53.16 Family Satisfaction in the Trauma and Surgical Intensive Care Unit: Another Important Quality Measure

Posted on January 18, 2018

T. Maxim1, A. Alvarez1, Y. Hojberg1, D. Antoku1, C. Moneme1, A. Singleton1, C. Park1, M. Lewis1, K. Inaba1, D. Demetriades1, K. Matsushima1  1University Of Southern California,Los Angeles, CA, USA

Introduction:  A growing body of research has explored patient satisfaction as one of the healthcare quality measures. Family is also a key component of the healing team for critically-ill patients. Therefore, it may follow that a highly-satisfied family member will be better prepared to provide support for their loved one, participate in the decision-making process, and positively influence patient outcomes. To date, scarce data is available in regards to family experience in the trauma and surgical intensive care unit (TSICU). The purpose of this study was to describe and analyze the results of a family satisfaction survey conducted in the TSICU.

Methods:  A prospective series of patients in the TSICU and their family members at a Level 1 Trauma Center were invited to participate in this study after 72 hours of ICU stay. Family members were instructed to complete the Family Satisfaction in the ICU (FS-ICU) questionnaire, a validated survey measuring family satisfaction in the domains of satisfaction with care and decision-making. Data collection spanned from April 2016 to July 2017. Patient characteristics were compiled from the medical record. Quantitative analysis was performed using a 5-point Likert score, converted to a scale of 0 (poor) to 100 (excellent).

Results: A total of 103 family members submitted responses. Respondents were mostly young (median age 41, interquartile range 29-56) and female (75%). Forty five percent had been involved as family of an ICU patient in the past, and 60.8% reported living with the patient. Language fluency was 44.6% English-only, 31.7% Spanish-only, and 23.8% bilingual. Overall satisfaction with care was high. Mean scores ± standard deviation for the TSICU staff’s concern/caring for the patient and respondent were 86.8 ± 21.5 and 82.8 ± 21.8 respectively. Pain (85.8 ± 21.7) and agitation management (81.0 ± 22.9) earned high scores as well. Respondents were mostly satisfied with their level of inclusion in the decision making process (76.3 ± 24.5) and frequency of communication with ICU nursing staff (79.2 ± 22.8), but less satisfied with the frequency of communication with physicians (70.7 ± 27.4). Language translation at the medical center scored 73.2 ± 31.2, and satisfaction was lowest with the atmosphere of the waiting room (64.8 ± 31.4).

Conclusion: While overall family satisfaction with the care provided to patients in the TSICU is high, opportunities for improvement were noted in the frequency of communication between physicians and family. Given the large cohort of exclusively Spanish-speaking family members, language translation services at the medical center are another area for improvement.

53.13 Selecting Patients for Early Tracheostomy After Spinal Cord Injury

Posted on January 18, 2018

D. Scantling1, E. Gleeson1, J. Fazendin1, A. Galvez1, A. Teichman1, J. Eakins2, B. McCracken1  1Drexel University/Hahnemann University Hospital,Surgery,Philadelphia, PA, USA 2AtlantiCare Regional Medical Center,Trauma Surgery,Atlantic City, NJ, USA

Introduction:
Cervical spinal cord injuries (CSCI) often necessitate ventilator dependence. Although endotracheal tubes are the initial airway access of choice, they convey substantial morbidity and tracheostomy is recommended if ventilator support is anticipated to be 7 days. Identifying patients who will need this duration of support and performing early tracheostomy could prevent substantial morbidity, hospital costs and even survival. Prior attempts to identify these patients have been lacking and this provides little data to discuss with consenting family.

Methods:
A retrospective review of the Pennsylvania Trauma Outcome Study (PTOS) database was performed identifying patients with both a cervical spine fracture and CSCI from 2005-2014. 2,339 patients initially met this description. Patients were excluded for incomplete data, never requiring any ventilator support or death within 6 days. Patients with C1-4 CSCI were included. 223 patients met these metrics. Cohorts were created based on type of CSCI and those needing ventilator support for ≥7 days. ISS, AIS, age, GCS, LOS, ICU LOS, mortality, tracheostomy were evaluated. Analysis was accomplished using confidence intervals, Mann-Whitney U tests and Chi Square.

Results:
Of 223 patients meeting inclusion criteria, 142 had complete C1-C4 CSCI.133/142 required ≥7 ventilator days (93.7%, 95% CI 88.3% to 97.1%) and 120/142 underwent tracheostomy (84.5%, 95% CI 77.5% to 90%). Of those with ≥7 ventilator days, mean highest level of fracture was 3.35, ISS was 55.8, mean ventilator days were 30.54, GCS was 7.60  and GCS motor was 2.59. 20 died and 119 had a surgical airway placed (89.5%, 95% CI 83.0% to 94.1%). Of those with ≤6 ventilator days, mean highest associated fracture level was 4.67, ISS was 35.11, age was 46.33, mean ventilator days was 2.11 (range 1-4). Mean GCS was 14.25 and all patients had a motor score of 6. One underwent tracheostomy. Significant differences were identified between groups for highest level of fracture, ISS, GCS and GCS motor score (p=0.012, p=0.030, p=0.0001, p=0.0001). AIS head, face and neck were not significant (p=0.803, p=0.412 and p=0.624). Compared to previously published data, our methodology identified significantly more patients receiving tracheostomy (84.5% vs 64.2%, p=0.007).

Conclusion:
This data should be used to guide family discussions to promote very early tracheostomy for patients with complete C1-C4 injuries associated with a cervical spine fracture, require any ventilator support and are expected to survive for a week. We anticipate decreases in morbidity, length of stay and hospitalization costs amongst these patients. 

53.14 Trauma/Acute Care Surgeries Performed in the Emergency Room Impact on the Timeliness.

Posted on January 18, 2018

K. Ito1, K. Nakazawa1, T. Nagao1, H. Chiba1, T. Fujita1  1Teikyo University Hospital Trauma And Resuscitation Center,Department Of Emergency Medicine, Division Of Acute Care Surgery, Teikyo University School Of Medicine,Tokyo, , Japan

Introduction:  Timely surgical interventions are important for patients with trauma or acute general surgical diseases. At our institution, we have emergency rooms (ERs) with the operating room (OR) set-up which allow surgeons to perform thoracotomy and/or laparotomy without transferring patients to the OR. This practice pattern is not standard in the United States or other western countries. We conducted this study to assess the overall outcomes of this practice, as well as, to test the hypothesis that the ERs with OR set-up improve the timeliness of surgery for trauma / acutely ill general surgical patients.

