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  • 1
    Online Resource
    Online Resource
    Proceedings from the Consensus Conference on Trauma Patient-Reported Outcome Measures
    Ovid Technologies (Wolters Kluwer Health) ; 2020
    In:  Journal of the American College of Surgeons Vol. 230, No. 5 ( 2020-05), p. 819-835
    Details
    In: Journal of the American College of Surgeons, Ovid Technologies (Wolters Kluwer Health), Vol. 230, No. 5 ( 2020-05), p. 819-835
    Type of Medium: Online Resource
    ISSN: 1072-7515
    URL: Article
    DOI: 10.1016/j.jamcollsurg.2020.01.032
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2020
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  • 2
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    Unplanned readmission after traumatic injury: A long-term nationwide analysis
    Ovid Technologies (Wolters Kluwer Health) ; 2019
    In:  Journal of Trauma and Acute Care Surgery Vol. 87, No. 1 ( 2019-7), p. 188-194
    Details
    In: Journal of Trauma and Acute Care Surgery, Ovid Technologies (Wolters Kluwer Health), Vol. 87, No. 1 ( 2019-7), p. 188-194
    Abstract: Long-term outcomes after trauma admissions remain understudied. We analyzed the characteristics of inpatient readmissions within 6 months of an index hospitalization for traumatic injury. METHODS Using the 2010 to 2015 Nationwide Readmissions Database, which captures data from up to 27 US states, we identified patients at least 15 years old admitted to a hospital through an emergency department for blunt trauma, penetrating trauma, or burns. Exclusion criteria included hospital transfers, patients who died during their index hospitalizations, and hospitals with fewer than 100 trauma patients annually. After calculating the incidences of all-cause, unplanned inpatient readmissions within 1 month, 3 months, and 6 months, we used multivariable logistic regression models to identify predictors of readmissions. Analyses adjusted for patient, clinical, and hospital factors. RESULTS Among 2,763,890 trauma patients, the majority had blunt injuries (92.5%), followed by penetrating injuries (6.2%) and burns (1.5%). Overall, rates of inpatient readmissions were 11.1% within 1 month, 21.6% within 6 months, and 29.8% within 6 months, with limited variability by year. After adjustment, the following were associated with all-cause 6 months inpatient readmissions: male sex (adjusted odds ratio [aOR], 1.10; 95% confidence interval [95% CI] , 1.09–1.10), comorbidities (aOR, 1.21; 95% CI, 1.21–1.22), low-income quartiles (first and second) (aOR, 1.08; 95% CI, 1.07–1.10 and aOR, 1.04; 95% CI, 1.03–1.06, respectively), Medicare (aOR, 1.65; 95% CI, 1.62–1.69), Medicaid (aOR, 1.51; 95% CI, 1.48–1.53), being treated at private, investor-owned hospitals (aOR, 1.15; 95% CI, 1.12–1.18), longer hospital length of stay (aOR, 1.01; 95% CI, 1.01–1.01) and patient disposition to short-term hospital (aOR, 1.55; 95% CI, 1.49–1.62), skilled nursing facility (aOR, 1.43; 95% CI, 1.42–1.45), home health care (aOR, 1.27; 95% CI, 1.25–1.28), or leaving against medical advice (aOR, 1.85; 95% CI, 1.78–1.92). CONCLUSION Unplanned readmission after trauma is high and remains this way 6 months after discharge. Understanding the factors that increase the odds of readmissions within 1 month, 3 months, and 6 months offer a focus for quality improvement and have important implications for hospital benchmarking. LEVEL OF EVIDENCE Epidemiological study, level III.
