care hospitals from 2013-2015; the HSCRC includes unique identifiers to track patient admissions statewide across institutions. We compared patients readmitted within 30 days of discharge from an initial trauma admission to those not readmitted. We included variables previously identified as potentially affecting readmission (Table). After univariable comparison, we included potentially statistically significant (p < 0.1) factors not collinear with others in a multiple logistic regression analysis to identify those independently associated with readmission (p < 0.05).

Results: We identified 300,925 index trauma admissions. 50,309 (17%) were followed by a readmission; 14,724 (29%) of these were admissions to a different hospital. All variables evaluated except injury mechanism were statistically significant on univariable and multivariable analyses, each independently associated with readmission risk (Table). For this complex model, the area under the receiver operating characteristic curve is only 0.61, suggesting even the inclusion of all variables is inadequate for predicting readmission. 

Conclusion: These data demonstrate a small number of variables will not adequately predict readmissions; rather, a broad swath of variables is needed to quantify readmission risk. Future formulations should use a wider range of available data and may need to be combined with advanced techniques to determine a patient’s individual risk of readmission.

14.09 Comparison of Penetrating Colon Trauma Outcomes between African American and Caucasian Men

Posted on January 18, 2018

S. J. Skube1, B. Lindgren1, Y. J. Fan1, S. Jarosek1, G. B. Melton1, M. D. McGonigal1,2, M. R. Kwaan1  1University Of Minnesota,Minneapolis, MN, USA 2Regions Hospital,St. Paul, MN, USA

Introduction:
The colon is the second most commonly injured organ in patients sustaining penetrating abdominal trauma. The standard of care for colon injury has evolved from repair with fecal diversion to primary anastomosis or primary repair. Previous studies have demonstrated a ten-fold higher rate of penetrating abdominal trauma in African American men. Racial disparities have been both published and disputed in trauma patient mortality, functional outcomes, and rehabilitation. The aim of this project was to assess racial disparities in the surgical care of trauma patients with penetrating colon trauma by evaluating differences in stoma formation and post-operative outcomes.

Methods:
We identified men over the age of 14 in the National Trauma Data Bank between 2010-2014 who had operative intervention for colon trauma. Patients with rectal injury and those transferred to another facility were excluded. The primary outcome was stoma formation with secondary outcomes including post-operative morbidity and mortality. A multivariate logistic regression was performed for ostomy formation controlling for race and significant co-variates.

Results:
Our query resulted in identification of 7,324 men with penetrating colon trauma requiring operative intervention (4916 African American, 2408 Caucasian). 18.5% of Caucasian patients and 19.6% of African American patients underwent fecal diversion with stoma formation (p = 0.283). African American patients were younger with a median age of 27 (range 15-86) versus 35 (range 15-88), more likely to self-pay (37.1% versus 29.9%), and more likely to be injured by firearm (88.3% versus 70.2%). African American patients had less overall post-operative morbidity (50.7% versus 63.0%, p = <0.001). On multivariate analysis, the odds of receiving an ostomy for African American vs Caucasian patients was similar (odds ratio=0.95, 95% CI: 0.83-1.10). Factors associated with stoma formation in penetrating colon trauma are shown in Table 1.

Conclusion:
This analysis did not demonstrate a difference in stoma formation between African American and Caucasian men. Multivariate analysis confirmed expected findings that trauma severity (firearm, GCS, ISS) increased the odds of receiving ostomy. The protocol-based management approach to emergency trauma care potentially decreases the risk for the racial biases that could lead to these disparities demonstrated in other healthcare settings.
 

14.05 The Only Color that Matters is Green

Posted on January 18, 2018

K. L. Haines1, T. Zens1, C. Warner-Hillard1, H. Jung1, S. Agarwal1  1University Of Wisconsin,Surgery,Madison, WI, USA

Introduction: To date, many studies have shown both racial and socioeconomic disparities exist with regard to outcomes in trauma. This study evaluates all trauma patients over a 3-year period to determine what factors contribute to their mortality, controlling for injury severity. 

