Diane A. Schwartz

Evaluation and Management of Blunt Traumatic Aortic Injury: A Practice Management Guideline from the Eastern Association for the Surgery of Trauma

BACKGROUND Blunt traumatic aortic injury (BTAI) is the second most common cause of death in trauma patients. Eighty percent of patients with BTAI will die before reaching a trauma center. The issues of how to diagnose, treat, and manage BTAI were first addressed by the Eastern Association for the Surgery of Trauma (EAST) in the practice management guidelines on this topic published in 2000. Since that time, there have been advances in the management of BTAI. As a result, the EAST guidelines committee decided to develop updated guidelines for this topic using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework recently adopted by EAST. METHODS A systematic review of the MEDLINE database using PubMed was performed. The search retrieved English language articles regarding BTAI from 1998 to 2013. Letters to the editor, case reports, book chapters, and review articles were excluded. Topics of investigation included imaging to diagnose BTAI, type of operative repair, and timing of operative repair. RESULTS Sixty articles were identified. Of these, 51 articles were selected to construct the guidelines. CONCLUSION There have been changes in practice since the publication of the previous guidelines in 2000. Computed tomography of the chest with intravenous contrast is strongly recommended to diagnose clinically significant BTAI. Endovascular repair is strongly recommended for patients without contraindications. Delayed repair of BTAI is suggested, with the stipulation that effective blood pressure control must be used in these patients.

National estimates of predictors of outcomes for emergency general surgery.

BACKGROUND Identifying predictors of mortality and surgical complications has led to outcome improvements for a variety of surgical conditions. However, similar work has yet to be done for factors affecting outcomes of emergency general surgery (EGS). The objective of this study was to determine the predictors of in-hospital complications and mortality among EGS patients. METHODS The Nationwide Inpatient Sample (2003–2011) was queried for patients with conditions encompassing EGS as determined by the American Association for Surgery of Trauma, categorizing them into predefined EGS groups using DRG International Classification of Diseases—9th Rev.—Clinical Modification codes. Primary outcomes considered included incidence of a major complication (pneumonia, pulmonary emboli, urinary tract infections, myocardial infarctions, sepsis, or septic shock) and in-hospital mortality. Separate multivariate logistic regression analyses for complications and mortality were performed to identify risk factors of either outcome from the following domains: patient demographics (age, sex, insurance type, race, and income quartile), comorbidities, and hospital characteristics (location, teaching status, and bed size). RESULTS This study included 6,712,151 discharge records, weighted to represent 32,910,446 visits for EGS conditions. Mean age was 58.50 (19.74) years; slightly more than half (54.66%) were female. Uninsured patients were more likely to die (odds ratio,1.25; 95% confidence interval, 1.20–1.30), whereas patients in the highest income quartile had the least likelihood of mortality (odds ratio, 0.86; 95% confidence interval, 0.84–0.87). Old age was an independent predictor of mortality for all EGS subdiagnoses. The overall mortality rate was 1.76%; the overall complication rate was 10.03%. Of the patients who died, 62% experienced at least one major complication. Patients requiring resuscitation had the highest likelihood of mortality followed by patients with vascular disease and hepatic disease. CONCLUSION Death patterns of EGS patients were discerned using an administrative data set. Understanding patterns of mortality and complications derived from studies such as this could improve hospital benchmarking for EGS, akin to trauma surgery’s previous success. LEVEL OF EVIDENCE Prognostic and epidemiologic study, level III.

Outcomes after emergency general surgery at teaching versus nonteaching hospitals.

BACKGROUND Previous analyses demonstrate teaching hospitals to have worse outcomes raising concerns for quality of care. The purpose of this study was to compare outcomes between teaching and nonteaching hospitals for emergency surgical conditions in a national sample. METHODS The Nationwide Inpatient Sample (2005–2011) was queried for patients with emergency general surgery (EGS) conditions as determined by the American Association for Surgery of Trauma. Outcomes of in-hospital mortality, major complications, length of stay (LOS) and hospital cost were compared between patients presenting to teaching versus nonteaching hospitals. Propensity scores were used to match both groups on demographics, clinical diagnosis, comorbidities, and disease severity. Multivariate regression analyses were performed further adjusting for hospital-level factors including EGS volume. Small effect estimates were further tested using standardized differences. RESULTS A total of 3,707,465 patients from 3,163 centers were included. A majority of patients (59%) (n = 2,187,107) were treated at nonteaching hospitals. After propensity score matching and adjustment, teaching hospitals had a slightly higher odds likelihood of mortality (odds ratio, 1.04; 95% confidence interval, 1.02–1.06), slightly lower rate of major complications (odds ratio, 0.99; 95% confidence interval, 0.98–0.99), slightly decreased LOS (5.03 days [4.98–5.09] vs. 5.22 days [5.16–5.29]), and slightly higher hospital costs [

Worse outcomes among uninsured general surgery patients: Does the need for an emergency operation explain these disparities?

12,846 [

Military-to-civilian translation of battlefield innovations in operative trauma care.

12,827–

Reliability adjustment: A necessity for trauma center ranking and benchmarking

12,865] vs.

Does relative value unit-based compensation shortchange the acute care surgeon?