    Type of Medium: Online Resource
    ISSN: 2163-0763 , 2163-0755
    URL: Article
    DOI: 10.1097/TA.0000000000002339
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2019
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  • 3
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    Emergency general surgery in geriatric patients: A statewide analysis of surgeon and hospital volume with outcomes
    Ovid Technologies (Wolters Kluwer Health) ; 2018
    In:  Journal of Trauma and Acute Care Surgery Vol. 84, No. 6 ( 2018-6), p. 864-875
    Details
    In: Journal of Trauma and Acute Care Surgery, Ovid Technologies (Wolters Kluwer Health), Vol. 84, No. 6 ( 2018-6), p. 864-875
    Abstract: Geriatric patients undergoing emergency general surgery (EGS) face significant morbidity and mortality. We assessed how surgeon and hospital volumes affected these outcomes. METHODS We identified patients at least 65 years old in Maryland’s Health Services Cost Review Commission database from 2012 to 2014 who underwent one of 12 EGS procedures, as defined by the American Association for the Surgery of Trauma, and then calculated four outcomes: mortality rate, the incidence of at least one of eight common in-hospital EGS complications, failure-to-rescue (death after experiencing a postoperative complication), and the 30-day readmission rate. Median annual volumes of geriatric-EGS procedures divided both surgeons and hospitals into two groups (low volume and high volume). Multivariable logistic regressions calculated associations between the volume groups and outcomes after adjusting for patient, surgeon, and hospital factors, and hospital clusters. RESULTS We identified 3,832 patients who had an EGS procedure by 302 surgeons (median: 8 geriatric-EGS/year, IQR: 3–18) at 44 hospitals (median: 82 geriatric-EGS/year, IQR: 35–132). While operating on 16.5% of all geriatric-EGS patients, low-volume surgeons had higher risk-adjusted adverse outcomes: mortality (7.0% vs. 4.0%, p = 0.005), in-hospital complications (22.1% vs. 19.7%, p = 0.13), failure-to-rescue (17.3% vs. 12.1%, p = 0.021), and 30-day readmissions (11.2% vs. 10.0%, p = 0.55). After adjustment, low-volume surgeons were associated with higher mortality (adjusted odds ratio [aOR] 1.86, 95% CI [1.21–2.86] ) and failure-to-rescue rates (aOR 1.74 [1.09–2.80]) but not in-hospital complications (aOR 1.20 [0.95–1.51] ) or 30-day readmissions (aOR 1.07 [0.85–1.34]). In contrast, low-volume hospitals relative to high-volume hospitals, and hospitals serving lower proportions of geriatric-EGS patients, were not associated with adverse outcomes. CONCLUSION Relative to their higher-volume counterparts, surgeons performing eight or fewer geriatric-EGS procedures annually were associated with an 86% higher odds of death and 74% higher odds of failure-to-rescue in this elderly EGS patient population. These findings underscore the need for focused care of elderly surgical patients. LEVEL OF EVIDENCE Prognostic and epidemiological, level IV.
    Type of Medium: Online Resource
    ISSN: 2163-0763 , 2163-0755
    URL: Article
    DOI: 10.1097/TA.0000000000001829
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2018
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  • 4
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    Online Resource
    Recurring emergency general surgery: Characterizing a vulnerable population
    Ovid Technologies (Wolters Kluwer Health) ; 2019
    In:  Journal of Trauma and Acute Care Surgery Vol. 86, No. 3 ( 2019-3), p. 464-470
    Details
    In: Journal of Trauma and Acute Care Surgery, Ovid Technologies (Wolters Kluwer Health), Vol. 86, No. 3 ( 2019-3), p. 464-470
