29.10 Blunt Cerebrovascular Injury Incidence, Stroke-Rate, and Mortality with the Expanded Denver Criteria

Posted on January 18, 2018

A. Grigorian1, N. Kabutey1, S. Schubl1, M. Dolich1, V. Joe1, D. Elfenbein1, C. De Virgilio2, J. Nahmias1  1University Of California – Irvine,Division Of Trauma, Burns & Surgical Critical Care,Orange, CA, USA 2University Of California – Los Angeles,Harbor-UCLA Medicine Center, Department Of Surgery,Los Angeles, CA, USA

Introduction: Screening for blunt cerebrovascular injury (BCVI) (carotid artery injury [CAI] or vertebral artery injury [VAI]) requires computed tomographic angiography (CTA) of the neck. Conventional indications for screening may miss up to 20% of BCVI. Expanded indications for BCVI screening (expanded Denver criteria [eDC]) were created in 2012. The eDC includes additional signs, symptoms and risk factors to help capture that “missing” 20%. We hypothesized that the introduction of eDC would lead to an overall increase in the incidence of BCVI.  We also sought to identify risk factors for CAI and VAI, as well as whether an increased detection of BCVI would lead to a decrease in stroke rate and mortality.

Methods: The National Trauma Data Bank was queried for all blunt trauma admissions between 2007-2015. Two groups were stratified based on pre-eDC (2007-2011) or post-eDC era (2012-2015). The primary outcome was the incidence of BCVI. Secondary outcomes were stroke-rate and mortality. After a univariate logistic regression model identified significant covariates we performed a multiple logistic regression for analysis.

Results: Of the total 5,635,700 blunt trauma admissions there were 11,741 BCVIs (97.7% CAI, 2.9% VAI). The pre-eDC group was younger (median, 43.5 vs 47.1) with a higher injury severity score (mean, 10.8 vs 9.3). The post-eDC group had a higher prevalence of smokers (14.1% vs 6.1%), history of stroke (2.3% vs 1.9%) and hypertension (29.6% vs 21.3%) (all p<0.001). There were 5,085 BCVI in the pre-eDC group (0.20%), and 6,656 BCVI in the post-eDC group (0.23%) (p<0.001) translating to a 15% increase incidence of BCVI (OR 1.25, CI 1.20-1.30, p<0.001). The stroke-rate in the post-eDC was significantly higher (5.74% vs 13.49%) (OR 2.75, CI 2.40-3.15, p<0.001). There was no difference in mortality or number of patients with traumatic brain injury (p>0.05). The strongest predictors for BCVI were skull base fracture (OR 3.61, CI 3.46-3.77, p<0.001) and cervical spine fracture (OR 3.43, CI 3.29-3.57, p<0.001). The most significant independent traumatic risk factor for VAI was cervical spine fracture (OR 19.98, CI 15.85-25.19, p<0.001) while skull base fracture was the most significant for CAI (OR 3.62, CI 3.46-3.78, p<0.001). CAI was more likely to be associated with stroke than VAI in blunt trauma victims (OR 19.62, CI 18.25-21.10, p<0.001).

Conclusion: The incidence of BCVI following blunt trauma has significantly increased in the past few years.  This increase may be related to the adoption of expanded criteria for CTA of the neck in at risk patients.  Skull base fracture was the strongest traumatic risk factor for BCVI. CAI is more likely to be associated with stroke than VAI. Although detection may have increased, the stroke-rate doubled. Future research will be needed to investigate this further.

29.08 Effect of a Dedicated Pain Management Service on Trauma Patients with Rib Fractures

Posted on January 18, 2018

S. A. Bellister1, R. D. Betzold1, S. E. Nelson1, D. P. Stonko1, R. A. Guyer1, T. J. Hamilton1, J. P. Wanderer1, O. L. Gunter1, O. D. Guillamondegui1, B. M. Dennis1  1Vanderbilt University Medical Center,Division Of Trauma And Surgical Critical Care,Nashville, TN, USA

Introduction:   Rib fractures are a source of significant morbidity. Inadequate pain
control compromises respiratory function which can lead to respiratory complications and
adverse outcomes. A dedicated pain management service provides expertise in
multimodal pain management techniques which may mitigate these events. We sought to
assess the effect of a comprehensive pain service (CPS) on the outcomes of patients with
rib fractures.

Methods: A retrospective analysis on all adult patients (age ≥ 16) with more than 2 rib
fractures at a level 1 trauma center from September 2010 through December 2015 was
executed. 1:1 propensity matching was performed on the likelihood of receiving a CPS
consult. Demographic, injury data and medication use were examined. The primary
outcome was in-hospital mortality, secondary outcomes included pneumonia,
tracheostomy, 30-day ventilator-free days and 30-day ICU-free days. Mortality,
pneumonia and tracheostomy were analyzed using logistic regression, while 30-day
ventilator-free days and 30-day ICU-free days required proportional odds ordinal logistic
regression.

Results: 3,215 patients that met inclusion criteria, with a final matched cohort of 1,022
patients receiving CPS consults and 1,022 without consult. Demographics (mean age)
and injury (ISS and rib fractures) were similar in both groups. CPS consult was associated
with decreased mortality (OR 0.52, 95% CI 0.30-0.88). CPS consultation was associated
with decreased pneumonia (OR 0.58, 95% CI 0.37-0.89), tracheostomy (OR 0.54, 95%
CI 0.36-0.81), and 30-day ICU-free days (OR 0.68, 95% CI 0.58-0.80). There was
increase in 30-day ventilator-free days (OR 1.28, 95% CI 1.03-1.60) with CPS consult.

Conclusion: A comprehensive pain service consultation in rib fracture patients is
associated with a nearly 50% reduction in mortality, as well as reductions in pneumonia
and tracheostomy rates. There also is an increase in ventilator-free days in patients with
CPS consults.

 

29.09 Isolated Parafalcine Subdural Hematoma: A Clinically Insignificant Finding

Posted on January 18, 2018

B. N. Cragun1, M. R. Noorbakhsh1, F. Hite Philp1, M. F. Ditillo1, E. R. Suydam1, A. D. Murdock1  1Allegheny General Hospital,Pittsburgh, PA, USA

Introduction:
Isolated parafalcine subdural hematoma (SDH) represents a common cause of trauma admission.  Although no distinction is made with regard to location or type of bleed in the guidelines for management of SDH, parafalcine SDH may represent a distinct clinical entity with differing clinical behavior.  We hypothesize that isolated parafalcine bleeds, as compared to other SDH, were unlikely to require neurosurgical intervention and do not benefit from critical care monitoring. 

Methods:
Trauma registry data was used to identify patients presenting to a single level I trauma center with isolated intracranial hemorrhage (ICH) from February 2016 to April 2017.  Isolated ICH was defined as abbreviated injury score (AIS) of ≥3 for head and <3 for any other body location, and we further identified patients with isolated SDH.  Data reviewed included: neurosurgical interventions, radiographic worsening of the bleed, mortality, level of care, GCS on admission and discharge, disposition, and demographics.