Methods: All trauma patients ≥ 15 years old from 2012 to 2015 were queried from The National Trauma Data Bank. Pearson Chi2 and multivariate logistic regression models for mortality were performed controlling for patient age, gender, co-morbidities, injury severity (ISS), insurance, race, and ethnicity. 

Results: When evaluating 2,921,790 patients, uninsured patients are 2.2 times more likely to die as compared to insured patients (OR 2.2, p<0.0001). Patients with Medicare are 1.5 times more likely to die, government-insured patients were 2.0 times, Medicaid 1.2 times, and auto insurance 1.4 time more likely to die than privately insured patients (p<0.0001). African Americans (p=0.99, American Indians (p=0.86), and Hispanics p=0.26) controlling for socioeconomic status had the same mortality risk as Caucasian patients. History of bleeding disorder, current chemotherapy or disseminated cancer, diabetes, cirrhosis, respiratory disease, history of MI, peripheral vascular disease, CHF, renal failure, esophageal varices, history of CVA all significantly contributed to mortality and were controlled for in this model (p<0.05). ISS (OR 1.1), gender (OR 1.4), age (OR 1.0), and alcohol use (OR 1.2) significantly correlated with mortality in this regression (p<0.001). 

Conclusion: When analyzing all trauma patients, every patient despite their injury severity, medical comorbidities, race and ethnicity was more likely to die if they did not have private or worker’s compensation insurance. Patients identified as African American, American Indian, or Hispanic had identical outcomes as Caucasian patients. Currently, mortality in trauma directly correlates with financial wellbeing.

 

14.06 Factors Associated with Secondary Over-triage in Trauma Patients

Posted on January 18, 2018

P. P. Parikh1, P. Parikh2, J. A. Pestana2, J. V. Sakran3  1Wright State University,Department Of Surgery, Boonshoft School Of Medicine,Dayton, OH, USA 2Wright State University,Department Of Biomedical, Industrial And Human Factors Engineering,Dayton, OH, USA 3Johns Hopkins University School Of Medicine,Department Of Surgery,Baltimore, MD, USA

Introduction: Transfer of the injured patient is centered on improving outcomes. However, at times minimally injured patients are also transferred to Level I/II trauma centers resulting in secondary over-triage (SO). SO is a resource-sensitive challenge to trauma centers. The purpose of this study is to evaluate the burden of SO in a state-wide trauma system and identify factors that may lead to a SO.

Methods: The Ohio Department of Public Safety trauma and EMS registries were used to identify patients during 2008–2012. The inclusion criteria were: patients taken to Level III/non-trauma center (NTC) from the scene, ISS<15, and discharged alive. The subgroup of patients subsequently transferred to Level I/II trauma center, who had no surgical intervention, and were discharged alive within 48 hours of admission were analyzed. This subgroup was defined as SO and the remainder were included in the non-transferred group. The SO group was analyzed descriptively. Multivariable logistic regression was then used to identify factors associated with SO. The analysis included patient level factors (demographics), clinical factors (Glasgow comma scale, respiratory rate, systolic blood pressure, injury type, and pre-existing conditions), and insurance type.  We also included system level factors, such as number of LI/LII in the region and EMS reasons for selecting the first facility from the field.

Results:A total of 34,494 trauma patients were identified, and 7,881 (22.85%) patients met the inclusion criteria, out of which 965 (12.2%) met our definition of SO. The median age in the SO group was 40 years and majority (70%) of these patients were discharged home. After adjusting for age, gender, pre-existing conditions, and insurance type, the presence of penetrating injury (adjusted odds ratio [AOR] 1.71; 95% CI, 1.12-2.60; P = 0.01) and burns (AOR 2.82; 95% CI, 1.35-5.76; P = 0.006) were associated with SO (model area under the curve [AUC]=0.88). Further, system level factors, such as number of LI/II in the region (>2 vs ≤2) significantly impacted SO (AOR 1.30; 95% CI, 1.11-1.54; P < 0.001). The reason for destination choice, specifically closest facility (AOR 1.67; 95% CI, 1.40-2.00; P <0.0001) and use of on field trauma triage protocol (AOR 2.20; 95% CI, 1.70-2.85; P <0.0001), significantly increased the likelihood of SO. 

