35.10 Stapler vs. Looped Suture in Appendectomy: A Comparative Outcomes Analysis

Posted on January 25, 2017

P. P. Parikh1, J. Tashiro1, A. E. Wagenaar1, M. Curbelo2, N. Joudi1, E. A. Perez1, H. L. Neville1, A. R. Hogan1, J. E. Sola1  1University Of Miami,Surgery,Miami, FL, USA 2Baptist Children’s Hospital,Surgery,Miami, FL, USA

Introduction:  The appendix may be ligated using several methods in laparoscopic appendectomy (LA). There exists controversy regarding the use of looped suture or stapler devices. We sought to compare outcomes between LA performed by two surgeons using looped suture or stapler devices, exclusively. 

Methods:  Cases performed by two experienced pediatric surgeons were compared for fiscal years 2013 and 2014. One surgeon used looped suture exclusively, the other used staplers exclusively. Chi-square tests were performed to analyze associations.

Results: A total of 238 cases were analyzed, with 128 LA performed by stapler (54%) and 110 performed by looped suture (46%). Operating room costs were $707.12 for stapler LA and $317.10 for looped suture LA. The only significant differences in costs were those associated with ligation type. Acute appendicitis was diagnosed in 75% of cases, with the remainder being perforated or gangrenous (25%). Mean patient age was 12.1 ± 3.7 years. Patients were 58% male, 42% female. Children were most frequently of Hispanic (76%), followed by Caucasian (13%) and African American (6%) descent. Transferred patients comprised 62% of patients at the facility. CT scans were ordered in 16% of cases. Antibiotics were prescribed upon discharge for a small number of individuals (29%). Complications occurred during the admission in 3 cases. Complications occurred within 30 days of LA in 12 cases.

On bivariate analysis, length of stay and rates of in-hospital or 30-day complications, return to ER, readmissions within 30 days did not significantly differ between the two ligation methods.

Conclusion: On comparison of looped suture and stapler devices for laparoscopic appendectomy, complications, readmissions, ER visits, and length of stay were not significantly different. Although outcomes were unaffected by ligation type, significant cost savings ($390/case) are achievable with looped suture LA.

 

35.09 Reassessing the Utility of CT Arteriograms in Penetrating Injuries to the Extremities

Posted on January 25, 2017

L. A. Gurien1, B. K. Yorkgitis1, J. W. Dennis1  1University Of Florida College Of Medicine – Jacksonville,Surgery,Jacksonville, FL, USA

Introduction:
Advanced imaging for penetrating limb injuries is commonly performed.  The practice of relying on mandatory conventional arteriography in the 1970’s fell out of favor in the 1990’s, evolving towards a more physical examination based approach for the detection of clinically significant vascular injuries.  However, with the rapid availability of CT scans in trauma centers, the use of CT arteriography (CTA) has steadily increased as a method to evaluate such patients.  The purpose of this study was to evaluate the efficacy of physical exam findings compared to CTA in the detection of clinically significant vascular injuries associated with penetrating extremity trauma.

Methods:
Using an IRB approved protocol, the medical records and radiologic results of over 9000 trauma patients presenting to a single level I trauma center during a 27-month period (January 2013 – March 2015) were queried.  Patient with penetrating extremity trauma to both upper and/or lower extremities were included.  Extremity physical examination findings were documented in all cases permitting review.

Results:
We identified 92 patients with penetrating trauma to the extremities who underwent a CTA during their initial trauma evaluation. None of these 92 patients had documented hard signs of vascular injury on initial physical examination. Soft signs and/or diminished (yet present) distal pulse were documented in 20 (21.7%) patients.  Two patients were found to have vascular injuries demonstrated on CTA, but had an initial distal pulse documented on their trauma survey.  However, one of these patients had a loss of pulses in the extremity on repeat examination.  The remaining 90 patients had no abnormalities requiring surgical or endovascular repair.  These findings indicate that serial vascular exams, in the setting of penetrating extremity trauma, have an accuracy of 98.9% in detecting vascular injuries needing procedural intervention.  The cost of the CTA with physician interpretation was over $4000 in each case and the performance of the study involved administration of intravenous contrast (155mL average).

Conclusion:
The findings from our study suggest that use of CTA is routinely performed in the evaluation and management of penetrating extremity injuries regardless of the physical exam.   This imaging modality is associated with known economic and non-economic risks.  Utilizing CTA in the setting of benign physical examination findings burdens the patient and healthcare system with these risks.  Patients with no hard signs of vascular trauma do not require CTA for safe and accurate assessment of their injuries and need for surgical repair.  Serial physical examination may provide similar detection of vascular injury requiring procedural intervention.

35.08 Surgical Tray Optimization is a Simple Way to Decrease Perioperative Costs

Posted on January 25, 2017

J. S. Farrelly1, C. Clemons2, S. Witkins2, W. Hall2, E. Christison-Lagay1,2, D. Ozgediz1,2, R. Cowles1,2, D. Stitelman1,2, M. G. Caty1,2  1Yale University School Of Medicine,Department Of Surgery,New Haven, CT, USA 2Yale New Haven Hospital,New Haven, CT, USA

Introduction:
Healthcare spending in the US remains excessively high. Aside from complicated, large-scale efforts at healthcare cost reduction, there are still relatively simple ways in which individual hospitals can cut unnecessary costs from everyday operations. Inspired by recent publications, our group sought to decrease costs associated with surgical instrument processing at a large, multi-hospital academic center.

Methods:

This was a single-site observational study conducted at a large academic medical center. At the study start, all attending surgeons within the section of Pediatric Surgery agreed to standardize the Pediatric Surgery trays and to eliminate instruments that were deemed unnecessary from each tray. A multi-disciplinary start-up meeting was held, and this meeting included stakeholders from central sterile processing, operating room nursing, scrub technicians, and materials management along with all 5 pediatric surgeons. Each tray was addressed individually. Instruments were eliminated from trays only if there was unanimous agreement among all the surgeons in the group. If no instruments in a given surgical tray were deemed necessary, the entire tray was eliminated from sterile processing rotation. Feedback questionnaires were drafted by the multi-disciplinary team that participated in the start-up meeting. Surgeons were allowed to request for certain instruments to be placed back into the trays at any time, and the questionnaires also allowed for free-hand comments.

 

Surgical kit preparation time was obtained from the institutional barcode scanning system. The cost per second of sterile processing labor was calculated using regional median salary for sterile processing technicians in the state of Connecticut. Using the Pediatric Surgery section as the model unit, this method was then applied to Pediatric Urology, Neurosurgery, Spine surgery, and Orthopedics. 

