78.10 Oral Nutrition for Patients Undergoing Tracheostomy: The Use of an Aggressive Swallowing Program

Posted on January 31, 2019

J. Wisener1,2, J. Ward2, C. Boardingham2, P. P. Yonclas1,2, D. Livingston1,2, S. Bonne1,2, N. E. Glass1,2  1Rutgers New Jersey Medical School,Trauma Surgery,Newark, NJ, USA 2University Hospital,Trauma Surgery,Newark, NJ, USA

Introduction:
The insertion of a tracheostomy is thought to compromise protective swallowing mechanisms leading to aspiration and dysphagia. Consequently, clinicians are reluctant to allow oral nutrition for patients with tracheostomies and continue nasoenteric tube feeds. To maximize the number of patients receiving oral nutrition and to minimize aspiration, we began an aggressive swallowing program by dedicated speech and language pathologists (SLP) using fiberoptic endoscopic evaluation of swallowing (FEES). We hypothesized that despite the presence of a tracheostomy, most patients would be able to be safely fed orally and this approach is optimal for this patient population.

Methods:
Retrospective chart review of all trauma patients who underwent a tracheostomy between 7/1/2016-6/30/2018. Data collected included, demographics, injury severity, time to tracheostomy, ICU and hospital lengths of stay. The time to SLP evaluation and FEES as well as outcomes of those assessments were also captured.

Results:
115 patients underwent a tracheostomy during this period with 90 (78%) evaluated by SLP.  72 (80%) underwent FEES and 53 (76%) of those passed and were allowed oral nutrition. 11 (61%) of the 18 patients seen by SLP and not evaluated by FEES had swallowing evaluated by another method and 5 of those were allowed to eat. 40 patients (55%) passed their first FEES. Among those who failed, 21 (66%) underwent a second FEES approximately a week later, and 10 (48%) passed. Total success rate for patients undergoing SLP ± FEES was 70% (58/83). Days between tracheostomy and time of first FEES was not significant between groups (11 vs 15, p=0.486). The median time to passing FEES was 13 days [IQR 7, 20.5]. Patients who passed FEES were younger (42 vs 55 years, p=0.005) and had more severe injuries (ISS 20 vs 14, p=0.03) compared to those who did not pass FEES. Both groups had similar ICU and hospital lengths of stay (32 vs 31, p=0.95 and 43 vs 36, p=0.14). 12 patients underwent PEG placement prior to SLP evaluation; 7 of which passed their FEES and were fed orally.  There were few incidences of documented aspiration in all patients who were orally fed (3/55).

Conclusion:
Over two-thirds of trauma patients who have undergone a tracheostomy can safely take oral nutrition. Aggressive use of SLP and FEES allows oral nutrition, less use of nasoenteric tubes and gastrostomies which likely improves patient satisfaction. Failure to pass a FEES within the first 2 attempts allows objective indications for a gastrostomy tube. As patients who failed FEES were older, age may be a factor in the decision for earlier gastrostomy tube placement. In conclusion, oral nutrition is not only possible, but preferable in trauma patients undergoing tracheostomy and all eligible patients should be evaluated by FEES.
 

78.09 Stop Flying the Patients! Evaluation of the Overutilization of Helicopter Transport of Trauma Patients

Posted on January 31, 2019

C. R. Horwood1, C. G. Sobol1, D. Evans1, D. Eiferman1  1The Ohio State University,Departemnt Of Trauma And Critical Care,Columbus, OH, USA

Introduction: On average, helicopter transport is $6,000 more compared to ground transportation of a trauma patient. Air transport has the theoretical advantage of allowing patients to receive injury treatment more promptly.  However, there are no defined criteria for which patients require expedited transport. The primary study objective is to evaluate the appropriateness of helicopter transport determined by operative care within 1-hour of transfer at an urban level 1 trauma center.

Methods: All trauma patients transported by helicopter from January 2015-December 2017 to an urban level 1 trauma center from referring hospitals or the scene were retrospectively analyzed. The entire cohort was reviewed for level of trauma activation, disposition from trauma bay, median time to procedure. A subgroup analysis was performed evaluating patients that required a procedure within 1-hour of transport compared to the remainder of the patient cohort who were transported via helicopter. Data was analyzed using summary statistics, chi-square test and Mann-Whitney test when appropriate. 

