Phillip K. Chang

Imaging may delay transfer of rural trauma victims: a survey of referring physicians.

BACKGROUND Delayed transfer to a trauma center due to unnecessary imaging results in suboptimal patient outcome and increases healthcare costs. Unnecessary imaging may result from beliefs regarding trauma center requirements and legal concerns. We hypothesized that referring physicians consider factors other than clinical criteria when deciding to order imaging studies before transfer of trauma patients. METHODS A mail survey of 218 referring physicians to a level I trauma center elicited factors affecting decision to obtain imaging studies before transfer. Graded answers to six questions were obtained and demographics of the physician respondent. Statistical analysis was performed using Fishers exact test. RESULTS One hundred forty-nine of 218 surveys were returned (68.3%). One-third (33.1%) of respondents obtain imaging because of perceived expectations of the receiving trauma center, independent of patient acuity. Twenty percent incorrectly think that the law prohibits transfer before patients are stabilized. Twenty-eight percent obtain imaging because of liability concerns, even if that imaging delays transfer. Overall, 45% obtain imaging for either perceived requirement or liability concern. Non-advanced trauma life support (ATLS)-certified physicians are more likely to use all available resources before transfer than ATLS-certified physicians. CONCLUSIONS Factors other than patient care dictate imaging acquisition in almost half of those surveyed. Misperception of expectations, misunderstanding of legal imperatives, and liability concerns all delay transport of the injured. ATLS-certified individuals use imaging more appropriately, thus, promoting more timely transfer. State-wide protocols, education, and liability reform may reduce transport delays.

Retained Surgical Sponges: Findings from Incident Reports and a Cost-Benefit Analysis of Radiofrequency Technology

BACKGROUND Retained surgical items (RSIs) are serious events with a high potential to harm patients. It is estimated that as many as 1 in 5,500 operations result in an RSI, and sponges are most commonly involved. The adverse outcomes, additional medical care needed, and medico-legal costs associated with these events are substantial. The objective of this analysis was to advance our understanding of the occurrence of RSIs, the methods of prevention, and the costs involved. STUDY DESIGN Incident reports entered into the University HealthSystem Consortium (UHC) Safety Intelligence database on incorrect surgical counts and RSIs were analyzed. Reported cases of retained surgical sponges at organizations that use radiofrequency (RF) technology and those that do not were compared. A cost-benefit analysis on adopting RF technology was conducted. RESULTS Five organizations that implemented RF technology between 2008 and 2012 collectively demonstrated a 93% reduction in the rate of reported retained surgical sponges. By comparison, there was a 77% reduction in the rate of retained sponges at 5 organizations that do not use RF technology. The UHC cost-benefit analysis showed that the savings in x-rays and time spent in the operating room and in the medical and legal costs that were avoided outweighed the expenses involved in using RF technology. CONCLUSIONS Current standards for manual counting of sponges and the use of radiographs are not sufficient to prevent the occurrence of retained surgical sponges; our data support the use of adjunct technology. We recommend that hospitals evaluate and consider the use of an adjunct technology.

Red blood cell arginase suppresses Jurkat (T cell) proliferation by depleting arginine

BACKGROUND Transfusion of packed red blood cells (PRBC) suppresses immunity, but the mechanisms are incompletely understood. PRBCs contain arginase, an enzyme which converts arginine to ornithine and depletes arginine in vitro. Arginine depletion suppresses proliferation of Jurkat T cells in other models. We hypothesize that PRBC arginase-mediated arginine depletion will suppress proliferation of T cells. METHODS A transfusion model was designed adding PRBC to culture RPMI media with or without an irreversible arginase blocker (nor-NOHA), incubating for 6-48 hours and then removing the PRBCs. Amino acid concentrations in the media were measured using liquid chromatography mass spectrometry. T cells were then added to the pre-conditioned media, cultured for 24 hours, and proliferation was measured. RESULTS PRBC depleted arginine significantly and increased ornithine in media compared to baseline PRBC treated wells and significantly decreased T cell proliferation. These effects were enhanced with volume of PRBC exposure. Nor-NOHA inhibition of arginase restored T cell proliferation in PRBC treated cultures. CONCLUSIONS Jurkat T cell proliferation was impaired by PRBC in clinically relevant volumes. The mechanism influencing T cell impairment appears to result from arginine depletion by arginase. Arginine depletion by PRBC arginase may be a novel mechanism for immunosuppression after transfusion.

