51.06 Assessing Racial And Socio-economic Disparities In Bariatric Surgery: The Impact On Patient Outcomes?

Posted on January 26, 2017

V. Pandit1, A. Azim1, I. Ghaderi1, C. A. Galvani1  1University Of Arizona,Department Of Surgery,Tucson, AZ, USA

Introduction:
Differences in outcomes among patients undergoing general surgical intervention based on racial and socio-economic profile are well established. However; the impact of these differences among bariatric patients still remains unclear. The aim of this study was to evaluate the impact of racial and insurance status on patient outcomes undergoing bariatric surgery (BS).

Methods:
National estimates for BS procedures were abstracted from the National Inpatient Sample (NIS) database (2011). Patients undergoing BS (sleeve gastrectomy, gastric banding) were included. Patients were stratified based on race and insurance status. Outcome measures were: hospital length of stay (LOS), complications, and mortality. Regression analysis was performed after adjusting for age, gender, race, Charlson co-morbidity index (CCI), and type of procedure

Results:
A total of 3,305 patients undergoing BS were analyzed. The mean age was 47.19±13.8 years, 74.8% were females and the mean CCI was 2 [2-3]. 64.1% patients were white and 10.6% were Hispanics. 52.2% patients were private pay. Hispanics patients and non-Hispanic black patients were more likely to develop intra-hospital complications (p=0.031, p=0.043) and have longer hospital stay (p=0.026, p=0.037) compared to non-Hispanic and white patients respectively.  On assessing insurance status, patients with Medicare/Medicaid insurance were more likely to have in-hospital complications (p=0.029) compared to private payers. Self-pay patients had lower complication rate ((p=0.041) and length of stay (p=0.033) compared to private payers. On regression analysis, Hispanic (1.28 [1.05-1.45]), non-Hispanic black (1.35 [1.18-2.05]), and Medicare/Medicaid insurance status (1.89 [1.2-3.1]) were independent predictors for development of in-hospital complications. There was no difference in mortality based on racial or socio-economic profile

Conclusion:
Racial and socio-economic disparities are prevalent among patients undergoing bariatric surgery with worse outcomes among Hispanic, Non-Hispanic black, and patients insured with Medicare/Medicaid insurance. Further assessing the causes for these disparities may help improve outcomes among patients undergoing bariatric surgery.
 

51.05 Black Race and Lack of Insurance are Associated with Increased Risk of Urgent Resection for Colon Cancer

Posted on January 26, 2017

M. C. Turner1, Z. Sun1, M. L. Cox1, M. A. Adam1, B. F. Gilmore1, C. R. Mantyh1, J. Migaly1  1Duke University Medical Center,Department Of Surgery,Durham, NORTH CAROLINA, USA

Introduction: Emergent surgery for colon cancer is associated with poor short-term outcomes and worse long-term survival compared to elective resection. However, the socioeconomic factors predisposing patients towards emergent or urgent operations are not well defined. We aim to evaluate the impact of race and insurance coverage for patients undergoing urgent colon resection.

Methods: We performed a retrospective analysis of the 2006-2013 National Cancer Data Base (NCDB) for stage I-III colon adenocarcinomas. Differentiating the level of urgency of resection is difficult in retrospective studies. However, when the definitive resection and the diagnosis of cancer occur on the same day, the operation was likely non-elective. Patients with matching date of diagnosis and date of definitive operation were categorized as urgent surgery. We reviewed the oncologic outcomes of urgent compared to elective colon resection, while adjusting for patient, operation, tumor, and facility characteristics. We utilized multivariate regression to evaluate the socioeconomic factors of race and insurance coverage for patients requiring urgent resection. 

Results: Among the 244,094 patients identified following colon resection, 59,918 (24.5%) underwent urgent resection. Those undergoing urgent operations had higher rates of positive margins (OR 1.36, p<0.01), 30-day mortality (OR 1.80, p<0.01), and worse long-term survival (HR 1.27, p<0.01). Overall, black patients (OR 1.15, p<0.01), and uninsured patients (OR 1.54, p <0.01) were more likely to undergo urgent resection. When stratified by race, among white patients those who are uninsured (OR 1.54, p <0.01) or have government insurance (OR 1.04, p <0.01) were more likely to undergo urgent resections compared to those who were privately insured. Similarly, among black patients, those who are uninsured (OR 1.42, p <0.01) were more likely to undergo urgent resections. When stratified by insurance status, race impacts urgent operations for those with private insurance (OR 1.12, p<0.01) and government insurance (OR 1.17, p <0.01), but not those who are uninsured (OR 1.07, p=0.27). 

Conclusions: Urgent resection for colon adenocarcinoma has inferior oncologic outcomes than elective resection. Black race and a lack of insurance are associated with higher risk of urgent operation. Resources to mitigate this risk, such as screening colonoscopy, should be designated to these at-risk populations to improve equitable oncologic care.

51.04 Improved Surgical Outcomes and Disparities for Asian-Americans with Colorectal Cancer

Posted on January 26, 2017

K. C. Mulhern1, A. A. Gullick1, L. Goss1, J. Richman1, G. D. Kennedy1, H. Chen1, M. S. Morris1, D. I. Chu1  1University Of Alabama at Birmingham,Division Of Gastrointestinal Surgery,Birmingham, Alabama, USA

Introduction:  Racial disparities in surgical outcomes exist. Studies in gastric cancer and hepatocellular carcinoma have suggested that Asian-Americans may have improved outcomes; however, no studies have focused on outcomes in Asian-Americans undergoing colorectal surgery for colorectal cancer. We hypothesized that Asian-Americans with colorectal cancer would have improved surgical outcomes in mortality, post-operative complications (POCs), length-of-stay (LOS) and readmissions compared to other races.     

Methods:  We queried the 2011-2014 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) cohort for all patients who underwent surgery for colorectal cancer and stratified patients by race. Primary outcome was 30-day mortality. Secondary outcomes included POCs, LOS and 30-day readmission. Unadjusted univariate and bivariate comparisons were made. Chi-square and Wilcoxon Rank Sums tests were used to determine differences among categorical and continuous variables, respectively. Stepwise backwards logistic regression analyses and incident rate ratio (IRR) calculations were performed to identify risk factors for disparate outcomes.