Methods:  Patients who underwent emergent surgeries by our acute care surgery group (4/2013 – 6/2017) were reviewed. Patients’ demographics, diagnoses, the location of operation (ER vs regular OR),  type of operations, time from admission to operation, preoperative interventions, postoperative outcomes, and in-hospital mortality were analyzed. These data were compared with patients who underwent surgery in the ER (ER group) and patients who underwent surgery in the OR (OR group). Parametric data were analyzed by Chi-square test. Non-Parametric data were analyzed by Mann-Whitney U test.

Results: There were 322 consecutive patients (105 traumas [33%] and 217 emergent general surgeries [67%]) who met inclusion criteria. Among them, there were 68 patients who underwent surgery in the ER (21%, ER group) and 254 patients in the OR (79%, OR group). Compared to the OR group, The ER group had more trauma patients (74% vs 24%, p<0.001). The time from admission to operation was shorter in the ER group than the OR group (median 57 minutes [range 4 – 1069] vs 170 minutes [range 25 – 1320], p<0.001). For trauma patients, the Injury Severity Score was higher in the ER group than the OR group (median 34 [range 1 – 59] vs 9 [4 – 45], p<0.001). The in-hospital mortality rate was higher in the ER group than the OR group (42% vs 13%, p<0.001). Details of surgeries in the ER were shown on the Table 1.

Conclusion: The ERs with the OR set-up can allow surgeons to start surgery quicker. These surgeries tended to be performed in sicker patients and likely associated with higher. Further study is warranted for selecting patients who benefit best from this approach.

 

53.11 Elderly Pedestrians Struck by Vehicles Are More Likely to Be Admitted in the Morning

Posted on January 18, 2018

D. C. Patel1, T. Li1, N. K. Dhillon1, N. T. Linaval1, L. Kirillova1, D. R. Margulies1, E. J. Ley1, G. Barmparas1  1Cedars-Sinai Medical Center,Los Angeles, CA, USA

Introduction:  Elderly patients are at high risk for mortality following traumatic injury and prevention is of paramount importance. This study’s aim was to identify specific times of the day during which the elderly are more likely to be injured.

Methods:  The Los Angeles County TEMIS database was retrospectively reviewed for all pedestrians ≥ 18 years who were struck by vehicles over a 16-year period (2000-2015). Elderly (≥ 65 years) patients were compared to non-elderly (18-64 years) with respect to the time of admission and mortality.

Results: Of 36,358 patients, 4,871 (13%) were elderly. The proportion of elderly pedestrian injuries was highest between 6-11am (average 21%), peaking between 10-11 am (23%). This proportion started to abruptly drop at noon, reaching the lowest levels between 2-3 am (2%). Compared to their non-elderly counterparts, the elderly were more likely to have a Glasgow Coma Scale ≤ 8 (11% vs. 7%, p < 0.01), a systolic blood pressure < 90 mmHg (6% vs. 3%, p < 0.01), and a higher Injury Severity Score (median 9 vs. 5, p < 0.01). Overall mortality was 6%, significantly higher in the elderly (14% vs. 4%, p<0.01). Elderly pedestrians had almost a 7-fold higher adjusted odds for death (AOR: 6.8, p<0.01).

Conclusion: Elderly pedestrians struck by vehicles are more likely to be admitted during the morning hours and their mortality risk is high. Preventative strategies with lower speed limits or high surveillance during morning hours in highly populated areas may result in a decreased incidence of these injuries.

53.12 The Depth of Sternal Fracture Displacement is Not Associated with Blunt Cardiac Injury

Posted on January 18, 2018

L. Heidelberg1, R. Uhlich1, P. Bosarge1, J. Kerby1, P. Hu1  1University Of Alabama at Birmingham,Acute Care Surgery,Birmingham, Alabama, USA

Introduction:
Despite little evidence to support an association of sternal fractures with blunt cardiac injury (BCI), displaced sternal fractures are viewed as more severe and more likely to result in BCI. Common recommendations include inpatient evaluation for observation and additional diagnostic screening. Little information exists regarding the depth and severity of sternal fracture displacement and it remains unclear if there is increased risk of BCI with increasing sternal fracture depth. The purpose of this study was to quantify fracture severity by the degree of displacement and evaluate the association of fracture severity with BCI.

Methods:
A retrospective review was performed at an American College of Surgeons verified level 1 trauma center from 2011-2014. All adult patients admitted to the trauma surgery service were eligible for inclusion, with patients excluded for pregnancy, age <18 years old, or lack of imaging. Patients with sternal fracture were identified from the trauma registry using ICD-10 codes. Sternal fracture displacement was measured by posterior displacement in the axial plane of computerized tomography of the chest. Fracture displacement was defined as mild (>0 mm, <5 mm), moderate (≥5 mm, <10 mm), or severe (≥10 mm). BCI was diagnosed using electrocardiogram or echocardiograph and graded according to standard AAST grading.  Analysis was performed using χ2 and Student's t-test or one-way ANOVA for categorical and continuous variables respectively. Multivariate regression analysis was subsequently performed to assess the association of sternal fracture displacement with BCI. The primary outcome of interest was the association of BCI with severity of sternal fracture displacement. 

Results:

235 patients with sternal fractures were identified and eligible for inclusion during the study period. 45% of patients suffered a displaced fracture, with the majority of these being mild (65.1%) or moderate (24.5%) in severity. Only 10.4% of patients had severely displaced fractures. Overall, 42.6% of patients were diagnosed with BCI. Of patients with BCI, there was no difference in mean fracture displacement when compared to patients without BCI (2.4 vs 1.6 mm, p=0.07)[Office1] . There was no significant increase in BCI with sternal fracture displacement when compared to patients with non-displaced fractures (44.3% vs 41.1%, p=0.62)[Office2] . While among patients with displaced fractures, the incidence of BCI increased with increasing severity (39.1% vs 50.0% vs 63.6%, p=0.25), this was not significant. Further, neither fracture displacement (OR 1.10, CI 95% 0.65-1.88) nor severe displacement (OR 2.34, CI 95% 0.64-8.54) were associated with significantly increased risk of BCI on multivariate analysis.

Conclusion:
There is no significant association between the depth of sternal fracture displacement and BCI. Further evaluation and management for BCI should be reserved in the absence of additional symptoms or findings.