Results:
The Pediatric Surgery section eliminated an average of 31.5% of instruments from each tray resulting in an overall reduction of 1826 (39.5%) instruments from rotation, 45,856 fewer instruments processed per year, and 9 trays eliminated completely from regular rotation. Processing time for 6 commonly used trays was reduced by an average of 28.7%.  The Urology section eliminated 18 trays from regular rotation and 179 (10.1%) instruments in total. Pediatric Orthopedics, Neurosurgery, and Spine sections eliminated 708 (17.1%), 560 (92.7%), and 31 (32.2%) instruments, respectively, resulting in approximately 18804 fewer instruments processed per year.  Among all 5 surgical sections, instrument cost avoidance after tray optimization was estimated at $531,929 per year. Negative feedback and requests for instrument replacement were both minimal on feedback questionnaires.

Conclusion:
Surgical tray optimization represents a relatively simple microsystem improvement that could result in significant hospital cost reduction. Though difficult to quantify, other gains from surgical kit optimization include decreased weight per tray, decreased materials cost, and decreased labor required to count, decontaminate, and pack surgical trays.

35.07 In by Helicopter Out by Cab: The Financial Cost of Aeromedical Overtriage of Trauma Patients?

Posted on January 25, 2017

S. K. Madiraju3, J. Catino1, C. Kokaram1, T. Genuit3, M. Bukur2  1Delray Medical Center,Trauma/Critical Care,Delray Beach, FL, USA 2Bellevue Hospital Center,Trauma/Critical Care,New York, NY, USA 3FAU Charles E Schmidt College Of Medicine,N/A,Boca Raton, FL, USA

Introduction:  Aeromedical evacuation of trauma patients is a potentially lifesaving intervention targeted to benefit those with severe injuries. Helicopter transport of less severely injured patients is controversial and costly. This study aims to identify the financial costs associated with helicopter evacuation of over triaged patients using a complex trauma activation algorithm at a Level I Trauma Center.

Methods:  A 6-year retrospective analysis was conducted (2010-2015) of all Adult Trauma Activations presenting to a Level I Trauma center. Exclusion criteria were patients with non-survivable injuries, missing variables, or those transferred from the Emergency Department (ED). Patients were dichotomized by transportation method as well as trauma activation criteria. Our complex trauma algorithm is loosely based upon CDC criteria and includes Red (physiological), Blue (Mechanistic), and Grey (County/Paramedic Judgement) classifications. Our primary outcome was over triage rate of aeromedical patients defined as those that were discharged from the ED, medically admitted without injuries, or admitted to observation status only. Our secondary outcomes were adjusted mortality rates and total financial costs of unnecessary helicopter use.

Results: During the 6-year period 4,218 patients arrived as Trauma Activations with 28% arriving by Helicopter. Patients arriving by air were more likely to be young males that were uninsured with a penetrating mechanism (15.5% vs. 10%, p<0.001) higher injury burden (Median ISS 8 vs. 6, p<0.001) and need for Operative intervention (17% vs. 13%, p<0.001) than those arriving by ground. Red alerts were the most common (63%) criteria for air transport followed by Blue (31%) and Grey (6%). Over triage (Median ISS 4 [IQR 1-5]) increased significantly from 51% to 77% with lower tier activation criteria (p<0.001). Adjusted mortality between air and ground transport was not significantly different for activation criteria (Red 10.9% vs. 8.5%, Adjusted p=0.548, Blue 3.2% vs. 3.6%, Adjusted p=0.270, Grey 2.7% vs. 0%, Adjusted p=1.000). Median charges for air evacuated patients was $10,478 (IQR $10,387 – $10,661, vs. $800 via ground). By eliminating over triage of air patients, this would result in a cost savings of $3,603,442 annually.

Conclusion: Using a complex trauma activation protocol results in significant over triage (52%) and unnecessary air evacuation of minimally injured patients at great financial cost. Revision of trauma activation protocols may result in more judicious air transport use and subsequent significant reductions in health care costs.          

 

35.06 Saving Time: A Single Center Experience with Eliminating the Post-PICC Placement Chest X-Ray

Posted on January 25, 2017

Y. W. Chang1, J. Park1, S. Safford1  1Virginia Tech Carilion School Of Medicine,Roanoke, VA, USA

Introduction:  The use of peripherally inserted central catheters (PICCs) in adults is a safe and reliable form of vascular access. However, the placement of a PICC usually requires crude estimates and a chest x-ray (CXR) for confirmation. The ideal catheter tip location is at the cavoatrial junction, a target area 1.6-3.6 cm long in adults. A newly developed catheter has shown to accurately guide PICC placement in adults. This study examines the impact of using the ARROW VPS G4 (AVG) system for PICC placement.

Methods:  We designed a retrospective cohort study of patients (≥18 years old) who received a PICC at our institution between 9/1/2012 and 6/1/2013. Patients were divided into three groups: the pretrial group had a PICC placed without the AVG, the trial group had a PICC placed with the AVG and CXR confirmation and the post-trial group required no CXR confirmation. We excluded patients who had a midline catheter placed, a non-sinus rhythm prior to PICC placement, and anyone with a pacemaker. All PICCs were placed by the PICC team of the hospital staffed by CRNAs.

Results: We enrolled 497 total patients: 196 (pretrial group), 148 (trial group) and 153 (post-trial group). First pass success rates and average procedure lengths were comparable between groups. The readjustment rate was 9.4%, 2.8% and 1.3% for the pretrial, trial and post-trial group respectively (p<0.01). Significantly, CXR confirmation after PICC placement averaged 121 minutes. If readjustment was required, final confirmation averaged 247 minutes. Financially, the post-trial group incurred a savings of $42 per PICC placement translating to a yearly savings of $28,000.

Conclusion: Our data supports the use of the AVG with PICC placement to reduce cost and line downtime in the adult population.

 

35.05 Decision Analysis Supports the Use of Amylase Based Enhanced Recovery Pathway After Esophagectomy

Posted on January 25, 2017

B. Jiang2, V. P. Ho2, J. Ginsberg1, S. J. Fu1, Y. Perry1, L. Argote-Greene1, P. A. Linden1, C. W. Towe1  1University Hospitals Case Medical Center,Thoracic And Esophageal Surgery,Cleveland, OH, USA 2University Hospitals Case Medical Center,Surgery,Celeveland, OH, USA

Introduction:
A common post-operative complication after esophagectomy is anastomotic leak. Radiographic imaging of anastomotic leaks (by esophagram) is frequently inaccurate and is often performed after 5-7 days of observation. Prior study has supported the use of perianastomotic drain amylase (DA) on postoperative day 4 to identify patients at low-risk and high-risk for anastomotic leak.  . The aim of this study was to determine if decision analysis supports the use of a DA-based accelerated care pathway to decrease hospital length of stay and cost.

