59.05 Midline Catheters: An Underutilized, Cost-Effective Means of Decreasing Central Venous Catheter Use

Posted on January 31, 2019

X. Shanja-Grabarz1, L. Santoriello1, G. Ritter1, V. Patel1, J. Nicastro1, R. Barrera1  1North Shore University And Long Island Jewish Medical Center,Department Of Surgery/Zucker School Of Medicine At Hofstra/Northwell,Manhasset, NY, USA

Introduction:  Central line associated blood stream infections (CLABSI) remain a significant source of morbidity and
increased healthcare costs in patients in ICU’s and other hospital areas. In this study we aimed to show
that by having a midline dedicated team of physician assistants for the placement and monitoring of
midline catheters, the number of central lines placed on medical and surgical wards could be decreased.
Patients with and without CVCs with difficult peripheral access were instead given midline catheters,
decreasing the overall cost of line placement as well as the number of CVC associated complications.

Methods: Data regarding central line days and CLABSI were collected from 2009 to 2017. In that time period, system changes including designated CVC monitoring and midline placment teams were implemented. Data from Jan 2016 through December 2017 pertaining to patients in the SICU, CTICU, NSICU and surgical wards was reviewed, comparing the overall number of CVC and midline catheters placed. Our primary endpoint was decrease in the number of central line days and consequently the number of associated complications in ICU and Non-ICU settings.

Results: Midline catheters were used more often than CVC’s in both years included in the study and in both the ICU and floor setting. There was an appreciable decrease in the number of central-line days and CLABSI that corresponded to various hospital system changes including utilizing a team of trained designated housestaff and PAs to monitor central lines and place midline catheters sterilely in patients with difficult peripheral access.

Conclusion: 

Our data show that with the implementation of teams to monitor CVC's and place midline catheters, the number of midline catheters placed increase and patients have fewer central line days and fewer central line associated complications. Staff members that are already proficient in ultrasound guided placement of central lines can easily be taught the placement of midline catheter, as both procedures require a similar skill set. In a patient with difficult IV access, midline catheter placement is a safer and more cost-effective way to provide acess without resorting to unceccesary central line use.

59.04 Optimal Time of Abdominal Radiography after Gastrografin Administration for Small Bowel Obstruction

Posted on January 31, 2019

M. D. Ray-Zack1, O. Alnachoukati2, J. Dunn2, S. Godin2, B. Smoot2, M. Zielinski1  1Mayo Clinic,Rochester, MN, USA 2UCHealth North Medical Center of the Rockies,Loveland, CO, USA

Introduction:
Gastrografin (GG) is a commonly administered contrast to evaluate and treat adhesive small bowel obstruction (SBO).  Resolution of SBO can be confirmed by identifying GG contrast in the colon either via a single abdominal x-ray (AXR), i.e. GG Challenge (GGC); or via a series of AXRs until the contrast reaches the colon, i.e. small bowel follow-through (SBFT). In this study, we aimed to determine the optimal time of the first AXR following GG administration for SBFT.

Methods:
A retrospective review included patients with SBO undergoing SBFT at one institution vs. GGC at another institution from Mar 2015 –Jan 2018.  Patient characteristics and medical history were recorded to calculate Charlson Age-Comorbidity Index (CACI). SBO severity was graded according to the American Association for the Surgery of Trauma imaging criteria. The primary outcome was the time of noting GG contrast in the colon on AXR. Additional outcomes following GG administration were also analyzed. Time intervals were described as median hours/days [interquartile range]. Multivariable regression model controlled for patients’ age, sex, BMI, CACI, previous SBO admissions, abdominal surgeries, and SBO severity grade.

Results:
A total of 255 patients were included: SBFT= 128; GGC=127. No significant difference in patients’ age, sex, prior SBO admissions, or SBO severity grade was noted (Table 1). SBO resolved following GG administration for 103 (80.5%) of SBFT patients, and 100 (78.7%) of GGC patients. GG in colon was confirmed on AXR earlier among SBFT patients compared to GGC patients:  4 [2-6] vs. 8.5 [8-9] hrs, p <0.001. However, SBFT patients underwent imaging more often: 3 [2-4] vs. 1 [1-1] AXRs, p <0.001. Time from hospital admission to operative exploration for SBFT was not significantly different: 34 [20-94] vs. 47 [21-105] hrs, p=0.70. SBFT patients were not significantly different from GGC patients in terms of GG aspiration: 0.8% vs. 1.6%, p =0.3127; time to soft diet toleration: 2 [1-4] vs. 1 [1-3] days, p =0.05; and hospital length of stay: 2 [3-5] vs. 2 [1-5] days, p=0.10.

Conclusion:
SBFT and GGC are effective approaches for managing SBO. Earlier imaging confirmation of SBO resolution was not associated with earlier operative exploration or shorter hospital stay. Practice guidelines to confirm GG in colon at 4 hrs & 8 hrs AXRs may be more efficient for non-operative SBO management.
 

59.03 A Selective Approach for the Evaluation of Bladder Injuries in Patients with Pelvic Fractures.

Posted on January 31, 2019

T. J. Herron1, J. Chipko1, S. Dosal1, S. Lorch1, D. J. Ciesla1  1University Of South Florida College Of Medicine,Division Of Trauma & Acute Care Surgery,Tampa, FL, USA

Introduction:  Bladder injury is a rare but serious complication of pelvic fractures.  Diagnosis usually requires CT cystography, however, scanning all patients with pelvic fractures is inefficient and increases radiation exposure. The purpose of this study was to identify associated clinical findings to guide a selective approach to diagnostic imaging in blunt trauma patients with pelvic fractures.  

Methods:  Adult (Age>18) Trauma patients with pelvic fractures at a Level 1, academic medical center were retrospectively reviewed from a prospective database over a three-year period. All patients underwent an initial CT of the abdomen and pelvis as well as a microscopic urinalysis as part of their initial trauma evaluation. An arbitrary cut off of microscopic hematuria was designated as >100 RBC per high power field (HPF).  Patients who had a penetrating mechanism as well as those who did not have both components of the aforementioned evaluation were excluded.   