Conclusion:A proportion of minimally injured patients are subject to SO that impact regional and statewide trauma system utilization. System level factors, such as number of major trauma centers in the region and taking patients to the closest facility, significantly impacts SO. Subsequent investigation to identify optimal distribution of trauma centers is, therefore, critical. Targeted education and outreach to EMS personnel on the interpretation of triage protocol and further guidance to the NTC on when to transfer an injured patient may further reduce SO.

 

14.04 Racial Disparities in Post-Discharge Healthcare Utilization after Trauma

Posted on January 18, 2018

S. Chun Fat1, J. P. Herrera-Escobar1, S. S. Al Rafai1, Z. Hashmi1, M. Villanyi2, J. Nabi1, C. Velmahos3, K. Brasel4, G. Kasotakis2, A. Salim1, A. H. Haider1, D. Nehra1  1Brigham And Women’s Hospital,Boston, MA, USA 2Boston University,Boston, MA, USA 3Massachusetts General Hospital,Boston, MA, USA 4Oregon Health And Science University,Portland, OR, USA

Introduction:  Previous studies have shown that minority patients have worse in-hospital outcomes than white/Caucasian (WC) patients after trauma. However, very little is known about racial differences in utilization of post-discharge healthcare services after trauma. The purpose of this study is to determine if there is a difference in utilization of healthcare resources between black/African American (BAA) and WC trauma patients after discharge from the hospital.

Methods:  Adult trauma patients with an Injury Severity Score (ISS) ≥9 were identified using the institutional trauma registry of three Level I trauma centers and contacted 6- or 12-months post-injury to participate in a telephone interview. Participants were asked about 1) utilization of post-discharge services (inpatient and outpatient rehabilitation, physical/occupational therapy and speech/language therapy), 2) emergency department (ED) visit and 3) outpatient visits for injury related issues. Univariate analyses were performed using chi-squared test. To address for potential confounding, coarsened exact matching (CEM) algorithm was used to match WC and BAA patients on age, sex and Injury Severity Score (ISS). Conditional logistic regression was then used to compare WC versus BAA patients in terms of post-discharge healthcare utilization.

Results: A total of 694 patients were followed. This included 128 BAA patients who were then matched to 566 WC patients. The mean age was 64 years (SD: 20.4) for WC and 44 years (SD: 19.6) for BAA. Mean ISS was not significantly different between groups (14 for WC vs 15 for BAA, p=0.142). Unadjusted analyses revealed that compared to WC patients, BAA patients were less likely to use post-discharge services (80% vs 63% p: <0.001) and had fewer injury-related outpatient visits (42% vs 33% p: 0.054) after discharge. Furthermore, BAA patients were more likely to visit the emergency department for injury-related issues compared to WC (15% vs 8% p: 0.023). After coarsened exact matching, we found significant differences in utilization of healthcare resources post-discharge between the two racial groups (Figure).

Conclusion: This study demonstrates the existence of racial disparities in post-discharge healthcare utilization after trauma for otherwise similarly injured, matched patients. This may partially explain previously reported discrepancies in long-term patient reported outcomes between WC and BAA patients. Interventions aimed at ensuring equitable access to post discharge resources are needed. 