53.09 A Review of Hydroxocobalamin Use in Patients with Inhalation Injury at a Regional Burn Center

Posted on January 18, 2018

J. S. Vazquez1,2, L. S. Johnson1,2, T. E. Travis1,2, L. T. Moffatt2, J. W. Shupp1,2  1MedStar Washington Hospital Center,The Burn Center, Department Of Surgery,Washington, DC, USA 2Firefighters’ Burn And Surgical Research Laboratory,Washington, DC, USA

Introduction:
Hydrogen cyanide is produced during combustion of several different types of household materials such as synthetic polymers. This small lipid soluble molecule inhibits oxidative phosphorylation and produces a severe lactic acidosis in affected patients. Early identification of cyanide (CN) toxicity allows for treatment with Hydroxocobalamin, a CN binding agent that forms cyanocobalamin, a non-toxic substance excreted by the kidneys. However, even though the medication has a mild safety profile, its high cost should guide judicious use. We evaluated the appropriateness of a single burn center’s administration of Hydroxocobalamin in patients with inhalation injury suspected of having CN intoxication.

Methods:
In this single center retrospective study, pharmacy records where queried for patients that received Hydroxocobalamin between January 2014 through June 2017. Twenty-seven patients received treatment based on the suspicion of inhalation injury and CN toxicity and where included in this study. The electronic medical record of those patients was queried to collect data regarding survival status, clinical parameters, and details surrounding Hydroxocobalamin administration. Blood CN levels were drawn either prior to or immediately after Hydroxocobalamin administration in 20 patients. Clinical criteria for out of hospital administration of Hydroxocobalamin by EMS was decreased GCS in the setting of inhalation injury. As for patients arriving to the trauma bay clinical criteria for physician administration of Hydroxocobalamin was acidosis out of proportion to CO2 retention and an elevated CO level in the setting of inhalation injury.

Results:
A total of 27 patients (mean age 48.9 years; 17 men) were treated with Hydroxocobalamin based on the suspicion of CN poisoning in the setting of inhalation injury. House fires (74%) were the most common cause injury overall. Sixteen patients had GCS <8. A concomitant burn injury was present in 78% of patients (%TBSA 0-95). After correcting for smoking status, 70% of patients had CN levels above normal range (Max 2.79mg/L). Presence of an elevated CN level was used as a surrogate for accuracy of administration. All patients arrived at the burn center within the cyanide half-life. Mortality was 37% in this patient cohort.

Conclusion:

A high index of suspicion should be maintained for the presence of CN toxicity in patient with concomitant burn and inhalation injury. Treatment for CN poisoning should be initiated in any patients with inhalation injury, unexplainable lactic acidosis, or impaired consciousness that cannot be explained only by CO poisoning. In this study, we demonstrated that the medication was administered correctly in 70% of patients. Given the broad therapeutic index of Hydroxocobalamin and the mortality associated with cyanide toxicity, this medication should be used when the correct clinical scenario is present, although the high cost might be a barrier for some centers around the world.

53.10 The Bigger They Are, the Harder They Fall: Obesity and Severity of Proximal Humerus Fractures

Posted on January 18, 2018

R. Belayneh1,2, J. Haglin1, A. Lott1, S. Konda1, K. A. Egol1  1New York University School Of Medicine,New York, NY, USA 2Howard University College Of Medicine,Washington, DC, USA

Introduction: The prevalence of obesity in adults has increased significantly in the United States and worldwide. It has been extensively reported in the literature to cause not only medical problems, but musculoskeletal issues as well. In addition to being associated with high rates of osteoarthritis as compared to normal weight populations, obese patients have a 48% increased risk of trauma, including minor injuries and fractures.  Obesity is also associated with an increased risk of injury to the upper limbs resulting from falls from an individual’s own height, including proximal humerus fractures, which account for 4-6% of all fractures. The purpose of this study is to evaluate if there is a relationship between obesity and proximal humerus fracture characteristics.

Methods:   : Proximal humerus fractures at one academic medical center were prospectively followed. Fractures were classified according to the international AO-Müller/Orthopedic Trauma Association (AO/OTA) classification in order to determine their severity. All Type OTA 11-A proximal humerus fractures were categorized as less severe and type OTA 11-B or 11-C were categorized as more severe. Patients’ Body Mass Indexes (BMI) were calculated and used to identify two groups, BMI ≥ 30 kg/cm (obese) and < 30 kg/cm (non-obese). Variables such as age, gender, height, weight, Charlson Comorbity Index (CCI), AO classification; number of complications, latest follow-up shoulder range of motion (ROM), latest follow-up Disabilities of the Arm, Shoulder, and Hand (DASH) survey scores were also recorded. Independent t-tests were used for statistical analysis of continuous variables and χ2 tests for categorical variables. Regression analysis was performed to determine if BMI was a predictor of severity of fractures as determined by the AO classification. Statistical significance was considered as  p<0.05.

Results: Overall, 190 patients who sustained proximal humerus fractures were available for analysis where the average age at time of injury was 59.6±13.9 years. There were 56 OTA 11-A, 67 OTA 11-B, and 67 OTA 11-C fracture types. 58 patients (30.5%) were obese, while 132 patients (69.5%) were non-obese. No significant differences were seen between groups in regards to age, gender, height, CCI, complication rates, or functional and clinical outcomes as determined by follow-up DASH scores and shoulder ROM, respectively. Statistical analysis also demonstrated that obese patients had greater fracture severity per the AO classification (P=0.025).

Conclusion: Based on the results of this study, obesity is associated with more severe fractures of the proximal humerus as determined by the AO/OTA classification. However, there are no differences outcomes or complication rates between obese patients and non-obese patients. With increasing rates of obesity, this relationship may have important epidemiological implications in the future, including predicting proximal humerus fracture burden and severity in society. Additionally, orthopaedic surgeons should be reassured that performing proximal humerus fixation in obese patients yields similar outcomes and complication rates to non-obese patients.
 

53.07 Impact of Red Blood Cell Transfusion in Severe Pediatric Thermal Injury

Posted on January 18, 2018

A. Nordin1, N. Shah2, R. Devine1, R. Fabia1, R. K. Thakkar1  1Nationwide Children’s Hospital,Department Of Pediatric Surgery,Columbus, OH, USA 2Ohio State University College Of Medicine,Columbus, OH, USA

Introduction:
Blood transfusions in adult trauma patients increase the risk of nosocomial infections, and similar results have been found in adult burn patients. However, the literature regarding transfusion practices and their consequences in pediatric burns is limited. We therefore sought to determine the impact of packed red blood cell (pRBC) transfusions in pediatric patients with severe thermal injury, and hypothesized that pRBC administration would be associated with increased risk of infection and greater length of stay.