    Abstract: Limited data exist for long-term outcomes after emergency general surgeries (EGSs) in the United States. This study aimed to characterize the incidence of inpatient readmissions and additional operations within 6 months of an EGS procedure. METHODS In this retrospective observational study, we identified adults (≥18 years old) undergoing one of seven common EGS procedures (appendectomies, cholecystectomies, small bowel resections, large bowel resections, control of gastrointestinal [GI] ulcers and bleeding, peritoneal adhesiolysis, and exploratory laparotomies) who were discharged alive in the 2010–2015 National Readmissions Database. Outcomes included the rates of all-cause inpatient readmissions and of undergoing a second EGS procedure, both within 6 months. Multivariable logistic regression models identified risk factors of reoperation, adjusting for patient, clinical, and hospital factors. RESULTS Of 706,678 patients undergoing an EGS procedure 131,291 (18.6%) had an inpatient readmission within 6 months. Among those readmitted, 15,178 (11.6%) underwent a second EGS procedure, occurring at a median of 45 days (interquartile range, 15–95). After adjustment, notable predictors of reoperation included male sex (adjusted odds ratio [aOR], 1.06 [95% confidence interval, 1.01–1.10] ); private, nonprofit hospitals (aOR, 1.09 [1.02–1.17]); private, investor-owned hospitals (aOR, 1.09 [1.00–1.85] ); discharge to short-term hospital (aOR, 1.35 [1.04–1.74]); discharge with home health care (aOR, 1.19 [1.13–1.25] ); and index procedure of control of GI ulcer and bleeding (aOR, 9.38 [8.75–10.05]), laparotomy (aOR, 7.62 [6.92–8.40] ), or large bowel resection (aOR, 6.94 [6.44–7.47]). CONCLUSION One fifth of patients undergoing an EGS procedure had an inpatient readmission within 6 months, where one in nine of those underwent a second EGS procedure. As half of all second EGS procedures occurred within 6 weeks of the index procedure, identifying patients with the highest health care needs (index procedure type and discharge needs) may identify patients at risk for subsequent reoperation in nonemergency settings. LEVEL OF EVIDENCE Epidemiological, level III.
    Type of Medium: Online Resource
    ISSN: 2163-0763 , 2163-0755
    URL: Article
    DOI: 10.1097/TA.0000000000002151
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2019
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  • 5
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    A Pilot Machine Learning Study Using Trauma Admission Data to Identify Risk for High Length of Stay
    SAGE Publications ; 2023
    In:  Surgical Innovation Vol. 30, No. 3 ( 2023-06), p. 356-365
    Details
    In: Surgical Innovation, SAGE Publications, Vol. 30, No. 3 ( 2023-06), p. 356-365
    Abstract: Trauma patients have diverse resource needs due to variable mechanisms and injury patterns. The aim of this study was to build a tool that uses only data available at time of admission to predict prolonged hospital length of stay (LOS). Methods Data was collected from the trauma registry at an urban level one adult trauma center and included patients from 1/1/2014 to 3/31/2019. Trauma patients with one or fewer days LOS were excluded. Single layer and deep artificial neural networks were trained to identify patients in the top quartile of LOS and optimized on area under the receiver operator characteristic curve (AUROC). The predictive performance of the model was assessed on a separate test set using binary classification measures of accuracy, precision, and error. Results 2953 admitted trauma patients with more than one-day LOS were included in this study. They were 70% male, 60% white, and averaged 47 years-old (SD: 21). 28% were penetrating trauma. Median length of stay was 5 days (IQR 3-9). For prediction of prolonged LOS, the deep neural network achieved an AUROC of 0.80 (95% CI: 0.786-0.814) specificity was 0.95, sensitivity was 0.32, with an overall accuracy of 0.79. Conclusion Machine learning can predict, with excellent specificity, trauma patients who will have prolonged length of stay with only physiologic and demographic data available at the time of admission. These patients may benefit from additional resources with respect to disposition planning at the time of admission.