Results: A total of 434 patients were reviewed.  Of these, 120 patients met exclusion criteria, for a sample size of 314 patients. There were no identified bladder injuries in the 231 patients with microscopic hematuria <100 RBC per HPF (NPV=100%). Nine bladder injuries (2.87%) were identified in the 83 patients with microscopic hematuria >100 RBC per HPF; two of the 83 patients with microscopic hematuria >100 RBC per HPF, but without gross hematuria, had bladder injuries (NPV=96%). Six of the bladder injuries were extraperitoneal and treated with bladder decompression alone. Three of the bladder injuries were intraperitoneal ruptures requiring operative intervention.  All patients with bladder injuries had high energy transfer mechanisms with anteroposterior compression and lateral compression fracture patterns being most common.  The mean ISS of patients without a bladder injury [n=305] was 18.24 vs. 27.44 in patients with a bladder injury [n=9] (p=0.029) 95% CI [0.91, 17.51]   

Conclusion: In trauma patients presenting with pelvic fractures, a microscopic hematuria of <100 RBC per HPF excludes bladder injury (NPV=100%).  In patients without gross hematuria, a selective use of CT cystogram in the evaluation of bladder injury can be applied to patients with higher energy transfer mechanisms resulting in pelvic fractures.
 

59.02 Maintaining Optimal Trauma Outcomes: Resilience in the Midst of a Ransomware Attack

Posted on January 31, 2019

J. F. Narvaez1, J. Zhao1, J. Pugh2, W. Guo1  1University at Buffalo,Department Of Surgery,Buffalo, NY, USA 2University at Buffalo,Department Of Emergency Medicine,Buffalo, NY, USA

Introduction: On April 9, 2017, Erie County Medical Center, Western New York’s sole level I trauma center was under cyberattack. The perpetrators utilized ransomware that gained access to the hospital’s web server and encrypted hospital data, forcing a system-wide downtime for nearly 2 months. Electronic medical records, imaging, and interdepartmental communication were severely affected, forcing the hospital to temporarily return to pre-EMR era operations. We examined the impact of this cyber disaster on the outcomes of trauma care.

Methods:  Hospital trauma registry data and operating room case logs from April 9th through June 9th, 2017 were examined and compared to the previous year. Baseline characteristics were examined using the chi-square test for categorical variables and the Student’s t-test for continuous variables that were normally distributed.

Results: There were 427 trauma admissions with patients aged 50.91 ± 22.4 from April 9th – June 9th, 2017 (n=417, aged 50.57 ± 21.95 during the same period in 2016). Blunt to penetrating ratio was 8:1 in both years. The mean injury severity score was 10.33 ± 8.33 in 2017 vs 9.86 ± 6.52 in 2016, and revised trauma score was 7.40 ± 1.32 vs 7.56 ± 0.92. There were 504 trauma/acute care operations in 2017 compared to 565 in 2016. Mean ICU length of stay (LOS) was 5.08 ± 4.59 days and hospital LOS was 6.95 ± 6.63 days in 2017 vs 4.79 ± 4.45 and 6.65 ± 7.34 days, respectively, in 2016. The in-hospital mortality was 4.92% in 2017 compared to 2.9% in 2016. Of these discharges in 2017, 34.3% went to a rehabilitation facility, 64.4% were discharged home and 0.5% were transferred to a different hospital, compared with 37.2%, 60.6% and 0.7%, respectively, in 2016. There were no statistically significant differences in all reported covariates.

Conclusion: Our results suggest that trauma patient outcomes have remained optimal despite the temporary loss of electronic health records and computer functionality. This is likely due to operational back-ups in place, increased communication between providers and staff, prioritization of patient care over documentation/ electronic tasks, and increased resilience of surgical care providers. With cyber security threats increasing in healthcare, proper preparedness should be included at different levels in hospital operations.  It is important to have policies, processes, and procedures in place for the hospital administration, information technology department, and clinical staff in order to continue to provide optimal care during such downtimes of unprecedented scale.

 

59.01 Chronic Alcohol Consumption And Risk Of Deep Venous Thrombosis: A Propensity-Matched Analysis

Posted on January 31, 2019

K. Hanna1, M. Zeeshan1, T. O’Keeffe1, N. Kulvatunyou1, A. Tang1, E. Zakaria1, L. Gries1, A. Northcutt1, B. Joseph1  1University Of Arizona,Trauma And Acute Care Surgery,Tucson, AZ, USA

Introduction:
Alcohol consumption is associated with a decrease in coagulation factors. The relationship between chronic alcoholism and occurrence of venous thromboembolic (VTE) events in trauma patients in unknown. The aim of our study was to analyze the association between chronic alcohol consumption and risk of VTE in trauma patients.

Methods:
We performed a two-year (2013-14) analysis of all patients in the TQIP. All trauma patients with ISS>16 were included. Patients with acute alcohol intoxication, hematological disorders, and cancer were excluded. Patients were divided into two groups (alcoholic and non-alcoholic) and were matched in a 1:1 ratio using propensity score matching for demographics, injury severity, injury location, and admission vitals. Outcomes measures were the prevalence of VTE (DVT and PE) in each group.

Results:
A total of 91,066 trauma patients were included in our analysis of which 35,460 patients (alcoholics: 17,730, non-alcoholics: 17,730) were matched. Mean age 45±18y, and 81% were males. Matched groups were similar in age (p=0.32), HR (p=0.31), SBP (p=0.46), location of injury (p=0.85), ISS (p=0.76) and GCS (p=0.38). Prevalence of DVT was lower in alcoholics compared non-alcoholics (2.34% vs. 5.12%, p=0.01).  Overall Incidence of PE was 1.2% and there was no difference between the two groups (1.1% vs.1.3%, p=0.22). Similarly, there was no difference in mortality (14.8% vs 15.4%, p=0.32) between the two groups.