Methods:
We utilized our institutional trauma registry to identify all patients 0-18 years old admitted for burns 10% total body surface area (TBSA) or greater between 2007and 2015. Data points collected included demographics, mechanism of injury, TBSA and clinical outcomes including overall and intensive care unit (ICU) length of stay (LOS), number of operative procedures, and the number of nosocomial infections. Nosocomial infections were defined as positive cultures treated with a complete course of antibiotics. The volume of pRBC administered was also analyzed, and patients who received transfusions were compared against those who did not. Variables were analyzed using either student’s t-test or chi square analysis as appropriate.

Results:
142 patients were identified during the study period, and 15 were excluded for incomplete records. Of the remaining 127, 39 (30.7%) received pRBC transfusions and 88 (69.3%) did not require transfusion. The two groups of patients were not significantly different in terms of age, sex or weight. Mean TBSA in the transfused group was 28.7%, as compared to 14.9% among those not transfused (p < 0.001). The volume of blood transfused increased with TBSA burned. Transfused patients had significantly longer overall LOS (45.5 v 11.7 days; p < 0.001), ICU LOS (18.2 v 1.1 days; p < 0.001), and increased ventilator days (8.2 v 0.6 days; p < 0.001).The average number of operations (4.5 v 0.6; p < 0.001) and infections (3.5 v 0.2; p < 0.001) also increased relative to non-transfused patients. There were no mortalities in either group.

Conclusion:
Transfusions in pediatric burn patients are associated with adverse outcomes, including prolonged hospital and ICU LOS and increased infections. However, pRBC transfusion increased with increasing TBSA, suggesting a possible confounding factor. Our results add to existing literature on the prevalence and impact of blood transfusions in severe pediatric burns, and may have implications for the resuscitation and management of children with severe thermal injuries.
 

53.08 Use of Serum Amylase Levels to Diagnose Traumatic Pancreatic Injury

Posted on January 18, 2018

R. Uhlich1, J. Kerby1, P. Hu1, P. Bosarge1  1University Of Alabama at Birmingham,Acute Care Surgery,Birmingham, Alabama, USA

Introduction:
Pancreatic injury is a rare, although potentially devastating consequence of trauma. Diagnosis of and appropriate grading of these injuries remains challenging, with variable sensitivity reported for CT. Other methods, such as magnetic resonance cholangiopancreatography (MRCP) or endoscopic retrograde cholangiopancreatography (ERCP) may improve diagnostic accuracy, however are limited to specialized centers and take longer to perform. Serum amylase has been suggested for use as an adjunctive test to help identify patients with pancreatic injury, but remains controversial. We sought to evaluate its role in the diagnosis and management of pancreatic trauma.

Methods:
A retrospective case control study was performed at an American College of Surgeons verified level 1 trauma center from 2011-2017. All adult patients admitted to the trauma surgery service were eligible for inclusion, while patients with pregnancy or age <18 years old were excluded. Patients with pancreatic injury were identified from the trauma registry using ICD-10 codes. Corresponding controls with thoracic trauma, but without pancreatic or hollow viscus injury, were identified and matched using injury severity score (ISS), age, then gender in a 1:1 fashion. Pancreatic injuries were graded according to the AAST guidelines (Grades 1-5), with major injury identified as ≥ grade 3 (pancreatic ductal injury). Serum amylase levels were recorded from admission and throughout hospitalization. Hyperamylasemia was defined as a serum amylase >103 U/L, according to institutional standard. Analysis was performed using χ2 or Student's t-test for categorical and continuous variables respectively. The primary outcome of interest was admission serum amylase level. Secondary outcomes included serum amylase levels in isolated pancreatic injury and grade of pancreatic injury with elevated serum amylase.

Results:
51 patients with pancreatic injury and 51 corresponding controls were identified. Admission hyperamylasemia was identified in 18 patients with pancreatic injury and 2 controls (p<0.001). Average admission serum amylase levels were significantly increased in patients with pancreatic injury compared to without (122.24±136.37 vs 53.90±60.59, p=0.002), which persisted when controlling for hollow viscus injury (145.93±171.13 vs 48.93±32.35, p=0.006). Among patients with pancreatic injury, 36% (18/51) had hyperamylasemia on admission. Hyperamylasemia did not predict major pancreatic injury (50.0% vs 40.6%, p=0.57), need for operative intervention (100% vs 84.4%, p=0.15), or pancreatic resection (38.9% vs 37.5%, p=0.94) when compared to patients with normal admission amylase. 

Conclusion:
Pancreatic injury results in higher mean levels of admission serum amylase. However, measurement of serum amylase is of questionable clinical value as hyperamylasemia fails to differentiate major and minor pancreatic trauma or need for operative intervention. 
 

53.06 What’s in a name? Provider perception of injured John Doe patients

Posted on January 18, 2018

C. F. Janowak1, S. K. Agarwal2, B. L. Zarzaur3  1University Of Cincinnati,Trauma And Surgical Critical Care,Cincinnati, OH, USA 2University Of Wisconsin,Department Of Surgery,Madison, WI, USA 3Indiana University School Of Medicine,Department Of Surgery,Indianapolis, IN, USA

Introduction:
We previously demonstrated that unidentified, aliased patients, John Doe’s (DOE) are one of the highest risk and medically fragile populations of injured patients.  Aliasing can result in misplaced information and confusion that must be overcome by healthcare professionals.  DOE alias use is institutionally dependent and not uniform.  We sought to determine if healthcare practitioners experience confusion and deliver compromised care by caring for injured DOE patients.

Methods:
After obtaining institutional review board (IRB) approval we surveyed critical care nurses, nurse practitioners, resident physicians and surgeons who care for DOE patients at two academic level I trauma centers with separate DOE alias practices.  Surveys asked whether caring for DOE patients created possible or actual confusion, and possible or actual patient care errors.  In one institution (System 1) only unidentified patients were given an alias that was reconciled when information became available.  In the other (System 2) all trauma patients were admitted with an alias that was reconciled within 24 hours.  Respondents were invited to complete an anonymous questionnaire regarding the care for DOE patients.  Results were analyzed with Wilcoxon rank-sum tests and significance was assessed at a level of 0.05.

Results:
Out of 176 total respondents, 120 (68.2%) reported from System 1, and 56 (31.8%) from System 2.  Overall 53.1% reported that DOE alias use can cause serious confusion possibly resulting in errors affecting patient care.  Specifically, 31.3% reported experiencing actual confusion, although only 4% reported actual errors.  Nurses had significantly higher perceived risk of confusion in the system of all DOE versus selective DOE assignment (35.4% vs. 8.2%, p < 0.01).  Resident physicians reported significantly more frequent actual mistakes within the System 2 versus System 1 (61.9% vs. 17.5%, p < 0.01) despite finding no significant difference in resident perception of confusion (54.5% vs. 37.5% respectively, p = 0.2).