Results: A total of 1,590 patients were transported by helicopter. Only 32% (n=507) were level 1 activations, 60% (n=962) were level 2 activations and 8% (n=121) were not a trauma activation upon arrival. 39% percent of patients (n=612) were admitted directly to the floor from the trauma bay and 16% (n=249) of patients required only observation or were discharged home after helicopter transfer. Roughly 1/3 of the entire study cohort (36%, n=572) required any procedure, with a median time to procedure of 31.5 hours (IQR 54.4). Of which, 13% (n= 74) required a procedure within 1-hour of helicopter transport. There was a significant difference in median ISS score for patients who required a procedure within 1- hour of transport (median 22, IQR=27) vs remainder of cohort transported via helicopter (median 9, IQR=12) (p-value<0.001). The average distance (in miles) if the patient had been driven by ground transport rather than helicopter was 67.0 miles (SD±27.9) and would take an estimated 71.5 minutes (±28.4) for patients who required a procedure within 1-hour compared to 61.6 miles (SD±30.9) with an estimated 66.1 minutes (SD±30.8) for the remainder of the cohort (p-value=0.899 and p-value=0.680 respectively). In the group who required a procedure within 1- hour 24.3% of patients had a penetrating injury compared to 6.4% for the remainder of the cohort (p-value<0.001).

Conclusion: This analysis demonstrates that helicopter transport was not necessary for the vast majority of trauma patients as they did not meet Level 1 trauma activation and did not require emergent interventions to treat injuries. However, there was a significant difference in ISS and type of injury for patients who required a procedure within one hour of transport. Stricter selection is necessary to determine which patients should be transported by helicopter.

78.08 Variability of Radiological Grading of Blunt Cerebrovascular Injuries in Trauma Patients

Posted on January 31, 2019

A. K. LaRiccia1,2, T. W. Wolff1,2, M. O’Mara1, T. V. Nguyen1, J. Hill1, D. J. Magee4, R. Patel4, D. W. Hoenninger4, M. Spalding1,3  1Ohiohealth Grant Medical Center,Trauma And Acute Care Surgery,Columbus, OH, USA 2Ohiohealth Doctors Hospital,Surgery,Columbus, OH, USA 3Ohio University Heritage College of Osteopathic Medicine,Dublin, OH, USA 4Ohiohealth,Columbus Radiology,Columbus, OH, USA

Introduction:  Blunt cerebrovascular injury (BCVI) occurs in 1-2% of all blunt trauma patients. Computed tomographic angiography of the neck (CTAn) has become commonplace for diagnosis and severity determination of BCVIs. Management often escalates with injury grade and inaccurate grading can lead to both under- and over-treatment of these injuries. Several studies have investigated the sensitivity of CTAn, however, there remains a lack in understanding the inter-reader reliability. In this study, we determine the extent of variability in BCVI grades among neuro-radiologist interpretation of CTAn in traumatically injured patients.

Methods:  This was a retrospective review of trauma patients with a BCVI reported on initial CTAn imaging, admitted to an urban, Level I trauma center from January 2012 to December 2017. Patients were randomly assigned for CTAn re-evaluation by two of three blinded, independent neuro-radiologists. The evaluations were compared and the variability among the BCVI grades was measured using coefficient of unalikeability (u), which can quantify variability for categorical variables on a scale of 1-100 where the higher the value, the more unalike the data. Inter-reader reliability of the radiologists was calculated using weighted Cohen’s kappa (k).

Results: In total, 228 BCVIs in 217 patients were analyzed. Seventy-six (33%) involved the carotid vessels, 144 (63%) involved only vertebral vessels, and 8 (4%) involved both. The initial grades consisted of 71 (31%) grade 1, 74 (32%) grade 2, 26 (11%) grade 3, 57 (25%) grade 4, and 0 grade 5. Interpretation variability was present in 93 (41%) of all BCVIs. Initial grade 1 injuries had the lowest occurrence of uniform consensus (u = 1) with a mean of 31% among all interpretations (see figure). Grade 4 injuries had the highest consensus (92%). Grade 2 and 3 injuries had a mean consensus of 63% and 61%, respectively. Total variability of grade interpretations (u = 100) occurred most frequently with grade 3 BCVIs (21%). No significant differences were found between carotid and vertebral injuries. Weighted Cohen’s k calculations had a mean of 0.07, indicating poor reader agreement. Treatment recommendations would have been affected in 30% of these patients, with the treatment scope downgraded in 22% and upgraded in 8%.