Methods:
We designed a decision tree model to compare costs and lengths of stay of DA leak detection versus the standard of care (esophagram) using data extracted from cohort of post-esophagectomy patients from an academic medical center that has been routinely measuring DA. We assessed the model outcome using historical cost and length of stay from retrospective review of consecutive patients undergoing elective esophagectomy. We performed a Monte Carlo simulation to assess the effects of base-case variables on model outcomes. We also performed one-way sensitivity analyses to identified thresholds where a decision alternative dominated the model (both less expensive and shorter stay than the alternative).

Results:
Using DA cutoff value of 31U/L on post-operative day 4, 38% of patients were assigned to an accelerated recovery pathway, of which 10% were found to have a leak. Patients with DA over 125U/L were defined as ‘high risk’ for leak (20% of cohort), of which 50% were diagnosed with a leak. Decision analysis demonstrated that a DA-based accelerated recovery pathway was associated with an improvement in overall LOS of 0.96 days and a cost saving of $2,773.96. Monte Carlo simulation confirmed this finding, with a median saving of 0.78 days and $2078.46.

Conclusion:
Current methodologies to detect anastomotic leaks after esophagectomy radiographically are associated with prolonged hospitalization, but drain amylase can identify patients at low risk and high risk of anastomotic leak. Decision analysis supports the use of post-operative day 4 perianastomotic DA to predict anastomotic leak to reduce hospital length of stay and cost.
 

35.03 The Cost Consequences of Age and Comorbidity in Accelerated Postoperative Discharge After Colectomy

Posted on January 25, 2017

S. P. Shubeck1,5,6, A. H. Cain-Nielsen1, E. Norton2,3,4, S. Regenbogen1,5  2University Of Michigan,Department Of Health Management,Ann Arbor, MI, USA 3University Of Michigan,Department Of Economics,Ann Arbor, MI, USA 4National Bureau Of Economic Research,Cambridge, MA, USA 5University Of Michigan,Center For Health Outcomes & Policy (CHOP),Ann Arbor, MI, USA 6University Of Michigan,National Clinician Scholars Program,Ann Arbor, MI, USA 1University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA

Introduction: As payment for inpatient surgery transitions to bundled payments for surgical episodes, hospitals face increasing pressure to reduce utilization in and out of hospital. We previously found that early routine postoperative discharge after major surgery incurred lower total episode payments without compensatory increase in post-discharge expenditures. Whether this strategy can succeed for older patients and those with higher levels of comorbidity is unknown.

Methods: We evaluated a cross-sectional cohort of 189,229 Medicare beneficiaries 65 or older undergoing colectomy 2009-2012 and computed associations between episode payments and hospitals’ length of stay (LOS) stratified by patients’ age and health status, according to the Elixhauser Comorbidity Index. Hospitals’ LOS was characterized by the mode to reflect typical hospital practice and minimize the influence of outliers. To focus on patients adhering to hospitals’ typical care, we then restricted analysis to the 73,212 patients discharged within one day of the mode LOS for each hospital. In this cohort, we evaluated risk-adjusted, price-standardized 90-day overall episode payments including index hospitalization, outlier payments, unplanned readmissions, professional services, and post-acute care.

Results: Total episode payments were lower in shortest LOS than longest LOS hospitals in all age categories (65-69: $33,084 vs. $41,006; >=80 $32,239 vs. $42,526; both p<0.001). The oldest patients had greater post-discharge care expenditures than youngest patients, but the disparity was similar in shortest and longest LOS hospitals (+$289 vs +$1,275, p=0.20). Conversely, patients with greatest comorbidity had no reduction in total episode payments in shortest LOS hospitals ($42,848 for 3 day LOS vs. $44,647 in >=7 day LOS, p=0.06, figure). The increase in post-discharge care expenditures for patients with highest comorbidity was greater in shortest versus longest LOS hospitals (+$4,101 vs. +$1,863, p=0.002).

Conclusion: Even the oldest Medicare beneficiaries experience lower total episode payments without compensatory increase in post-acute care expenditures when undergoing colectomy in hospitals with shortest post-operative LOS pathways. In contrast, those with greatest comorbiditiy accrue no savings in short LOS hospitals as they require more post-acute care services to achieve early discharge. These findings suggest that payment reform and initiatives to improve the efficiency of perioperative care must consider overall health status more than age alone. 

35.02 Improving On Time Surgical Starts: The Impact of Implementing Pre-OR Timeouts and Performance Pay

Posted on January 25, 2017

J. Langell1,2, L. Martin1,2, J. Langell1,2  1University Of Utah,School of Medicine, Department Of Surgery,Salt Lake City, UT, USA 2VA Salt Lake City Health Care System,Center Of Innovation,Salt Lake City, UT, USA

Background: Operating room (OR) time is expensive.  Underutilized OR time negatively impacts efficiency and is an unnecessary cost for hospitals.  A major contributor to underutilization is delayed surgical starts. The purpose of this study was to evaluate the impact of a pre-OR timeout and performance pay incentive on the frequency of on time, first surgical starts.

Methods: At a single Veteran’s Affairs Medical Center, we implemented a pre-OR timeout in the form of a safety briefing checklist.  The timeout occurs at the bedside in the pre-operative holding area, and attendance of the surgical attending, OR nurse circulator, and anesthesia provider is required.  Initial implementation occurred in late 2008 and was quickly rolled out across all surgical divisions.  Additionally, a performance pay incentive for on time starts (>90% compliance) for attending surgeons was introduced in 2009.  Data were collected on all first-start cases beginning prior to implementation in 2008 and continued through 2015.

Results: Each year an average of 960 first starts occurred across 9 surgical divisions (General Surgery, ENT, Neurosurgery, Orthopedic Surgery, Plastic Surgery, Podiatry, Thoracic Surgery, Urology, and Vascular Surgery).  Prior to implementation of either the timeout or pay incentive, only 15% of cases started on time, and by 2015, greater than 72% were on time (p<0.001) [Figure].  Over the study period, there was a significant improvement in on time starts (p=0.01), of delays <15 minutes (p=0.01), and of delays 16-30 minutes (p=0.04). The trends for delays of 31-60 minutes or >60 minutes were not significant (p=0.31; p=0.81).  Subgroup analysis showed that the trends were significant for improving on time starts for each of the 9 divisions.  Assuming a loss of 7 minutes per case for delays <15 minutes and 20 minutes per case for delays of 16-30 minutes, the total OR time saved from implementing these measures was 37,556 minutes.  At an estimated cost of  $20/minute, gross savings from this project were $751,120.  We observed that attending surgeons were more likely to have prompt arrivals for first-start cases knowing that their attendance at the pre-OR time out was required for the case to proceed, and that consistent promptness would result in financial gain.