Results: Of the 28,283 patients who underwent surgery for colorectal cancer, racial groups were divided into white (84%), African-American (12%), or Asian-American (4%). Asian-Americans were more likely than other racial groups to be of normal weight (53%, p<0.001), not smoke (90%, p<0.001), and have a low ASA score of 1 or 2 (55%, p<0.001). Compared to other racial groups, Asian-Americans were found to have the shortest LOS (5 days, p<0.001) and lower POCs due to ileus (10.3%, p<0.001), respiratory complications (3.1%, p<0.01), and renal complications (0.9%, p<0.001). There were no differences in 30-day mortality (1.5%, p>0.05) or 30-day readmissions (9.3%, p>0.05) (Table 1). On multivariate analyses, Asian-American race remained independently associated with less post-operative ileus (odds ratio [OR] 0.8, 95%-confidence interval [CI] 0.66-0.98) and decreased LOS by 13% as compared to African-Americans (IRR 0.87, p<0.001) and 4% as compared to whites (IRR 0.96, p<0.001).

Conclusion: Asian-Americans undergoing surgery for colorectal cancer have shorter LOS and lower POCs such as ileus when compared to other racial groups. There were no differences in mortality or 30-day readmissions. The mechanism(s) underlying these disparities will require further study, but may be a result of patient, provider, and healthcare system differences.

51.03 Variations in Bariatric Surgery Outcomes by Socioeconomic Status Among African-American Patients

Posted on January 26, 2017

M. Pichardo1, G. Ortega2, L. Bacon1, I. Yi1, C. Emenari1, N. Changoor3, D. Tapscott1, D. Tran3, T. Fullum3  1Howard University College Of Medicine,Washington, DC, USA 2Howard University College Of Medicine,Outcomes Research Center, Department Of Surgery,Washington, DC, USA 3Howard University College Of Medicine,Howard University Hospital, Department Of Surgery,Washington, DC, USA

Introduction: Bariatric surgery plays a vital role in the management of refractory obesity and comorbidities. The relationship between socioeconomic status (SES) and bariatric surgery has not been well elucidated, specifically among minority populations. Our study aims to assess the relationship between bariatric surgery outcomes, insurance status and SES among African-American patients.

 

Methods: Conducted a retrospective chart review with a 12-months follow up. Included 256 African-American patients who underwent bariatric surgery at an urban, academic institution between 2008 and 2013. Data collected included preoperative risk factors, BMI, procedure type, excess weight loss and resolution of comorbidities. Median Household Income (MHI), obtained from census-tract level neighborhood SES data, was a proxy for patients’ SES and categorized into 3 groups: group 1 (>$101,578), group 2 ($62,435 to $101,577), and group 3 ($38,515 to $62,434). No patient had an MHI below $38,515. Insurance status at time of surgery was defined as public or private insurance. Outcomes of interest included percent excess weight loss (%EWL) and resolution of comorbidities (hypertension, diabetes, dyslipidemia, obstructive sleep apnea (OSA)). Chi-square and students’ T tests were used to assess the relationship between our outcomes of interest, insurance status, and MHI.

 

Results: The mean pre-operative BMI was 48.0 kg/m2. A majority of patients had private insurance (90%) and underwent LRYGB (82%). Forty-nine percent of the sample lived in neighborhoods with an MHI of $62,435 – $101,577 (group 2). Group 1 patients had a lower proportion of diabetes remission compared to group 2 and 3 patients (p=0.016). No differences in resolution of hypertension, diabetes, and dyslipidemia were observed by MHI. A greater proportion of patients with private insurance relative to public insurance experienced OSA remission (p=0.021). Remission of other comorbidities did not significantly differ in the two insurance populations. The highest %EWL was observed among patients residing in areas with MHI of $101,578 or more (p=0.0096; group 1). No difference was observed in %EWL among patients with private vs public insurance.

 

Conclusions: Our findings reveal differences in SES and insurance status in bariatric surgery outcomes among an African-American population. Patients with private insurance experienced improved OSA outcomes relative to patients with public insurance. Patients in higher MHI neighborhoods experienced greater %EWL than those in lower income areas. However, lower and middle MHI neighborhood patients had better resolution of diabetes compared to patients living in the highest income areas. Further research is warranted to fully understand the effect of SES. Moreover, healthcare providers and policy makers should consider means of mitigating the effects of SES and insurance status among minority and low-income populations that can benefit from bariatric surgery.

51.02 Disparities in Thyroidectomy Outcomes at a Public and Private Hospital: Leveling the Playing Field

Posted on January 26, 2017

E. A. Alore1, S. Molavi1, C. J. Balentine2,3, J. W. Suliburk1  1Baylor College Of Medicine,Department Of Surgery,Houston, TX, USA 2University Of Alabama at Birmingham,Department Of Surgery,Birmingham, Alabama, USA 3University Of Alabama at Birmingham,Institute For Cancer Outcomes And Survivorship,Birmingham, Alabama, USA

Introduction:
Surgical outcomes for underserved patients facing social and economic disparities are frequently suboptimal. Our institution developed a multidisciplinary endocrine surgical team with carefully implemented postoperative care pathways to aid in the care of disadvantaged patients at our county safety net hospital. The purpose of this study is to compare surgical outcomes after thyroidectomy at our public hospital to outcomes at the private hospital in our institution. We hypothesized that our multidisciplinary patient-centered approach would largely eliminate disparities in postoperative outcomes.

Methods:
We performed a retrospective cohort study of 512 patients undergoing partial or total thyroidectomy at a private teaching hospital and a public safety net hospital within the same academic institution over 77 months from 1/2010 to 5/2016. The cases were performed by the same clinical team including surgery, endocrinology, anesthesiology and pathology. Temporary nerve injury was defined as injury that resolved within 6 months, temporary hypocalcemia was defined as immediate postoperative PTH <10, permanent nerve injury and hypocalcemia were defined as those which persisted >6 months post operatively.

Results:
A total of 358 patients from the public hospital and 154 patients from the private hospital were studied. 91% of patients at the public hospital were from racial/ethnic minorities compared with 42% of private hospital patients (p<0.001). 26% of patients at the public hospital were insured versus 100% at the private hospital (p<0.001). There were no significant differences in age, gender, cancer stage, or size of the thyroid gland. Rates of temporary nerve injury, permanent nerve injury, permanent hypoparathyroidism, postoperative hematoma or ER visits did not differ between groups (Table 1). Rates of temporary hypocalcemia at the public hospital (34.4%) were higher than at the private hospital (17.5%, p=0.001). We performed additional analyses stratified by type of insurance again finding rates of nerve injury, permanent hypoparathyroidism, postoperative hematoma or ER visits did not differ by type of insurance, but temporary hypocalcemia was more common in patients without insurance (38.5% vs 19.8%, p<0.001, Table 1).