Results:
We identified 164 isolated SDH, of which 45 had isolated parafalcine ICH.  Antiplatelet or anticoagulant use was equally prevalent in both groups (49% of parafalcine bleeds vs 54% in other SDH).  Average age was 68 ± 21.  Parafalcine SDH had a similar rate of radiographic progression (8.9% vs 11.8%), but none had neurological deterioration and none required neurosurgical intervention.  Mortality was significantly lower in parafalcine SDH as compared to other SDH (0% vs 10.1%, p=0.04).  Mortality, length of stay (LOS), neurological deterioration, radiographic worsening, and need for neurosurgical intervention are compared between the two groups as summarized in Table 1.

Conclusion:
Our data showed no mortality, no clinical worsening, and no neurosurgical intervention in parafalcine SDH, suggesting that parafalcine bleeds represent a benign entity as compared to other SDH.  While several patients with parafalcine bleeds had radiographic progression, this did not translate to neurological deterioration or need for intervention.  This data suggests that admission to an ICU, as well as interval imaging, are unlikely to be helpful in the setting of isolated parafalcine SDH.  Collectively, these data begin to build evidence for our consideration of a change in practice in the management of parafalcine SDH, as they appear to be a distinct clinical entity from other types of SDH in our trauma population. 

29.07 Trauma Recidivism and Mortality Following Violent Injuries in Young Adults

Posted on January 18, 2018

A. M. Kao1, K. A. Schlosser1, M. R. Arnold1, P. D. Colavita1, R. F. Sing2, T. Prasad1, A. E. Lincourt1, B. R. Davis1, B. T. Heniford1  1Carolinas Medical Center,Gastrointestinal And Minimally Invasive Surgery,Charlotte, NC, USA 2Carolinas Medical Center,Trauma/Critical Care,Charlotte, NC, USA

Introduction: Trauma recidivism accounts for a significant number of emergency department and trauma center admissions. Injuries associated with recurrent violent trauma result in increased treatment costs and are a significant public health burden due to higher rates of morbidity and mortality in this patient cohort.

Methods: A prospectively maintained registry of patients presenting to a Level 1 Trauma Center was queried for patients ages 18 to 25 years who sustained a gunshot wound (GSW), stab wound, or blunt assault between 2009-2015. Demographics, injury data, and discharge disposition were reviewed. Patients presenting with violent injuries were compared using Chi square, Fisher’s exact tests and Kruskal-Wallis test. Primary outcomes included mortality and trauma recidivism, identified by patients who presented with at least two unrelated violent traumas during the study period. Re-hospitalization for complications resulting from the initial injury was excluded. Out-of-hospital mortality was identified using the Social Security Death Database.

Results:A total of 6,484 patients between 18-25 years presented to the Level 1 Trauma Center; 1,215 (18.7%) had sustained a blunt assault, GSW, or stab wound. Patients with violent injuries were 87.4% male, with mean age of 22.1±2.2 years; the distribution of injuries included 64.4% GSW, 21.1% stab, and 14.8% blunt assault. Compared to patients in the same age cohort who sustained non-violent injuries, patients with violent injuries had a greater risk of mortality (8.0% vs. 2.1%, p<0.0001).  Out-of-hospital mortality was 1.3% (vs 0.46% in non-violent, p<0.0005), with average time to death of 5.2±14.6 months from initial injury. The delayed mortality was significantly more likely in patients who initially presented after a GSW (89.7% vs 5.2% stab wound or 5.2% blunt assault, p<0.0001). Recidivism was 23.5% with mean time to second violent injury at 31.9±21.0 months; 15.0% had two unrelated trauma readmissions and 6.0% had 3 or more unrelated admissions. 90% of subsequent injuries occurred within 5 years, with 19% in the first 12 months. Initial injury in recidivists was GSW in 63.3%, compared to 22.3% with initial injury of stab wound and blunt assault 22.3% (p<0.001). 59.6% of patients who returned with an unrelated, second violent injury sustained a blunt assault, followed by GSW (26.6%) and stab wound (13.7%). There was no difference in age, length of stay, initial ED vitals, or injury severity score that correlated with trauma recidivism.

Conclusion:
In young trauma patients sustaining a violent injury, the burden of injury extends past discharge as patients have a significantly higher rate of mortality after discharge.  Nearly one-quarter of patients will represent due to violent trauma.  Improved medical, psychological, and social collaborative treatment of these high-risk patients is needed to interrupt the cycle of violent injury.

29.05 Alcohol Intoxication and Burn Injury Outcomes: A Propensity Score Analysis

Posted on January 18, 2018

L. T. Knowlin1,2, B. A. Cairns1, A. G. Charles1  1University Of North Carolina At Chapel Hill,Surgery,Chapel Hill, NORTH CAROLINA, USA 2Howard University Hospital,Surgery,Washington, DISTRICT OF COLUMBIA, USA

Introduction: Approximately half  of burn-injured patients have detectable blood alcohol levels at the time of hospital admission. Alcohol use has been hypothesized to exacerbate the immunosuppression process that occurs following burn injury leading to increase morbidity and mortality. We sought to examine the effects of alcohol intoxication on burn injury outcomes.

Methods: Patients ≥14 years old admitted to a large, tertiary care referral burn center between 2002 and 2012 were eligible for inclusion. The effect of alcohol intoxication on infection complications and in-hospital mortality was evaluated using standardized Cox proportional hazard regression. Models were standardized using inverse-probability of treatment weights to account for confounding by patient demographics and burn characteristics.

Results:A total of 1,719 patients were included in the study. Of these,19% (n = 329) had blood alcohol concentration (BAC) > 0 on admission and 13% (n =221) had a blood alcohol concentration above the legal limit (> 0.08). 31% (n=548) developed an infection complications such as pneumonia, wound infectin, urinary tract infection, or sepsis. There was no difference in the crude mortality rate for patients with any positive alcohol use (11% vs 8.6%, p> 0.05) and those with a BAC above the legal limit (12.6% vs 8.6%, p>0.05)  compared to sober patients. Intoxicated patients had a higher infection rate compared to sober patients (26% vs 15%, p<0.05).  A weighted Cox regression estimated increase hazard of progression to 30 day in-hospital mortality of 12% (HR = 1.12, 95% CI = 0.63-2.00) for positive alcohol use and 64% (HR = 1.64, 95% CI 0.84- 3.22) for BAC above legal limit compared to sober patients but was not significant.The adjusted 60-day cumulative risk for infection complications in alcohol intoxicated patients with inhalation injury was the highest at 35% compared to sober patients with inhalational injury, alcohol intoxicated without inhalational injury and sober without inhalational injury (35% vs. 29.1%, 27.2%, and 22.1%, respectively).(Figure 1)

Conclusion:Alcohol intoxication did not significantly increase risk of inpatient mortality compared to sober individuals following burn injury. However, alcohol intoxication had a significantly higher cumulative risk of infection complications. The immunosuppression response after burn injury is magnified in alcohol intoxicated individuals prompting the need for future therapeutic interventions to reduce poor outcomes among burn patients who drink alcohol.

