Failure to Rescue in Emergency Surgery: Is Precedence a Problem?

BACKGROUND

Mortality in emergency general surgery (EGS) is often attributed to patient condition, which may obscure opportunities for improvement in care. Identifying failure to rescue (FTR), or death after complication, may reveal these opportunities. FTR has been problematic in trauma secondary to low precedence rates (proportion of deaths preceded by complication). We sought to evaluate this in EGS, hypothesizing that precedence is lower in EGS than in similar elective operations.

METHODS

National Inpatient Sample data from January 2014 through September 2015 were used. 150,027 adult operative EGS complete cases were defined by emergent admission, one of seven International Classification of Diseases, ninth revision (ICD-9) procedure group codes for common EGS operations, and timing to operation (<48 h); these represent 750,135 patients under the National Inpatient Sample sampling design. Deaths were precedented if one of eight prespecified complications was identified. Chi-squared tests were used to compare precedence rates between selected emergent and elective operations.

RESULTS

There was a 2.5% mortality rate in this cohort of operative EGS patients, with an 84.1% (95% CI: 82.7%-85.4%) precedence rate. Among the seven listed procedure groups, those with clinically reasonable elective analogs were cholecystectomy, colon resection, and laparotomy. Emergent versus elective precedence rates were 90.2% versus 82.0% (P = 0.004) for colon resection, 81.3% versus 86.8% (P = 0.26) for cholecystectomy, and 68.8% versus 92.7% (P < 0.001) for laparotomy.

CONCLUSIONS

Precedence rates in EGS were higher than expected and were similar to previously published rates in nonemergent surgery, suggesting that FTR is likely to be reliable using standard methodology. Management of complications after emergency operation may represent significant opportunities to prevent mortality.

A 'weekend effect' in operative emergency general surgery

BACKGROUND

Evidence of a "weekend effect" is limited in emergency general surgery (EGS). We hypothesized that there are increased rates of complications, death, and failure-to-rescue (FTR) in patients undergoing weekend EGS operations.

METHODS

National Inpatient Sample (NIS) data, January 2014-September 2015 were used. Operative EGS patients were identified by ICD-9 procedure code and timing to operation. Complications were defined by ICD-9 code. We performed survey-weighted multivariable regression analyses.

RESULTS

Of 438,110 EGS patients, 103,450 underwent weekend operation. There was no association between weekend operation and FTR (OR 1.17; 95%CI 0.95-1.45) or complications (OR 1.04; 95%CI 0.97-1.13). There was a weekend effect on mortality (OR 1.22; 95%CI 1.02-1.46) and an interactive effect between weekend operation and teaching status on complications (teaching OR 1.22; 95%CI 1.15-1.29; interaction OR 1.13; 95%CI 1.03-1.25).

CONCLUSIONS

There is evidence for a "weekend effect" on mortality, but not complications or FTR, in this cohort.

Disparities in Timing of Trauma Consultation: A Trauma Registry Analysis of Patient and Injury Factors

BACKGROUND

Efficient trauma systems rely on field and emergency department (ED) personnel to triage patients to the appropriate level of care. Undertriage puts patients at risk, whereas overtriage results in system strain. Although much research has focused on prehospital triage, little is known about trauma triage processes within the ED. We investigated the timing of trauma consultation in the ED of a level I trauma center. We hypothesized that patient characteristics and injury type would be associated with time to consultation, with women, Black patients, older patients, and those with head and torso injuries experiencing longer time to consult.

MATERIALS AND METHODS

Patients aged ≥18 y referred to the trauma service via consultation were recruited retrospectively. Bivariable and multivariable negative binomial regressions were used to assess the association between patient and injury characteristics and time to consult. We used multivariable logistic regression adjusted for patient and injury characteristics to assess for association between time to consult and mortality and length of stay.

RESULTS

Among 588 adult consult patients, median time to consult was 177 min (interquartile range 106-265). In multivariable analysis, Black patients had longer time to consult (incidence rate ratio [IRR] 1.33, 95% confidence interval [CI] 1.10, 1.60) as did women (IRR 1.15, 95% CI 1.02, 1.29). Head injury was associated with shorter time to consult (IRR 0.81, 95% CI 0.71, 0.92). Time to consult was not associated with mortality or length of stay.