    Type of Medium: Online Resource
    ISSN: 1553-3506 , 1553-3514
    URL: Article
    DOI: 10.1177/15533506221139965
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2023
    detail.hit.zdb_id: 2233576-6
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  • 6
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    Emergency Department Visits For Firearm-Related Injuries In The United States, 2006–14
    Health Affairs (Project Hope) ; 2017
    In:  Health Affairs Vol. 36, No. 10 ( 2017-10), p. 1729-1738
    Details
    In: Health Affairs, Health Affairs (Project Hope), Vol. 36, No. 10 ( 2017-10), p. 1729-1738
    Type of Medium: Online Resource
    ISSN: 0278-2715 , 1544-5208
    URL: Article
    DOI: 10.1377/hlthaff.2017.0625
    Language: English
    Publisher: Health Affairs (Project Hope)
    Publication Date: 2017
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  • 7
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    Optimal timing of initiation of thromboprophylaxis in spine trauma managed operatively: A nationwide propensity-matched analysis of trauma quality improvement program
    Ovid Technologies (Wolters Kluwer Health) ; 2018
    In:  Journal of Trauma and Acute Care Surgery Vol. 85, No. 2 ( 2018-8), p. 387-392
    Details
    In: Journal of Trauma and Acute Care Surgery, Ovid Technologies (Wolters Kluwer Health), Vol. 85, No. 2 ( 2018-8), p. 387-392
    Abstract: Patients with spinal trauma are at high risk for venous thromboembolic events (VTE). Guidelines recommend prophylactic anticoagulation but they are unclear on timing of initiation of thromboprophylaxis. The aim of our study was to assess the impact of early versus late initiation of venous thromboprophylaxis in patients with spinal trauma who underwent operative intervention. METHODS We performed a 2-year (2013–2014) review of patients with isolated spine trauma (spine-Abbreviated Injury Scale score, ≥ 3 and no other injury in another body region with Abbreviated Injury Scale score, 〉 2) who underwent operative intervention and received thromboprophylaxis postoperatively. Patients were divided into two groups based on the timing of initiation of thromboprophylaxis: early( 〈 48 hours) and late(≥48 hours), and were matched in a 1:1 ratio using propensity score matching for demographics, admission vitals, injury parameters, type of operative intervention, hospital course, and type of prophylaxis(low molecular weight heparin vs. unfractionated heparin). Outcomes were rates of deep vein thrombosis (DVT) and/or pulmonary embolism, red-cell transfusions, the rate of operative interventions for spinal cord decompression and mortality after initiation of thromboprophylaxis. RESULTS Nine thousand five hundred eighty-five patients underwent operative intervention and received anticoagulants, of which 3554 patients (early, 1,772; late, 1,772) were matched. Matched groups were similar in demographics, injury parameters, emergency department vitals, hospital length of stay, rates of inferior vena cava (IVC) filter placement and time to operative procedure. Patients who received thromboprophylaxis within 48 hours of operative intervention, unlike those who did not, were less likely to develop DVT (2.1% vs. 10.8%, p 〈 0. 01). However, the rate of pulmonary embolism was similar in both groups ( p = 0.75). Additionally, there was no difference in postprophylaxis red cell transfusion requirements ( p = 0.61), rate of postprophylaxis decompressive procedure on the spinal cord ( p = 0.27), and mortality ( p = 0.53). CONCLUSION Early VTE prophylaxis is associated with decreased rates of DVT in patients with operative spinal trauma without increasing the risk of bleeding and mortality. The VTE prophylaxis should be initiated within 48 hours of surgery to reduce the risk of DVT in this high-risk patient population. LEVEL OF EVIDENCE Therapeutic studies, level IV.
    Type of Medium: Online Resource
    ISSN: 2163-0763 , 2163-0755
    URL: Article
    DOI: 10.1097/TA.0000000000001916
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2018
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  • 8
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    Emergency general surgery in geriatric patients: How should we evaluate hospital experience?