 

14.02 Racial Disparities in Emergency General Surgery Go Beyond Hospital-Level and Geographic Factors

Posted on January 18, 2018

C. E. Sharoky1, M. M. Sellers1, J. H. Fieber1, C. J. Wirtalla1, G. E. Tasian2, R. R. Kelz1  1University Of Pennsylvania,Department Of Surgery, Center For Surgery And Health Economics,Philadelphia, PA, USA 2Perelman School Of Medicine,Center For Clinical Epidemiology And Biostatistics,Philadelphia, PA, USA

Introduction:  Racial disparities exist in the management of many acute medical conditions. Prior studies examining racial disparities in emergency general surgery (EGS) have pointed to hospital-level factors as major contributors. We sought to examine whether racial disparities in death and serious morbidity (DSM) after EGS exist independent of hospital-level and geographic factors.

Methods:  Using Florida inpatient hospital discharge claims (2010-2013), we identified all patients ≥18 with an EGS condition admitted through the emergency department who had an EGS operation ≤2 days from admission. Multivariable logistic regression with multilevel mixed effects to control for both the county and specific hospital where care was received was used to estimate the association between race and DSM in black patients (BL) compared to white patients (WH). Two subgroup analyses, one of urban counties and one of rural counties, were performed to examine geographic variation in the association between race and DSM. 

Results: A total of 154,377 patients were identified, of which 17,540 (11%) were BL. Compared to WH, BL had 16% increased odds of DSM (95%CI 1.10,1.25) after adjusting for patient comorbidities, severity of illness on presentation, EGS operation performed, county and hospital. In a subgroup of urban counties, BL had 23% increased odds of DSM (95%CI 1.11,1.36) compared to WH. In a subgroup of rural counties, BL had a 17% increased odds of DSM (95%CI 1.01,1.35) compared to WH.

Conclusion: Black race is associated with increased DSM after EGS, and this association holds true in both urban and rural regions. This suggests that racial disparities in EGS exist even when controlling for the county and hospital where patients receive care. Further research is needed to identify processes of care that underlie these associations to help improve racial disparities in EGS across hospitals and geographic regions. 

14.03 A Model for Spatio-Temporal Injury Surveillance

Posted on January 18, 2018

J. O. Jansen1, J. J. Morrison2, T. Cornulier3  1University Of Alabama At Birmingham,Division Of Acute Care Surgery,Birmingham, AL, USA 2University Of Maryland,R Adams Cowley Shock Trauma Center,Baltimore, MD, USA 3University Of Aberdeen,School Of Biological Sciences,Aberdeen, SCOTLAND, United Kingdom

Introduction:
The Centers for Disease Control and the World Health Organisation have promoted the concept of “injury surveillance”, to inform the provision of services. Such analyses tend to rely either on the evaluation of temporal trends or of geographical variations in case volume, both having important implications for trauma system configuration. However, spatial variation in these temporal trends (or changes in these distributions) are more difficult to estimate particularly in sparsely populated areas, and have received relatively little attention as a consequence. The aim of this study was to propose a model to facilitate the spatio-temporal surveillance of injuries, using Scotland as a case study.

Methods:
This is a retrospective analysis of five years’ of trauma incident location data, as collected routinely by the Scottish Ambulance Service, for incidents attended from 2009 to 2013. The source data was geocoded by postcode district (PCD), a medium-sized spatial unit. There are 444 PCDs in Scotland. We analysed the study population as a whole, as well as a number of predefined subgroups, such as those with abnormal physiological signs. Our analysis aimed at characterising the geographical distribution of expected incident numbers and identifying spatial variation in their temporal trends. In order to leverage sufficient statistical power to detect temporal trends in rare events over short time periods and small spatial units, we used a geographically weighted regression model, which assumed a Poisson distribution for the counts of incidents per PCD and per year, and used a Markov random field to condition estimates for each PCD on those from adjacent PCDs. The results are displayed as choropleth maps, showing percentage change per year, with hatched areas indicating statistically significant changes over 5 years.