 

29.06 Nationwide Analysis of Motor Vehicle Collision Readmission and Reinjury

Posted on January 18, 2018

J. Parreco1, T. L. Zakrison1, A. D. Badilla1, R. Rattan1  1University Of Miami,Miami, FL, USA

Introduction:

No nationally representative studies of motor vehicle collision reinjury have tracked readmission across different hospitals, having been previously limited to single hospitals. The purpose of this study was to perform the first nationwide analysis of risk factors for motor vehicle collision reinjury and readmission, including to different hospitals, among non-motorcycle and motorcycle collisions.

 

Methods:

The Nationwide Readmissions Database for 2013-2014 was queried for all admissions involving motor vehicle collisions. Survey weights were used to provide national estimates. Reinjury and all-cause readmission were identified. Multivariable logistic regression was used to identify risk factors.

 

Results:

In the 399,763 patients admitted during the study period index admission mortality rate was 2.8%, 1-year readmission rate was 10.1%, and 1-year reinjury rate was 0.85%. Motorcycles were involved in 17.7% of collisions and had a higher reinjury rate (0.99% vs 0.82%, p<0.01), and had higher median admission cost ($15,014 [$8,650-$29,559] vs $12,803 [$7,356-$25,026], p<0.01). After controlling for confounding factors through multivariable logistic regression, motorcycle collision was associated with an increased risk for reinjury (OR 1.19, p<0.01) compared to non-motorcycle collisions. Risk factors for reinjury included: leaving against medical advice (OR 2.26, p<0.01), age 25-41 (OR 1.47, p<0.01), and ISS > 15 (OR 1.32, p<0.01). Protective factors included: admission to large (OR 0.75, p<0.01) or medium-sized hospitals (OR 0.82, p=0.01) and private insurance (OR 0.80, p<0.01).

 

Conclusions:

This is the first nationwide study representing the largest evaluation of readmission and reinjury after motor vehicle collision, including readmission to different hospitals. Motorcyclists have higher reinjury rates. The identified risk factors offer areas for further study in injury and reinjury prevention.

 

29.03 Keeping Your Head: Making the Case for a Hospitalist Neurosurgeon

Posted on January 18, 2018

E. Turner1, K. A. Hollenbach1, W. D’Angelo1, B. Chung1, J. Rappold1  1Maine Medical Center,Acute Care Surgery/Surgery/Tufts University School Of Medicine,Portland, MAINE, USA

Introduction: Traumatic brain injury (TBI) affects patients of all ages and genders and often results in significant morbidity and mortality. This is particularly true for patients with moderate to severe TBI (GCS 3-12) who often require emergent neurosurgical (NS) interventions (ICP monitoring, EVD, craniotomy and/or craniectomy). In rural states, this access is often limited or requires transfer to higher level of care facilities, resulting in a significant delay to intervention. To address this issue, our rural ACS verified Level I trauma center (TC) instituted a program whereby a single, dedicated neurosurgeon was available Monday through Friday for emergent NS consultations and operative procedures as indicated.

Methods: A retrospective cohort study was conducted at a rural Level I trauma center utilizing the institution’s trauma registry. Information on all trauma admissions from 1 October 2012 through 30 September 2016 with TBI were included. Standard demographics and injury related variables were abstracted. Survival by period of care (pre-hospitalist NS; 1 October 2012-30 September 2014 to post-hospitalist NS: 1 October 2014-30 September 2016) was analyzed using logistic regression to control for patient age and injury severity. Subsequent analyses were conducted by whether care was provided Monday – Friday versus Saturday – Sunday across the entire study period and for each of the two periods of interest.

Results:

A total of 7005 patients were admitted to the trauma service of which 1968 TBI patients were identified: 959 pre-hospitalist NS (PRE) and 1009 post-hospitalist NS (POST) with mortalities of 8.76% and 7.04%, respectively.  Patients were slightly older and had significantly greater ISS score in POST group. After adjusting for the confounding effect of age and ISS, POST patients were significantly less likely to die than PRE patients (OR = 0.62; 95% CI = 0.42, 0.90).  Stratification by weekend or weekday treatment identified an even stronger protective effect among patients with TBI during the weekdays when the dedicated neurosurgeon was available (OR = 0.55; 95% CI = 0.34, 0.89).    

Conclusion: This study demonstrates significant decreased mortality after instituting a designated hospitalist neurosurgeon readily available for emergent consultation and rapid operative intervention for patients with TBI. When restricted to weekday treatment, the effect was more pronounced, lending support for expanding the designated NS hospitalist role within our hospital as well as encouraging other TCs to explore the potential benefit of a dedicated hospitalist NS at their centers.

 

29.04 The Burden And Epidemiology Of Gun-related Hospital Admissions In The United States: 2003-2014

Posted on January 18, 2018

S. C. Gale1, J. Kocik1, J. S. Murry1, V. Y. Dombrovskiy1  1East Texas Medical Center,Acute Care Surgery,Tyler, TX, USA

Introduction:
Despite the important social, political, and financial implications, the nationwide annual burden and trends for gun-related hospital admissions in the US are not well described. We examined the epidemiology of all gunshot wound (GSW) related hospital admissions in the US over a 12-year period

Methods:
The Nationwide Inpatient Sample was queried (2003-2014) for GSW-related admissions using all pertinent ICD-9-CM codes. Demographics, injury circumstances, and mortality were compiled and examined. Chi square, t-test and Armitage trend test were used. P<0.05 was significant.

Results:
Of 445,884,043 US admissions over 12 years, 354,043 (0.08%) sustained GSW. Mean GSW admissions were 29504 ± 3127 annually. Notwithstanding a 2010 spike, GSW admissions trended lower over time (Figure 1) and remained stable and very small proportion of total admissions (0.076% to 0.077%; p=0.50). Over 12 years, the population rate of GSW hospitalizations per 100000 decreased from 9.7 to 8.6 (p<0.0001). Demographically, patients were most likely male (89%), African-American (49%), in the South (43%), and uninsured (p<0.0001 for all). Mean age was 31±13.  Data on circumstances (assault (64.4%), unintentional (24.4%), suicide (9.3%), and legal (2%)) demonstrate that rates for assaults decreased significantly over time, while suicide attempts, unintentional injury and legal intervention all remained stable. Mortality was 8% with a slight increase over time (p<0.04) and was highest amongst suicides (34%), followed by legal intervention (7.8%). During the study period, costs increased by 24% (p<0.0001) while length of stay remained stable at 7 days. In 2014, the uninsured rate markedly dropped while rates for Medicaid enrollment sharply rose.