Conclusion:
Chronic alcohol consumption is associated with a low risk of DVT in trauma patients. This association warrants further investigation of the possible physiological effects of alcohol in trauma patients.
 

58.20 Characteristics and Complications of G-Tube Placement Among Surgical and Non-Surgical Services.

Posted on January 31, 2019

P. M. Alvarez1, J. Herb2, A. Vijay1, C. Cunningham1, K. Anderson1, S. Francois1, K. Herbert1, N. Bartl1, E. Hoke2, J. Jadi1, N. Rodriguez-Ormaza2,3, R. Maine2, E. Dreesen2, A. Charles2, T. Reid2  1University Of North Carolina At Chapel Hill,School Of Medicine,Chapel Hill, NC, USA 2University Of North Carolina At Chapel Hill,Department Of General Surgery,Chapel Hill, NC, USA 3University Of North Carolina At Chapel Hill,Department Of Epidemiology,Chapel Hill, NC, USA

Introduction:  While surgical and non-surgical services routinely place gastrostomy tubes, few investigations have examined the procedure’s outcomes based on performing service. This study describes baseline characteristics, complications, and mortality among patients who had gastrostomy tubes placed by either a surgical or non-surgical service.

Methods:  This is a retrospective study of all adult patients who underwent gastrostomy tube placement at UNC from March 2014 to July 2017. Baseline characteristics included age, sex, BMI, substance abuse, comorbidities, previous abdominal surgery, and prior gastrostomy tube. We compared placement by surgical versus non-surgical services outcomes, including severe and minor complications, and mortality, overall and gastrostomy tube related.

Results: Of the 1,339 adults who underwent gastrostomy tube placement, 45%(n=626) were placed by surgical services and 55% (n=713) were placed by non-surgical services. Baseline characteristics were similar although non-surgical services had higher rates of congestive heart failure (p=0.004) and COPD (p=0.05). Non-surgical services placed all gastrostomy tubes percutaneously, while surgical services placed 52.6% percutaneously, 37.3% laparoscopically, and 10.1% open. Mortality related to gastrostomy tube placement was similar (surgical 0.6% vs nonsurgical 0.5%, p=1.0), however overall mortality was higher among non-surgical services (23.7% vs 16.5%, p=0.004). There was no difference in major or minor complication rate (27.3% surgical vs 27.2% non-surgical, p=0.88).

Conclusion: Surgical and non-surgical service placement of gastrostomy tubes had equivalent gastrostomy tube related mortality and complication rates, although patients with gastrostomy tubes placed by non-surgical services experienced higher overall hospital mortality. The high in-hospital mortality and complication rates underscore the need for thoughtful patient selection for this procedure.

58.19 Pancreatic Cancer: A Topic Related Bibliometric Analysis

Posted on January 31, 2019

Q. D. Gibson1, H. Chen1, J. B. Rose1  1University Of Alabama at Birmingham,Surgery,Birmingham, Alabama, USA

Introduction:
While there is ongoing controversy regarding the utility of bibliometric indices such as impact factor, h-index, and eigenfactor in the evaluation of academic journals and author productivity, there is generally agreement that such factors have value when used appropriately. The current study aims to perform a topic related bibliometric analysis on journal articles about pancreatic cancer.

Methods:
A Scopus database search relating to pancreatic cancer was performed. The search parameters included the keyword “Pancreatic Cancer” in the subject area of “Medicine”. The search was further limited to English language articles from academic journals published after 1993. Publication and citation counts with varying measures of centricity were used to calculate a modified topic specific impact factor

Results:
The search yielded 21,710 articles from 1,690 journals. The article with the most citations dealing solely with pancreatic cancer appeared in the Journal of Clinical Oncology.  The journal with the most publications over the past 25 years is Pancreas. The journal with the most pancreatic cancer related publications per year is Oncotarget with 78.43 articles per year for its 7 years of existence. Six of the top twenty articles were surgery related articles and all six detailed experiences with pancreaticoduodenectomies at a single institution. Of the top 30 journals by article count, the Journal of Clinical Oncology had the highest median citation count.

Conclusion:
Topic related bibliometric analysis provides unique insights into a field of interest.  This analysis demonstrates the value in relating institutional experiences with surgical procedures which is supported by the fact that 30% of the top twenty articles reported institutional experiences with the Whipple procedure. Topic related bibliometric analyses also allow institutions and individuals to target journal submissions, journal subscriptions and literature research.
 

58.18 Pneumoretroperitoneum with Subcutaneous Emphysema after a Post Colonoscopy Colonic Perforation

Posted on January 31, 2019

S. Jaafar1, S. Hung Fong1, S. Misra1,2, K. Chavda1  1Brandon Regional Hospital,GME – Surgery,Brandon, FL, USA 2HCA,West Florida,Tampa, FL, USA

Introduction: Colonoscopy is considered one of the most commonly performed procedure for both diagnostic and therapeutic purposes. However, serious complications such as bleeding, and much rarely, colonic perforation can still occur at a rate of 0.03-0.8% Colonic perforation can be classified as intraperitoneal, extraperitoneal or a combination of both. Majority of the perforations are intraperitoneal, while extraperioneal perforations can manifest as pneumoretroperitoneum, pneumomediastinum, pneumothorax and/or subcutaneous emphysema. We report a rare case of post colonoscopy colonic perforation presenting with peritonitis, pneumoretroperitoneum and subcutaneous emphysema.

 

Methods: A case report was described of a 80-year-old female who underwent a routine colonoscopy and presented with colonic perforation associated with pneumoperitoneum, pneumoretroperitoneum, and subcutaneous emphysema and surgically treated with Hartmann procedure. Related articles were searched through Pudmed, Google Scholar and Cochrane and a review of literatures regarding risk factors; most common site of perforation and the mechanism of perforation; the difference of manifestations and management approach between intraperitoneum and extraperitoneum.