Results:
There were 509,725 incidents. Overall, there were increases in case volume in the Glasgow area, the central Southern part of the country, the Northern parts of the Highlands, the North-East, and the Orkney and Shetland Islands. Statistically significant increases were largely restricted to major cities, with the notable exception of Edinburgh. Significant decreases in the number of incidents were seen in Western Scotland, Fife and Lothian, and the Borders. Subgroup analyses showed markedly different spatio-temporal patterns.

Conclusion:
This project has demonstrated the feasibility of population-based spatio-temporal injury surveillance. Even over a relatively short period, the geographical distribution of where injuries occur may change, and different injuries present different spatio-temporal patterns. These findings have potential implications for health policy and service delivery.
 

13.19 Computed Tomography Findings Predict the Need for Intervention in Children with Blunt Liver injuries

Posted on January 18, 2018

J. E. McMillan1,3, T. F. Boulden2, A. Gosain1, J. W. Eubanks1, R. F. Williams1  1University Of Tennessee Health Science Center,Surgery And Pediatrics,Memphis, TN, USA 2University Of Tennessee Health Science Center,Pediatric Radiology,Memphis, TN, USA 3University Of Tennessee Health Science Center,College Of Medicine,Memphis, TN, USA

Introduction:

A standardized method for classifying blunt solid organ injury in adults has existed for nearly three decades. However, there is not a standard approach for pediatric patients and management varies widely among centers. We hypothesize that radiologic findings in pediatric abdominal trauma can be used to predict the need for intervention.

Methods:

Following IRB-approval, a retrospective study was performed at an ACS-verified Level 1 Pediatric Trauma Center for 134 children (<18 years) who had sustained liver injuries. Radiologic findings were extracted from CT reports or, when missing, measured from original imaging. Radiologic variables included liver laceration size, number of Couinaud segments involved, presence of hemoperitoneum, hepatic vessel involvement, lobe involvement, and the presence of subcapsular or pericapsular hematoma.  Interventions included surgical intervention, angiography, or blood transfusion. Continuous variables were compared with a t-test, and a chi-square analysis was used for categorical variables.

Results:

The mean age was 7.5 +/- 5.2 years with 59% male and 52% African-American.  Hemoperitoneum, length of liver laceration and number of Couinaud segments involved predicted the need for intervention in children with blunt liver injuries (table).  Normalizing continuous variables by age did not change the significance. However, the presence of hematoma and the proximity of the injury to the major hepatic vessels, important variables in the adult grading system, did not predict the need for intervention in children.

Conclusions:

Pediatric patients who present with liver injury from abdominal trauma with hemoperitoneum, larger laceration and more liver segments involved are more likely to require intervention. Contrary to the adult trauma guidelines, hematoma and proximity to the major hepatic vessels did not predict the need for intervention in children.  These findings build upon the expanding literature indicating the need for pediatric-specific guidelines for trauma management.

14.01 Location, Location, Location! Falling Short on Stepping Up to Reach Seniors for Fall Prevention?

Posted on January 18, 2018

S. Fantal1, K. Ladowski3, J. Vosswinkel3, R. Jawa3  1Stony Brook University,Program In Public Health,Stony Brook, NY, USA 3Stony Brook University Medical Center,Division Of Trauma,New York, NY, USA

Introduction:

Falls are the leading cause of injury-related morbidity/mortality in older adults. Despite demonstrated efficacy of fall prevention programs in randomized control trials, a gap remains between research and effective implementation and participant retention. The literature suggests interest in programs declines as distance, time, cost and effort to get to a class increase. Since 2012, our county has implemented community-based fall prevention programs. This study analyzed factors contributing to program completion.

Methods:

Evaluation was conducted on data from the Stepping On program, a multifaceted falls prevention program offered once/week, for 2 hours, over 7 weeks, free of charge. Program topics include exercise, vision, medication, and environmental risk factors. Variables examined include demographic data, program completion (≥5 classes), post program survey results, and census data.