Conclusion:
National data demonstrate an overall decrease in GSW-related hospitalizations over the 12-year period – most attributable to a decrease in assault-related shootings. Suicide attempts were most likely associated with in-hospital mortality. Despite high-profile events, hospitalization data do not support publicized claims of increased gun-related violence in the United States.
 

29.01 Indicators of Shock In Trauma: Anything Is Better Than Nothing, But Lactate Is Best!

Posted on January 18, 2018

A. Jordan1, W. Terzian1, T. R. Wojda3, M. S. Cohen2, J. Luster4, J. Seoane4, P. Salen2, H. Stankewicz2, E. McCarthy3, S. P. Stawicki1,3  1St. Luke’s University Health Network,Department Of Surgery,Bethlehem, PA, USA 2St. Luke’s University Health Network,Department Of Emergency Medicine,Bethlehem, PA, USA 3St. Luke’s University Health Network,Department Of Research & Innovation,Bethlehem, PA, USA 4Temple University,St. Luke’s University Hospital Campus,Bethlehem, PA, USA

Introduction: Mortality prediction in trauma continues to be challenging, with unexpected deaths continuing despite better understanding of pathophysiology and clinical management of trauma-related shock. Several laboratory variables have been evaluated for their ability to quantitate mortality risk in injured patients. Despite individual drawbacks, popular indicators of physiologic stress are serum bicarbonate (SB), anion gap (AG), base deficit (BD), and lactate. The aim of this study was to compare the utility and mortaliy prediction for each of these variables in a large, single institution trauma patient sample.

Methods: After IRB approval, we queried our Level I Trauma Center registry records for patient sex, age, ISS, GCS, mortality, and initial (trauma bay) laboratory assessments (comprehensive metabolic panel + subcomponents, arterial + venous blood gases). Main outcome variable was 30-day mortality. Analyses included the examination of stratified AG (≤3, 6, 9, etc), BD (≥16, 12, 8, etc), SB (≤10, 14, 18, etc) and lactate (≤1, 2, 3, etc) versus 30-day mortality (adjusted for sex, age, and ISS). Additional comparisons evaluated the ability of each of the above variables to predict mortality using receiver operating characteristic (ROC) curves (DeLong method). Data are reported as mean±standard deviation (SD) or median with interquartile range (IQR). AUC values are reported as area±standard error (SE). Statistical significance was set at α<0.01.

Results: The study sample included 2,811 patients (70% male; median age 44 yrs with IQR 26-58 yrs, median ISS 9 with IQR 4-16, and 5% mortality). Available laboratory values included: mean serum lactate 2.83±2.51 (n=371), mean BD 1.27±5.01 (n=1,167), mean SB 24.8±5.29 (n=2,165), and AG 11.2±6.80 (n=2,128). Mortality increased with escalating physiologic stress, as reflected by each indicator corrected for age, sex, and ISS (Fig 1; all p<0.001). Overall, serum lactate was the best predictor for mortality (AUC, 0.75±0.04SE) followed by BD (0.724±0.03), SB (0.679±0.03) and AG (0.661±0.03). Combinations of the above parameters did not improve mortality prediction.

Conclusion: Although all of the variables examined in this study offer predictive value for trauma-related mortality, initial serum lactate and BD are superior to serum bicarbonate or AG. Initial serum lactates ≥3 are associated with doubling of mortality, while lactates ≥7 carry more than quadruple baseline mortality. For BD, mortality increases from <5% for BD <4 to >40% for BD >16. In the absence of lactate or BD assessments, serum bicarbonate and AG may be helpful in crude mortality risk stratification.

29.02 National Evaluation of High Ratio Massive Transfusion in the Trauma Quality Improvement Program

Posted on January 18, 2018

B. R. Stultz1, D. Milia1, T. Carver1, C. Dodgion1  1Medical College Of Wisconsin,Milwaukee, WI, USA

Introduction:  Forty percent of trauma related in-hospital deaths involve massive hemorrhage. Recent studies have demonstrated that high ratio massive transfusions are related to improved outcomes but this has not been evaluated in a national cohort. The purpose of this study was to use the Trauma Quality Improvement Program (TQIP) database to determine the adoption and efficacy of high ratio transfusions.

Methods:  A retrospective analysis of adult massive transfusions from 2013-2015 within the TQIP database was performed. Massive transfusions were defined as ≥4 and ≥10 units of packed red blood cells (PRBC) at 4 and 24 hours, respectively. High ratio transfusion (HRT) was defined as plasma:platelets:pRBC ≥1:1:2.  Multivariate logistic regression was used to evaluate morbidity and mortality of patients receiving HRT with ratios of ≥1:1:1 and ≥1:1:2. Rate of adoption of HRT transfusion was evaluated by year.

Results: 20,009/689,072 (2.8%) patients underwent a massive transfusion in 318 level I & II trauma centers. The median age was 38 with median injury severity scores of 26. Seventy-six percent were male and median LOS was 11 days. Thirty-three percent suffered penetrating injuries, 61% underwent operative intervention and 44% underwent HRT. Overall mortality rate was 31%. Ratios of ≥1:1:1 decreased mortality (OR 0.88, p=0.012), with significant improvement if met at 4 hours (OR 0.61, p<0.01). ≥1:1:2 decreased mortality at 24 hours (OR 0.71, p<.0001) but not 4h.  Those with HRT had increased risk for complications (OR 1.5, p<.0001). In 2015, patients were significantly more likely (OR 1.2 p≤.0001) to receive HRTs when compared to previous years.

Conclusion: Adoption of HRT is significantly increasing overtime with early ratios of 1:1:1 or better conferring the greatest mortality benefit. However, there remain opportunities for significant improvement since more than half of the patients did not reach the high ratio transfusion threshold.

 

28.08 Bowel Preparation with Antibiotics Decreases Surgical-Site Infection for Both Left & Right Colectomy

Posted on January 18, 2018

A. J. Hjelmaas1, A. Kanters1, R. Anand1, J. Cedarbaum1, Y. Chen1, L. Ly1, N. Kamdar1, D. Campbell1, S. Hendren1, S. Regenbogen1  1University Of Michigan,Michigan Medicine,Ann Arbor, MI, USA

Introduction:
Despite recent studies demonstrating the effectiveness of mechanical bowel preparation with oral antibiotics for decreasing rates of surgical site infections (SSI) after colectomy, there remains inconsistency in practice with particular controversy over the role of bowel preparation in right-sided resections. Generally, bacterial concentration and stool solidity increases with progression through the colon, and there persists a belief that bowel preparation is needed only for left-sided resections. To understand whether there is heterogeneity in the efficacy of bowel preparation, we evaluate rates of SSI by the anatomy of resection and type of bowel preparation.