 

Results: Some of the risk factors include advance age, female sex, diverticulosis, previous abdominal surgery and colonic strictures. The most common site of perforation is the sigmoid colon followed by the cecum due to shearing forces applied during endoscopic insertion during dilation, biopsy and/or resection. Majority of the perforation are intraperitoneal, but extraperitoneal can manifest in the mediastinum, pleura, scrotum and subcutaneous tissue. 60% of the combined intraperitoneal and extraperitopeal perforations were treated surgically, while 75% of the isolated extraperitoneal perforation were treated conservatively.

 

Conclusion: Colonoscopy is considered the gold standard for screening colorectal cancer and is useful in the workup of many gastrointestinal conditions, but complication associated with colonic perforation is rare that can manifest intraperitoneal, extraperitoneal or a combination of both. Majority of the intraperitoneal perforation warrant a surgical intervention whereas isolated extraperitoneal perforation can mostly be managed conservatively. Understanding the manifestation of extraperitoneal perforation will help us properly identify the associated morbidities and preventing mortality in these patients.

58.17 Assessment of Post-Trauma Care Provided by Primary Care Providers in the Rural Nebraska Setting.

Posted on January 31, 2019

R. Muehling1, M. R. Goede1, J. I. Summers1, P. J. Schenarts1  1University Of Nebraska College Of Medicine,Department Of Surgery,Omaha, NE, USA

Introduction:   Management of trauma patients in both the pre-hospital and rural hospital setting has been studied extensively.  However, studies evaluating follow-up care by rural primary care providers are nonexistent.  This study aims to answer questions regarding the availability of follow-up and comfort level in rural providers managing discharged trauma patients in the rural setting in Nebraska.

Methods:   The survey was sent to providers in rural Nebraska, which were obtained via the University of Nebraska Medical Center Health Professions Tracking Service. The survey inquired about individual communities and general, orthopedic, and neurosurgeon access, followed by a Likert scale assessing providers’ comfort level treating various trauma conditions.

Results:  The table illustrates the results of the survey, which had a 4.51% response rate.  51.95% of rural hospitals transfer over half of trauma patients, even with surgeon access in the community.  74.71%, 80.46% and 39.08% of communities report general, orthopedic and neurosurgeon access, respectively.  In follow-up, the results demonstrate overall comfort in treating patients after discharge from a trauma center by primary care providers.  Write-in responses mention that continued medical education and communication of discharge plans were important to improve post-discharge care.

Conclusion:  The majority of primary care providers polled are comfortable in handling follow-up care of trauma patients, with the exception being chest, spine, and traumatic brain injuries.  Trauma surgeons can assist providers by supplying educational opportunities and improving communication at discharge between trauma centers and the rural provider.  Future efforts are to survey trauma surgeons in urban areas to determine how comfortable they believe rural providers are with follow-up care to compare perceptions with reality.

 

58.16 Influence Of The Opioid Epidemic On Firearm Violence.

Posted on January 31, 2019

S. Dittmer1, S. Slavova1, D. Davenport1, D. Oyler1, A. Bernard1  1University Of Kentucky,College Of Medicine,Lexington, KY, USA

Introduction:
The opioid crisis is a major public health emergency, killing more Americans than motor vehicle collisions and firearms combined. However, current data likely underestimates the full impact on mortality due to limitations in reporting and toxicology screening that have been previously described. Given the established relationship between illicit drug use and gun-related behaviors, we aimed to explore the relationship between opioid overdose ED visits (ODED) and firearm-associated ED visits (FAED).

Methods:
For the years 2010 to 2017 we analyzed county-level emergency department visits in Kentucky for ODED (per 1,000) and FAED (per 10,000) using Office of Health Policy and US Census Bureau data. Additional variables analyzed included: insurance status, ethnicity, median household earnings, unemployment rate, and education level.

Results:
ODED and FAED visits were correlated (Rho = .178, p < .001) and both increased over the study period, remarkably so after 2013 (p < .001 for increase, Figure 1). FAED visits were higher in rural compared to urban counties (p < .001), while ODED visits were not. In multivariable analysis, FAED visits were associated with ODED visits (B= 0.17, p=.001), rural status (B = 0.33, p = .012), white race rate (B = -2.4, p = .012), and high school diploma rate (-6.45, p < .001) after adjustment for year. Unemployment and earnings were univariate correlates with FAED visits (rho = .19, p < .001 and -.15, p < .001 resp.) but were not significant in the multivariable model.

Conclusion:
In addition to existing nonfatal consequences of the opioid crisis (e.g,. neonatal abstinence, burden on the criminal justice & foster care systems, incidence of opioid use disorder, etc.), firearm violence appears to be a corollary impact, particularly in rural counties. Future analyses should examine opioid use characteristics (e.g., prescription vs. illicit) as well as the impact of interventional models to reduce associated harm.
 

58.15 A System Dynamics Model of Violent Trauma and the Role of Violence Recovery Programs

Posted on January 31, 2019

J. Cirone1, P. Bendix1, G. An1  1University Of Chicago,Surgery,Chicago, IL, USA

Introduction:

Prior exposure to violence is a known predictor for subsequent interpersonal violence (IPV). Violence recovery programs (VRPs) reduce IPV among high-risk individuals using multifactorial, case management approaches (1), however, little is known of the contribution of the individual VRP components. System dynamics models (SDMs) are a type of dynamic computational modeling that has shown utility in understanding other complex healthcare processes (2). SDMs represent systems as a series of “stocks” (populations) that are linked by interconnected “flows” (transitions) that can be configured as complex feedback loops. Running a SDM produces changes in the various population levels due to programmed transition rates linking one population type to another. Here, we model the general epidemiologic dynamics of IPV and how a VRP may influence IPV risk and recovery.