Conclusions: Implementation of a pre-OR timeout and performance pay for on time starts significantly improves OR utilization and reduces unnecessary costs.

 

35.01 Hot Spotting as a Strategy to Identify High Cost Surgical Populations

Posted on January 25, 2017

S. P. Shubeck1,2,3, M. Healy1,2, J. Thumma1,2, E. Norton4,5,6, J. Dimick1,2, H. Nathan1,2  1University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA 2University Of Michigan,Center For Health Outcomes & Policy (CHOP),Ann Arbor, MI, USA 3University Of Michigan,National Clinician Scholars Program,Ann Arbor, MI, USA 4University Of Michigan,Department Of Health Management And Policy,Ann Arbor, MI, USA 5University Of Michigan,Department Of Economics,Ann Arbor, MI, USA 6National Bureau Of Economic Research,Cambridge, MA

Introduction: The Affordable Care Act’s emphasis on value over volume has signaled a shift in responsibility for healthcare costs from payers to providers. Bundled payment programs are increasingly focused on surgical procedures. Population-based management of surgical costs requires that providers can prospectively identify high cost surgical patients. This strategy, known as “hot spotting,” is well developed in medical populations, but little investigation has focused on high cost surgical patients. We sought to assess the feasibility of prospectively hot spotting high cost surgical patients.

Methods: Using 100% Medicare claims data for 2010-2013, we identified patients aged 65-99 years undergoing four elective procedures: colectomy, coronary artery bypass grafting (CABG), total hip arthroplasty (THA), or total knee arthroplasty (TKA). We calculated price-standardized Medicare payments for index hospitalization, physician services, post-acute care, and readmissions for the entire “surgical episode” from the index admission through 30 days after discharge. Patient level factors associated with payments were analyzed by multivariable linear regression.

Results: Medicare patients in the highest decile of spending accounted for a disproportionate share of aggregate costs: 30% in colectomy, 22% in CABG, 19% in THA, and 18% in TKA. Medicare expenditure differences between the highest and lowest deciles (colectomy: $75,164 vs $9,366; CABG: $77,788 vs $20,814; THA: $36,688 vs $11,406; TKA: $35,248 vs $11,647) were explained primarily by a 5-fold difference for colectomy and 3-fold difference for CABG in index hospitalization cost. In contrast, there was an 80-fold difference for THA and 47-fold difference for TKA in post-acute care expenditures between highest and lowest deciles (Figure). In multivariable analyses, patient age, gender, and socioeconomic status had minimal association with episode cost, but patients with ≥3 comorbidities had significantly higher costs compared to those with 0-1 comorbidities (colectomy: +$9,022; CABG: +$3,751; THA: +$3,172; TKA: +$2,604).

Conclusion: We found that a subset of patients was responsible for a disproportionate share of total Medicare spending for these procedures. The individual components of spending that primarily drive expenditures vary by procedure. Providers may control cost by through patient selection when spending is driven by multimorbidity, while limiting post-acute care may be effective in other procedures. These findings suggest that targeting high cost Medicare patients (i.e., hot spotting) for prehabilitation or selective referral would be a potentially effective strategy to reduce costs in surgical populations.

34.10 Increasing Number and Age of Blood Increases Mortality in Massively Transfused Trauma Patients

Posted on January 25, 2017

R. Uhlich1, R. Patel1, J. Pittet1, P. Bosarge1, M. Marques1, H. Wang1, J. Kerby1  1UAB,Acute Care Surgery,Birmingham, AL, USA

Introduction:
Numerous studies have examined the association between blood age and mortality among trauma patients. This study was designed to account for the time-varying nature of exposure to stored blood and its effect on mortality.

Methods:
Patients receiving at least one unit of red blood cells between 2011 and 2014 were included. Blood bank data was queried for the age of blood and time of transfusion. Demographics, injury, and clinical characteristics were obtained from the trauma registry. The time at which a patient received at least one unit of blood stored > 7 days, > 14 days, or > 21 days was calculated. A Cox proportional hazards model adjusted for age, Injury Severity Score, and injury mechanism estimated hazard ratios (HRs) for the association between death in 24 hours and receiving at least one unit of stored blood. A separate model was created for each blood age category, and exposure to at least one unit of stored blood was entered as a time-varying covariate. Models were stratified by whether the patient received > 10 units of blood in 24 hours.

Results:
1,654 patients received at least one unit of PRBC (187 massively transfused). Increased hazard of 24-hour mortality was observed for those with exposure to at least one unit of blood > 7 days (HR 1.83, 95% CI 1.31-2.56), > 14 days (HR 1.49, 95% CI 1.05-2.10), or > 21 days (HR 1.75, 95% CI 1.17-2.62). The hazard increased when patients received at least 4 units of blood > 14 days (HR 3.54, 95% CI 2.20-5.71) or 21 days (HR 5.21, 95% CI 2.53-10.76). Patterns of association were observed among massively transfused patients.

Conclusion:
Exposure to increasing number and age of stored blood increases the hazard of 24-hour mortality for patients requiring large blood volume replacement. Clinical trials evaluating the effect of blood storage age on clinical outcomes in trauma are warranted.
 

34.09 Risk of Death in Elderly Blunt Trauma Patients: Complications Count

Posted on January 25, 2017

V. Gahlawat1, J. A. Vosswinkel1, A. J. Singer1, M. J. Shapiro1, J. E. McCormack1, E. Huang1, R. S. Jawa1  1Stony Brook University Medical Center,Stony Brook, NY, USA

Introduction:  A variety of factors are thought to influence outcomes following geriatric trauma. However, there is little detailed information regarding the effects of complications on outcomes following admissions for blunt trauma in the elderly.

Methods:  We performed a retrospective review of the trauma registry at a suburban regional trauma center from 2010 to 2015 for all elderly (>65 y) blunt trauma admissions with hospital length of stay (LOS) ≥ 3 days. Deaths in Emergency Department, burns and cardiac arrest were excluded. Patients were divided into three groups- No Complications [NC], minor complications only [MC], and major complications with or without minor complications [SC]. Major and Minor complications were defined as per TQIP. Univariate and multivariate analyses were performed.