Conclusion:
Our study sheds light on clinical consequences of EMR use and aliases for end users.  We show that nurses perceive there are greater potential complications associated with DOE aliases use, and this varies dependent upon the system used for managing unidentified patients.  Provider confusion, risk for error, and patient safety should be considered in DOE alias use.
 

53.04 Treatment of ICU Delirium with QTc Prolonging Medications Does Not Lead to Cardiac Arrhythmias

Posted on January 18, 2018

J. Zakko1, A. Francis2, C. V. Murphy2, D. A. Eiferman1  1Ohio State University Wexner Medical Center,Department Of Surgery,Columbus, OH, USA 2Ohio State University Wexner Medical Center,Department Of Pharmacy,Columbus, OH, USA

Introduction:  ICU delirium is common in the SICU population and many patients are treated with medications that can cause QTc prolongation, which is a risk factor for the development of Torsades de Pointes (TdP). Serial ECGs are often ordered in this population to assess for QTc prolongation, and effective medications are routinely discontinued due to an increase in QTc for fear of progression to TdP. There is limited data available to determine the risk of TdP in the surgical intensive care unit (SICU) patient population as well as any morbidity from QTc prolongation. This study aims to determine if QTc prolongation is associated with development of TdP.

Methods: A single-center retrospective cohort study was conducted to evaluate QTc prolongation and development of TdP amongst non-cardiac SICU patients being treated for ICU delirium at a large academic medical center. Delirium treatment included at least one of the following medications: haloperidol, risperidone, quetiapine, or olanzapine. QTc prolongation was defined as QTc > 500 milliseconds or >20% increase from baseline. Exclusion criteria included ventricular pacing, bundle branch blocks, incarceration, pregnancy, patients on select antipsychotics prior to admission, and congenital long QT syndrome. The primary outcome was to determine prevalence of QTc prolongation and TdP. Secondary outcomes included SICU mortality and risk factors for QTc prolongation. Univariate and multivariate logistic regression models were constructed for assessment of the outcomes.

Results: Eighty patients were eligible for evaluation. Eight (10%) patients had QTc prolongation. There were no cases of TdP. Assessing patient demographics, concomitant antiarrhythmic and antidepressant use, history of heart disease, diuretic use, hepatic dysfunction, SICU length of stay, length of delirium treatment, and SICU mortality in univariate and multivariate analysis yielded no statistically significant association with development of QTc prolongation, morbidity, or mortality.

Conclusion: Among SICU patients receiving treatment for ICU delirium, the frequency of QTc prolongation was only 10% in our cohort with no cases of TdP. Furthermore, univariate and multivariate analysis did not demonstrate a significant correlation between QTc prolongation and morbidity or mortality. These results suggest that QTc prolongation due to medications used to treat delirium does not lead to the development of cardiac arrhythmias. Furthermore, we propose that serial ECG monitoring may be overused and the subsequent discontinuation of delirium-treating medications may not be necessary in this patient population.

53.05 The Epidemiology of Injuries and Related Surgical Intervention in Aftermath of Tornados in America

Posted on January 18, 2018

M. Rajaei1, R. Griffin2, P. Hu1, T. Swain2, J. Kerby1  1UAB,Division Of Acute Care Surgery, Department Of Surgery, School Of Medicine,Birmingham, ALABAMA, USA 2UAB,Department Of Epidemiology, School Of Public Health,Birmingham, ALABAMA, USA

Introduction: Since 1900, natural disasters in the United States have affected more than 26.5 million people and caused almost $737 billion in damage. Tornadoes are common in North America, where the majority of the 1,000 annual tornadoes occur. These disasters result in hundreds of deaths and further injuries every year. Studying the most common injuries and associated operative interventions in the aftermath of the disasters contributes to more efficient mass casualty management. The purpose of this study was to describe the most prevalent injuries and operative procedures perform on victims of tornadoes in the United States.

Methods: A cross-sectional study was performed using National Trauma Data Bank. Tornado-related injuries were identified using ICD-9 codes. Patient information was collected on demographic, injury location, procedures, and clinical characteristics. Injury severity was measured by Abbreviated Injury Scale (AIS), Injury Severity Score (ISS), and Glasgow Coma Scale (GCS).

Results: From 2003-2013, 1,059 individual-injuries were included. Age was 44±39 years with 53% female. The length of hospital and ICU stay were 10±23 and 8±16 days respectively. The average ISS and GCS were 17±22 and 13±5, with 24.6% having a GCS < 8. Most common injury locations were thorax (53.3%), head (52.2%), lower (51.7%) and upper (53.6%) extremities. Severe injuries happened most commonly in the thorax (40.0%), head (15.2%), and lower extremities (15.2%). Head (85.6%), thorax (79.9%), and spinal (64.3%) injuries were the most common injuries among fatal cases. Severe thoracic injuries occurred nearly twice as common as severe head injuries in patient who didn’t survive the incidents (66.3% vs. 35.9%). Patients were equally admitted to the ICU (35.6%) or regular floor (31.5%) with 20.1% requiring operative intervention prior to admission. The most common procedures were performed on skin/ soft tissue (17.9%); fractures/ dislocations (16.9%); injured vessels (11.0%); chest (7.9%); and muscle/ tendons (5.6%).

Conclusion: ~~Head and thoracic injuries were most common in tornadoes, with the latter being the most prevalent severe injury associated with mortality. While more study is needed, these data could potentially inform disaster preparedness and injury prevention approaches.

53.03 Prehospital Blunt Traumatic Cardiac Arrest: Is It Worth the Resuscitative Investment?

Posted on January 18, 2018

N. R. Manley1, J. Holley1,2, J. Martin2, T. Stavely1, M. Croce1, P. E. Fischer1  1University Of Tennessee Health Science Center,Surgery,Memphis, TENNESSEE, USA 2Memphis Fire Department,Memphis, TENNESSEE, USA

Introduction:  Prehospital resuscitation of patients with blunt traumatic cardiac arrest (BTCA) is known to have extremely poor outcomes when success is considered hospital discharge. However, the results are unknown when survival is defined as hospital discharge or organ donation. Prehospital protocols must be adjusted to decrease futile resource utilization while not sacrificing potential survivors or donors, as one donor can potentially provide 7 organs. We sought to identify factors associated with survival (discharge or organ donation) of patients with BTCA.

Methods:  All adult patients with BTCA transported by our city EMS for 2013-2015 were included.  Data on demographics, prehospital resuscitation, prehospital injury assessment, hospital course and outcomes were collected and analyzed.  Survival was considered either hospital discharge or consideration for organ donation.  