Methods:
We conducted a retrospective cohort study of patients who underwent elective colorectal resection with anastomosis and without stoma between 2012 and 2015, using prospectively-collected data from the Michigan Surgical Quality Collaborative, a state-wide consortium encompassing 73 community, academic, and tertiary hospitals. MSQC nurse reviewers collect a variety of colectomy-specific processes of care, including the type of bowel preparation – mechanical preparation with antibiotics, mechanical preparation without antibiotics, and no bowel preparation. We categorized resections by type of anastomosis according to CPT code – ileocolic (IC), colo-colonic (CC), or colorectal (CR); then compared the incidence of SSI between bowel preparation subtypes. We compared adjusted rates of SSI using logistic regression, including known patient-specific risk factors for SSI.

Results:
A total of 6192 patients were included in the study. 1134 underwent IC anastomosis, 3537 underwent CC anastomosis, and 1521 underwent CR anastomosis. Adjusted comparisons are shown in the Figure. For all cases, adjusted rates of SSI were 8.3% for no bowel preparation, 7.1% for mechanical preparation, and 4.6% for mechanical preparation with antibiotics (p<0.001). For right-sided colectomy, the adjusted rates of postoperative SSI were 11.1%, 5.4%, and 5.1% for no prep, mechanical prep, and mechanical prep with antibiotics, respectively (p=0.005).

Conclusion:
As in previous studies, we find overall rates of SSI are lowest when mechanical preparation is used in conjunction with oral antibiotics. Contrary to the assumption that bowel preparation is unnecessary for right colectomy, we found that bowel preparation led to significantly fewer SSIs even among resections with ileocolic anastomosis. This finding will reinvigorate efforts in our statewide collaborative to encourage bowel preparation with antibiotics for all colorectal resections. 
 

28.09 Patient-Reported Health Literacy Scores Associated With Readmissions Following Surgery

Posted on January 18, 2018

S. Baker1,2, L. Graham1,2, E. Dasinger1,2, T. Wahl1,2, J. Richman1,2, L. Copeland3, E. Burns4, J. Whittle4, M. Hawn5, M. Morris1,2  1University Of Alabama at Birmingham,Birmingham, AL, USA 2VA Birmingham Healthcare System,Birmingham, AL, USA 3VA Central Western Massachusetts Health Care System,Leeds, MA, USA 4Milwaukee VA Medical Center,Milwaukee, WI, USA 5VA Palo Alto Healthcare Systems,Palo Alto, CA, USA

Introduction: Hospital readmissions following surgery can be expensive and taxing on patients. Identifying mutable factors in predicting readmissions would be advantageous to both patients and healthcare systems. We hypothesized that patients with lower health literacy (HL) were more likely to be readmitted to the hospital following surgery.

Methods: We enrolled 734 patients undergoing general, vascular, or thoracic surgery at 4 Veterans Affairs (VA) Medical Centers, August 2015-June 2017. Patients were eligible if their post-operative hospital stay was more than 48 hours and they were discharged alive. Trained interviewers assessed patients’ overall health on the day of discharge using the Veterans Health Survey (VR12) Physical and Mental Component Scores (PCS; MCS). Health literacy was assessed by the 3-question Chew Health Literacy Questionnaire (HLQ), and the quality of the discharge transition by the Care Transition Measure (CTM-15). Patients were followed for 30 days post-discharge for readmission or emergency department (ED) use. A follow-up telephone interview at day 30 identified readmissions to non-VA hospitals. The HLQ summed three 5-point items (range 0-12); scores of 0-3 indicated adequate health literacy while scores of 4-12 indicated marginal or possibily inadequate health literacy. Bivariate and multivariable analyses examined correlations between HL and each outcome, 30-day readmission or ED use. Logistic regression models adjusted for clinical and demographic covariates.

Results: At the time of discharge, 33% of patient responses were consistent with inadequate HL (HL-low, n=245). Patients with adequate HL (HL-high) had better overall physical and mental health compared to patients with HL-low (PCS 32.0 vs. 29.5, p=0.01; MCS 49.7 vs 45.7, p<0.01) and reported higher-quality discharges (CTM-15 Mean: 3.3 vs 3.2, p<0.01). The overall 30-day readmission rate was 16% (n=124), however, it was 14% for patients with HL-high compared to 21% with HL-low (p<0.01). After adjusting for overall health (VR12), patients with HL-low were 1.5 times more likely to experience a readmission versus HL-high (OR=1.5, 95% CI=1.0-2.2); patterns of ED use were similar (OR for HL-low =1.38; 95% CI=0.95-2.01). Among the HL factors, patients who reported: (1) always having difficulty understanding written information were 2.8 times more likely to be readmitted (95% CI= 1.0-2.3), (2) not always confident filling out medical forms were 1.6 times more likely to be readmitted (95% CI= 1.1-2.4), and (3) ever requiring help to read hospital materials were 1.5 times more likely to be readmitted (95% CI= 1.2-6.5).

Conclusion: Low health literacy is common among VA surgery patients and an important contributor to readmission. Future work should focus on early identification of inadequate HL and the development of interventions to educate and empower this vulnerable population prior to discharge. 

28.10 Parathyroidectomy is Underutilized in the Treatment of Primary Hyperparathyroidism in Veterans

Posted on January 18, 2018

E. A. Alore1, J. W. Suliburk1, D. J. Ramsey2, C. J. Balentine3, K. I. Makris1,4  1Baylor College Of Medicine,Michael E. DeBakey Department Of Surgery,Houston, TX, USA 2Michael E. DeBakey Veterans Affairs Medical Center, Health Services Research And Development Center Of Innovation,Center For Innovations In Quality, Effectiveness And Safety,Houston, TX, USA 3University of Alabama at Birmingham,Department Of Surgery,Birmingham, AL, USA 4Michael E. DeBakey Veterans Affairs Medical Center,Operative Care Line, Division of General Surgery,Houston, TX, USA

Introduction:
Untreated hyperparathyroidism significantly impairs quality of life and incurs substantial costs to both patients and health care systems. Parathyroidectomy is the only cure for primary hyperparathyroidism (pHPT), yet there is evidence that parathyroidectomy is underutilized in single-institution and regional studies. The purpose of our study is to assess the utilization of parathyroidectomy in pHPT within a national population sample. We hypothesized that parathyroidectomy is underutilized in the treatment of pHPT.

Methods:
We performed a retrospective search of all patients within the national VA corporate data warehouse between 2000-2010. Adults with pHPT were identified using a validated algorithm by meeting the following criteria: elevated serum parathyroid hormone (PTH) level (> 88 pg/mL), elevated serum calcium level (>10.5 mg/dL) and serum creatinine < 2.5 mg/dL. Patients with secondary or tertiary hyperparathyroidism were excluded based on serum creatinine ≥2.5 mg/dL, history of dialysis, or prior renal transplantation. Rates of parathyroidectomy were calculated amongst patients with pHPT. A reverse stepwise logistic regression using p>0.2 as a criterion for removal from the model was used to identify predictive factors of parathyroidectomy.