Conclusion: Our study revealed BCVI variability of initial radiological grade interpretation in more than a third of patients and poor reader agreement. The reliability of CTAn interpretation of BCVI grades is not uniform, potentially leads to 8% under treatment and worse neurologic outcomes. Comparisons with variability in digital subtraction angiography may be beneficial to further understand the complexity of BVCI radiologic injury grading.

78.07 Does Time Truly Heal All? A Longitudinal Analysis of Recovery Trajectories One Year After Injury

Posted on January 31, 2019

A. Toppo6,7, J. P. Herrera-Escobar6, R. Manzano-Nunez6, J. B. Chang3, K. Brasel2, H. M. Kaafarani3, G. Velmahos3, G. Kasotakis5, A. Salim1, D. Nehra1, A. H. Haider1,6  1Brigham And Women’s Hospital,Division Of Trauma, Burn, & Surgical Critical Care,Boston, MA, USA 2Oregon Health And Science University,Department Of Surgery,Portland, OR, USA 3Massachusetts General Hospital,Division Of Trauma, Emergency Surgery, & Surgical Critical Care,Boston, MA, USA 5Boston University School Of Medicine,Division Of Acute Care, Trauma Surgery, & Surgical Critical Care,Boston, MA, USA 6Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA 7Tufts University School Of Medicine,Boston, MA, USA

Introduction:  We are increasingly aware of the fact that trauma patients that survive to hospital discharge often suffer from significant long-term consequences of their injury including physical disability, psychological disturbances, chronic pain and overall reduced quality of life. The recovery trajectory of traumatically injured patients is less well understood. In this study, we aim to describe the recovery trajectories of moderate-to-severely injured patients from 6 to 12 months after injury.

Methods:  Adult trauma patients with moderate-to-severe injuries (ISS ≥ 9) admitted to one of three Level 1 Trauma Centers in Boston between 2016 and 2018 were contacted by phone at 6 and 12 months post-injury. Patients were asked to complete 12 item Short-Form Health (SF-12) survey to assess physical health, mental health, social functioning, and bodily pain, a validated Trauma Quality of Life (TQoL) questionnaire, and a screen for PTSD. This information was linked to the index hospitalization through the trauma registry. A longitudinal analysis was conducted to evaluate the change in outcomes between 6 and 12 months post-injury. Outcomes were also evaluated for gender and age (young < 65 years of age, old ≥ 65 years of age) subgroups.

Results: A total of 271 patients completed the phone screen at both 6 and 12 months post-injury. Overall, physical health improved significantly from six to twelve months post-injury (p < 0.001), but still remained well below the population norm (Figure 1A). Conversely, mental health was similar to the population norm at both 6 months and 12 months post-injury (Figure 1B). The elderly exhibited better social functioning than the young at both time points and remained within population norms. Young males experienced a significant improvement in social functioning over time, getting to the population norm by 12 months post-injury. Young females in contrast demonstrated no improvement in social functioning over time and remained well below population norms even 12 months post-injury (Figure 1C). Overall, 50% of patients reported having pain daily at 6 months post-injury and 75% of these patients continued to have daily pain 12 months post-injury. Looking at the SF-12 pain scores, only young females experienced significant improvement in bodily pain scores over time (Figure 1D). PTSD screens were positive for 20% of patients 6 months post-injury, and 76% still screened positive at 12 months.

Conclusion: The recovery trajectories of trauma patients between 6 and 12 months post-injury are not encouraging with minimal to no improvement in overall physical health, mental health, social functioning, and chronic pain. These recovery trajectories deserve further study so that appropriate post-discharge support services can be developed.

78.06 Outcomes in Trauma Patients with Behavioral Health Disorders

Posted on January 31, 2019

M. Harfouche1, M. Mazzei1, J. Beard1, L. Mason1, Z. Maher1, E. Dauer1, L. Sjoholm1, T. Santora1, A. Goldberg1, A. Pathak1  1Temple University,Trauma,Philadelpha, PA, USA

Introduction:  The relationship between behavioral health disorders (BHDs) and outcomes after traumatic injury is not well understood and the data is evolving.  The objective of this study was to evaluate the association between BHDs and outcomes such as mortality, length of stay (LOS), and inpatient complications in the trauma patient population.