Conclusion:
A dedicated endocrine surgery team was able to deliver excellent outcomes for patients lacking insurance and being treated at a public safety net hospital. Our findings suggest that social and economic disadvantages can be largely overcome for endocrine surgery patients with a combination of dedicated surgical care, multidisciplinary team coordination and patient-centered care pathways.
 

51.01 Spatial analysis of surgery service areas in Virginia

Posted on January 26, 2017

A. Diaz1, A. B. Haynes2,3  1Virginia Commonwealth University,Department Of Surgery,Richmond, VA, USA 2Massachusetts General Hospital,Department of Surgery,Boston, MA, USA 3Ariadne Labs,Boston, MA, USA

Introduction:  Hospital service areas(HSA) were created in the 1990s to help identify local health care markets. Based on these HSAs, health professional shortage areas(HPSA) were developed to identify populations without access to primary care. No such metric exists for surgery. Furthermore, recent policy changes leading to financial constraints and closure of rural and critical access hospitals (CAH) have obscured local surgical care markets. HSAs have not been updated to reflect recent closures and changing markets. We propose an alternative method of defining surgical markets based on travel time.

Methods:  We used publicly available datasets from Census.gov, Virginia Health Information, and the Virginia Geographic Information Network. We tabulated general surgeons, hospitals, and inpatient general surgery procedures per HSAs in Virginia using ESRI’s ArcGIS 10.3. Next, using the Network Analyst extension we created a network dataset of all roads with direction and speed limits in Virginia. We solved for the service area for acute care and critical access hospitals for various travel times.  Service areas were then overlaid on the 2010 census population block file and the total population within each respective service area was tabulated. 

Results: According to the 2010 census there were 8,001,024 people living in Virginia. There are 73 acute care hospitals and 7 CAHs. Of the 7 CAHs 3 do not perform any general surgery procedures and one performed only 2 procedures in 2014. These hospitals were excluded from the analysis.  700 physicians in the Virginia physician masterfile self identified as general surgeons. 9 of 23 HSAs were found to have fewer than 6 general surgeons per 100k residents; 1 of the 9 had fewer than 3 general surgeons per 100k residents.  Hospitals per 100k residents ranged from 0.39 to 3.71 per HSA and inpatient general surgeries ranged from 58.22 to 923.71 per 100k residents. Based on the service area analysis, we found that 595,070 residents lived further than 30 minutes from any hospital providing general surgical services. When modeled for closure of critical access hospitals an additional 69,234 residents would have to drive 30 minutes or more to the next nearest hospital. 

Conclusion: HPSAs based on HSAs have proven to be effective for primary care. Surgical service areas have been more elusive due to the added complexity of requiring a facility and staff to perform surgery. Furthermore, time may be of the essence in general surgery where an uncomplicated appendicitis or diverticulitis can become complicated in a matter of minutes to hours. A more accurate surgical service area might be reflected in metrics that take travel time into account. 

 

 

 

50.20 Impact of Genitourinary Trauma on Mortality and Post-Traumatic Infections

Posted on January 26, 2017

J. G. Tyburski1,2, H. S. Dolman1,2, W. Zimmerman2, L. Hall Zimmerman2, A. E. Baylor1,2, T. T. Lavery1,2, J. Ciullo1, R. F. Wilson1,2  1Wayne State University,Surgery,Detroit, MI, USA 2Detroit Medical Center,Detroit, MI, USA

Introduction:

In patients having emergency surgery for abdominal trauma, the presence of genitourinary (GU) injury has a high incidence death and infection. The objective of this study is to evaluate the factors associated with mortality and infections in patients with emergency surgery for abdominal trauma and GU injury. 

Methods:

This retrospective study evaluated patients who were admitted with abdominal trauma requiring emergency surgery at a Level 1 Trauma Center over 30 years (1980–2010). Concomitant injuries, emergency department (ED), and operating room (OR) data were evaluated.   Infections evaluated were pneumonia (PNA), bacteremia (BSI), intraabdominal (IAI), urinary tract (UTI), or surgical wound (SWI).

Results:
Of 1105 patients requiring emergency surgery for abdominal trauma, 234 (21%) had GUI (kidney 170 (73%), ureter 35 (15%), and urinary bladder 44 (19%)).  Patient’s mean age was 31 ± 12years with Injury Severity Score 21 ± 11 and 210 (90%) being penetrating trauma. Of 234 patients evaluated, 46 (20%) died ≤ 48 hours and 11 (5%) died later primarily due to infection (7/11, 64%). Overall mortality rate (MR) was 29% kidney, 17% ureter, and 9% urinary bladder injuries with 50/57 (88%) of all deaths having kidney injury. Major factors affecting MR were emergency/operating (ED/OR) blood transfusions and initial OR systolic blood pressure (SBP). The MR for 10+ units, 1-9 units, no transfusion were 41% (34/82), 26% (20/77), 4% (3/75), p<0.001. The MR for initial OR SBP < 70, 70-89, 90-119, 120+mmHg were 88% (23/26), 39% (11/28), 26% (16/61), 6% (7/119), p<0.001.  In patients requiring nephrectomy, MR was 27/50 (54%) with 32/50 (64%) required massive transfusion.  There were 157 infections in 64 of 188 patients surviving >48 hours, 34 intraabdominal, 26 wound, 42 pneumonia, 32 bacteremia, 23 urinary. The major factors affecting the infection rates (IR) were ED/OR transfusions and initial OR SBP.  The IR for 10+units, 1-9 units, no transfusion were 58% (28/48), 38% (26/68), 14% (16/72), p<0.001. The IR for initial OR SBP < 90, 90-119 and 120+mmHg were 58% (14/28), 41% (20/49), and 26% (30/115), p<0.001.

Conclusion:
Genitourinary trauma in patients requiring an emergency laparotomy are associated with high mortality and morbidity.  Factors associated with mortality and infections were blood transfusions and initial OR SBP.

 

50.19 A Comparison of Outcomes between Pediatric and Adult Patients with Traumatic Pancreatic Injuries

Posted on January 26, 2017

T. Iurcotta1,2, P. Addison1,2, L. Amodu1, M. Ackerman3, D. Galvin1, A. Glazer1, N. Christopherson1, J. Prince1, M. Bank1, C. Sorrentino1, J. Nicastro1,2, G. F. Coppa1,2, E. Molmenti1,2, H. L. Rodriguez Rilo1,2  3Feinstein Institute For Medical Research,Department Of Biostatistics,Manhasset, NY, USA 1Hofstra Northwell School Of Medicine,Department Of Surgery,Hempstead, NY, USA 2Northwell Health System,Pancreas Disease Center,Manhasset, NY, USA

Introduction: Traumatic injuries of the pancreas are very rare. Though both adults and pediatric patients may suffer these injuries, differences in outcome as a result of age group have not been demonstrated. This study was conducted to determine whether patterns and outcomes of injury differ significantly between adult and pediatric patients.