Results: There were 2,469 admissions meeting inclusion criteria, NC (n=1,984), MC (n=211) and SC (n=274).  There was no significant difference amongst groups in terms of age (median years; NC- 81, MC- 82, SC- 81, p=0.60) and frequency of low fall as the mechanism of injury (NC- 74.7%, MC- 73.5%, SC- 72.3%, p=0.64). Pre-admission Do Not Resuscitate directive (DNR, NC- 6.6%, MC- 10.4%, SC- 9.9%, p=0.025) and Injury severity score (ISS, median [IQR]; NC- 9[5.5-13] , MC- 10[9-16], SC- 12[9-17], p<0.001) were lower in no complications group. With regards to outcomes, patients who suffered major complications after blunt trauma had increased intensive care unit (ICU) LOS, mechanical ventilation, hospital LOS, in-hospital mortality and fewer discharge to home (Table 1). In-hospital mortality increased with increasing number of major complications (0-2.6%, 1-12%, 2-29%, 3-20.0%, 4-50%). On multivariate stepwise forward logistic regression analysis, factors significantly associated with in-hospital mortality (Odds Ratios with 95%CI) were mechanical ventilation (9.56 [5.08-18.00]), pre-admission DNR (5.01 [2.64-9.49]), ICU stay (2.12 [1.06-4.23]), low fall mechanism of injury (2.07 [1.12-3.83]), major complications (1.56 [1.17-2.06]), ISS (1.08 [1.05-1.12]), and age (1.04 [1.01-1.07]).

Conclusion: Low fall was the most frequent mechanism of injury. There was a near linear relationship between the number of major complications and in-hospital mortality in elderly patients admitted with blunt trauma. The multivariate model had excellent discriminative characteristics for mortality, with an AUCROC of 0.911. The probability of death during hospitalization increased by a factor of 1.56 with each major complication (i.e. OR 6.24 with 4 complications). Once even a single major complication has occurred, great vigilance is warranted to prevent in-hospital mortality. Further study in a larger cohort is warranted.

34.08 Trauma-Induced Coagulopathy is associated with an Early, Discoordinated Inflammatory Response

Posted on January 25, 2017

R. A. Namas1, X. Zhu1, D. Liu1, O. Abdul-Malak1, J. Sperry1, Y. Vodovotz1, T. Billiar1  1University Of Pittsburgh,General Surgery,Pittsburgh, PA, USA

Introduction: Trauma-induced coagulopathy (TIC) is often associated with a broad systemic inflammatory response that can predispose patients to follow a complicated clinical course. Despite significant recent advancements associating post-traumatic inflammation with TIC, a better understanding of this complex interaction is needed. To characterize the systemic inflammatory response accompanying TIC, we analyzed an extensive time course of circulating inflammatory mediators coupled with data-driven modeling.

Methods: From a cohort of 472 blunt trauma survivors, 114 patients had TIC (defined by admission INR ≥ 1.3). After excluding patients with history of anticoagulant intake pre-trauma, 98 TIC patients (71 males [M] and 27 females [F], age: 39.7 ± 2, injury severity score [ISS]: 23.7 ± 1) were matched to 98 non-TIC patients (71/27 M/F, age: 39.8 ± 2, ISS: 23.4 ± 1) for age, gender ratio, and ISS using IBM SPSS®. Three samples within the first 24 h were obtained from all patients and then daily up to day 7 post-injury and assayed for twenty four inflammation biomarkers using Luminex™. Two-way analysis of variance was used to determine statistical significance (p<0.05) between the TIC and non-TIC sub-groups. Dynamic network analysis (DyNA) was used to infer dynamic connectivity and complexity among the inflammatory mediators.

Results: ICU length of stay (LOS), total LOS, and days on ventilation were statistically significantly prolonged in the TIC group when compared to non-TIC group. In addition, the TIC group had a greater requirement of operative intervention within the first 24 h post-admission. The TIC group had a higher degree of organ dysfunction from days 1 to 7 when compared to the non-TIC group. Importantly, circulating levels of IL-6, IL-10, MCP-1, MIG, IP-10, and IL-8 and were significantly elevated in the TIC group. DyNA suggested that the inflammatory response in the non-TIC group had a higher coordinated degree of interconnectivity while the response in TIC consisted of multiple sparse nodes with reduced interconnectivity within the initial 4 h post-injury.

Conclusion: These results suggest that post-traumatic coagulopathy, identified by elevated admission INR, is associated with a markedly differential inflammatory response when compared to patients that present without TIC despite similar injury patterns. Reduced dynamic network connectivity in the TIC patients suggests a discoordinated inflammatory response that might promote immune dysfunction and hence worse outcome.

 

34.07 Palliative Care Assessment for Injured Patients: Perspectives from Trauma and Palliative Care Teams

Posted on January 25, 2017

M. J. Keating1, N. D. Patel1, M. Nishtala1, C. W. Towe1, C. S. Koniaris2, J. George2, V. P. Ho1  1Case Western Reserve University School Of Medicine,Surgery,Cleveland, OH, USA 2Case Western Reserve University School Of Medicine,Medicine,Cleveland, OH, USA

Introduction:
Palliative care is a medical specialty focused on improving quality of life and alleviating symptoms for patients facing life-threatening illness. Barriers to the integration of Palliative Care team (PCT) services into the care of trauma patients have not been clearly defined. We sought to prospectively evaluate whether trauma team (TT) and PCT members differed regarding perceived benefit of PCT (PBP) consultation in trauma patient care.

Methods:
TT and PCT clinicians attended weekday trauma service sign out for 12 weeks. Based on verbal report, each member of the TT and PCT independently assessed whether patients might benefit from a PCT consultation.  TT included trauma surgeons (TS), advance practice providers (APPs), and residents. Sign out typically involved 4-6 TT members. PCT included physicians and APPs; sign out typically involved 1-2 PCT members. Data were prospectively collected regarding assessments, demographics, injury severity, and outcomes. Patients who received a PCT consult were excluded from subsequent assessments. PBP between the TT and PCT clinicians was compared. Secondarily, we sought to identify clinical outcomes associated with PBP. Chi-square and Student’s t-test were used to compare groups (p<0.05 considered significant).

Results:
186 patients (median age 47.6, SD 23.9) had 2013 assessments performed by TT members and 522 assessments by PCT members. Mean injury severity score was 11.9 (SD 9.9). Mean length of stay was 5 days (SD 10.9). There were 5 deaths. TT members identified 76 patients (41%) as having PBP at least once during the hospital stay, compared with 59 patients (32%) identified by PCT (p<0.001), with 78% concordance. TS identified fewer patients with PBP than PCT (22% vs 32%, p<0.001), with 49% concordance with PCT. Eight (5%) patients received a formal PCT consult.  Patients identified as having PBP by any clinician were significantly more likely to change code status to “Do Not Resuscitate,” and were more likely to be discharged to a destination other than home.

Conclusion:
TT and PCT providers identify a high proportion of trauma patients who might benefit from PCT evaluation. Despite this, consultations are rarely requested. Further exploration should be performed to determine barriers to PCT consultation.