Methods:  We performed a review of the Trauma Quality Improvement Program (TQIP) database from the years 2013 to 2016 comparing patients with and without a BHD.  Patients were classified as having a BHD if they had a comorbidity listed as a psychiatric disorder, alcohol abuse, drug abuse, dementia, and attention deficit hyperactivity disorder (ADHD).  Psychiatric disorder included major depressive disorder, bipolar disorder, schizophrenia, anxiety/panic disorder, borderline or antisocial personality disorder and/or adjustment disorder/post-traumatic stress disorder.  Descriptive statistics were performed and multivariable regression examined mortality, LOS, and inpatient complications. Statistics were performed using Stata/IC v15.

Results: In the study population, 254,882 (25%) patients were reported to have a BHD. Of these, psychiatric disorders were most prevalent at 38.3% (n=97,668) followed by alcohol abuse (33.3%, n=84,845), substance abuse (26.4%, n=67,199), dementia (20.2%, n=51,553), and ADHD (1.7%, n= 4,301).  There was no difference in age between the groups (mean 44.1 v 44.3 in BHD v non-BHD groups), however, the BHD group was more likely to be female (38.4% v 37.4%, OR 1.04, CI 1.03-1.05, p<0.001).  The overall mortality was lower in the BHD group (OR 0.81, CI 0.79-0.83 p<0.001) when controlling for age, gender, race, injury severity score and non-BHD comorbidities such as stroke, chronic obstructive pulmonary disease, congestive heart failure, diabetes and hypertension. Within the BHD group, patients with dementia had an increased likelihood of mortality when controlling for other risk factors (OR 1.62, CI 1.56-1.69, p<0.001). LOS was 8.4 days (s=0.02) for patients with a BHD versus 7.3 days (s=0.01) for patients without a BHD (p<0.001). Comorbid BHD was significantly associated with any inpatient complication (OR 1.19, CI 1.18-1.20, p<0.001). Select complications are presented in Table 1.

Conclusion: Trauma patients with a BHD have a lower overall mortality risk when compared to those without a BHD. However, subgroup analysis revealed that among patients with a BHD, those with dementia have an increased mortality risk. BHD increased risk for any inpatient complication overall and prolonged the LOS.  Further study is needed to define and understand the risk factors for these associations.

 

78.05 Elderly Falls Hotspots – A Novel Design for Falls Research and Strategy-Implementation Programs

Posted on January 31, 2019

S. Hawkins1, L. Khoury1, V. Sim1, A. Gave1, M. Panzo1, S. M. Cohn1  1Staten Island University Hospital-Northwell Health,Surgery,Staten Island, NY, USA

Introduction:
Falls in the elderly remain a growing public health burden despite decades of research on a variety of falls-prevention strategies. This trend is likely due to current strategies only capturing a limited proportion of those in the community at risk for falls. A new approach to falls-prevention focused on wider community-based dissemination of falls-prevention strategies is called for. We created a model of falls that identifies high risk areas or “hot-spots” for fall risk, identifying community-based study populations for subsequent falls-reduction strategy and implementation research.  

Methods:
We queried the trauma registry of a level 1 trauma center, representing a relatively captured trauma population in a dense urban-suburban setting.  We extracted the resident addresses of all patients age 60 and over who were admitted with a mechanism of falls over the period 2014 to 2017.  We used geographic information systems software to map the addresses to census zones, and generated a heat map representing the fall density within each zone in our region. 

Results:
The area is served by two trauma centers that capture nearly all of the trauma volume of a region with a population of nearly half a million. The county is divided into 107 populated census tracts that range from 0.3 to 1.1 square km. The incidence of falls in the elderly was consistent over the 4 years of study throughout the populated census zones within the hospital’s catchment area. The density of residents who presented to the trauma center with a fall mechanism ranged from less than 1 to 180 per sq km. There were 6 census zones with falls density above 80, which can be considered “hot-spots” for falls risk (see Figure). These zones are similar with respect to land use, population, and demographics.

Conclusion:
Using Geographic Information Systems with trauma registry data identified discreet geographic regions with a higher density of elderly falls. These “hot-spots” will be the target of future community-directed falls-reduction strategy and implementation research.
 