Results:  There were 61 patients with BTCA and overall survival was 5% (1 discharge, 2 organ donation). Two kidneys and one liver were successfully procured allowing 3 transplants.  There was no difference in survivors regarding mean prehospital CPR time (25 vs 24 min) or initial cardiac rhythm.  On prehospital assessment, 36 patients (59%) had documented head trauma and 2 survived (8%).  22 patients (36%) had torso trauma and none survived.  All patients required extensive prehospital resources with an average ambulance service time of 103 minutes. 

Conclusion:  Prehospital resuscitation of BTCA patients with evidence of torso trauma appears futile and these patients should be declared in the field.  However, BTCA patients with no apparent trauma or injuries isolated to the head/face have a small chance of survival to discharge or organ donation and resuscitation should be attempted until further study can elucidate more prehospital predictors of death.

 

52.21 Increasing “Off-label” use of GnRH Agonists among Pediatric Patients in the United States

Posted on January 18, 2018

C. M. Lopez1, D. Solomon1, R. A. Cowles1, D. E. Ozgediz1, D. H. Stitelman1, M. G. Caty1, E. R. Christison-Lagay1  1Yale University School Of Medicine,Department Of Surgery, Section Of Pediatric Surgery,New Haven, CT, USA

Introduction: Gonadotropin releasing hormone (GnRH) agonists are FDA approved for the treatment of precocious puberty. Therapy consists of either histrelin acetate (Supprelin, Endo Pharmaceuticals), a surgically implanted device seen as the preferred form of treatment, or leuprolide acetate (Lupron Depot, Abbvie) injections. In recent years, the use of these agents has been extended to include the “off-label” treatment of a heterogeneous group of pediatric conditions with normally timed puberty including hyperandrogenism, endometriosis, short stature, and gender dysphoria. We sought to investigate the trends in the “off-label” use of GnRH agonists among pediatric patients, hypothesizing that “off-label” usage would preferentially favor those patients covered by commercial insurers.  

Methods: We analyzed data on the use of Supprelin and Lupron reported to the Pediatric Health Information System (PHIS) from 2013 to 2016.  Demographic information and payer status were collected. ICD-9 and ICD-10 diagnostic codes were analyzed to determine whether the indication for therapy was for precocious puberty (“on-label use”) or for other diagnostic codes (“off-label use”).

Results: 39 children’s hospitals within the PHIS provided outpatient surgical and billing data on the administration of GnRH agonist therapies during the study period. During this period, the annual number of unique pediatric patients treated with GnRH agonists for precocious puberty increased modestly, from 283 to 303; meanwhile, the number of procedures for an off-label indication more than tripled from 39 to 125. The increasing use of the Supprelin implants to treat short stature and gender dysphoria were largely responsible for this increase in off-label use, the former increasing from 10 to 46 patients and the latter from 3 to 57 patients over the study period.

When compared to the distribution of patients treated for precocious puberty, commercially insured patients were more likely to receive GnRH agonists for an off-label indication (p=0.047) than those qualifying for public insurance. This disparity was more pronounced in those in whom GnRH agonists were being used to treat short stature or gender dysphoria (p=0.028).

Conclusion: From 2013 to 2016, off-label use of GnRH agonists in children increased more than threefold with the greatest increases seen in the treatment of short stature and gender dysphoria. Patients treated for these conditions were more likely to be privately insured than the larger cohort of patients receiving on-label treatment for precocious puberty, thus identifying a potential disparity in access to care which requires future investigation.  

53.02 Impact of Aggressive Treatments in Trauma: Using the Emergency Department Thoracotomy to Death Ratio

Posted on January 18, 2018

D. C. Patel1, N. K. Dhillon1, A. Ko1, C. Colovos1, N. Melo1, D. R. Margulies1, E. J. Ley1, G. Barmparas1  1Cedars-Sinai Medical Center,Los Angeles, CA, USA

Introduction:  More than 50 years after its introduction, Emergency Department Thoracotomy (EDT) remains a heavily debated procedure due to the absence of high level evidence in its support. We have previously shown that there is significant variation among trauma centers in performing EDT for trauma patients in extremis, with liberal such centers performing additional, unnecessary procedures. We sought to explore the correlation between trauma center practices in regards to the performance of EDT and survival of patients admitted to these centers. We hypothesized that centers that are liberal in performing EDT would not necessarily have increased survival.

Methods:  Level I and II trauma centers contributing data to the National Trauma Data Bank between 2007 to 2011 were included. Centers with < 200 subjects reported and ≤ 25 ED deaths (EDD) during the study period were excluded. The data was aggregated and the counts for EDT and EDD were calculated for each center. All centers were then divided into quartiles based on the ratio of EDT:EDD. A multivariate logistic regression model was then utilized to calculate the adjusted odds ratio (AOR) for mortality for patients admitted to each quartile. Patients admitted to centers with the lowest quartile (Q1) were used as the reference group. The primary outcome was overall mortality and mortality among subgroup of patients, including those with penetrating trauma and those with critical injuries (ISS≥25).

Results: A total of 174 trauma centers admitting 1,432,811 subjects were included. The median EDT:EDD ratio ranged from 0 for Q1 to 17.6% for centers in the highest quartile (Q4). Q4 centers were more likely to be Level I (Q4: 53% vs. Q1: 44%, p=0.03) and an academic center (Q4: 67% vs. Q1: 42%, p=0.05). Compared to patients admitted to Q1 centers, those admitted to Q4 centers had a significantly higher adjusted mortality (AOR: 1.06, p<0.01). This difference applied also to the subgroup of patients with a penetrating injury (AOR: 1.21, p<0.01). There was no difference in mortality for patients with critical injuries (AOR: 1.02, p=0.52).

Conclusion: Trauma centers where emergency department thoracotomy is liberally performed for trauma patients in extremis had higher adjusted mortality compared to less liberal centers. This paradoxical finding might be explained in part by triaging patients at extremely high risk for mortality to these centers that are liberal in performing those procedures. Further investigation of this phenomenon is required to identify areas for potential improvement and standardization of the management of the trauma patient in extremis, avoiding unnecessary interventions.
 