34.06 Outcomes Of Patients with Traumatic Brain Injury in Skilled Nursing Facilities

Posted on January 25, 2017

S. N. Lueckel1,2, D. S. Heffernan1,3, T. Kheirbek1,3, M. D. Connolly1,3, S. F. Monaghan1,3, C. A. Adams1,3, W. G. Cioffi1,3, K. Thomas2  3Brown University,School Of Medicine,Providence, RI`, USA 1Rhode Island Hospital,Department Of Surgery Division Of Trauma Surgery And Critical Care,Providence, RI, USA 2Brown Universtiy,School Of Public Health,Providence, RI, USA

Introduction:
Traumatic brain injury (TBI) is a leading cause of death and disability in the United States. In 2010, 2.5 million people suffered TBI at a cost of $76.5 billion. Within the survivors, TBI remains a leading contributor to long term disability. It is estimated that 5.3 million people are living with physical, emotional, cognitive and behavioral disabilities attributable to TBI, many of whom require placement in long term skilled nursing (SNFs). Despite this very large population of TBI patients, very little is known about the long term outcomes of TBI survivors, including rates of discharge to home or risk of death in long term nursing facilities.

Methods:
This is a retrospective review of the prospectively maintained Federal Minimum Data Set (MDS) combined with the CMS Vital Status database from 2012-2013. Records were reviewed for clinical characteristics upon admission to the SNF including cognitive function (CFS), ability to communicate, and motor function. Activities of daily living were reassessed at 30 days post SNF admission to calculate Functional Improvement at 30 and 60 days and 1 year (FI). Records were also reviewed for discharge to home, readmission rates and death at 30 and 60 days and 1 year. For analysis we used robust Poisson regression to estimate relative risk (RR).

Results:
Overall, 65,099 individuals were admitted to SNFs with a TBI diagnosis in the US. The mean age was 71.6 years with 26% over the age of 85yrs. Overall, poor cognitive or functional status upon presentation to a SNF was associated with increased risk for poorer outcomes. Patients who were unable to communicate upon presentation to the SNF had a 42% lower risk of showing any FI at 30 days compared to those who could communicate. Patients with motor dysfunction had a 17% lower risk of showing any FI. Patients with communication impairment and patients with motor impairment had lower risk of being discharged to home, 86% and 85% respectively. Overall, older patients (> 65yrs) with TBI had a 3.6 times higher risk of death at 30 days in SNF compared to younger patients with TBI (RR=3.6, 95%CI=2.9,4.3). The risk of death was higher in patients with poor cognitive function was (RR=8.9, 95%CI=7.4, 10.6) significant motor impairment (RR=5 95%CI=4.5, 5.6) and in patients with impairment in communication (RR=5.5, 95%CI=5.0, 6.0) compared to those without the respective deficits.

Conclusion:
Our results further suggest that among a population with TBI admitted to SNFs, the likelihood of adverse outcomes varies significantly by key clinical and demographic characteristics. Understanding this can help set expectations to patients, families, as well as providers.  Moreover, this data might help guide future therapies and calls for dedicated TBI rehabilitation facilities. 
 

34.05 The “Lethal Triad” in Blunt Traumatic Hemorrhagic Shock: What is Contributing to “Lethal?”

Posted on January 25, 2017

J. O. Hwabejire1, C. E. Nembhard1, T. A. Oyetunji3, W. R. Greene2, M. Williams1, E. E. Cornwell III1, S. M. Siram1  1Howard University College Of Medicine,Surgery,Washington, DC, USA 2Emory University Hospital,Surgery,Atlanta, GEORGIA, USA 3Northwestern University Feinberg School Of Medicine,Surgery,Chicago, ILLINOIS, USA

Introduction:  The combination of acidosis, coagulopathy and hypothermia in a trauma patient is a harbinger of death. Resuscitation and control of bleeding are two key tenets of trauma care designed to halt this vicious cycle. We examine clinical variables that contribute to mortality in blunt traumatic shock patients presenting with this triad.   

Methods:  The Inflammation and the Host Response to Injury database was analyzed. Patients who, on presentation to the emergency room (ER), had the triple combination of severe hyperlactatemia (serum lactate >4 mg/dL), coagulopathy (INR >1.5) and hypothermia (body temperature ≤ 36 °C) were included. Univariate analyses were used to compare survivors and non-survivors while multivariable analysis was used to determine predictors of mortality.

Results: A total of 172 patients met all three criteria. The mean age of the cohort was 39 years, 70% were male, and 90% were White. Their overall mortality was 30.8%. There was no difference in pre-injury comorbidities, body mass index, Injury Severity Score, multiple organ dysfunction score, ER systolic BP, ER heart rate, ER body temperature, crystalloid volume administered within 12 hours, WBC count, and platelet count between survivors and non-survivors. Compared to survivors, non-survivors were older (46±22 vs. 37±18 years, p=0.005), more coagulopathic (ER INR 2.6±1.5 vs. 2.1±1.2, p=0.021), had higher ER lactate (7.8±3.2 vs. 6.5±2.2 mg/dL, p=0.002), higher APACHE II score (37±6 vs. 31±5, p<0.001), larger volume of transfused blood within 12 hours (6848±5574 vs. 3232±2779 mL, p<0.001) and were more likely to have a cardiac arrest (50.9% vs. 2.5%, p<0.001) or myocardial infarction (7.5% vs. 0.8%, p=0.032).  Non-survivors were more likely to undergo angiographic embolization (37.7% vs. 14.3%, p=0.001) or an operative thoracic procedure (thoracotomy, sternotomy, or VATS, 26.4% vs. 7.6%, p=0.01), although they had similar laparotomy rates (52.8 % vs. 49.6%, p=0.694). Independent predictors of mortality in this cohort include APACHE II score (OR: 1.15, CI: 1.04-1.28, p=0.005), cardiac arrest (OR: 21.21, CI: 5.06-88.87, p<0.001), and angioembolization (OR: 4.31, CI: 1.45-12.83, p=0.009). For patients who underwent angiographic embolization, mortality was 54.1%, and for those who suffered a cardiac arrest, mortality was 90%. 

Conclusion: In blunt trauma patients with hemorrhagic shock who met criteria for the lethal triad on presentation to the ER, angiographic embolization, APACHE II score, and cardiac arrest independently predict mortality. The exact role of angiographic embolization, which should be a life-saving procedure, deserves further study.

 

34.04 Complications in the Morbidly Obese After ORIF of Isolated Open Tibia Fractures

Posted on January 25, 2017

N. N. Branch1, R. Wilson1  1Howard University College Of Medicine,Washington, DC, USA

Introduction: Obesity is known to be associated with postoperative complications. Few articles investigate the association between obesity and isolated open tibia fractures {IOTF), thus understanding how this condition will affect patient outcomes is critical. We aim to determine perioperative complications after open reduction and internal fixation (ORIF) of IOTF in morbidly obese (MO) patients using a large national sample.