Results:
Of 383,701 patients with hypercalcemia, 80,250 (20.9%) were tested for PTH. A total of 21,465 patients met diagnostic criteria for pHPT across the VA system during the study period. An average of 1,951 patients (0.03%) per year were diagnosed with pPTH out of an average of 6,997,378 patients treated at the VA per year. Of all patients with pPHT, only 1,679 (7.8%) underwent parathyroidectomy. In a subgroup analysis, of the 1,501 patients with pHPT presenting with serum Ca >11.5 mg/dL (an established indication for parathyroidectomy), only 301 (16.7%) underwent parathyroidectomy. On the reverse stepwise logistic regression, significant predictors of parathyroidectomy included a documented diagnosis of hyperparathyroidism in the medical record by ICD-9 code, high serum calcium level, history of kidney stones, osteoporosis, younger age and normal EGFR (Table 1).

Conclusion:
Despite being the only definitive treatment of pHTP, parathyroidectomy is extraordinarily underutilized nationally within the VA, even when a clear indication for operation exists. Further studies are needed to identify the underlying reasons for this underutilization and guide corrective interventions.

28.07 Less Telemetry, Better Outcomes: University Network Implementation Of SafetyNet Monitoring System

Posted on January 18, 2018

A. Cipriano1, C. Roscher2, A. Carmona2, J. Rowbotham3, S. P. Stawicki1  1St. Luke’s University Health Network,Department Of Surgery,Bethlehem, PA, USA 2St. Luke’s University Health Network,Department Of Anesthesiology,Bethlehem, PA, USA 3St. Luke’s University Health Network,Quality Resource Department,Bethlehem, PA, USA

Introduction: Effective detection of clinical patient deterioration (CPD) on medical-surgical units (MSU) continues to pose a significant challenge. Inefficient utilization of hospital resources negatively affects institutional quality, safety, and finances. The goal of this study is to evaluate a pilot implementation of pulse oximetry-based SafetyNet monitoring system (SNMS) as a method of resource-efficient CPD detection on MSU at a tertiary referral center. We hypothesized that the deployment of SNMS will be associated with improved detection of CPD and fewer intensive care unit (ICU) transfers.

Methods: This is a post-hoc, IRB exempt analysis of a quality improvement initiative’s designed to increase CPD detection and to prevent unplanned ICU transfers on our orthopedic MSU through the use of SNMS (Masimo, Irvine, CA). Concurrently, we sought to reduce telemetry overutilization. Primary outcome was the ICU transfer rate, with telemetry utilization and non-clinical alarm burden (NCAB) as secondary outcomes. We compared study outcomes on two adjacent MSUs (P8 + P9). The P8 unit served as “control” both during pre- and post-SNMS implementation periods (e.g., the SNMS was only deployed on the P9). Quality reporting methods, Fisher’s Exact and Mann-Whitney U-test were used to compare pre-/post-SNMS periods, with significance set at α=0.05.

Results: Study duration was 30 months (Jan-Dec 2015 "pre-implementation" and Jan 2016-Jun 2017 "post-implementation" period). We examined 21,189 patient-days on the P9 MSU (11,702 and 9,487 pre/post-intervention, respectively) and 23,388 patient-days on the P8 MSU (13,616 and 9,772 pre/post-intervention). Median case-mix index (CMI) was higher for P9 than P8 during the duration of the study (2.08 [IQR 1.98-2.17] vs 1.67 [IQR 1.64-1.76], respectively). SNMS implementation was associated with significant reduction of ICU transfers form P9. Median ICU transfers per 1000 pt-days declined from 11.7 pre-SNMS to 8.8 post-SNMS (Fig 1, p<0.03). Median telemetry utilization per 1,000 pt-days declined from 20.8 pre-SNMS to 16.5 post-SNMS (p<0.01). Targeted staff training and “sensor off” delay implementation resulted in significant reduction in NCAB, from 72.3 to 36.5 pages/device (p<0.01).

Conclusion: Implementation of SNMS was associated with 25% reduction in ICU transfers per 1,000 pt-days on our P9 MSU. At the same time, median telemetry utilization on P9 MSU was reduced by 21%. In addition, we were able to reduce the number of non-clinical nursing notifications by 50% through the combination of staff education and “sensor off” delay implementation. Due to its success, this pilot program is undergoing active expansion.

28.06 Impact of a Continuous Local Anesthetic Pain Ball on Post-operative Pain in Kidney Transplant Recipients

Posted on January 18, 2018

E. M. Betka1, J. Ortiz2, M. Rees2, S. Spetz1, P. Samenuk1, L. Eitniear1  1University Of Toledo Medical Center,Pharmacy,Toledo, OH, USA 2University Of Toledo Medical Center,Transplant Surgery,Toledo, OH, USA

Introduction:  The management of post-operative pain is critical for improving patient satisfaction, recovery time, and reducing hospital length of stay. In 2016, the American Pain Society (APS) and the American Society of Anesthesiologist (ASA) teamed up to provide the first evidenced based guidelines for the management of post-operative pain. The APS/ASA strongly recommend utilizing a multimodal approach for the management of post-operative pain as this approach is supported by a high quality of evidence. This approach for post-operative pain management has proven to be efficacious for procedures involving the abdominal wall. However, data are controversial in regards to this approach for kidney transplant recipients.

Methods:  This retrospective cohort study was approved by the Institutional Review Board at The University of Toledo Medical Center (UTMC). Patients 18 years and older admitted to UTMC from July 1, 2006 through July 30, 2016 who underwent kidney transplantation were included. Patients received one of the following post-operative pain management regimens: the standard of care (SOC) consisting of intravenous (IV) and/or oral (PO) opioids, with or without the addition a local anesthetic pain ball (LAPB). The primary outcome was the cumulative opioid requirements in IV morphine equivalents at 48 hours following transplantation. Secondary outcomes included post-operative pain scores at 24 and 48 hours following transplantation, and hospital length of stay.

Results: Information on baseline characteristics and study endpoints were collected for 102 patients. Propensity scores were utilized to match the patients based on the following confounders: age, sex, race, body mass index, baseline opiate use, previous abdominal procedure, repeat transplantation, type of transplant, and intra-operative morphine requirements. After matching, 38 subjects remain in each group. The median (IQR) IV morphine equivalent dose at 48 hours was 19.85 mg (14.85, 42.18) in the SOC group and 17.65 mg (4.95, 30.56) in the LAPB group (p= 0.120). There was no significant difference in median pain scores at 24 hours (p= 0.059) or 48 hours (p-value=0.139) in those receiving the LAPB versus those receiving the SOC. Also, there was no significant effect on hospital length of stay in those receiving the LAPB versus the SOC (3 days versus 4 days, respectively; p=0.449). 

Conclusion: This study demonstrates that the use of a LAPB as a alternative to IV/PO opioids did not reduce the post-operative opioid requirements in kidney transplant recipients following transplantation. The current literature regarding the use of LAPB for abdominal procedures outside of kidney transplantation remains positive. However, the literature supporting the use in kidney transplant recipients remains controversial. The data obtained from this trial supports the need for further randomized control trials that heavily control for confounding factors that are likely to affect post-operative opioid utilization. 