 

Methods:

A SDM was created based on an abstract process model of IPV. The model initially simulates flow between low- and high-risk populations, then through IPV and hospitalization events, a potential for death, and a return to the at-risk population. Risk factors such as prior exposure to violence, gang membership, and education were included in IPV risk and event calculations. We included points at which the interventions of a VRP could influence the transition from high-risk to low-risk populations. Model outputs include: trajectories of population distributions, number of IPV events, hospitalizations, and deaths.

Results: 

The VRP SDM was successfully implemented using the System Dynamics Modeler in NetLogo and incorporated the features noted above. Simulation experiments involved parameter sweeps of initial population levels, IPV event likelihood and population transition rates. Initial validation of the VRP SDM was achieved by observing output behaviors consistent with known patterns of IPV. Simulation runs converged to stable steady states with the greatest effect on IPV produced by varying the transition propensity between high- and low-risk populations. The VRP also functioned in a recognizable fashion, producing the greatest effect in reducing IPV events by increasing the shift from high- to low-risk populations.

Conclusion: 

This initial implementation of the VRP SDM produced recognizable baseline behavior while incorporating the possible effects of a VRP. The VRP SDM will allow us to compare hypotheses of the epidemiology of IPV and evaluate the components of a VRP intervention. Future work will emphasize adding complexity to the VRP SDM and identifying real-world metrics to aid in testing, validation and prediction of the model.

 

References:

1. Cooper C, Eslinger DM, Stolley PD. Hospital-based violence intervention programs work. Journal of Trauma. 2006;61(3):534-537.

2. Homer JB, Hirsch GB. System Dynamics Modeling for Public Health: Background and Opportunities. American Journal of Public Health. 2006;96(3):452-458.

58.14 Cholecystectomy: Exploring the Interplay Between Access to Care and Emergent Presentation

Posted on January 31, 2019

A. Moore1, H. Carmichael1, L. Steward1, C. G. Velopulos1  1University Of Colorado Denver,Department Of Surgery,Aurora, CO, USA

Introduction:
The burden of Emergency General Surgery (EGS) leads to higher cost and less compensation to institutions. A recent study quantified the top 7 conditions contributing to 80% of the burden of EGS; cholecystectomy accounted for >150,000 cases/yr, the highest number of EGS cases that have a potentially elective course. Implications of variation in demographics and access at the local level are unclear, preventing clear strategy formation. We sought to study this more specifically in our population. We hypothesized that our cholecystectomy patient pool would have unique characteristics informing healthcare access in our area.

Methods:
We identified cholecystectomy patients at our academic hospital over a 6-month period from January to June of 2018 and classified them as emergent or elective.  We excluded pregnant patients, patients <18, and patients who had undergone another major procedure concurrently. Cases that initially presented emergently, with interval elective surgery were also excluded from the study. We abstracted patient demographics and clinical course from the EMR.

Results:
Of 289 patients who underwent cholecystectomy, 267 met inclusion criteria. There were no differences in age, sex or BMI between the two groups. Most patients (n=196, 73.4%) had surgery emergently. Emergent patients were more likely to be minorities (65.8% vs. 40.8%, p < 0.001), less likely to have insurance or a primary care physician, and notably 25% of them required an interpreter (see Table). While patients in the elective setting had higher prevalence of chronic symptoms (more than one-month duration), many patients in the emergent setting had duration of symptoms of months to years (n=107 patients, 56.3%). Most patients in the emergent group had acute cholecystitis (n=94, 48%), choledocholithiasis (n=27, 14%) or pancreatitis (13.3%). Elective patients most commonly had symptomatic cholelithiasis (n=43, 61%). Emergent patients had a longer length of stay (2 vs. 0 days, p<0.001). Overall, rates of conversion to an open procedure or other complication were low, without significant differences in emergent versus elective (7.1% vs. 4.2%, p=0.56).

Conclusion:
Significant differences in insurance status and utilizing primary care in our EGS population compared to elective patients indicates several targets for gallbladder disease at our institution. There was also a trend towards increased use of interpreters in this population. The majority of patients in the emergent group experienced chronic symptoms, indicating an opportunity to prevent the necessity of emergency surgery as treatment. This study provides local population characterization for improvements in access to care which can lead to decreases in emergency gallbladder.
 

58.13 A Comparison between Pediatric and Adult Patients Transported to a Rural Trauma Center by Helicopter

Posted on January 31, 2019

E. C. Gray1, M. A. Quinn1, S. Brown1, J. B. Yarger1, J. B. Burns1  1East Tennesse State University,Quillen College Of Medicine Department Of Surgery,Johnson City, TN, USA

Introduction: Helicopter Emergency Medical Services (HEMS) allow rapid transport of trauma patients over long distances which is beneficial in a rural trauma setting. However this rapid transit comes with an increase in monetary cost and risk to both crew and patient. We compared pediatric and adult trauma patients who were transported via HEMS to determine if pediatric patients would have a lower Injury Severity Score (ISS) and be more likely to be discharged home from the emergency department (ED).

Methods: Retrospective data was collected from January 1, 2010 to December 31, 2016 from the trauma registry data for an Appalachian Level 1 adult and pediatric general referral center. All trauma patients arriving via helicopter were included. A chi-square test was used to compare ISS for pediatric and adult patients. Patient disposition was also compared to explore rate of discharge from the ED. Pediatric patients were considered those younger than 16 years of age.

Results: Of 1,604 trauma patients transported by HEMS, 9.8% were pediatric patients and 90.2% were adults. A statistically higher percent of pediatric patients had an ISS of 0-15 versus adults (72.1% versus 59.4% p=0.002) and fewer pediatric patients had an ISS of 16-75 compared to adults (27.9% versus 40.6% p=0.002).  Additionally, pediatric patients were more likely to be discharged to home from the ED (33.1% versus 23.2%)

Conclusion: Pediatric patients transported via HEMS were significantly more likely to have a lower ISS and to be discharged to home. Currently there is no standardized system to triage pediatric patients to HEMS versus ground transport. Based on the data it would appear that EMS providers may benefit from standardization to reduce cost and risk associated with HEMS usage.