12,304 [12,290–12,318]). Although these differences were statistically significant at p < 0.05, the absolute difference was very small. Further testing of these effect estimates using standardized differences revealed an insignificant difference of 0.5% for mortality, 0.4% for major complications, 0.2% for LOS, and 3.1% for hospital cost. CONCLUSION National estimates of outcomes for EGS conditions demonstrate comparable results between teaching and nonteaching hospitals. Concerns regarding quality of care and higher costs at teaching hospitals may be unfounded. Further research to test for differences by specific EGS conditions, operative management, and hospital costs are warranted.

Operative delay to laparoscopic cholecystectomy: Racking up the cost of health care

BACKGROUND We hypothesize that lack of access to care results in propensity toward emergent operative management and may be an important factor in worse outcomes for the uninsured population. The objective of this study is to investigate a possible link to worse outcomes in patients without insurance who undergo an emergent operation. METHODS A retrospective cross-sectional analysis was performed using the Nationwide Inpatient Sample (NIS) 2005-2011 dataset. Patients who underwent biliary, hernia, and colorectal operations were evaluated. Multivariate analyses were performed to assess the associations between insurance status, urgency of operation, and outcome. Covariates of age, sex, race, and comorbidities were controlled. RESULTS The uninsured group had greatest odds ratios of undergoing emergent operative management in biliary (OR 2.43), colorectal (3.54), and hernia (3.95) operations, P < .001. Emergent operation was most likely in the 25- to 34-year age bracket, black and Hispanic patients, men, and patients with at least one comorbidity. Postoperative complications in emergencies, however, were appreciated most frequently in the populations with government coverage. CONCLUSION Although the uninsured more frequently underwent emergent operations, patients with coverage through the government had more complications in most categories investigated. Young patients also carried significant risk of emergent operations with increased complication rates. Patients with government insurance tended toward worse outcomes, suggesting disparity for programs such as Medicaid. Disparity related to payor status implies need for policy revisions for equivalent health care access.

Use of Bronchoscopy in Percutaneous Dilational Tracheostomy

BACKGROUND Historic improvements in operative trauma care have been driven by war. It is unknown whether recent battlefield innovations stemming from conflicts in Iraq/Afghanistan will follow a similar trend. The objective of this study was to survey trauma medical directors (TMDs) at level 1-3 trauma centers across the United States and gauge the extent to which battlefield innovations have shaped civilian practice in 4 key domains of trauma care. METHODS Domains were determined by the use of a modified Delphi method based on multiple consultations with an expert physician/surgeon panel: (1) damage control resuscitation (DCR), (2) tourniquet use, (3) use of hemostatic agents, and (4) prehospital interventions, including intraosseous catheter access and needle thoracostomy. A corresponding 47-item electronic anonymous survey was developed/pilot tested before dissemination to all identifiable TMD at level 1-3 trauma centers across the US. RESULTS A total of 245 TMDs, representing nearly 40% of trauma centers in the United States, completed and returned the survey. More than half (n = 127; 51.8%) were verified by the American College of Surgeons. TMDs reported high civilian use of DCR: 95.1% of trauma centers had implemented massive transfusion protocols and the majority (67.7%) tended toward 1:1:1 packed red blood cell/fresh-frozen plasma/platelets ratios. For the other 3, mixed adoption corresponded to expressed concerns regarding the extent of concomitant civilian research to support military research and experience. In centers in which policies reflecting battlefield innovations were in use, previous military experience frequently was acknowledged. CONCLUSION This national survey of TMDs suggests that military data supporting DCR has altered civilian practice. Perceived relevance in other domains was less clear. Civilian academic efforts are needed to further research and enhance understandings that foster improved trauma surgeon awareness of military-to-civilian translation.

Evaluation and management of blunt traumatic aortic injury: A practice management guideline from the Eastern Association for the Surgery of Trauma

BACKGROUND Currently, trauma center quality benchmarking is based on risk adjusted observed-expected (O/E) mortality ratios. However, failure to account for number of patients has been recently shown to produce unreliable mortality estimates, especially for low-volume centers. This study explores the effect of reliability adjustment (RA), a statistical technique developed to eliminate bias introduced by low volume on risk-adjusted trauma center benchmarking. METHODS Analysis of the National Trauma Data Bank 2010 was performed. Patients 16 years or older with blunt or penetrating trauma and an Injury Severity Score (ISS) of 9 or greater were included. Based on the statistically accepted standards of the Trauma Quality Improvement Program methodology, risk-adjusted mortality rates were generated for each center and used to rank them accordingly. Hierarchical logistic regression modeling was then performed to adjust these rates for reliability using an empiric Bayes approach. The impact of RA was examined by (1) recalculating interfacility variations in adjusted mortality rates and (2) comparing adjusted hospital mortality quintile rankings before and after RA. RESULTS A total of 557 facilities (with 278,558 patients) were included. RA significantly reduced the variation in risk-adjusted mortality rates between centers from 14-fold (0.7–9.8%) to only 2-fold (4.4–9.6%) after RA. This reduction in variation was most profound for smaller centers. A total of 68 “best” hospitals and 18 “worst” hospitals based on current risk adjustment methods were reclassified after performing RA. CONCLUSION “Reliability adjustment” dramatically reduces variations in risk-adjusted mortality arising from statistical noise, especially for lower volume centers. Moreover, the absence of RA had a profound impact on hospital performance assessment, suggesting that nearly one of every six hospitals in National Trauma Data Bank would have been inappropriately placed among the very best or very worst quintile of rankings. RA should be considered while benchmarking trauma centers based on mortality.