    Ovid Technologies (Wolters Kluwer Health) ; 2019
    In:  Journal of Trauma and Acute Care Surgery Vol. 86, No. 2 ( 2019-2), p. 189-195
    Details
    In: Journal of Trauma and Acute Care Surgery, Ovid Technologies (Wolters Kluwer Health), Vol. 86, No. 2 ( 2019-2), p. 189-195
    Abstract: As the aging American population poses unique challenges to acute care services, we determined if either hospital proportion or annual volume of geriatric patients undergoing emergency general surgery (EGS) procedures is associated with outcomes. METHODS Using criteria from the American Association of the Surgery of Trauma, we identified five EGS procedures in the 2012–2015 Nationwide Inpatient Sample common in geriatric patients (65+ years). We defined hospital proportion as the fraction of geriatric EGS patients divided by all EGS patients, where volume was the raw number of geriatric EGS patients. We then divided hospitals into quartiles both by proportion and then by volume of geriatric patients. Multivariable logistic regressions compared four outcomes between these quartiles: mortality, complications, failure to rescue (FTR; death after a complication), and extended length of stay (LOS; procedure-specific top decile of patients). RESULTS We identified 25,084 complex EGS procedures in geriatric patients at 3,528 hospitals (mortality, 10.6%; complications, 30.5%; FTR, 27.7%; extended LOS, 9.1%). The median hospital proportion of geriatric patients among EGS procedures was 42.8% (interquartile range, 33.3–52.2%), whereas the median hospital geriatric EGS volume after nationwide weighting was 40 per year (interquartile range, 20–70/year). After adjustment, the lowest hospital proportion quartile relative to the highest was associated with adverse outcomes: mortality (odds ratio, 1.21 [95% confidence interval, 1.03–1.44]), complications (1.16 [1.05–1.29] ), FTR (1.32 [1.08–1.63]), and extended LOS (1.30 [1.12–1.50] ). The lowest volume quartile relative to the highest was not associated with adverse outcomes. As the hospital proportion of geriatric patients increased by 10%, the odds of all adverse outcomes decreased: mortality by 7%, complications by 4%, FTR by 9%, and extended LOS by 8%. CONCLUSION When accounting for both, hospital proportion of geriatric EGS patients but not hospital volume is associated with postoperative outcomes, having important implications for quality improvement initiatives, benchmarking endeavors, and health services research. LEVEL OF EVIDENCE Care management, level IV; prognostic, level III.
    Type of Medium: Online Resource
    ISSN: 2163-0763 , 2163-0755
    URL: Article
    DOI: 10.1097/TA.0000000000002142
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2019
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  • 9
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    Hospital variation in mortality after emergent bowel resections: The role of failure-to-rescue
    Ovid Technologies (Wolters Kluwer Health) ; 2018
    In:  Journal of Trauma and Acute Care Surgery Vol. 84, No. 5 ( 2018-5), p. 702-710
    Details
    In: Journal of Trauma and Acute Care Surgery, Ovid Technologies (Wolters Kluwer Health), Vol. 84, No. 5 ( 2018-5), p. 702-710
    Abstract: Hospital variation in failure-to-rescue (FTR) rates has partially explained nationwide differences in mortality after elective surgeries. To examine the role of FTR among emergency general surgery, we compared nationwide risk-adjusted mortality, complications, and FTR rates after emergent bowel resections. METHODS We identified patients who underwent emergent small or large bowel resections in the 2010 to 2011 Nationwide Inpatient Sample using the American Association for the Surgery of Trauma criteria. We then calculated risk-adjusted mortality rates for each hospital using multivariable logistic regressions and postestimation, which adjusted for patient age, sex, race and ethnicity, payer status, comorbidities, and hospital clustering. After excluding hospitals with fewer than 10 resections per year, we ranked the remaining hospitals by their risk-adjusted mortality rates and divided them into five quintiles. We compared both risk-adjusted complication rates and FTR rates between the top (lowest mortality) and bottom (highest mortality) quintiles. RESULTS We identified 21,564 emergent bowel resections, weighted to 105,925 procedures nationwide. The bottom quintile of hospitals had an overall risk-adjusted mortality rate that was 10.9 times higher than that of the top quintile of hospitals (15.3% vs. 1.4%). While risk-adjusted complication rates were similarly high for both the bottom and the top quintiles of hospitals (22.5% vs. 15.7%), the risk-adjusted FTR rates were 10.8 times higher in the bottom quintile of hospitals relative to the top quintile of hospitals (33.4% vs. 3.1%). Using larger hospital volume thresholds yielded similar findings. Furthermore, large variations existed in complication-specific FTR rates (surgical site infection [6.6%] to myocardial infarction [29.4%] ). CONCLUSION Nationwide hospital variation in risk-adjusted mortality rates exist after emergent bowel resections. As complication rates were similar across hospitals, the significantly higher FTR rates at higher-mortality hospitals may drive this variation in mortality. System-level initiatives addressing the management of postoperative complications may improve patient care and reduce variation in outcomes. LEVEL OF EVIDENCE Prognostic and epidemiological study, level IV.