 

28.04 Improvements in Surgical Mortality: The Roles of Complications and Failure to Rescue

Posted on January 18, 2018

B. T. Fry1,2, J. R. Thumma2, J. B. Dimick2,3  3University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA 1University Of Michigan,Medical School,Ann Arbor, MI, USA 2University Of Michigan,Center For Healthcare Outcomes And Policy,Ann Arbor, MI, USA

Introduction: Surgical mortality has declined considerably over the last decade. While most hospitals have reduced mortality to some degree, much can be learned from how hospitals with the largest reductions achieved their improvement. Specifically, the roles of reducing complications and improving rescue from complications once they occur (known as failure to rescue or FTR) remain unclear. This study sought to understand which of these factors plays a larger role in reducing surgical mortality.

Methods: Using Medicare Provider Analysis and Review files, we performed a retrospective, longitudinal cohort study of patients who underwent abdominal aortic aneurysm (AAA) repair, pulmonary resection, colectomy, and pancreatectomy. We then calculated hospital-level risk- and reliability-adjusted rates of 30-day mortality, serious complications, and FTR for these patients in two time periods: 2005-2006 and 2013-2014 (n=699,771 patients). Serious complications were defined as the presence of one or more of eight complications plus a procedure-specific length of stay of greater than the 75th percentile. FTR was defined as death occurring in a patient with at least one serious complication. Hospitals were stratified into quintiles by change in mortality over time with average rates of 30-day mortality, serious complications, and FTR reported for each quintile. Variance partitioning was used to determine the relative contributions of differences in complication and FTR rates to the observed changes in hospital-level surgical mortality between time periods.

Results: After stratifying by reductions in mortality from 2005-2014, the top 20% of hospitals had decreased mortality rates by 3.4% (8.9 to 5.5%, p<0.001), decreased complication rates by 1.8% (15.2 to 13.4%, p<0.001), and decreased FTR rates by 7.4% (25.8 to 18.4%, p<0.001). In contrast, the bottom 20% of hospitals had actually increased mortality rates by 1.1% (6.9 to 8.0%, p<0.001), increased complication rates by 0.9% (14.6 to 15.5%, p<0.001), and increased FTR by 0.6% (22.1 to 22.7%, p<0.001). When examining the factors most associated with reductions in mortality, we found that decreased FTR explained 69% of the improvement in hospitals’ mortality rates over time, whereas decreased complication rates accounted for only 6% of this improvement. 

Conclusion: Hospitals with the largest reductions in surgical mortality achieved these improvements largely through reducing FTR rates and not by reducing serious complication rates. This suggests that hospitals aiming to reduce surgical mortality should engage in efforts focused on improving rescue from serious complications.  

28.05 Inconsistent Benchmarking by Mortality vs Readmission: Implications for Medicare Payment Metrics

Posted on January 18, 2018

C. K. Zogg1,2,3, Z. G. Hashmi3, J. R. Thumma2, A. M. Ryan2, J. B. Dimick2  1Yale University School Of Medicine,New Haven, CT, USA 2University Of Michigan,Center For Healthcare Outcomes And Policy,Ann Arbor, MI, USA 3Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA

Introduction: Since passage of the 2010 ACA, the Centers for Medicare & Medicaid Services have begun to tie surgical reimbursements to hospital performance on 30-day mortality and readmission rates. Under this system, there remain concerns that some high-performing hospitals with a lower risk of 30-day mortality may suffer from higher readmissions simply by saving lives. This creates the potential for reimbursement strategies to unfairly penalize such hospitals for providing superior care. The objective of this study was to determine whether benchmarking results are similar when hospitals are profiled based on 30-day mortality versus readmission rates.

Methods:  Older adult (≥65y) patients presenting for 3 common operations (elective colectomy, CABG, AAA) were identified using 2013-2014 100% Medicare fee-for-service claims. Each hospital was benchmarked on each outcome using risk-adjusted observed-to-expected (O/E, current Medicare standard) and shrinkage-adjusted (SA) rates (multilevel-modeling that accounts for variability due to hospitals with small sample-size). These estimates were then used to generate hospital performance profiles which were compared using: 1) linear regression with weighted correlation coefficients, 2) concordance among high/average/low performers with thresholds set as ±1 SD above/below the mean, and 3) magnitude of difference in quintile rank.

Results: Little to no correlation was found between mortality and readmission (Figure)—colectomy r=0.110; κ=0.002, p-value=0.111. Only 26.4% (707/2673) of hospitals performing colectomies had identical rankings for both metrics (CABG 24.8%, AAA 26.2%). Four percent had completely different rates (CABG 12.9%, AAA 12.5%)—an inverse association which became significant, r=-0.241, and markedly more pronounced, 25.0%, among high-risk patients with LOS ≥30d. SA demonstrated similar results. Discrepancies between mortality/readmission ranks were most pronounced among large hospitals (4-quintile difference vs no difference, ≥400 beds: 21.5 vs 17.9%, p=0.014), with more surgical admissions (highest quartile: 32.3 vs 29.3%, p<0.001), lacking certifications from organizations such as the Joint Commission and Council of Teaching Hospitals but with a larger resident role, more complex case-mix, and lower number of RNs/bed (p≤0.013 for each).

Conclusion: Mortality and readmission benchmarking do not identify high-quality hospitals in the same way. This creates a dichotomy between standards used to determine Medicare reimbursement rates. Implementation of benchmarking that reflects multiple aspects of quality is needed in order to avoid inconsistent penalization of large, outlying, teaching hospitals providing high-quality mortality care.

28.01 The Impact of ERAS protocol on Urinary Tract Infections after Free Flap Breast Reconstruction.

Posted on January 18, 2018

B. Sharif-Askary1, R. Zhao1, S. Hollenbeck1  1Duke University Medical Center,Division Of Plastic And Reconstructive Surgery,Durham, NC, USA

Introduction:  Hospitals are evaluated for quality based on a number of metrics including the occurrence of complications. Recently, our hospital instituted the Enhanced Recovery After Surgery (ERAS) protocol for patients undergoing free flap breast reconstruction. Urinary tract infections are among the most common healthcare-associated infections, with the majority seen after prolonged urinary catheterization. The ERAS protocol calls for early removal of urinary catheters. In this study, we compare the rate of UTI in patients who have undergone traditional recovery after surgery (pre-ERAS) to those who were enrolled in the ERAS protocol. We hypothesized that early catheter removal would decrease the rate of UTI in patients undergoing breast reconstruction with free flaps.

Methods:  We retrospectively reviewed the charts of 238 patients who underwent free flap breast reconstruction. We initiated the ERAS protocol in May of 2015. This study includes patients seen between March 2012 and June 2017 to capture both pre- and post-ERAS cohorts. UTI was defined using the American College of Surgeons NSQIP definition. Statistical analyses were conducted using SPSS software (Version 24.0, IBM Corp). We compared the incidence of UTI before and after ERAS initiation using a logistic regression while controlling for age, BMI, rate of diabetes and length of surgery.