78.04 Early versus late venous thromboembolism: a secondary analysis of data from the PROPPR trial

Posted on January 31, 2019

S. P. Myers1, J. B. Brown1, X. Chen1, C. E. Wade2,3,4, J. C. Cardenas2,3, M. D. Neal1  1University Of Pittsburgh,Division Of Trauma And General Surgery, Department Of Surgery,Pittsburgh, PA, USA 2McGovern Medical School at UTHealth,Division Of Acute Care Surgery, Department Of Surgery, McGovern School Of Medicine,Houston, TX, USA 3McGovern Medical School at UTHealth,Center For Translational Injury Research,Houston, TX, USA 4McGovern Medical School at UTHealth,Center For Translational And Clinical Studies,Houston, TX, USA

Introduction: Venous thromboembolic events (VTE) are common after severe injury, but factors predicting their timing remain incompletely understood. As the balance between hemorrhage and thrombosis is dynamic during a patient’s hospital course, early and late VTE may be physiologically discrete processes. We conducted a secondary analysis of the Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial hypothesizing that risk factors would differ between early and late VTE.

Methods:  A threshold for early and late events was determined by cubic spline analysis of VTE distribution. Univariate analysis determined association of delayed resuscitation with early or late VTE. Multinomial regression was used to analyze association of clinical variables with early or late VTE compared to no VTE adjusting for predetermined confounders including mortality, demographics, injury mechanism/severity, blood products, hemostatic adjuncts, and comorbidities. Serially collected coagulation assays were analyzed for differences that might distinguish between early and late VTE and no VTE.

Results: After plotting VTE distribution over time, cubic spline analysis established a threshold at 12 days corresponding to a change in odds of early versus late events (Figure 1). Multinomial regression revealed differences between early and late VTE.  Variables associated with early but not late VTE included older age (RR 1.03; 95%CI 1.01, 1.05; p=0.01), femur fracture (RR 2.96; 95%CI 0.99, 8.84; p=0.05), chemical paralysis (RR 2.67; 95%CI 1.20, 5.92; p=0.02), traumatic brain injury (RR 14.17; 95%CI 0.94, 213.57; p=0.05), and plasma transfusion (RR 1.13; 95%CI 1.00, 1.28, p=0.05). In contrast, late VTE events were predicted by vasopressor use (RR 4.49; 95%CI 1.24, 16.30; p=0.02) and ICU length of stay (RR 1.11; 95%CI 1.02, 1.21; p=0.02). Sepsis increased risk of early (RR 3.76, 95% CI 1.71, 8.26; p<0.01) and late VTE (5.91; 95% CI 1.46, 23.81; p=0.01). Coagulation assays also differed between early and late VTE. Prolonged lag time (RR 1.05, 95% CI 0.99, 1.1; p=0.05) and time to peak thrombin generation (RR 1.03; 95% CI 1.00, 1.06; p=0.02) were associated with increased risk of early VTE alone. Delayed resuscitation approaching ratios of 1:1:1 for plasma, platelets, and red blood cells among patients randomized to 1:1:2 therapy was a risk factor for late (RR 6.69; 95% CI 1.25, 35.64; p=0.03) but not early VTE.

Conclusion: There is evidence to support that early and late thromboembolic events may differ in their pathophysiology and clinically relevant risk factors. Defining chronologic thresholds and clinical markers associated with temporal trends in VTE distribution may allow for a more individualized approach to thromboprophylaxis.

 

78.03 Association of TXA with VTE in Trauma Patients: A Preliminary Report of an EAST Multicenter Study

Posted on January 31, 2019

L. Rivas1, M. Vella8, J. Pascual8, G. Tortorello8, D. Turay9, J. Babcock9, A. Ratnasekera4, A. H. Warner6, D. R. Mederos5, J. Berne5, M. Mount2, T. Schroeppel7, M. Carrick3, B. Sarani1  1George Washington University School Of Medicine And Health Sciences,Surgery,Washington, DC, USA 2Spartanburg Medical Center,Surgery,Spartanburg, SC, USA 3Plano Medical Center,Surgery,Plano, TX, USA 4Crozier Keystone Medical Center,Surgery,Chester, PA, USA 5Broward Health Medical Center,Surgery,Fort Lauderdale, FL, USA 6Christiana Care Medical Center,Surgery,Newark, DE, USA 7University of Colorado Colorado Springs,Surgery,Colorado Springs, CO, USA 8University Of Pennsylvania,Surgery,Philadelphia, PA, USA 9Loma Linda University School Of Medicine,Surgery,Loma LInda, CA, USA

Introduction: Tranexamic acid (TXA) is an anti-fibrinolytic agent that lowers mortality of injured patients who are bleeding or at risk of bleeding. It is commonly used in trauma centers as an adjunct to massive transfusion protocols in the management of bleeding patients. But, its potent antifibrinolytic activity may result in an increased risk of venous thromboembolism (VTE). We hypothesized that the incidence of VTE events was greater in injured persons receiving TXA along with massive transfusion. 