Methods: Using ICD-9 codes we reviewed the National Trauma Data Bank (NTDB) from 2007- 2010. Patients 18 years and older with open IOTF who underwent ORIF at level I or II trauma centers were identified. Multivariate logistic regression and univariate analyses were used to investigate postoperative complications. The NTDB defines obesity as a body mass index (BMI) of 40 or greater, which for the purposes of this study is reference as morbid obesity.

Results: 7,201 cases met inclusion criteria. The majority were white males ages 25-44 with private insurance injured in motor vehicle collisions. 248 (3.44%) of those patients were MO. On multivariate analysis morbidly obese patients had a 40% increased odds (OR: 1.41 CI: 1.07-1.84 p=0.014) of undergoing ORIF after hospital day 2 and were two times more likely to develop acute respiratory distress syndrome (OR: 2.0 Cl: 1.08-3.71 p=0.028). MO patients were more likely to develop superficial (OR: 3.19 Cl: 1.17-8.74 p=0.024), organ/space (OR: 1.75 Cl: 1.08-2.85 p=0.024), or any surgical site infection (OR: 1.93 Cl: 1.23-3.03 p=0.004). MO patients were two times more likely to have at least one complication (OR: 2.01 Cl: 1.35-2.99 p=0.001), and more than four times more likely to develop cardiac arrest (OR: 4.28 Cl: 1.31-13.71 p=0.014). Mortality and length of stay were not associated with being MO (Table 1).

Conclusion: Morbid obesity was found to be associated with increased perioperative complications in IOTF. These patients are at greater risk of infectious complications, most notably superficial surgical site infections. Delays in time to surgical fixation may be secondary to concurrent trauma related injuries while optimizing the patient for surgery. Despite having a significantly higher risk of cardiopulmonary complications, morbidly obese patients did not have an increased mortality.

34.03 Can We Truly Impact The Incidence Of Post-Traumatic Seizures Using Anti-Epileptic Drug Prophylaxis?

Posted on January 25, 2017

M. B. Singer1, B. Zangbar1, K. Williams1, B. Joseph1, A. Tang1, N. Kulvatunyou1, P. Rhee1, T. O’Keeffe1  1University Of Arizona,Division Of Trauma, Critical Care, Burns, And Emergency Surgery,Tucson, AZ, USA

Introduction:  Patients who sustain traumatic brain injury (TBI) are at risk for post-traumatic seizures (PTS). The reported incidence of early PTS varies widely from 2% to 14% but there is disagreement over which patients are at highest risk. We hypothesize that the PTS rate is lower than previously reported and that specific types of brain injury are not predictive of PTS.

Methods:  We conducted a retrospective cohort analysis of all TBI patients admitted to our level one academic trauma center over a nine year period (January 1, 2006 to December 31, 2015). Demographic and injury data including ISS, head AIS, TBI type, history of seizure disorder, time of seizure and prophylactic AED use were collected for all patients who experienced PTS. Seizures were defined by clinical criteria due to the fact that electroencephalography is not routinely performed at our institution. Multivariate logistic regression was used to identify independent predictors of PTS.

Results: 10,001 TBI patients were evaluated at our institution during the nine-year study period, 180 (1.8%) of whom experienced PTS. 63 (34.8%) of these patients seized in the field or in the trauma bay and 23 (12.7%) had a prior history of seizure disorder. Of the 118 patients who seized after hospital admission, 28 (23.7%) were receiving AED prophylaxis at the time of PTS.  Head abbreviated injury scale (AIS) ?  3, injury severity score, and subdural hematoma were independent predictors of PTS (Table 1). PTS did not independently predict mortality.

Conclusion: The rate of PTS at our institution is significantly lower than other published reports. This may reflect a change in the natural history of PTS or changes in intensive care unit management. In light of the high rates of pre-admission and breakthrough PTS (approximately 50%), we question the effectiveness of routine AED prophylaxis in reducing early PTS. Specific risk factors for PTS remain elusive.
 

34.02 Concussion Among The Elderly: A Silent Epidemic

Posted on January 25, 2017

A. Caiado1, S. Armen1, R. Staszak1, J. Chandler1, K. Fitzgerald1, S. Allen1  1Penn State Hershey Medical Center,Hershey, PA, USA

Introduction: A significant amount of attention has been given to the identification and consequences related to mild traumatic brain injury (mTBI) or concussion among young athletes and combat veterans. The interest in concussion is the result of the insidious yet devastating long-term sequelae of these seemingly minor head injuries. The effects of concussion among the elderly are largely unstudied; furthermore, the incidence and identification of concussions in this age group is not well delineated. The goal of this study was to investigate the incidence of the diagnosis of concussion among the elderly population as compared to an injury matched younger cohort. We hypothesized that elderly patients who meet criteria for the diagnosis of a concussion are under-diagnosed compared to a younger, injury matched cohort.

Methods: The trauma registry of an academic Level 1 trauma center was retrospectively queried over a 2 year study period. Adult patients (>18 years of age) with an abbreviated injury score (AIS) head of 1-2 from a blunt mechanism of injury and who met criteria for mTBI as set forth by the American Association of Neurosurgeons (AANS) were evaluated. Demographic information, as well as Glasgow coma score (GCS), the GCS motor score (MS), injury severity score (ISS), blood alcohol concentration (BAC), ICU length of stay, and hospital length of stay were studied. The charts of all patients were queried for the specific diagnoses of mTBI or concussion (n=618). An older cohort (>65 years of age) (n=231) was then compared to a younger cohort (18-64 years) (n=387) matched on MS, GCS and ISS. The difference in the incidence of the diagnosis of concussion was calculated. Chi-squared tests as well as student’s t-tests were used for statistical analysis as appropriate.

Results:There was a steady and statistically significant decrease in the incidence of the diagnosis of concussion across the older decades of life. Nearly 90% of patients 18-24 years of age were diagnosed with concussion as compared to just over 50% of those over the age of 75 years and is inversely related to the incidence pre-existing dementia. There were no differences in ISS, MS and GCS among the two study groups. Concussion was formally diagnosed significantly less in older patients as compared to the injury matched younger group.

Conclusion:Mild traumatic brain injuries are common among patients who sustain blunt injuries. However, while younger patients are frequently diagnosed with concussion, only 50% of elderly adults who meet criteria for mTBI are formally diagnosed with concussion. The failure to recognize this ubiquitous injury among the elderly may lead to less interventions and significantly poorer long-term outcomes, especially in those with a prior history of dementia. Future studies should focus on early and aggressive interventions for concussion in the elderly in an effort to mitigate the negative sequelae of these injuries and improve quality of life.