52.18 The Impact of Sociodemographic and Hospital-Related Factors on Length of Stay After Pyloromyotomy

Posted on January 18, 2018

M. Joseph1, E. Hamilton1, K. Tsao1, M. T. Austin1,2  1McGovern Medical School At The University Of Texas Health Science Center At Houston,Pediatric Surgery,Houston, TX, USA 2University Of Texas MD Anderson Cancer Center,Surgical Oncology,Houston, TX, USA

Introduction: Hypertrophic pyloric stenosis (HPS) is a common surgical problem in infants and pyloromyotomy is the curative treatment of choice in this population. Hospitalizations following pyloromyotomy for HPS are usually short, often less than one day.  Recent research has focused on evaluating the presence of health disparities in children and their impact on clinical outcomes.  The purpose of this study was to evaluate the association sociodemographic and hospital factors with post-operative length of stay (LOS) in patients with HPS.

Methods: We identified all patients age < 1 year old hospitalized with a primary diagnosis of HPS in 2006, 2009 and 2012 using the Health Care Utilization Project-Kids Inpatient Database. We included all patients who received an open or laparoscopic pyloromyotomy during the hospital admission. Patient demographics, hospital characteristics and clinical outcomes were collected.  All patients with secondary procedures during the same admission were excluded. Prolonged post-operative length of stay (LOS) was defined as greater than 1 day.  Neonatal age is defined as <= 28 days in the KIDS database.  Binary logistic regression was used to calculate odds ratios (OR) with 95% confidence intervals using SPSS version 24.

Results: A total of 12,401 cases were identified with a diagnosis of HPS. Most (n=7387, 60%) were non-Hispanic White (NHW) followed by Hispanic (n=3159, 26%), non-Hispanic Black (NHB) (n=923, 7%) and Other (n=932, 7%).  The majority had public insurance (n=7551, 61%) followed by private insurance (n=4076 33%) with only 3% uninsured/self-pay.  The median post-operative length of stay was 1.00 + 0.93 days.  By multivariate analysis, the presence of fluid/ electrolyte disorders (OR=1.56, 95%CI:1.41-1.72), neonatal age (OR=1.38, 95%CI:1.26-1.51), NHB and Other race/ethnicity (OR=1.34, 95%CI: 1.15-1.62; OR=1.32, 95%CI:1.12-1.55, respectively), and rural hospital location (OR= 1.67, 95%CI:1.29-2.16) were all independently associated with prolonged post-operative LOS.  Compared to the North, all hospital regions were associated with decreased post-operative LOS: Midwest (OR= 0.72, 95% CI: 0.63-0.82), South (OR= 0.87, 95% CI: 0.77-0.99) and West (OR= 0.83, 95% CI: 0.72-0.94). Insurance status and zip-code based income quartile were not statistically significant predictors of prolonged post-operative LOS.

Conclusion: NHB and Other race/ethnicity were independently associated with prolonged post-operative LOS following pyloromytomy for HPS. Other hospital-related factors were important including rural versus urban location and geographic region.  Further research is needed to better describe and address disparities in the clinical management and outcome of children with HPS.

 

52.20 Severity of Congenital Heart Disease and Timing of Non Cardiac Procedures

Posted on January 18, 2018

K. Weitzel1, D. L. Colon1, J. Philip1, M. S. Bleiweis1, S. Islam1  1University Of Florida,Pediatric Surgery,Gainesville, FL, USA

Introduction: Infants with severe congenital heart disease commonly have other abnormalities requiring general anesthesia and surgical intervention. In cases of elective or semi-elective procedures (non-cardiac), there is little data on when to perform these surgeries and what outcomes are associated with timing differences. The purpose of this study is to assess whether the severity of the condition correlated with any complications in other procedures.

 

Methods: Patients were identified as having cardiac surgical intervention (CI) within their first year using ICD codes and analyzed to identify those patients requiring other procedures with general anesthesia (non-cardiac interventions, NCI). Data regarding demographics, hospital course, CI, NCI, long-term complications and outcomes were collected. The cohort was divided by RACHS scores (risk adjustment for congenital heart surgery) as a proxy for severity of the heart condition. Comparative statistics were performed using the Student’s t test, the Mann Whitney u test, and Fisher’s exact test as appropriate, and a p value of less than 0.05 was considered significant.

 

Results: A total of 343 patients identified had CIs, of which 153 were included who had NCIs. This cohort was subdivided into patients with RACHS of 1-2 (N= 55) and patients with RACHS of 3-6 (N=79).  There were no differences in gender, race, prenatal diagnosis, chromosomal abnormalities, rhythm or other disturbances, type of major procedure, or infection rates between the two groups. There were differences found in gestational age (higher RACHS had higher gestational age), the higher RACHS had higher bypass times, higher RACHS had more major procedures and more inotropes were used after NCI. Complications or mortality were not different (see table please). We also separated the main cohort by the timing of the cardiac surgery (whether the CI was first or the NCI was first) and found no difference in outcomes.

 

Conclusion:  In this cohort of patients, there was no overall difference in morbidity or mortality based on the RACHS. Patients with higher scores were more likely to need inotropes after non-cardiac interventions. There were no differences in the morbidity or mortality when analyzed by the sequence of the procedure. Further analysis is needed to understand the potential differences of inter-stage procedures requiring general anesthesia and what support these patients require postoperatively to help decisions on the appropriate care and treatment of this unique class of patients. 

 

52.15 Racial and Ethnic Disparities in Hospital Resource Utilization Following Appendicitis in Children?

Posted on January 18, 2018

J. G. Ulugia1, T. L. Duncan1, E. R. Scaife1, B. T. Bucher1  1University Of Utah,Division Of Pediatric Surgery, Department Of Surgery,Salt Lake City, UT, USA

Introduction: We sought to assess the impact of race and ethnicity, among other factors, on post-discharge hospital resource utilization following the treatment of acute appendicitis in children.

Methods:  We performed a retrospective cohort study of 45 Children’s Hospitals from 2010-2015. Patients were included if they were diagnosed with acute appendicitis based on International Classification of Diseases, 9th edition, and were 18 years of age or less during the study timeframe. Patients were excluded if they expired during the encounter. The primary predictor was patient defined race and ethnicity, and grouped into non-Hispanic white (NHW), non-Hispanic Black (NHB), Hispanic/Latino (HL) or other. The primary outcome was 30-day post-discharge emergency department (ED) visit or inpatient readmission. Baseline characteristic differences were adjusted to account for disease severity including perforated appendicitis, procedure type, length of stay, and insurance type. The association of race and ethnicity on the primary outcome was assessed using univariate and multivariate logistic regression models computed in R (Version 3.4.0).