Methods: We performed a retrospective review of data from four trauma centers in New York from 1990-2014, comparing pediatric patients (age < 18 years) to adult patients (age ≥ 18 years) at the time of injury. We compared continuous and categorical variables using the Mann-Whitney, Chi-square, Fisher’s exact, and log-rank tests as appropriate.

Results: Of 26 pediatric and 43 adult patients identified, median age in years was 11.4 and 42.3 respectively. There were significant differences between the pediatric and adult groups in: type of blunt injury (MVC, 17.4% vs. 64.9%; bicycle accidents, 43.5% vs. 0.00%, p <0.0001), median time to presentation (12.5 vs. 0.6 hours, p = 0.006), median amylase (155.0 vs. 75.0, p = 0.009), ALT (26.5 vs. 62.0, p = 0.022), alkaline phosphatase (192.5 vs. 69.0, p = 0.000), lactate (13.4 vs. 3.2, p = 0.012), ISS (6.5 vs. 12.0, p = 0.030), blood transfusion (19.2% vs. 52.4%, p = 0.007), chest injuries (11.5% vs. 48.8%, p = 0.002), other abdominal injuries (48.0% vs. 72.1%, p = 0.047), operative management (30.8% vs. 67.4%, p = 0.003), post-injury pancreatitis (57.7% vs. 20.9%, p = 0.002), and median hospital LOS (5.0 vs. 11.0 days, p = 0.005). There was no significant difference in mortality or other long- or short-term complications.

Conclusion: Compared to pediatric patients, adult patients were more severely injured, more often required surgical intervention and blood transfusions, and had longer hospital stays. Pediatric patients had more metabolic derangements and a higher incidence of post-injury pancreatitis compared to adults. In spite of the differences in mechanisms of injury and treatment, morbidity and mortality was comparable between pediatric and adult patients with traumatic pancreatic injuries.
 

50.18 The Effect of Dual Antiplatelet Therapy on Intracranial Hemorrhage

Posted on January 26, 2017

M. Choi1, N. K. Dhillon1, E. J. Smith1, R. C. Kolus1, D. Polevoi1, N. Linaval1, G. Barmparas1, E. J. Ley1  1Cedars-Sinai Medical Center,Los Angeles, CA, USA

Introduction:  With the increasing use of anticoagulant and antiplatelet (ACAP) medication, it is common for trauma patients to present with brain injury while taking one or more of these medications. While patients with traumatic brain injury who are taking ACAP are known to be at greater risk for progression of intracranial hemorrhage (ICH) how dual antiplatelet therapy affects ICH is unknown.

Methods:  A retrospective review was conducted at a Level 1 trauma center from January 2011 to December 2015 for patients who were admitted with a diagnosis of ICH. Patients on a single antiplatelet agent, dual antiplatelet therapy, and warfarin were identified and compared to patients not on an ACAP. Data was collected on patient demographics, mechanism of injury, injury severity scores, admission GCS, ICU length of stay (LOS), hospital LOS, prior to admission medications, results of imaging studies, information regarding procedures, and mortality.

Results: Of the 317 patients analyzed, 246 (77.6%) were not on any ACAP, while those who were included: aspirin alone 38 (12%), clopidogrel alone 6 (1.9%), combined aspirin and clopidogrel 15 (4.7%), and warfarin 12 (3.8%). The mean age was 56 (34.3-78) years and 69.4% were male, median head AIS was 4 (3-4) and median ISS was 18 (14.5-26). ICU and hospital LOS were 3 (2-5) and 6 (4-14.75) days, respectively. Patients taking ACAP did not have a higher rate of ICH progression on imaging compared to those who were not (Table). Those on warfarin required more interventions compared to patients not on an ACAP (41.6% vs. 14.6%, p=0.03) or on aspirin alone (41.6% vs. 7.9%, p=0.01). When imaging and interventions were combined, patients on dual antiplatelet had significant disease progression compared to no ACAP (60% vs 33.3%, p=0.04) and aspirin alone (60% vs. 23.7%, p=0.01). Mortality was similar among all cohorts.

 

Conclusion: Dual antiplatelet therapy was associated with a greater rate of clinical progression of ICH. Patients who present with dual antiplatelet therapy should be identified as high risk for deterioration.

 

50.17 Poor Compliance With 8-Week Boosters After Trauma Splenectomy: An Opportunity For Improvement

Posted on January 26, 2017

A. R. Alvarado1, K. F. Udobi1, S. D. Berry1, K. K. Assmann1, T. McDonald1, J. M. Howard1, A. W. Bennett1, M. Moncure1, J. Green1, R. D. Winfield1  1University Of Kansas,Surgery Trauma/Critical Care & Acute Surgery Division,Kansas City, KS, USA

Introduction:

Splenic injury is one of the most common injuries requiring surgical intervention. Following a total splenectomy, certain measures must be taken post-splenectomy to better prevent infection; namely, the postoperative administration of conjugate vaccinations against encapsulated bacteria (S. pneumoniae, N. meningitidis, and H. influenzae). While initial immunization is frequently completed prior to discharge from an acute inpatient stay, the Advisory Council on Immunization Practices (ACIP) recommends administration of an 8-week vaccination boosters against S. pneumoniae and N. meningitidis, and compliance with this practice is unknown. We hypothesized that patients undergoing splenectomy for trauma would not routinely receive the recommended immunization and subsequent booster.

Methods:

All trauma admissions at our Level I Trauma center who required a splenectomy secondary to trauma between January 1, 2010 and November 1, 2015 were included. Demographic and injury data, dates of splenectomies, immunization documentation, subsequent vaccination boosters received, and outcomes were collected from the medical record.

Results:

9,965 trauma patients were admitted during the time period studied. 44 patients underwent splenectomy, with 39 patients meeting all inclusion and exclusion criteria. Median age of the patient population was 45 years, 82% were male, and median injury severity score was 29. Seven patients expired during their index admission and were not immunized. The remaining 32 patients received initial immunizations prior to discharge, making in-hospital administration 100% compliant. Three received subsequent boosters during office or hospital visits; however, no patient received any booster within ACIP’s recommended eight-week timeframe with median time to subsequent boosters of 12 months, (range 6 to 32 months). Eight patients have had a subsequent admission for infection or sepsis, with one patient expiring secondary to infection. None of the patients subsequently admitted for infection or sepsis had received subsequent boosters.