 

58.12 The Readability of Patient Discharge Education Materials Among Gastrointestinal Surgery

Posted on January 31, 2019

E. R. Kaplan1, K. Perkins1, A. Liwo1, I. Marques1, J. A. Cannon1, G. D. Kennedy1, M. Morris1, J. Richman1, D. I. Chu1  1University Of Alabama at Birmingham,Birmingham, Alabama, USA

Introduction: Health literacy is a key determinant of health outcomes. Printed material, such as discharge instructions, are commonly utilized in healthcare, but it is unclear if these materials are health literate by readability/understandability standards. According to the American Medical Association (AMA) and National Institute of Health (NIH), a readable document is at or below the 6thgrade reading level. It is unclear whether discharge materials in surgery are at this recommended level. We hypothesized that discharge instructions on a gastrointestinal surgical division are written above a 6thgrade reading level and lack readability. 

Methods: Patient discharge materials were collected from a single-institution surgical service line. Four instruments were used to assess the readability and understandability of the materials: (i) the Flesch-Kincaid Grade Level instrument, (ii) SMOG (Simple Measure of Gobbledygook), (iii) PEMAT (Patient Education Materials Assessment Tool), and (iv) Print Communication Rating (PCR) from the Health Literacy Environment of Hospitals and Health Centers (HLEHH). Two independent observers rated these education materials.

Results:We collected 42 printed education materials from the gastrointestinal surgical service line. Of these, 24 were pre-operative and 18 were post-operative instructions. The overall average FKGL for all materials was 6.90 (standard deviation [SD] ± 0.82), with 90% of the documents scoring higher than a 6thgrade reading level. Material describing vacuum-assisted closure therapy was the most readable (FKGL = 5.3), while the most unreadable material explained general anesthesia and wound care after surgery (FKGL =9. 7). None of the materials were at or below a 6thgrade reading level when analyzed with SMOG. The average SMOG reading grade level of all printed education materials was 10.79 ± 1.34 SD, exceeding the recommended reading grade level by an average of 4.79 grade levels. 40 out of the 42 materials collected were at or greater than a high school reading level. The average PEMAT understandability and actionability score was 57.96% ± 6.28 and 49.13% ± 14.35, respectively, both having a total possible score of 100%. For both understandability and actionability, all but two documents scored lower than 70%, which is unacceptable. The average PCR score was 49.38 ± 1.49 out of a possible 72 points. 

Conclusion:The readability of patient discharge instructions on a surgical service deviates significantly from AMA/NIH recommendations. The majority of material was not at the recommended 6thgrade level. Additionally, all materials lacked understandability and tools for engagement for overall decision making. Increased efforts are needed to eliminate literacy-related barriers of discharge materials. 

 

58.11 Preoperative Frailty Correlates with Postoperative Outcomes in Major Abdominal and Thoracic Surgery

Posted on January 31, 2019

M. M. Mrdutt1, B. Robinson1, E. Bird1, H. Papaconstantinou1, C. Isbell1  1Baylor Scott & White Medical Center-Temple,Department Of Surgery,Temple, TEXAS, USA

Introduction:   Frailty is a measure of physiologic reserve and an emerging metric for risk stratification.  Ideally frailty assessment would be objective, easily administered  during a preoperative assessment, and offer timely information with regard to postoperative complication risk.  We examined the correlation of frailty with postoperative outcomes following major abdominal and thoracic surgery to determine its potential as a risk-assessment tool.

Methods:   Frailty was prospectively measured at a single institution in all elective surgery patients using the Modified Hopkins Frailty Score.  Frailty classification—low (0), intermediate (1-2), or high (≥3)—was calculated based on shrinking (unintentional recent weight loss 10 pounds or greater in the last year), handgrip strength, hemoglobin, and ASA classification.  Demographics and surgical outcomes were obtained from institutional procedure-targeted National Surgical Quality Improvement Program (NSQIP) data for major abdominal (esophagectomy, pancreatectomy, hepatectomy, colectomy, proctectomy, nephrectomy, cystectomy) and thoracic (pulmonary resection) procedures January 2016-June 2017.  Outcomes included any NSQIP complication, readmission, unplanned reoperation or mortality within 30 days, along with discharge location and prolonged length of stay (> 75th percentile of 2015 NSQIP national average).  Logistic regression was performed accounting for demographics, comorbidities and frailty for each complication.   

Results:  Of the 548 patients identified, 426 (77.8%) had a complete frailty evaluation.  Cases included pulmonary resections (17.3%) and abdominal procedures (82.7%); the majority of patients were classified as intermediate (76.5%) or high (10.3%) frailty.  Incidence of any NSQIP complication, readmission and discharge to a facility correlated with frailty classification in univariate analysis (Figure, p<0.05).  Logistic regression demonstrated an increased odds ratio (OR) with increasing frailty for any NSQIP complication (intermediate OR 3.6, high OR 8.9), readmission (intermediate OR 7.5, high OR 15.3) and discharge to facility (intermediate OR 3.3, high OR 10).  There was no significant association with unplanned reoperation, prolonged LOS or mortality. 

Conclusion:  Higher frailty correlates with increased postoperative complications, readmission and discharge location.  These findings provide external validation for the Modified Hopkins Score in major non-cardiac elective cases and provide a link between postoperative morbidity and preoperative frailty.  Preoperative frailty assessment should contribute to perioperative patient optimization and care strategies, specifically in high risk procedures such as those captured by NSQIP procedure targeted cases. 