 

34.01 Bile Leak After Operative AAST Grade III-V Liver Injuries, Risk Factors and Management

Posted on January 25, 2017

R. J. Miskimins1, A. A. Greenbaum1, P. Kilen2, R. Preda1, S. W. Lu1, T. R. Howdieshell1, S. D. West1  1University Of New Mexico HSC,Department Of Surgery,Albuquerque, NM, USA 2University Of New Mexico HSC,School Of Medicine,Albuquerque, NM, USA

Introduction: Bile leak from the intrahepatic biliary tree is a major cause of morbidity after high grade liver injury. The rate of bile leak after hepatic trauma ranges from 0.5-21%. The risk of a bile leak increases with higher grade injury, however other risk factors have not been characterized. The aim of our study was to clarify the incidence, risk factors and management of intrahepatic bile leak following laparotomy for high grade liver injury.

Methods:  A retrospective review of patients with complex liver injuries, defined as AAST grade III-V, who underwent laparotomy from Jan 2008 to July 2015 at an ACS-verified Level I trauma center was performed. Patients who died within 72 hours or under the age of 14 were excluded. Bile leak was defined as bilious output lasting more than 14 days from a surgically or interventional radiology percutaneous drain (IRPD). The grade of liver injury, number of laparotomies, operative techniques, use of hepatic angioembolization (HAE), placement of surgical drains, reason for laparotomy, number of readmissions, and interventions for management of bile leak were recorded. The institutional trauma database was used to obtain demographics, initial vital signs, ISS, length of stay (LOS), ICU LOS, and mechanism of injury (MOI). Statistical analyses were performed using Chi-squared and Fisher exact tests for categorical data, and the Mann–Whitney U-test for continuous variables. P-values < 0.05 were significant.

Results: 117 patients met inclusion criteria, 29 (25%) developed a bile leak (BLG) and 88 (75%) had no leak (NLG).  There was no significant difference between the groups in age, sex, MOI, initial vitals, ISS, ICU LOS or reason for laparotomy. The BLG had higher grades of injury (Grade 5: 45% vs 10%, Grade 4: 41% vs 31%, Grade 3: 14% vs 60%,  P <0.01), longer hospital LOS (29 vs 21 days, p <0.01) and were more likely to be readmitted (41% vs 15%, P<0.01). No significant difference in the rates of perihepatic packing, argon beam hepatorrhaphy, gelfoam packing, or suture hepatorrhaphy was observed. The BLG required more laparotomies (3.5 vs 2.2, p<0.01), were more likely to have excisional debridement (38% vs 9%, p<0.01), and HAE (38% vs 6%, P=0.03). Ninety-seven percent (n=28) in the BLG had perihepatic drains placed prior to abdominal closure, and 65% (n=19) of bile leaks were managed entirely with these drains. Seventeen percent (n=5) required IRPD, 14% (n=4) underwent ERCP and insertion of biliary stent in addition to the perihepatic surgical drains, and 3% (n=1) underwent both IRPD and ERCP.

Conclusion: In patients with AAST Grade III-V liver injury who require laparotomy, the grade of injury, use of hepatic embolization and excisional debridement are assoicated with development of bile leak.Those who develop a bile leak have longer hospital LOS and are more likely to be readmitted. The majority of bile leaks can be managed conservatively with perihepatic drain placement prior to definitive abdominal closure.

33.10 Admission Of Older Blunt Thoracic Trauma Patients To The Intensive Care Unit (ICU) Improves Outcomes

Posted on January 25, 2017

O. Pyke1, J. A. Vosswinkel1, J. E. McCormack1, E. Huang1, R. Jawa1  1Stony Brook University Medical Center,Trauma,Stony Brook, NY, USA

Introduction: Blunt thoracic trauma in older adults is often associated with adverse outcomes.  As a quality improvement initiative in 2013, direct admission of older patients with clinically important thoracic trauma to the ICU was suggested.  We evaluated the effects of this counsel on outcomes.

Methods:  A retrospective review of the trauma registry at a Regional Trauma Center was performed for patients age > 55 years with blunt thoracic trauma, admitted between 2011 and 2014.  Burns, emergency department (ED) deaths, patients intubated in the ED or pre-hospital, direct transfers to the inpatient trauma service, and patients with hospital length of stay (LOS) < 48 hours were excluded.  Clinically important thoracic trauma was defined as ≥ 1 of the following risk factors: major chest injury, limited vital capacity (VC) on bedside incentive spirometry, or ≥ 2 comorbidities.

Results: After the recommendation (POST), 1239 patients met inclusion criteria, with 56 ICU admissions.  Prior to the recommendation (PRE), 920 patients met criteria, with 132 ICU admissions.  On analysis of ICU admissions, the POST-recommendation group was older (76.5+10.8 vs 72.1+11.1 years, p=0.011).  The frequency of ≥ 2 comorbidities (72.0% vs. 58.9%) and ISS (17.6+8.7 vs. 20.7+10.3) was similar (p=ns). Chest injury characteristics were similar (p=ns) between POST and PRE groups: sternal fractures (15.2% vs 21.4%), pneumothorax/hemothorax/both (12.9% vs 23.2%), thoracic spine injury (24.2% vs 35.7%), chest AIS≥ 3 (60.6% vs 58.9%), and rib fractures (85.6% vs 76.8%). However, the POST group had more isolated rib fractures (37.9% vs 16.1%, p=0.003).  Unplanned ICU (UP-ICU) admission (19.7% vs 39.3%, p=0.005), ICU length of stay (LOS) (6.7+7.8 vs 13.8+18.5 days, p<0.001), hospital LOS (12.8+10.2 vs 24.7+32.3 days, p<0.001), need for mechanical ventilation (16.7% vs 32.1%, p=0.018), and complication rate (27.3% vs 55.4%, p<0.001) were lower POST recommendation.  In-hospital mortality was 3.8% POST vs 10.7% PRE, p=0.065.  Subset analysis of ICU admissions age ≥65 years re-demonstrated these benefits (table) as well as reduced in-hospital mortality (4.8% vs. 15.4%, p=0.035) POST recommendation.  

Conclusion: Admission of older individuals with clinically significant blunt thoracic trauma directly to the ICU was associated with reduced UP-ICU, ICU LOS, hospital LOS, need for mechanical ventilation, and complication rates.  A further mortality benefit was noted in patients aged ≥65 years.  Closer patient monitoring and frequent pulmonary toilet, likely contributed to improved outcomes.   We recently introduced a guideline whereby patients age ≥65 years with ≥3 rib fractures, unless bedside VC exceeds 1000-1500 mL, are directly admitted to the ICU.

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