Conclusion:

While trauma patients at our institution routinely receive immunization against encapsulated bacteria following splenectomy prior to hospital discharge, they receive booster vaccinations at a suboptimal rate and beyond the advised eight-week window. We speculate that this phenomenon is widespread in the American trauma population. These data suggest a need for improved patient and provider education as well as coordination with primary care practitioners to ensure ideal defense against infectious complications.

 

50.16 Pediatric Perineal Trauma: A Ten-Year Retrospective Review

Posted on January 26, 2017

J. J. Lopez1, L. Kelley-Quon1, A. Kerlek3, M. Luken3, K. McCracken2, R. Thakkar1, B. Nwomeh1  1Nationwide Children’s Hospital,Department Of Pediatric Surgery,Columbus, OHIO, USA 2Nationwide Children’s Hospital,Department Of Pedatric And Adolescent Gynecology,Columbus, OHIO, USA 3Nationwide Children’s Hospital,Center For Family Safety And Healing,Columbus, OHIO, USA

Introduction: Injuries to the perineum, rectum, and vagina carry significant risk for morbidity particularly in the pediatric population.   While the frequency of perineal trauma is low, morbidity is high making it critical to understand the mechanisms, management, and outcomes. 

Methods: The trauma registry at a Level 1 free-standing pediatric trauma center was queried for patients from 2005 to 2014 diagnosed with perineal trauma. Demographics, hospital outcomes, and procedures were collected.

Results: A cohort of 111 patients with an average age 6.8 years (8 months to 19 years) who sustained trauma to the perineum was identified. The majority were female (n=108, 97.3%) and Caucasian (n=79, 71.2%). Seventy-six falls/straddle injuries, 6 cycle accidents, 2 pedestrians struck, 3 sport injuries, 15 physical/sexual assaults, and 9 other mechanisms (straining and animal incidents). Average length of hospitalization was 1.3 days (standard deviation 0.889). In this cohort, 109 patients (98%) sustained lacerations/abrasions of the rectum and vagina without the presence of hematoma. Fourteen episodes (12.6%) of sexual assault were noted. Ninety-nine patients (89%) underwent exams under anesthesia, within the first 24 hours of admission, and received simple to complex vaginal/perineal/rectal laceration repairs. No patients required surgical diversion. Thirty-two (28.9%) patients received a social work and Child Abuse Team consultation. Four patients (3.6%) were referred to foster care upon discharge while most were discharged home.

Conclusions: Early intervention with a multidisciplinary approach allows for optimal care of pediatric patients with perineal injuries. Future research should target patients at risk for perineal trauma to optimize safety, prevention, and emotional well-being.
 

50.15 Number of Rib Fractures Does Not Predict Outcomes In a Modern Population of Trauma Patients

Posted on January 26, 2017

R. Guyer1,2, B. Dennis2, O. Gunter2, O. Guillamondegui2  1Massachusetts General Hospital,Boston, MA, USA 2Vanderbilt University Medical Center,Nashville, TN, USA

Introduction: Prior studies have shown that the number of rib fractures strongly predicts morbidity and mortality, especially in elderly patients. Current therapy for rib fractures focuses on adequate analgesia. It is unknown whether improved care has affected morbidity and mortality in rib fracture patients or has attenuated the risk conferred by age. We readdressed the relationship between the number of rib factures and clinical outcomes in a modern population. We hypothesized that the number of rib fractures is associated with mortality and pneumonia. We also hypothesized that age and ISS would both predict mortality and pneumonia.

Methods: This is a retrospective review of adults admitted to a Level I academic trauma service with at least one rib fracture over five years. Pregnant patients were excluded. Patient characteristics included age, ISS, number of rib fractures, and associated injuries. The primary outcome measure was mortality, and pneumonia was a secondary outcome. A multivariate analysis was performed for outcome measures controlling for patient characteristics, injury severity, associated diagnoses/procedures, and pain control modality.

Results: Of the 4631 patients studied, the median age was 50 (IQR 30-64); 23% were elderly (>65).  Median ISS was 22, pneumothorax was seen in 38%, and hemothorax in 19%.  Pneumonia was diagnosed in 8%, and overall mortality was 8%. 17% of patients were given an epidural catheter, 40% were given patient-controlled analgesia, and 0.2% underwent a nerve block procedure.  We found no association between the number of rib fractures and either mortality or pneumonia among either elderly or non-elderly patients.  Elderly patients comprised a significantly greater fraction of decedents than of survivors (47% vs 21%, p<0.001).  Patients who died had a higher ISS (36 vs 21, p<0.01), and were more likely to have a pneumothorax (47% vs 37%, p<0.01), a hemothorax (28% vs 19%, p<0.01), and pneumonia (15% vs 7%, p<0.01).  Patients who died were significantly less likely to receive either an epidural (10% vs 17%, p<0.01) or PCA (10% vs 43%, p<0.01). Patients who developed pneumonia had a higher ISS (34 vs 22, p<0.01), were more likely to have a pneumothorax (52% vs 37%, p<0.01), and were more likely to have a hemothorax (28% vs 19%, p<0.01).  On multivariate analysis, age was a risk factor for mortality (OR 1.05, 95% CI 1.04-1.05) and patients with epidural catheters (OR 0.36 95% CI, 0.23-0.56) or PCA (OR 0.16 95% CI, 0.11-0.24) were less likely to die.

Conclusion: In this study of a modern population of trauma patients with rib fractures, we found that the number of fractured ribs did not predict outcomes.  Age and injury severity were both predictors of mortality, and injury severity was a predictor of pneumonia.  Contemporary management practices may have eliminated the stepwise risk of mortality and morbidity associated with each rib fracture.  Future studies are needed to identify modifiable risk factors.

50.14 Traumatic Rib Cage Hernias: Management, Outcomes, and a Proposed New Classification System

Posted on January 26, 2017

J. Kuckelman1, M. Lallemand1, M. Martin1, R. Karmy-Jones2, E. Windell2, S. Izenberg2, W. Long2  2Legacy Good Samaritan Medical Center,Trauma,Portland, OR, USA 1Madigan Army Medical Center,General Surgery,Tacoma, WA, USA

Introduction: Traumatic Rib Cage Hernias (TRCH) are an extremely rare but challenging problem in thoracic trauma. The original Morel-Lavelle criteria used only location and etiology for classification. However, this fails to quantify the size of the hernia or associated tissue damage, and does not help guide the optimal repair.