Results: There were 160 patients evaluated prior to ERAS implementation and 78 patients evaluated in the post-ERAS group. The overall incidence of UTI for all patients who underwent free flap reconstruction was 4.6%. Next, we compared patients from the pre-ERAS group to the post-ERAS group. There were no significant differences with regards to mean age, BMI, or length of surgery. However, the rate of diabetes was higher in the pre-ERAS group compared to the post-ERAS group (11% vs. 4%, p=0.04, t-test). Post-ERAS patients had a significantly higher rate of UTI than pre-ERAS patients when controlling for age, BMI, rate of diabetes and length of surgery (1.9% vs. 10.3% p=0.008, OR=6.72). Of post-ERAS patients who were found to have post-op UTI, 25% were found to have bacteria on a pre-operative urinalysis.

Conclusion: In contrast to our hypothesis, we found that the rate of UTI was significantly higher in the post-ERAS patients. Further analysis is needed to determine the cause of this finding but may include the need for re-catheterization after early catheter removal. Based on these findings, we suggest individualized decision-making within the ERAS protocol in regards to timing of urinary catheter removal.

 

28.02 A Comparison of Operative Approaches in Diverticulitis Requiring Urgent Intervention

Posted on January 18, 2018

C. E. Cauley1, Z. Fong1,2, D. Chang2, H. Kunitake1, R. Ricciardi1, L. Bordeianou1  1Massachusetts General Hospital,Department Of Surgery,Boston, MA, USA 2Massachusetts General Hospital,Codman Center For Clinical Effectiveness In Surgery,Boston, MA, USA

Introduction: Guidelines from the American Society of Colon and Rectal Surgeons support the use of sigmoid resection and primary anastomosis with proximal diversion as a safe option for hemodynamically stable patients with perforated diverticulitis (including feculent peritonitis) at the surgeon’s discretion.  However, there are concerns regarding the broad implementation of these guidelines across hospitals with varying expertise. This study evaluates and compares the outcomes of primary anastomosis with proximal diversion versus end colostomy and Hartmann’s pouch for patients with perforated diverticulitis at National Surgical Quality Improvement Program facilities.

Methods:   We abstracted data from the National Surgical Quality Improvement Program participant user file. Patients who underwent emergent colectomy for perforated diverticulitis between 1/1/2005 through 12/31/2015 were identified. To confirm purulent or feculent diverticulitis, we excluded patients with wound classification of 1 or 2. Outcomes of patients who underwent primary anastomosis with proximal diversion were compared to those treated with end colostomy before and after propensity score matching (caliber width 0.03). Factors associated with mortality, reoperation, and infection were also determined using logistic regression modeling.

Results: 5,254 patients requiring emergent colectomy for perforated diverticulitis were selected: 4,261 (81%) with end colostomy and 993 (18.9%) with primary anastomosis and proximal diversion.  The rate of primary anastomosis with proximal diversion was 10.3% in 2005 and 19.2% in 2015.  Median hospital stay was the same (10 [7-15] days for primary anastomosis with diversion vs. 10 [7-14] days for end colostomy, p=0.8). The reoperation rate was statistically similar (8.7% for end colostomy vs. 7.1% for primary anastomosis with diversion, p=0.1), and mortality rate was statistically equivalent (8.1% end colostomy vs. 6.5% for primary anastomosis with diversion p=0.08).   After propensity score matching, surgical outcomes remained similar with equivalent mortality (8.2% vs 7.0%).  Multivariable logistic regression analysis revealed that operation type (primary anastomosis or Hartmann resection) was not associated with the outcomes of reoperation, postoperative infection, or mortality. (Figure)

Conclusions: Our data demonstrate no difference in surgical outcomes for perforated diverticulitis patients treated with primary anastomosis and proximal diversion as compared to traditional Hartmann resection. These findings indicate that guidelines for perforated diverticulitis in hemodynamically stable patients may be safely and broadly applied to institutions participating in the National Surgical Quality Improvement Program.

28.03 Mapping Trauma Outcomes: The Road to Zero Preventable Trauma Deaths

Posted on January 18, 2018

Z. G. Hashmi1,2, M. P. Jarman1, T. Uribe-Leitz1, J. W. Scott1, N. R. Udyavar1, J. Havens1, A. Salim1, A. H. Haider1  1Brigham And Women’s Hospital,Boston, MA, USA 2Sinai Hospital Of Baltimore,Department Of Surgery,Baltimore, MD, USA

Introduction:  The recent National Academies of Sciences, Engineering and Medicine (NASEM) report states that 20,000-30,000 trauma deaths could be prevented each year if all patients were to receive the highest quality of trauma care. While this burden has been quantified, the nationwide geographic distribution of these preventable trauma deaths remains unknown. Knowing where these deaths occur in each state is important to appropriately allocate resources for the optimal care of the injured. The objective of this study is to identify the geographic distribution of preventable trauma deaths for the state of Florida.

Methods:  Adult trauma patients(age≥16) with blunt/penetrating injury in the Healthcare Cost and Utilization Project(HCUP) Florida State Inpatient Database(SID) 2010-2014 were included. Hospitals were linked to the United States Office of Management and Budget-defined Core Based Statistical Areas(CBSAs) using the American Hospital Association supplemental file. CBSAs are distinct geographic units with a high level of socioeconomic integration allowing appropriate population-level comparisons. Preventable deaths were defined as lives which could have been saved if treated at the best-performing CBSA-quintile for in-hospital mortality. We performed hierarchical logistic regression using an empiric Bayes approach to generate Reliability-Adjusted in-hospital mortality rates for each CBSA. These rates were then used to benchmark each CBSA into a performance quintile. Next, generalized linear modeling was used to calculate the relative-risk(RR) of mortality at each quintile, relative to the best-performing CBSA-quintile. This RR was then used to calculate the number of preventable deaths at each CBSA-quintile compared to the best-performers.

Results: A total of 405,126 patients representing 33 CBSAs were included. Overall, 15.8%(1319/8344) of all trauma deaths were deemed preventable. Most of these deaths[78.6% (1037/1319)] occurred at the two worst performing CBSA-quintiles. Figure1 demonstrates that while most of the burden appeared to be concentrated in south/central Florida, isolated areas outside of this cluster were also identified. Separate benchmarking for older trauma patients(≥65 years) demonstrated a higher proportion of preventable deaths(27.6%) versus younger patients(8.3%). 

Conclusion: Preventable trauma deaths have a heterogeneous geographic distribution and disproportionately affect certain patient populations. This study shows the feasibility of mapping these deaths using state-specific data. Similar nationwide mapping can offer a unique insight for regional prioritization of quality improvement and resource allocation to achieve the NASEM goal of “Zero Preventable Deaths After Injury.”

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