Methods:  A multicenter, retrospective study was performed. Inclusion criteria were: age 18 years or older, patients who received 10 units or more of blood in the first 24 hours after injury. Exclusion criteria included: death within 24 hours, pregnancy, and routine ultrasound surveillance for possible asymptomatic deep venous thrombosis (DVT). Patients were divided in 2 cohorts based on whether or not they received TXA. Incidence of VTE was the primary outcome. Secondary outcomes included myocardial infarction (MI), stroke (CVA), and death. Multivariate logistic regression analysis was performed to control for demographic and clinically significant variables. A power analysis using expected DVT and PE rates based on prior studies found that a total of 830 patients were needed to find a statistically significant difference with a minimum power of 80%.

Results:269 patients fulfilled criteria; 124 (46%)  of whom received TXA. No difference was noted in age (31 v 29, p=0.81), injury severity score (29 v 27, p=0.47), or mechanism of injury (62% penetrating v 61% blunt, p=0.81). Patients who received TXA had significantly lower systolic blood pressure on arrival (90 mmHg vs 107 mmHg, p=0.002). Incidence of VTE did not differ between the patients who received TXA and those who did not (DVT: 16% vs 13%, p=0.48 and PE 8% vs 6%, p=0.55). There was no difference in CVA or MI. There was no difference in mortality on multivariate analysis (OR 0.67, CI 0.30 – 1.12).

Conclusion:This preliminary report did not find an association between TXA and VTE or other prothrombotic complications.  It remains to be seen if more subtle differences between groups will become manifest when the study accrual is complete. 

 

78.02 Multicenter observational analysis of soft tissue infections: organisms and outcomes

Posted on January 31, 2019

A. Louis1, S. Savage2, W. Li2, G. Utter3, S. Ross4, B. Sarani5, T. Duane6, P. Murphy7, M. Zielinski8, J. Tierney9, T. Schroeppel10, L. Kobayashi11, K. Schuster12, L. Timsina2, M. Crandall1  1University of Florida College of Medicine Jacksonville,Surgery,Jacksonville, FL, USA 2Indiana University School Of Medicine,Surgery,Indianapolis, IN, USA 3University Of California – Davis,Surgery,Sacramento, CA, USA 4Cooper University Hospital,Surgery,Camden, NJ, USA 5George Washington University School Of Medicine And Health Sciences,Surgery,Washington, DC, USA 6JPS Health Network,Surgery,Fort Worth, TX, USA 7University of Western Ontario,Surgery,London, ON, Canada 8Mayo Clinic,Surgery,Rochester, MN, USA 9University Of Colorado Denver,Surgery,Aurora, CO, USA 10University of Colorado,Surgery,Colorado Springs, CO, USA 11University Of California – San Diego,Surgery,San Diego, CA, USA 12Yale University School Of Medicine,Surgery,New Haven, CT, USA

Introduction:  Skin and soft tissue infections (STIs) run the spectrum from mild cellulitis to life-threatening necrotizing infections.  The severity of illness may be affected by a variety of factors including organism involved and patient comorbidities.  The American Association for the Surgery of Trauma (AAST) has spent the last five years developing grading scales for impactful Emergency General Surgery (EGS) diseases, including STIs.  The purpose of this study was to characterize patient and infection factors associated with increasing severity of STI using the AAST EGS grading scale.

Methods:  This study was a retrospective multi-institutional trial, with each of 12 centers contributing 100 patients to the data set.  Patient demographics, comorbidities and infection data were collected on each patient, as were outcomes including management strategies, mortality and hospital and intensive care unit (ICU) length of stay (LOS).  Data were compared using Student’s t-test and Wilcoxon Rank Sum tests where appropriate.  Simple and multivariate logistic regression, as well as ANOVA, were also used in analysis.