58.10 Social Determinants of Falls: Are falls a disease of poor white females?

Posted on January 31, 2019

K. Sairafian2, C. Towe2,5, L. Brown1,2, L. A. Kreiner1,2, M. Crandall4, E. R. Haut3, V. P. Ho1,2  3Johns Hopkins University School Of Medicine,Baltimore, MD, USA 4University of Florida College of Medicine Jacksonville,Jacksonville, FLORIDA, USA 5University Hospitals,Thoracic And Esophageal Surgery,Cleveland, OHIO, USA 1MetroHealth Medical Center,Cleveland, OH, USA 2Case Western Reserve University School Of Medicine,Cleveland, OH, USA

Introduction:  

Falls are a leading cause of morbidity and mortality in the elderly.  It is unknown if there are racial or other disparities associated with falling. We sought to determine which social and/or demographic variables are associated with falls in the outpatient Medicare population.

Methods:

We examined data from the 2013 Medicare Current Beneficiary Survey Public Use File, a representatively sampled cross-sectional survey.  Fall was defined as at least one self-reported fall in the preceding year.  We performed a logistic regression, adjusted for survey data characteristics, to determine social/demographic factors (age, sex, race, ethnicity, income, education level, and marital status) associated with fall. In these data, patients <65 have more chronic disease than the general population to meet Medicare eligibility. Presence of physical or cognitive limitations were included in the analysis as possible confounders.  Data are presented as percent (± standard error). Adjusted odds ratios are presented with 95% confidence intervals.

Results:

13,924 Medicare beneficiaries, representing 47 million people, were included.  26.6% (±0.4) reported falling. Females, patients <65 or >74, and patients with physical/cognitive limitations were more likely to report a fall (Table).  Minority patients and males had significantly fewer self-reported falls than white patients and females (See Table, p<0.001 for each).  Low income patients (OR 1.17 [1.04-1.33]) were also significantly more likely to report a fall.

Conclusions:

Black and Hispanic Medicare patients are significantly less likely to have reported a fall than white patients. This finding differs from other health-related disparities in which minorities most commonly experience higher risk or more severe diseases.  These data may also represent differences in self-reporting, indicating disparities in self-reported data in these cohorts. Further studies on social factors related to falling are needed in this population.

58.09 Age-Related Microbiome Differences in Surgical Site Infections

Posted on January 31, 2019

R. Khatri2, T. L. Hedrick1, K. A. Popovsky1, R. G. Sawyer1,2  1University Of Virginia,Charlottesville, VA, USA 2Western Michigan University School of Medicine,Kalamazoo, MICHIGAN, USA

Introduction: Surgical site infections (SSI) contribute to overall morbidity and mortality of the surgical patient. There are numerous risk factors for the development of SSI. We propose that there are variations in the type of pathogen in SSI between different age groups.

Methods: We evaluated patients who underwent surgery at a university hospital from 1997 – 2017 that developed SSI. Patients were divided into age-related cohorts, age ≤ 45 years and age ≥65 years. We assessed immune response, disease severity, types of pathogens within wounds, mortality, and antibiotic therapy. Proportions were compared through use of chi square test and continuous variables were compared using Student’s t test.

Results: As compared to patients age ≥65 years who developed SSI (n=575), patients in age group ≤45 years (n=598) had increased leukocytosis (14.2K vs 13.4K, p=0.06), presence of fever (30.8% vs 20.9%, p<0.0001), and Tmax (37.9oC vs 37.6oC, p<0.0001) at time of diagnosis. Of those infections with positive growth on culture, patients age ≥65 years had higher percentage of Enterococcus spp (27.4% vs 17.5%; p=0.006) and P.aeruginosa (15.8% vs 9.6%; p=0.03) as primary wound pathogen as compared to those patients age ≤45 years. In addition, those patients age ≥65 had greater crude mortality rates (10.6% vs 2.7%; p<0.001). Those in age group ≤45 years had longer overall antibiotic treatment length (12.4 days vs 10.3 days, p<0.001) but were more likely to be prescribed oral antibiotics on discharge (51.3% vs 34.4%, p<0.0001).

Conclusion: Our data suggest that those in the older age group have less robust immune response and are colonized with more aggressive pathogens, which may require inpatient treatment with parenteral antibiotics. These findings may help tailor perioperative antibiotic prophylaxis according to age group and most common pathogens, and help prevent or improve overall morbidity from SSI.

 

 

58.08 Management of Blunt Kidney Injuries in Geriatric versus Non-Geriatric Trauma Patients

Posted on January 31, 2019

J. Saluck1,2, M. Crawford2, A. A. Fokin2, A. Tymchak1,2,3, J. Wycech2,3, M. Gomez3, I. Puente1,2,3,4  1Florida Atlantic University,College Of Medicine,Boca Raton, FL, USA 2Delray Medical Center,Trauma Services,Delray Beach, FL, USA 3Broward Health Medical Center,Trauma Services,Fort Lauderdale, FL, USA 4Florida International University,College Of Medicine,Miami, FL, USA

Introduction:
Nonoperative management (NOM) is the standard of care in majority of blunt kidney injuries (BKI). However, little is known about the effect of age on outcomes of NOM. The aim of this study was to assess the efficacy of NOM in BKI in geriatric vs non-geriatric patients.

Methods:
This IRB approved retrospective cohort study included 86 adult patients, admitted to a level 1 trauma center between 2012 and 2017 with computed tomography (CT) confirmed kidney injuries. 49 patients had isolated BKI, 25 BKI with other solid organ injuries, 9 BKI plus hollow viscus injury and 3 BKI plus abdominal vascular injuries. Patients were separated into 2 groups: Group I ≥65 years old (n=21) and Group II <65 years old (n=65). Age, Injury Severity Score (ISS), kidney organ injury scale (OIS) grade, comorbidities, packed red blood cells transfused within 24 hours of admission (PRBC24), rates of hemoperitoneum, angiography, embolization, Intensive Care Unit length of stay (ICULOS), hospital length of stay (HLOS) and mortality were compared.