Results: Overall, 80,913 patients were identified as meeting inclusion criteria. The median age of our cohort was 11 years (IQR 8-13 years) and 60.3% of them were male. The majority (49.8%) of patients were NHW, 7.1% were NHB, and 32.4% HL. The rate of perforated appendicitis in our cohort was 13.3%, and 92% of children underwent a laparoscopic appendectomy. The overall rate of an ED visit within 30 days of discharge was 5.1%, and the overall rate of inpatient readmission within 30 days post-discharge was 3.9%. Compared to NHW, both NHB (p<0.0001) and HL (p<0.0001) children had a significantly increased rate of 30-day post-discharge ED visits (Table). However, there was not a corresponding increase in 30-day inpatient readmission in NHB (p=0.13) and HL (p=0.13) children compared to NHW. After adjusting for differences in baseline characteristics and disease severity, NHB and HL children had a significantly increased risk of 30-day ED visits. However, there was not a significantly increased risk of inpatient readmission in NHB and HL children (Table).

Conclusion: Compared to NHW children, NHB and HL children treated for appendicitis at US Children’s Hospitals are at a significantly increased risk of returning to the ED within 30 days post-discharge, without a corresponding increase in risk of inpatient readmission. This data suggests a racial and ethnic disparity in post-discharge care of children with appendicitis, and the preferential use of the ED for post-operative follow-up care in NHB and HL children.?

 

52.16 Facilitating Factors In Same-day Discharge After Laparoscopic Appendectomy

Posted on January 18, 2018

O. Cheng1, L. Cheng2, S. Burjonrappa2  1Stony Brook University Medical Center,Stony Brook, NY, USA 2Montefiore Medical Center,Bronx, NY, USA

Introduction:  Appendicitis has been cited to be the most common abdominal disorder that requires acute care surgery in the pediatric population. Enhanced Recovery After Surgery (ERAS) protocols are multimodal perioperative care pathways designed to achieve early recovery after surgical procedures by maintaining pre-operative organ function and reducing the profound stress response following surgery. Such protocols have been found to enhance quality of care for surgical patients, as well as improve recovery and shorten hospital stays. ERAS protocols have been proven to help colorectal surgeries but there are no protocols in place yet for appendectomies in the pediatric population. The purpose of this study is to determine the key factors that facilitate same-day discharge and early return to normal activities after laparoscopic appendectomies in children.

Methods: This is a single-center retrospective chart review of pediatric patients (<18 years old) who underwent appendectomies for acute appendicitis from January 2015 to April 2017. The patient population was divided into two groups: those with same-day discharge and those who were discharged one or more days after surgery. Same day discharge (SDD) was defined as discharge less than 24 hours of surgical admission. Patient factors, including pre-hospital, pre-operative, peri-operative, and post-operative factors, were compared and analyzed between the two groups and statistically evaluated using Fisher two-test for categorical data and student t-test for continuous variables.

Results: 248 patients were found under ICD-9 and ICD-10 codes for acute appendicitis. Of these, 63 were excluded due to perforated appendicitis, non-operative management, interval appendectomies, or misdiagnosis. The remaining 185 had laparoscopic appendectomies; 59.5% (n=110) were SDDs and 40.5% (n=75) stayed more than one day. No significant difference was found for time between ER arrival and surgical admission (5.27 vs 5.38 hours; p=0.8) but SDD patients had a significantly shorter time between surgical admission and operation (5.8 vs 11.4 hours; p<0.001). SDD patients also had fewer intra/post-operative complications (1.8% vs 13%; p<0.01) and patients with complications were more likely to stay. There was no significant difference in readmission rates between the two groups (2.73% vs 2.63%; p=1). Total hospital costs were significantly less for SDD ($29,200 vs $33,700; p<0.001). See table for more values.

Conclusion: Surgical leadership can be effective in facilitating same-day discharge without increasing readmission rates or complications, and helps reduce hospital costs, decreases chances of nosocomial infection, and increases patient and family satisfaction.

 

52.17 Socioeconomic Disparities of Children with Umbilical Hernia Presenting to the Emergency Department.

Posted on January 18, 2018

L. G. Souza Mota1, M. F. Nunez3, G. Ortega2,3, C. M. Smith1, D. S. Rhee4, D. D. Tran2,3  1Howard University College Of Medicine,Washington, DC, USA 2Howard University College Of Medicine,Department Of Surgery,Washington, DC, USA 3Howard University College Of Medicine,Clive O. Callender, MD Howard-Harvard Outcomes Research Center/Department Of Surgery,Washington, DC, USA 4Johns Hopkins University School Of Medicine,Division Of Pediatric Surgery/Johns Hopkins Children’s Center,Baltimore, MD, USA

Introduction:  Children from lower socioeconomic status often experience longer wait times for elective surgery between diagnosis and the operating room, and are even less likely to undergo these procedures. The objective of this study is to investigate socioeconomic disparities among children with umbilical hernias presenting to the Emergency Department by analyzing a national dataset.

Methods:  A retrospective review utilizing the Nationwide Emergency Department Sample from 2009 to 2014 was performed. Patients under 18 with a diagnosis of umbilical hernia were selected. Hernias were categorized as uncomplicated and complicated. Insurance status and median household income were analyzed in unadjusted and adjusted models for the likelihood of presenting with an uncomplicated umbilical hernia to the emergency department.  

Results: A total of 31,327 pediatric patients with an umbilical hernia were identified. Of these patients 56.4% were male. Most of the patients were diagnosed with uncomplicated umbilical hernia (97%). Of which 20.3% had private insurance, 68.7% public, and 8.1% were uninsured. With respect to median household income (MHI), 42.1% were in the first quartile, 27.6% in the second, 19.2% in the third, and 11.2% in the fourth. Three percent of the population had a diagnosis of complicated umbilical hernia, of which 34.7% had private insurance, 56.0% public, and 6.5% uninsured. 34.9% were in the first MHI quartile, 26.3% in the second, 21.2% in the third, and 17.7% in the fourth. On multivariate analysis, uninsured patient and patients using public insurance were more likely to present to the emergency department with an uncomplicated umbilical hernia compared to private insurance, (OR 1.70 95%CI 1.22-2.38) and (OR 1.69 95%CI 1.40-2.04), respectively. Patients in the first and second MHI quartiles were also more likely to present with uncomplicated umbilical hernias compared to highest MHI quartile, (OR 1.42 95%CI 1.10-1.82) and (OR 1.40 95%CI 1.08-1.82), respectively. 

Conclusion: Pediatric patients who were uninsured, had public insurance, or of lower MHI were more likely to present to the emergency department with an uncomplicated umbilical hernia. This may represent a lack of access for publicly insured and uninsured pediatric patients resulting in utilization of the emergency department for non-emergent surgical care.
 

« Previous Page
Next Page »