Amy E. Liepert

A composite index for predicting readmission following emergency general surgery

BACKGROUND Preventable readmission has become a national focus. It is clear that surgical patients present specific challenges to those interested in preventing readmission. Little is known about this outcome in the emergent population. We are interested in determining if there are readily available data variables to predict risk of readmission. The surgical Apgar score (SAS) is calculated from objective intraoperative variables and has been shown to be predictive of postoperative mortality in the nonemergent setting. The objectives of this study were to characterize 30-day readmissions in emergent general surgery and to determine whether certain variables were associated with readmissions. We hypothesized that the SAS correlates with the risk for readmission in emergency general surgery patients. PATIENTS AND METHODS Variables of interest were obtained from a retrospective analysis of the American College of Surgeons’ National Surgical Quality Improvement Program database at an academic institution, paired with the electronic medical record. We identified adult general surgery patients who underwent an emergency procedure from 2006 to 2012. Univariate analysis identified factors associated with 30-day readmission. Factors with p < 0.1 were included in the multivariate analysis to reveal potential risk factors. SPSS version 20 was used for the statistical analysis, with p < 0.05 considered to be significant on multivariate analysis. RESULTS As compared with nonemergency surgery patients, emergency surgery patients had a higher readmission rate (11.1% vs. 15.2%, p = 0.004). The SAS (odds ratio, 3.297; 95% confidence interval, 1.074–10.121; p = 0.037) and the combined variable of the American Society of Anesthesiologists Physical Status Classification and length of stay (odds ratio, 4.370; 95% confidence interval, 2.251–8.486; p < 0.001) were associated with elevated risk for readmission in emergency general surgery patients. CONCLUSION We have identified readily available measures that allow for the stratification of patients into low- and high-risk groups for 30-day readmission. The stratification of patients will enable the study of prospective interventions designed to decrease unplanned readmissions in emergency surgery patients. LEVEL OF EVIDENCE Prognostic study, level II.

Protecting trauma patients from duplicated computed tomography scans: the relevance of integrated care systems

BACKGROUND Duplicated computed tomography (CT) scans in transferred trauma patients have been described in university-based trauma systems. This study compares CT utilization between a university-based nonintegrated system (NIS) and a vertically integrated regional healthcare system (IS). METHODS Trauma patients transferred to 2 Level I trauma centers were prospectively identified at the time of transfer. Imaging obtained before and subsequent to transfer and the reason for CT imaging at the Level I center were captured by real-time reporting. RESULTS Four hundred eighty-one patients were reviewed (207 at NIS and 274 at IS). Ninety-nine patients (48%) at NIS and 45 (16%) at IS underwent duplicate scanning of at least one body region. Inadequate scan quality and incomplete imaging were the most common reason category reported at NIS (54%) and IS (78%). CONCLUSIONS Fewer patients received duplicated scans within the vertically IS as compared with a traditional university-based referral system. Our findings suggest that the adoption of features of a vertically IS, particularly improved transferability of radiographic studies, may improve patient care in other system types.

Number of rib fractures thresholds independently predict worse outcomes in older patients with blunt trauma.

Background. There have been conflicting reports regarding whether the number of rib fractures sustained in blunt trauma is associated independently with worse patient outcomes. We sought to investigate this risk‐adjusted relationship among the lesser‐studied population of older adults. Methods. A retrospective review of the National Trauma Data Bank was performed for patients with blunt trauma who were ≥65 years old and had rib fractures between 2009 and 2012 (N = 67,695). Control data were collected for age, sex, injury severity score, injury mechanism, 24 comorbidities, and number of rib fractures. Outcome data included hospital mortality, hospital and intensive care unit durations of stay, duration of mechanical ventilation, and the occurrence of pneumonia. Multiple logistic and linear regression analyses were performed. Results. Sustaining ≥5 rib fractures was associated with increased intensive care unit admission (odds ratio: 1.14, P < .001) and hospital duration of stay (relative duration: 105%, P < .001). Sustaining ≥7 rib fractures was associated with an increased incidence of pneumonia (odds ratio: 1.32, P < .001) and intensive care unit duration of stay (relative duration: 122%, P < .001). Sustaining ≥8 rib fractures was associated with increased mortality (odds ratio: 1.51, P < .001) and duration of mechanical ventilation (relative duration: 117%, P < .001). Conclusion. In older patients with trauma, sustaining at least 5 rib fractures is a significant predictor of worse outcomes independent of patient characteristics, comorbidities, and trauma burden.

The salutary effect of an integrated system on the rate of repeat CT scanning in transferred trauma patients: Improved costs and efficiencies

BACKGROUND Duplication of Computed Tomography (CT) scanning in trauma patients has been a source of quality waste in healthcare and potential harm for patients. Integrated and regional health systems have been shown to promote opportunities for efficiencies, cost savings and increased safety. METHODS This study evaluated traumatically injured patients who required transfer to a Level One Trauma Center (TC) from either within a vertically integrated healthcare system (IN) or from an out-of-network (OON) hospital. RESULTS We found the rate of repeat CT scanning, radiology costs and total costs for day one of hospitalization to be significantly lower for trauma patients transferred from an IN hospital as compared to those patients transferred from OON hospitals. CONCLUSION The inefficiencies and waste often associated with transferred patients can be mitigated and strategies to do so are necessary to reduce costs in the current healthcare environment.

Acid–Base Physiology

The body is able to maintain an arterial pH in a very narrow range due to intracellular and extracellular mechanisms that are able to correct for large physiologic perturbations. The most common mechanisms for compensation of pH abnormalities is through the respiratory and renal systems which alter carbon dioxide (CO2) and bicarbonate (HCO3 −) resorption and excretion. Carbon dioxide, a volatile acid, is a byproduct of cellular aerobic respiration that combines with water to form carbonic acid (H2CO3) which can be catalyzed by carbonic anhydrase to produce protons (H+) and bicarbonate (HCO3 −).