    Type of Medium: Online Resource
    ISSN: 2163-0763 , 2163-0755
    URL: Article
    DOI: 10.1097/TA.0000000000001827
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2018
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  • 10
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    Association of Whole Blood With Survival Among Patients Presenting With Severe Hemorrhage in US and Canadian Adult Civilian Trauma Centers
    American Medical Association (AMA) ; 2023
    In:  JAMA Surgery Vol. 158, No. 5 ( 2023-05-01), p. 532-
    Details
    In: JAMA Surgery, American Medical Association (AMA), Vol. 158, No. 5 ( 2023-05-01), p. 532-
    Abstract: Whole-blood (WB) resuscitation has gained renewed interest among civilian trauma centers. However, there remains insufficient evidence that WB as an adjunct to component therapy–based massive transfusion protocol (WB-MTP) is associated with a survival advantage over MTP alone in adult civilian trauma patients presenting with severe hemorrhage. Objective To assess whether WB-MTP compared with MTP alone is associated with improved survival at 24 hours and 30 days among adult trauma patients presenting with severe hemorrhage. Design, Setting, and Participants This retrospective cohort study using the American College of Surgeons Trauma Quality Improvement Program databank from January 1, 2017, and December 31, 2018, included adult trauma patients with a systolic blood pressure less than 90 mm Hg and a shock index greater than 1 who received at least 4 units of red blood cells within the first hour of emergency department (ED) arrival at level I and level II US and Canadian adult civilian trauma centers. Patients with burns, death within 1 hour of ED arrival, and interfacility transfers were excluded. Data were analyzed from February 2022 to September 2022. Exposures Resuscitation with WB-MTP compared with MTP alone within 24 hours of ED presentation. Main Outcomes and Measures Primary outcomes were survival at 24 hours and 30 days. Secondary outcomes selected a priori included major complications, hospital length of stay, and intensive care unit length of stay. Results A total of 2785 patients met inclusion criteria: 432 (15.5%) in the WB-MTP group (335 male [78%]; median age, 38 years [IQR, 27-57 years] ) and 2353 (84.5%) in the MTP-only group (1822 male [77%]; median age, 38 years [IQR, 27-56 years] ). Both groups included severely injured patients (median injury severity score, 28 [IQR, 17-34]; median difference, 1.29 [95% CI, −0.05 to 2.64] ). A survival curve demonstrated separation within 5 hours of ED presentation. WB-MTP was associated with improved survival at 24 hours, demonstrating a 37% lower risk of mortality (hazard ratio, 0.63; 95% CI, 0.41-0.96; P  = .03). Similarly, the survival benefit associated with WB-MTP remained consistent at 30 days (HR, 0.53; 95% CI, 0.31-0.93; P  = .02). Conclusions and Relevance In this cohort study, receipt of WB-MTP was associated with improved survival in trauma patients presenting with severe hemorrhage, with a survival benefit found early after transfusion. The findings from this study are clinically important as this is an essential first step in prioritizing the selection of WB-MTP for trauma patients presenting with severe hemorrhage.
    Type of Medium: Online Resource
    ISSN: 2168-6254
    URL: Article
    DOI: 10.1001/jamasurg.2022.6978
    Language: English
    Publisher: American Medical Association (AMA)
    Publication Date: 2023
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