Results:

Total of 869 participants mean age 80, white (94%), female (73%), married/widowed (82%), with high school diploma or higher (96%), enrolled in 41 programs, with mean class size of 21 participants. Overall program completion rate (CR) was 73% during the study period with 58% of participants completing the post program survey. Choropleth mapping was used to evaluate the relationship between participants' zip code to older adult population distribution. In multivariate logistic regression, Distance Traveled (OR=1.06 p=0.20), Age (OR=1.04 p=0.11), Gender (OR=0.52 p=0.17, ref=Female), Race (OR=1.25 p=0.90 ref=White), Education (Some College OR=1.95 p=0.18, ≤ High School OR=1.39 p=0.53, ref=≥College), and Marital Status (Divorced OR=0.60 p=0.38, Widowed OR=1.01 p=0.99, Single OR=0.52 p=0.43, ref=Married) were not significantly associated with program completion. There was a significant association between site type and program completion (8 Senior Centers n=170, CR=88%, 13 Libraries n=273, CR=76%, 1 Church n=21, CR=90%, 5 Assisted Living n=149, CR=83%, 12 Independent Living n=219, CR=86%, 2 Gyms n=37, CR=100%, p≤0.001). In univariate analysis, there were significant differences in completion rates between Senior Centers and Libraries (p=0.001) and Gyms and Libraries (p=0.002), but only Senior Centers remained significantly associated in multiple logistic regression analysis.

Conclusion:

The program was offered in areas of larger older adult populations. Estimated distance traveled to programs (mean=5.6 miles) did not significantly impact program completion. An association between site type and completion rates was noted. Senior Centers appear to be the best location to ensure program completion, as they explicitly serve an older adult population.

13.16 Stop the Radiation: Limiting Chest CT scans in the Pediatric Trauma Patient

Posted on January 18, 2018

S. Azari2, T. Hoover1, M. Browne1,2  1Lehigh Valley Health Network,Pediatric Surgical Specialties,Allentown, PA, USA 2University Of South Florida College Of Medicine,Tampa, FL, USA

Introduction: National attention has been drawn to decreasing pediatric radiation exposure with a push to “image gently”, however there are currently no national pediatric CT guidelines.  CT scans aid in the evaluation and treatment of pediatric patients; unfortunately, they expose the child to a considerable amount of radiation.  This creates a challenge for physicians, especially those caring for the acute pediatric trauma patient.  Due to the flexibility of the pediatric chest wall, the incidence of thoracic injury with blunt trauma is low.  We hypothesize that chest CT scans after a normal chest xray will not add clinically relevant information to justify the risk of the radiation.  

Methods:  A retrospective chart review of all level 1 trauma patients < 15 years of age who were evaluated at our pediatric trauma center between January 2013 and June 2016 was performed.  Using our database and chart review, patients who had a chest CT scan during their initial evaluation were reviewed for demographics, mechanism of injury, radiological results, and change in management based on those results.  Patients were excluded if their radiological evaluations were performed at an outside facility; no radiological chest evaluation was preformed; or if their mechanism of injury was drowning.

Results: There were 257 patients who met our inclusion criteria.  Eighty-two percent (211/257) had a chest xray.  Though 44% (114/257) had a chest CT scan; only 60% (68/114) of those patients had a chest xray prior to CT.  Of those patients, 74% (50/68) had a normal x-ray. Thirty percent (15/50) of the chest CTs done after a normal x-ray had an abnormal result.  Only 1 patient (2%) had a result which changed clinical management.

Conclusion: Though chest CT scans increase abnormal diagnoses, the chance of their results changing clinical management is very low.  Chest CTs should be consider unnecessary when the chest xray is normal.  