Influence of In-House Attending Presence on Trauma Outcomes and Hospital Efficiency

BACKGROUND The influence of in-house (IH) attendings on trauma patient survival and efficiency measures, such as emergency department length of stay (LOS), ICU LOS, and hospital LOS, has been debated for more than 20 years. No study has definitively shown improved outcomes with IH vs home-call attendings. This study examines trauma outcomes in a single, Level I trauma center before and after the institution of IH attending call. STUDY DESIGN Patient data were collected from the University of Kentuckys trauma registry. Based on the Trauma-Related Injury Severity Score, survival rates were compared between the IH and home-call groups. To evaluate efficiency, emergency department LOS, ICU LOS, and hospital LOS were compared. A separate subanalysis for the most severely injured patients (trauma alert red) was also performed. RESULTS The home-call group (n = 4,804) was younger (p = 0.018) and had a higher Injury Severity Score (p = 0.003) than the IH group (n = 5259), but there was no difference in Trauma-Related Injury Severity Score (p = 0.205) between groups. In-house attending presence did not reduce mortality. Emergency department LOS, ICU LOS, and hospital LOS were shorter during the IH period. Emergency department to operating room time was not different. There was no change in trauma alert red mortality with an attending present (20.7% vs 18.2%, p = 0.198). CONCLUSIONS In-house attending presence does not improve trauma patient survival. For the most severely injured patients, attendings presence does not reduce mortality. In-house coverage can improve hospital efficiency by decreasing emergency department LOS, hospital LOS, and ICU LOS.

Nonopioid management of acute pain associated with trauma: Focus on pharmacologic options.

Despite the prevalence of acute pain in the trauma setting and known complications of its improper management, including risk of chronic pain, delayed recovery, and poorer quality of life, recent survey data suggest little has changed in the overall management of pain in the acute setting during the

Emergent Surgical Management of Ventral Hernias

The emergency care of ventral hernias is complex. The key to improved morbidity and mortality is operating on these patients prior to progressing to strangulation. The type of operation depends on many factors, including location of the hernia, patient’s physiology, imaging findings, and prior repairs with or without mesh. The operations can be open, laparoscopic, or a combination of both. The use of laparoscopy has a significant role in assessing bowel viability and repair. Dealing with large ventral hernias in a damage control surgery should focus on sepsis source control and abdominal closure. In these patients, definitive and complex abdominal wall closures with non-biologic prosthesis should be avoided. The goal is survival and planning a formal abdominal wall construction in the future with a non-biologic prosthesis. This chapter will review these topics.

Opioid use in the acute setting: A survey of providers at an academic medical center

OBJECTIVE To examine attitudes, beliefs, and influencing factors of inpatient healthcare providers regarding prescription of opioid analgesics. DESIGN Electronic cross-sectional survey. SETTING Academic medical center. PARTICIPANTS Physicians, advanced practice providers, and pharmacists from a single academic medical center in the southeast United States. MAIN OUTCOME MEASURES Respondents completed survey items addressing: (1) their practice demographics, (2) their opinions regarding overall use, safety, and efficacy of opioids compared to other analgesics, (3) specific clinical scenarios, (4) main pressures to prescribe opioids, and (5) confidence/comfort prescribing opioids or nonopioids in select situations. RESULTS The majority of the sample (n = 363) were physicians (60.4 percent), with 69.4 percent of physicians being attendings. Most respondents believed that opioids were overused at our institution (61.7 percent); nearly half thought opioids had similar efficacy to other analgesics (44.1 percent), and almost all believed opioids were more dangerous than other analgesics (88.1 percent). Many respondents indicated that they would modify a chronic regimen for a high-risk patient, and use of nonopioids in specific scenarios was high. However, this use was often in combination with opioids. Respondents identified patients (64 percent) and staff (43.1 percent) as the most significant sources of pressure to prescribe opioids during an admission; the most common sources of pressure to prescribe opioids on discharge were to facilitate discharge (44.8 percent) and to reduce follow-up requests, calls, or visits (36.3 percent). Resident physicians appear to experience more pressure to prescribe opioids than other providers. Managing pain in patients with substance use disorders and effectively using nonopioid analgesics were the most common educational needs identified by respondents. CONCLUSION Most individuals believe opioid analgesics are overused in our specific setting, commonly to satisfy patient requests. In general, providers feel uncomfortable prescribing nonopioid analgesics to patients.