Methods: Retrospective review of all TRCH over a 32 year period.  The presenting characteristics, type of repair undertaken, and postoperative courses were evaluated. A new TRCH grading system is proposed that includes size and associated tissue/bone injury, and can guide surgical repair.

Results: We identified 20 patients (16 blunt, 4 penetrating), all of whom underwent operative repair.  We grouped injuries into 5 TRCH grades based on the extent of tissue/bone damage, size of hernia, and location. The most commonly herniated organs and tissues were lung (89%), liver (5%), and pericardial fat (5%). The types of operative repair were well clustered by the assigned TRCH grade.  Most repairs required prosthetic mesh (74%) and/or mechanical rib plating (84%). A complex tissue flap reconstruction was required in 10% of cases. Operative time, EBL, and length of stay showed good correlation with the proposed TRCH grading system. All patients survived and there were no recurrences identified.

Conclusion: The size and degree of tissue/bone injury has important implications in the optimal surgical management of TRCHs. We propose an expansion of the TRCH classification to include these factors.  This system may be useful in operative decision making when dealing with these complex and rare injuries.

 

50.13 End-Stage Renal Disease Increases Mortality in Falls with Rib Fractures

Posted on January 26, 2017

M. Kwak1, P. J. Chung1, M. C. Smith1, V. Roudnitsky2, A. Alfonso1, G. Sugiyama1  1SUNY Downstate Medical Center,Department Of Surgery,Brooklyn, NY, USA 2Kings County Hospital Center,Department Of Acute Care Surgery/Trauma,Brooklyn, NY, USA

Introduction:
Falls are the most common mechanism of injury for which patients are admitted to trauma centers in the United States. Patients at highest risk for ground level falls (GLF) include the elderly, who are also more likely to have comorbidities such as end-stage renal disease (ESRD). Patients with ESRD are at higher risk for fractures and bleeding. We performed an observational study of a national database to assess whether ESRD affects outcomes of patients who suffer GLF with rib fractures.

Methods:
Using the Nationwide Inpatient Sample (NIS) from 2005-2012, we identified adult patients 18 years and older, experiencing a fall from standing or similar height (E-codes E880, E884, E885, E886, E888) with confirmed diagnosis of rib fracture(s) (ICD-9 807). Cases missing demographic or inpatient death information were excluded. The Trauma Mortality Prediction Model (TMPM) score and the Elixhauser-Van Walraven score were used to assess trauma and comorbidity status respectively. Multivariable logistic regression analysis, using inpatient mortality as the outcome, was performed adjusting for demographics, TMPM score, Elixhauser-Van Walraven score, ESRD status, and presence of hemothorax.

Results:
There were 58,095 patients meeting the inclusion/exclusion criteria. Median age was 80 years. The majority were White (86.81%) and female (55.52%), 1,096 (1.89%) had ESRD, and 4,633 (7.97%) had hemothoracies. Inpatient mortality occurred in 1,992 patients (3.43%).  On a multivariable logistic regression analysis, statistically significant independent variables associated with mortality were age (OR 2.43 [2.21-2.68, 95% CI], p<0.0001), male gender (OR 1.49 [1.36-1.64, 95% CI], p<0.0001), having private insurance vs Medicare (OR 1.33 [1.12-1.57, 95% CI], p=0.0079), no insurance vs Medicare (OR 1.50 [1.05-2.15, 95% CI], p=0.0079), TMPM score (OR 1.09 [1.08-1.10, 95% CI], p<0.0001), having hemothorax (OR 1.25 [1.09-1.45, 95% CI], p<0.0001), Elixhauser-Van Walraven Score (OR 2.22 [2.09-2.35, 95% CI], p<0.0001), and having ESRD (OR 1.74 [1.35-2.25, 95% CI], p<0.0001).  Protective variables included Black vs. White race (OR 0.72 [0.54-0.97, 95% CI], p=0.0481), and Hispanic vs. White ethnicity (OR 0.74 [0.58-0.95, 95% CI], p=0.0481).

Conclusion:
In this large observational study of a national database, we found that ESRD is highly associated with inpatient mortality for patients that sustain GLF resulting in rib fractures, even after adjusting for mechanism and sequelae of injury such as the development of hemothorax. In the setting of trauma, patients with ESRD are an especially vulnerable population for poor outcomes. Prospective studies are warranted to identify optimal treatment strategies to reduce the risk of mortality in patients with ESRD.

 

50.12 Patient and System Variability Impact Outcomes in Emergency General Surgery: A Qualitative Analysis

Posted on January 26, 2017

A. Columbus1, E. Lilley1, A. Harlow1, M. Morris2, A. Haider1,3, A. Salim1,3, J. Havens1,3  1Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA 2University Of Colorado Denver,Aurora, CO, USA 3Brigham And Women’s Hospital,Division Of Trauma, Burn, And Surgical Critical Care,Boston, MA, USA

Introduction:  Emergency General Surgery (EGS) patients are up to 8 times more likely to die than patients undergoing the same procedure electively.  One half of all EGS patients will have a major complication. Despite these burdens, few studies have identified modifiable factors that influence patient outcomes in EGS. Our purpose in this work was to identify modifiable factors linked to morbidity and mortality in EGS as perceived by EGS providers. 

Methods:  EGS providers, including anesthesiologists, nurses, and surgeons, from the four US census regions were recruited via purposive-stratified criterion based sampling to participate in semi-structured interviews and focus groups. Participants were asked to identify contributors to EGS outcomes, to define effective care for EGS patients, and to describe operating room (OR) team structure. Interviews were performed to thematic saturation. All data were audio-recorded and transcribed verbatim. Using a grounded theory approach, three members of our research team inductively coded all transcripts. Coded data were entered into Atlas.ti for data management and were analyzed within and across cases to identify emergent themes. 

Results: A total of 40 participants from 5 academic hospitals were interviewed either individually (n = 25 {9 anesthesia, 12 surgery, 4 nursing}) or within focus groups (n = 2 {15 nursing}). The impact of variability on EGS outcomes emerged as a major theme, with two subthemes: patient variability (acute physiology and comorbidities) and system variability (OR space and workforce). Participants from fixed staffing model institutions, characterized by dedicated EGS OR space and staffing, focused on patient variability as the primary contributor to negative EGS outcomes while participants from non-fixed staffing institutions cited disruption in case flow due to system variability as a major contributor. 