Results:1,140 patients were included in this analysis.  The mean age of the cohort was 53 years (SD 19) and 68% of the patients were male.  Hospital stay and mortality risk increased with STI grade (Table 1).  The only statistical difference was noted between Group 3 and Group 5 (p=0.002).  Higher EGS grade STIs were significantly associated with infection by Gram Positive Organisms (GPC) (when compared to Gram Negative Rods (GNR); OR 0.09, 95% CI 0.06-0.14, p<0.001 for Grade 5.  Polymicrobial infections were also significantly more common with higher grade STI (compared to STI Grade 1: Grade 2 OR 2.29 (95% CI 1.18-4.41); Grade 3 OR 5.11 (95% CI 3.12-8.39); Grade 4 OR 4.28 (95% CI 2.49-7.35); Grade 5 OR 2.86 (95% CI 1.67-4.87); all p-values were less than 0.001.  GPC infections were associated with significantly more surgical debridements per patient (GNR 1.64 (SD 1.83) versus 2.37 (SD 2.7), p < 0.001).  There were no significant differences in preponderance of organism based on region of the country except in Canada, which had a significantly higher incidence of GNRs compared to GPCs.  

Conclusion:This study provides additional insight into the nature of STIs.  Higher grade STIs are dominated by GPCs, which also require more aggressive surgical debridement.  Understanding the natural history of these life-threatening infections will allow centers to plan their operative and antibiotic approach more effectively.

 

78.01 Attenuation of a Subset of Protective Cytokines Correlates with Adverse Outcomes After Severe Injury

Posted on January 31, 2019

J. Cai1, I. Billiar2, Y. Vodovotz1, T. R. Billiar1, R. A. Namas1  1University Of Pittsburgh,Pittsburgh, PA, USA 2University Of Chicago,Chicago, IL, USA

Introduction: Blunt trauma elicits a complex, multi-dimensional inflammatory response that is intertwined with late complications such as nosocomial infection and multiple organ dysfunction. Among multiple presenting factors (age and gender), the magnitude of injury severity appears to have the greatest impact on the inflammatory response which in turn correlates with clinical trajectories in trauma patients. However, a relatively limited number of inflammatory mediators have been characterized in human trauma.  Here, we sought to characterize the time course changes in 31 cytokines and chemokines in a large cohort of blunt trauma patients and analyze the differences as a function of injury severity.

Methods: Using clinical and biobank data from 472 blunt trauma patients admitted to the intensive care unit (ICU) and who survived to discharge, three groups were identified based on injury severity score (ISS): Mild (ISS: 1-15, n=180), Moderate (ISS: 15-24, n=170), and Severe (ISS: ≥25, n=122). Three samples within the first 24 h were obtained from all patients and then daily up to day 7 post-injury. Thirty-one cytokines and chemokines were assayed using Luminex™ and were analyzed using Kruskal–Wallis test (P<0.05). Principal component analysis (PCA) was used to define the principal characteristics / drivers of the inflammatory response in each group.

Results: The severe group had statistically significantly longer ICU and hospital stays, days on mechanical ventilation, and higher prevalence of nosocomial infection (47%) when compared to the mild and moderate groups (16% and 24%; respectively). Time course analysis of biomarker trajectories showed that 21 inflammatory mediators were significantly higher in the severe group upon admission and over time vs the mild and moderate groups. However, 8 inflammatory mediators (IL-22, IL-9, IL-33, IL-21, IL-23, IL-17E/25, IP-10, and MIG) were significantly attenuated during the initial 16 h post-injury in the severe group when compared to the mild and moderate groups. PCA suggested that the circulating inflammatory response during the initial 16 h in the mild and moderate groups was characterized primarily by IL-13, IL-1β, IL-22, IL-9, IL-33, and IL-4. Interestingly, and over 16 h post-injury, IL-4, IL-17A, IL-13, IL-9, IL-1β, and IL-7 were the primary characteristics of the inflammatory response in the severe group.

Conclusion: These findings suggest that severe injury is associated with an early suppression of a subset of cytokines known to be involved in tissue protection and regeneration (IL-22, IL-33, IL-25 and IL-9), lymphocyte differentiation (IL-21 and IL-23) and cell trafficking (CXC chemokines) post-injury which in turn correlates with adverse clinical outcomes. Therapies targeting the immune response after injury may need to be tailored differently based on injury severity and could be personalized by the measurement of inflammatory biomarker patterns.

 

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. 

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