 

13.17 Pediatric Snakebites: comparing patients in two geographic locations in the United States

Posted on January 18, 2018

P. N. Chotai1, J. R. Watlington2, S. Lewis3, T. Pyo3, A. A. Abdelgawad4, E. Y. Huang5  1Vanderbilt University Medical Center,Department Of Surgery,Nashville, TN, USA 2University Of Tennessee Health Science Center,College Of Medicine,Memphis, TN, USA 3Texas Tech University Health Science Center,School Of Medicine,El Paso, TX, USA 4Texas Tech University Health Science Center,Department Of Orthopedic Surgery,El Paso, TX, USA 5University Of Tennessee Health Science Center,Division Of Pediatric Surgery, Department Of Surgery,Memphis, TN, USA

Introduction:

Management of children with snakebites may vary based on subjective criteria and geographic and climatic factors. We reviewed the incidence and management of snakebite injuries in children at two tertiary referral centers in separate geographic and climatic location to assess differences in management and outcomes of these patients.

Methods:

An institutional review board approved, retrospective chart review was performed for patients ≤18-year-old with ICD-9/E-codes for snakebite injuries at emergency department (ED) of two American College of Surgeons verified trauma centers (2006-2013). One center is located in south-east US and experiences a sub-tropical climate whereas the other is located in south-west US and experiences a semi-arid climate. Demographic and clinical parameters were extracted. Descriptive bivariate analysis using chi-square or Fisher exact test for nominal variables and Mann-Whitney U test for continuous variables was performed.

Results:

A total of 108 patients(59% male), median age of 9y(1y-17 y), were included. Snake type was identified by bystanders in 55.5% cases; copperhead was the most common(37%) subtype. About 30% patients received antivenin. One quarter of all patients were discharged from ED. Of the 83 admitted, 81% were admitted to floor and 19% were observed in the intensive care unit (ICU). Two patients received surgical intervention in 48 hours after presentation (fasciotomy for lower extremity rattlesnake bite and blister removal on thumb from unidentified snake bite). There was one gastrointestinal complication (emesis), one cardiovascular (premature atrial contractions, benign) and one neurologic (paresthesia at bite site). All patients were discharged home with one 30-day re-admission for unrelated trauma. There were no fatalities. Compared to patients who sustained a snakebite in semi-tropical regions, patients in semi-arid areas had shorter bite-to-ED time, presented directly to the referral center, were more frequently bitten by a rattlesnake, had longer length of hospital stay, required antivenin more frequently and at higher doses, and were more frequently admitted to the ICU (table 1). No differences were seen in gender, age at presentation, severity of wound, location of bite, abnormalities in coagulation profile or rate of admission to hospital amongst the two sites.

Conclusion:

Patients sustaining snakebites in semi-arid climates were more commonly exposed to dangerous snake types, resulting in higher antivenin requirement, as well as longer hospital stays and need for intensive monitoring. Although no fatalities were reported in our study, our data support early transfer of snakebite victims to higher centers of care, especially in semi-arid or high-risk areas.

13.18 A Ten Year Review of Firework-Related Injuries Treated at a Regional Pediatric Burn Center

Posted on January 18, 2018

P. H. Chang2,4, D. Toplauffe1, S. Wang1, S. Romo1, K. Hannigan1, R. Sheridan1,3  1Shriners Hospitals For Children-Boston,Boston, MA, USA 2Shriners Hospitals For Children-Cincinnati,Cincinnati, OH, USA 3Massachusetts General Hospital,Department Of Surgery,Boston, MA, USA 4University Of Cincinnati,Division Of Plastics/Burn Surgery,Cincinnati, OH, USA

Introduction:
In 2015, 11,900 firework-related injuries were reported in the United States. Laws regulating the use of consumer fireworks vary from state to state in our region. However, it is common practice for consumers to cross state borders to purchase fireworks illegal in their state. The objective of this study is to describe the population of patients treated for injuries involving fireworks at a single regional pediatric burn center.

Methods:
A retrospective chart review was conducted to analyze all patients aged 0-18 years admitted to our regional pediatric burn hospital with a firework-related injury between 2006 and 2015. Data collected included demographics, total body surface area (TBSA) involved, location of burn, state in which the injury occurred, and whether sparklers, firecrackers, or aerial fireworks were involved. 