Conclusion: EGS providers report patient and system variability as key contributors to poor EGS outcomes.  While EGS patient variability is not directly modifiable, variability due to system-based factors, including OR space and staffing of EGS care teams, is the product of differences in hospital systems and therefore is modifiable. These data support the use of a fixed staffing model for EGS. Further investigation into the effect of staffing models on EGS outcomes is needed. 

 

50.11 Nonoperative Management of Penetrating Solid Organ Injuries in Pediatric Patients: a NTDB Study

Posted on January 26, 2017

A. De Roulet1, K. Matsushima1, K. Beetham1, K. Inaba1, D. Demetriades1  1University Of Southern California,Division Of Acute Care Surgery,Los Angeles, CA, USA

Introduction:  Nonoperative management (NOM) of penetrating solid organ injuries (SOI) has not been well described in the pediatric population. The objective of this study is to characterize the epidemiology, injury patterns, and patient-level factors associated with trial of NOM and failure of NOM.

Methods:  This is a retrospective cohort analysis of the National Trauma Data Bank (NTDB) for the period of 2007-2014. The population under study includes patients ≤18 with penetrating injury to the liver, spleen, or kidney. Patients with severe concomitant injuries (abbreviated injury scale [AIS] ≥3 in other body regions) were excluded. Trial of NOM was defined as no operative intervention (exploratory laparotomy or operation involving the liver, spleen, or kidney) within 4 hours of emergency department (ED) arrival. Failed NOM was defined as operative intervention >4 hours after ED arrival. Multivariate logistic regression analysis interrogated factors potentially associated with trial of NOM and failed NOM.

Results: Of the 943,000 pediatric trauma patients included in the NTDB, 7,330 (0.7%) sustained penetrating SOI. After excluding patients with severe concomitant injuries in other body regions, 3,005 patients were analyzed. Median age was 17.0 (IQR 15-18) years; the majority (88.0%) were male. Gunshot wounds (GSW) accounted for 71.7% of injury mechanisms and cutting instruments accounted for the remaining 28.3%. Median injury severity score (ISS) was 9 (IQR 5-13); ED hemodynamics included mean heart rate 97.0 (23.1) and systolic blood pressure 129.8 (24.3). 2,121 (70.6%) patients sustained kidney injury, 1,795 (58.7%) liver injury, and 159 (5.3%) splenic injury. NOM was pursued in 667 (22.5%) patients. Factors significantly associated with trial of NOM included mechanism of injury (GSW OR: 0.51, 95% CI: 0.42-0.63, p<0.001), multiple SOI (OR: 0.74, 95% CI: 0.55-0.99, p=0.04), hollow viscus injury (OR: 0.24, 95% CI: 0.20-0.30, p<0.001), and ED hypotension (OR: 0.35, 95% CI: 0.18-0.70, p=0.003). Failed NOM was identified in 234 (34.6%) of the 677 patients that initially underwent NOM. Factors significantly associated with failed NOM included age 10-13 years (vs. 14-18 years) (OR: 2.99, 95% CI:1.37-6.53, p=0.006), mechanism of injury (GSW OR: 2.15, 95% CI: 1.42-3.24, p<0.001), hollow viscus injury (OR: 6.93, 95% CI: 4.64-10.33, p<0.001), and Grade IV/V SOI (OR: 2.26, 95% CI: 1.13-4.48, p=0.02). 

Conclusion: NOM can be performed in a carefully selected group of pediatric patients with penetrating SOI. Future prospective studies are warranted to validate its feasibility.

 

50.10 Validity of the Braden Scale in Grading Pressure Ulcers in Trauma and Burn Patients

Posted on January 26, 2017

L. H. Griswold4, R. L. Griffin3, T. Swain1, J. Kerby2  2University Of Alabama,Acute Care Surgery,Birmingham, Alabama, USA 3University Of Alabama,Epidemiology,Birmingham, Alabama, USA 4University Of Alabama,School Of Medicine,Birmingham, Alabama, USA 1University Of Alabama,Trauma, Burns And Surgical Critical Care,Birmingham, Alabama, USA

Introduction:  Pressure ulcers are a costly hospital-acquired condition in terms of clinical outcome and expense. The Braden Scale was developed in 1987 as a risk scoring method for pressure ulcers, and uses six different risk factors: sensory perception, moisture, activity, mobility, nutrition and friction and shear. A score of 18 or lower is considered high risk. To date, research on the utility of the Braden Scale has focused on general medicine and non-trauma/burn surgery patients. We hypothesize that the Braden Scale does not accurately discriminate who will get a pressure ulcer among trauma and burn patients. 

Methods:  Data from medical records regarding documented Braden scores and presence of pressure ulcers regardless of staging was collected. Patients with ulcers present on admission were excluded from analysis.  For each patient, the lowest Braden score documented prior to the occurrence of the pressure ulcer was determined. Logistic regression was used to estimate odds ratios and associated 95% confidence intervals for the association between pressure ulcer likelihood and lowest Braden Scale measurement. To determine the discriminatory ability of the Braden Scale on pressure ulcer risk, four measures of performance (i.e., sensitivity, specificity, positive predictive value, and negative predictive value) were calculated for four non-mutually exclusive groups: a Braden Scale measurement ≤18, ≤14, ≤12, and ≤9.

Results: From 2011 through 2014, a total of 2,660 patients were admitted to the TBICU. Of these patients, 63 (2.3%) subsequently developed a pressure ulcer. A Braden Scale of 18 or less as the threshold for being at-risk of pressure ulcers had a sensitivity of 100% and specificity of 0.6%, while a Braden Scale of 9 or less had a sensitivity of 28.6% and a specificity of 90%. For all Braden Scale measurements, the PPV was never above 6.5%.

Conclusion: The Braden Scale has mediocre discriminatory ability among the trauma/burn population. In addition, the extremely low PPV suggests that the Braden Scale may not be a useful clinical tool when treating trauma and burn patients as it may result in unnecessary expenditure of time and personnel resources in preventing pressure ulcer formation.

 

50.08 Incidence of Acute Kidney Injury in Patients with Minor Injury: Still Blame Intravenous Contrast?

Posted on January 26, 2017

K. Matsushima1, J. Cho1, M. Luttio1, A. Strumwasser1, K. Inaba1, D. Demetriades1  1University Of Southern California,Los Angeles, CA, USA

Introduction:  Contrast-enhanced computed tomography (CECT) has become the mainstay of diagnostic work up in patients following blunt trauma. Although the overall incidence of acute kidney injury (AKI) in trauma patients has been reported to be as high as 30%, the actual risk of iodinated intravenous (IV) contrast for developing AKI has been questioned with the increasing use of low- or iso-osmolar IV contrast agents. We hypothesized that the incidence of AKI would be extremely low in mildly injured patients who received CECT for trauma work-up.