Minimizing opioid use after acute major trauma

Purpose Results of an initiative at an academic medical center to reduce prescription opioid use in patients with acute traumatic injuries are reported. Methods In 2014, the University of Kentucky Hospital trauma service implemented a pain management strategy consisting of patient and provider education emphasizing the use of nonopioid analgesics to minimize opioid use without compromising analgesia effectiveness. To assess the impact of the initiative, a retrospective analysis of data on cohorts of patients admitted with acute trauma before (n = 489) and after (n = 424) project implementation was conducted. The primary endpoint was opioid use (prescribed daily milligram morphine equivalents [MME]) at discharge. Secondary endpoints included inpatient opioid and alternative analgesic use, pain control, ileus development, length of stay, and discharge disposition. Results Compared with the preintervention cohort, the postintervention cohort had a lower median daily discharge MME overall (45 MME versus 90 MME, p < 0.001); after stratification of MME data by baseline opioid use, this finding held true only for patients with no opioid prescription at admission. Although utilization of gabapentinoids, skeletal muscle relaxants, and clonidine increased during the postintervention period, inpatient opioid use did not differ significantly in the 2 cohorts. Utilization of both nonsteroidal antiinflammatory drugs and acetaminophen was lower in the postintervention cohort versus the preintervention cohort. Conclusion Targeted provider and patient education on minimizing opioid use was associated with a reduction in MME on discharge from the hospital after traumatic injury.

Emergency department repair of blunt right atrial rupture utilizing cardiopulmonary bypass

Blunt cardiac injury (BCI) with free wall rupture carries a high risk of pre-hospital death. Cardiopulmonary bypass (CPB) has been utilized as a bridge to repair of cardiac lesions in select patients. We present an interesting case of emergency department repair of right atrial rupture with cardiopulmonary bypass.

Antibiotics vs. Appendectomy for Acute Uncomplicated Appendicitis in Adults: Review of the Evidence and Future Directions

BACKGROUND Acute appendicitis is the most common abdominal surgical emergency in the United States, with a lifetime risk of 7%-8%. The treatment paradigm for complicated appendicitis has evolved over the past decade, and many cases now are managed by broad-spectrum antibiotics. We determined the role of non-operative and operative management in adult patients with uncomplicated appendicitis. METHODS Several meta-analyses have attempted to clarify the debate. Arguably the most influential is the Appendicitis Acuta (APPAC) Trial. RESULTS According to the non-inferiority analysis and a pre-specified non-inferiority margin of -24%, the APPAC did not demonstrate non-inferiority of antibiotics vs. appendectomy. Significantly, however, the operations were nearly always open, whereas the majority of appendectomies in the United States are done laparoscopically; and laparoscopic and open appendectomies are not equivalent operations. Treatment with antibiotics is efficacious more than 70% of the time. However, a switch to an antimicrobial-only approach may result in a greater probability of antimicrobial-associated collateral damage, both to the host patient and to antibiotic susceptibility patterns. A surgery-only approach would result in a reduction in antibiotic exposure, a consideration in these days of focus on antimicrobial stewardship. CONCLUSION Future studies should focus on isolating the characteristics of appendicitis most susceptible to antibiotics, using laparoscopic operations as controls and identifying long-term side effects such as antibiotic resistance or Clostridium difficile colitis.