Results:
Of the 61 patients who met the inclusion criteria for review, four times as many patients were males than females. The mean age of the study sample was 10.53 ± 5.42 years (range: 0.52-17.9 years) and the mean TBSA was 3% ± 7%. More than half of these patients were from MA (66%), while the other injuries occurred in: NH (21%), VT (7%), and less than 4% in NY, CT, ME, and VA. Seventy-one percent of these patients had to be admitted as inpatients for treatment. At least 40% of injuries were to critical areas (i.e. face, hands, feet, genitalia). Aerial fireworks were involved in 46% of these injuries, while sparklers and firecrackers were each involved in 28%.  

Conclusion:
Fireworks pose a serious danger to children in every state, regardless of mandated state legislation pertaining to fireworks sales. Sparklers, which are legal in six of the seven states included in our review, were responsible for more than a quarter of the injuries treated. Moreover, preliminary data suggests that laws regarding firework sales are not being properly implemented. Fireworks are illegal in the state of MA; however, 40 of the patients referred to our facility due to firework-related injuries were injured in MA. Additionally, although firecrackers are illegal in all of the states in which these injuries occurred, they were involved in more than a quarter of the injuries reviewed.   Over the past ten years, our pediatric burn center has treated numerous children injured due to fireworks. Our research demonstrates a need for clinicians and lawmakers to work together to help enact legislation limiting the sales and use of fireworks.
 

13.14 Prevalence and Perceptions of Team Training Programs for Pediatric Surgeons and Anesthesiologists

Posted on January 18, 2018

A. Esce1, D. A. Rodeberg2,4, M. Browne4,5, D. H. Rothstein3,4, D. Wakeman1,4  5Lehigh Valley Health Network,Division Of Pediatric Surgical Specialties/Department Of Surgery,Allentown, PA, USA 4American Academy Of Pediatrics Section On Surgey,Delivery Of Surgery Committee,Elk Grove Village, IL, USA 1University Of Rochester School Of Medicine,Rochester, NY, USA 2East Carolina University Brody School Of Medicine,Greenville, NC, USA 3Women & Children’s Hospital Of Buffalo,Pediatric Surgery,Buffalo, NY, USA

Introduction: Team training programs adapt crew resource management principles from aviation to foster communication and prevent medical errors. Although multiple studies have demonstrated team training programs such as TeamSTEPPS® improve patient outcomes and safety across medical disciplines, limited data exist about their application to surgical teams. The purpose of this study was to investigate usage and perceptions of team training programs by pediatric surgeons and anesthesiologists. We hypothesized that team training programs are not widely available to pediatric surgical teams.

Methods: We performed an online survey of Pediatric Surgery (General, Plastic, Urologic, Orthopedic, Otolaryngologic, and Ophthalmologic) and Anesthesiology members of the American Academy of Pediatrics. The survey inquired about completion and perceptions regarding efficacy of team-training programs. Simple descriptive statistics were used to interpret the data.

Results: 152 pediatric surgeons and 12 anesthesiologists completed the survey with a 10% response rate. Over half of the respondents were general pediatric surgeons. Home institutions offered TeamSTEPPS® or another team-training program in 39% of respondents. Of those with a program, 77% had completed training. Though most (76%) who participated in team training programs did so by requirement, 90% found it helpful. Of the 61% of surgeons who said their institution did not offer team-training programs, 60% said they would participate if one were offered and additional 32% said they might participate. The biggest barriers to participation were not enough free time or that the team training program was not offered to their department.

Conclusions: Team-training programs are considered beneficial amongst pediatric surgeons and anesthesiologists who have completed them. Unfortunately, despite substantial evidence showing training for team work improves team functioning and patient outcomes, many pediatric surgical teams do not have team training programs at their institutions. Further expansion of team-training programs may be valuable to improving a culture of safety in children’s hospitals.

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