Methods:  A prospectively collected institutional blunt trauma database was reviewed from 11/2014 to 5/2015. We included mildly injured patients (AIS<2 in all body regions) who had at least two creatinine level measured during their hospital stay. The incidence of AKI, defined by the Acute Kidney Injury Network criteria, in patients who received CECT (contrast group) was compared with that in patients without CECT as part of their trauma work-up (no-contrast group). A multivariate logistic regression analysis was performed to examine the impact of IV contrast use on the incidence of AKI.

Results: A total of 276 patients met our inclusion criteria. Median age: 35 years, male gender: 62.7%. Median length of hospital stay: 2 days. 247 patients (89.5%) underwent CECT for their initial trauma work-up. Median IV contrast volume was 100ml. A total of 5 patients developed AKI. The incidence of AKI in the contrast group and the no-contrast group was 1.6% and 3.4%, respectively (p=0.43). Each of these 5 patients developed stage 1 AKI and none required a prolonged hospital stay for the management of AKI. After adjusting for clinically significant covariates in a logistic regression model, the administration of IV contrast was not significantly associated with the incidence of AKI (OR: 0.40, 95% CI: 0.04-3.96, p=0.44).

Conclusion: The current study showed the extremely low incidence of AKI in patients with minor injury and, specifically, the minimal impact of IV contrast on the incidence of AKI.

50.07 Emergency General Surgeon Management of Complex Hepatopancreatobiliary Trauma at a Level I Trauma Center

Posted on January 26, 2017

P. Kilen2, A. Greenbaum1, R. Miskmins1, R. Preda1, T. Howdieshell1, S. Lu1, S. West1  1University Of New Mexico HSC,Surgery,Albuquerque, NM, USA 2University Of New Mexico HSC,School Of Medicine,Albuquerque, NM, USA

Introduction: The impact of integrating trauma specialists and emergency general surgeons on trauma patient outcomes has been debated.   Complex hepatopancreatobiliary (HPB) injuries present a particular challenge and often require specialized care.  At our institution both fellowship-trained trauma and critical care (TCC) specialists and general surgeons (GS) are responsible for the care of trauma patients. We predicted there would be no difference in the initial management or outcomes of patients sustaining complex HPB trauma between general and trauma specialist surgeons.

Methods:   A retrospective review of patients who underwent operative intervention for complex HPB trauma (defined as liver AAST grade III-V, pancreas II-V and duodenum II-V, and extrahepatic biliary injuries) from May 2008 to August 2015 at an ACS-verified Level I trauma center was performed.  We employed our state trauma database and chart review to obtain demographics, initial vital signs, ISS, length of stay (LOS), the training level of the initial attending surgeon,  HPB-directed interventions, frequency of damage control laparotomy (DCL) versus primary closure, drain placement, infectious complications and mortality. Statistical analyses were performed with Chi-square and Fisher exact tests. Student’s t-Tests were used to compare means of continuous values.  P-values < 0.05 were considered significant.

Results:  A total of 173 patients met inclusion criteria.  Between the GS group (n=37) and TCC group (n=136), there were no significant differences in patient demographics, mechanism of injury, presence of shock or need for intubation on admission, mean ISS, or GCS, initial vital signs or physiologic derangement on laboratory studies.  Most injuries were high-grade hepatic (84.6% for GS and 76.3% for TCC; p=0.492).  TCC treated more pancreas injuries (15.8% of all injuries vs. GS 7.7%) though this was not statistically significant.  Primary abdominal closure rates between GS and TCC (28.9% vs. 31.9% respectively) and DCL with temporary abdominal closure (71.1% vs. 69.1%) were performed at similar rates (p=0.85).   There were no significant differences in HPB-directed interventions at the initial operation (39.5% GS vs. 55.11% TCC; p=0.13).  No differences in mean operative pRBCs (2.6 vs. 3.6; p=0.28), estimated blood loss (1.2L vs. 1.7L TCC; p=0.11) rates of angioembolization, or intraoperative cholangiogram were found.   In patients that were closed at the primary operation, TCC were more likely to place an intraabdominal drain than GS (76.2% vs. 36.4%; p=0.03).  Both ICU LOS, total LOS, and septic complications of GS and TCC were comparable, as was 30-day mortality (13.2% vs. 10.3%; p=0.77).

Conclusion:

We found no major differences between general and fellowship-trained trauma and critical care surgeons in the initial operative management or clinical outcomes of complex HPB trauma at our Level I trauma center. The frequent and proper use of DCL likely contribute to these findings.

50.06 SNAP-CHAT: Survivor Needs Assessment Project…Let Them Talk!

Posted on January 26, 2017

E. K. Grill1, E. Hall1, F. Grissom1, M. Mcunn1  1University Of Maryland School Of Medicine,Trauma And Critical Care/Anesthesiology/ R. Adams Cowley Shock Trauma Center,Baltimore, MD, USA

Introduction:  Survival following traumatic injury is a quantitative measure that does not account for quality of life after discharge. Little is known about the global needs of trauma survivors or what outcome measures are meaningful from their perspective. Key informant interviewing is a qualitative technique that can characterize needs of trauma survivors. We hypothesize that trauma survivors and their “pit crew” – family and friends – can inform trauma care providers of unmet physical, mental health, social and financial needs after discharge. 

Methods:  Trauma survivors (S) and pit crew (PC) were invited to participate using snowball recruitment through the Trauma Survivors Network. Interviews were conducted in person or over the phone from 6/2015 to 6/2016. One of two researchers asked a combination of pre-determined open ended and probing questions. All interviews were recorded with a Livescribe™ pen and reviewed for thematic analysis.

Results: 25 survivors and 25 PC members were interviewed. Not all S had their PC represented, and vice-versa (e.g. these are not dyads). Recruitment was halted once thematic saturation was reached. Interviews lasted between 30 and 300 minutes (mean = 1.6 hr). 76% of trauma survivors expressed unmet mental health needs, including past suicidal ideations or attempts (20%). Over half of S were in financial difficulty as a result of their trauma. Both S and PC expressed challenges with pain control, with 44% of subjects expressing pain management or addiction difficulties. (Table I)

Conclusion: A substantial portion of those S and PCs interviewed had long-term mental health and financial needs. This finding allows tailored, patient-centered interventions to be designed and implemented for long-term trauma care. As the definition of a successful trauma intervention is revised, outcome measures informed by patient experience are essential in order to improve quality, not just quantity, of life after trauma. 

 

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