Results:

Mean age in Group I was 82.2 vs 36.8 years in Group II (p<0.001). The two groups had similar mean ISS (19.0 vs 22.4; p=0.4) and the same mean OIS grade of 2.3 (p=0.8). Group I had statistically more comorbidities than Group II (90.5% vs 60.0%; p=0.01). Main comorbidities in Group I included hypertension, anticoagulation therapy prior to trauma (p<0.001), and cardiovascular disease. Main comorbidities in Group II included hypertension, obesity, and substance abuse.

NOM was attempted in 100% of Group I patients and in 76.9% of Group II patients (p=0.02). The frequency of attempted NOM was lower in Group II due to higher prevalence of other abdominal injuries. For attempted NOM patients in Groups I and II, mean ISS (19.0 vs 18.1, p=0.9) and OIS grade (2.3 vs 2.1, p=0.7) were similar, which adds to the comparability of the groups. Attempted NOM was successful in 100% of Group I patients and in 93.8% of Group II (p=0.3). Of the 3 patients that failed NOM in Group II, 2 patients failed due to a liver injury and 1 patient due to a spleen injury.

For both groups rates of PRBC24 (33.3% vs 41.5%), hemoperitoneum (52.4% vs 61.5%), angiography (9.5% vs 18.5%), embolization (4.8% vs 4.6%), ICULOS (5.9 vs 7.4 days) and HLOS (8.1 vs 10.5 days) were similar (p>0.4). Group I tended to have higher mortality than Group II (19.0% vs 10.8%; p=0.3) but it did not reach statistical significance. Concomitant traumatic brain injury was the leading cause of mortalities in Groups I and II, at 50.0% and 57.1% respectively. None of the mortality in either group was due to the kidney injury.

Conclusion:
Even with more comorbidities, the advanced age was not a contraindication for NOM and did not affect the success of NOM in geriatric patients with BKI. The severity of kidney injury in both age groups was similar and did not affect the frequency of attempted NOM.

58.07 What are the Clinical Outcomes for Damage Control Laparotomy in Patients of Advanced Age?

Posted on January 31, 2019

A. A. Smith1, C. Guidry1, P. McGrew1, J. Friedman1, R. Schroll1, C. McGinness1, J. Duchesne1  1Tulane University,Surgery,New Orleans, LA, USA

Introduction:  Damage Control Laparotomy (DCL) is an integral component in the immediate management of critically ill trauma patients to control hemorrhage and intra-abdominal contamination. Patients of advanced age have less physiologic reserve and an altered response to traumatic injuries when compared to younger patients. As the population in the United States continues to age, the number of DCLs in patients of advanced age will ultimately increase.  There is a paucity of literature on outcomes for older patients managed with DCL. The objective of this study was to provide evidence for outcomes in older population who received DCL for trauma.

Methods:  A retrospective chart review of consecutive adult patients with DCL for abdominal trauma at a Level I trauma center was conducted from 2012-2017. The patients were stratified into two groups, advanced age (AA) for patients 40 years and older and younger age (YA) for patients less than 40 years of age.

Results: A total of 149 patients with DCLs were identified with an average age of 34.0 (range, 19-81 years). In regards to patient demographics, there was no difference in ISS (p=0.16), mechanism (p=0.44), and initial INR (p=1.0). The AA group did, however, have significantly lower ED SBP (p=0.01) and significantly higher initial fibrinogen (p<0.0001). When analyzing outcomes and interventions, AA patients received MTP more frequently (p=0.03). There was a trend toward increased mortality in the AA group (23% vs 11%) when compared to YA group, though this did not reach significance (p=0.08). Of significance, the AA group had an overall shorter time to mortality (4.5+0.4 vs 8.9+1.2 days, p=0.02).

Conclusion: With an aging population, it is likely that the number of DCLs in older patients will increase. AA patients managed with DCL had decreased initial ED SBP with more utilization of MTP resources and overall shorter time to mortality. Future research should emphasize strategies that will develop optimal management and resource utilization of older trauma patients.

 

58.06 Clinical Frailty Scores Predict Re-admission for Fall Following Trauma

Posted on January 31, 2019

V. H. Hatcher1, D. Skeete1, K. S. Romanowski2  1University Of Iowa,Surgery,Iowa City, IA, USA 2University Of California – Davis,Surgery,Sacramento, CA, USA

Introduction: Falls are a significant cause of morbidity and mortality in the elderly. Frailty scales have been developed, but most cannot be utilized in retrospective studies. The Canadian Study of Health and Aging clinical frailty scale (CSHA CFS) is a 7-point clinical opinion scale validated to predict mortality and institutionalization in elderly internal medicine patients. We hypothesize that patients with higher admission frailty will be admitted more frequently with falls post-index admission.

Methods:  Charts of patients ≥50 years of age admitted for traumatic injuries from 2010 to 2015 were reviewed. Demographics, admission data, and injury severity score (ISS) were collected. Frailty scores were calculated using the CSHA CFS. Statistical analyses were performed using R.

Results: Data were collected from 804 patients (70.3 ± 13.4 years), including 380 men (47.2%). Thirty patients (3.73%) died of their injuries. Frailty scores were similar between survivors and those who died. Mean ISS was 9.83 ± 7.92 and not different between frail (CSHA CFS 5-7) and non-frail patients (CSHA CFS 1-4). One hundred and sixteen (14.4%) patients previously presented with falls. Frailty scores of patients with a history of falls were higher than those of their counterparts (4.64 ± 1.0 vs. 3.85 ± 1.13; p < 0.001). Frailty scores of patients who were readmitted with a fall after traumatic injury were higher than those of their counterparts (4.49 ± 0.97 vs. 3.89 ± 1.15; p < 0.001). The number of falls in the year post-admission of frail patients was higher than that of non-frail patients (1.31 ± 0.74 vs. 0.92 ± 0.77; p < 0.001). On multivariate linear regression analysis, CSHA CFS predicted the number of falls in the year post-admission, while controlling for age and ISS (p < 0.001).

Conclusion: Frailty predicts fall readmission post-trauma and number of falls in the year following trauma admission, but does not influence mortality. 

 

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