CONCLUSIONS

Patient demographics and injury characteristics influenced the timing of trauma consultation. More robust criteria for equitable evaluation of patients are needed to eliminate disparities, prevent delays, and streamline care.

State Firearm Laws and Interstate Firearm Deaths From Homicide and Suicide in the United States: A Cross-sectional Analysis of Data by County

IMPORTANCE

Firearm laws in one state may be associated with increased firearm death rates from homicide and suicide in neighboring states.

OBJECTIVE

To determine whether counties located closer to states with lenient firearm policies have higher firearm death rates.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study of firearm death rates by county for January 2010 to December 2014 examined data from the US Centers for Disease Control and Prevention for firearm suicide and homicide decedents for 3108 counties in the 48 contiguous states of the United States.

EXPOSURES

Each county was assigned 2 scores, a state policy score (range, 0-12) based on the strength of its state firearm laws, and an interstate policy score (range, -1.33 to 8.31) based on the sum of population-weighted and distance-decayed policy scores for all other states. Counties were divided into those with low, medium, and high home state and interstate policy scores.

MAIN OUTCOMES AND MEASURES

County-level rates of firearm, nonfirearm, and total homicide and suicide. With multilevel Bayesian spatial Poisson models, we generated incidence rate ratios (IRR) comparing incidence rates between each group of counties and the reference group, counties with high home state and high interstate policy scores.

RESULTS

Stronger firearm laws in a state were associated with lower firearm suicide rates and lower overall suicide rates regardless of the strength of the other states' laws. Counties with low state scores had the highest rates of firearm suicide. Rates were similar across levels of interstate policy score (low: IRR, 1.34; 95% credible interval [CI], 1.11-1.65; medium: IRR, 1.36, (95% CI, 1.15-1.65; and high: IRR, 1.43; 95% CI, 1.20-1.73). Counties with low state and low or medium interstate policy scores had the highest rates of firearm homicide. Counties with low home state and interstate scores had higher firearm homicide rates (IRR, 1.38; 95% CI, 1.02-1.88) and overall homicide rates (IRR, 1.32; 95% CI, 1.03-1.67). Counties in states with low firearm policy scores had lower rates of firearm homicide only if the interstate firearm policy score was high.

CONCLUSIONS AND RELEVANCE

Strong state firearm policies were associated with lower suicide rates regardless of other states' laws. Strong policies were associated with lower homicide rates, and strong interstate policies were also associated with lower homicide rates, where home state policies were permissive. Strengthening state firearm policies may prevent firearm suicide and homicide, with benefits that may extend beyond state lines.

Where do bike lanes work best? A Bayesian spatial model of bicycle lanes and bicycle crashes

US municipalities are increasingly introducing bicycle lanes to promote bicycle use, increase roadway safety and improve public health. The aim of this study was to identify specific locations where bicycle lanes, if created, could most effectively reduce crash rates. Previous research has found that bike lanes reduce crash incidence, but a lack of comprehensive bicycle traffic flow data has limited researchers' ability to assess relationships at high spatial resolution. We used Bayesian conditional autoregressive logit models to relate the odds that a bicycle injury crash occurred on a street segment in Philadelphia, PA (n = 37,673) between 2011 and 2014 to characteristics of the street and adjacent intersections. Statistical models included interaction terms to address the problem of unknown bicycle traffic flows, and found bicycle lanes were associated with reduced crash odds of 48% in streets segments adjacent to 4-exit intersections, of 40% in streets with one- or two-way stop intersections, and of 43% in high traffic volume streets. Presence of bicycle lanes was not associated with change in crash odds at intersections with less or more than 4 exits, at 4-way stop and signalized intersections, on one-way streets and streets with trolley tracks, and on streets with low-moderate traffic volume. The effectiveness of bicycle lanes appears to depend most on the configuration of the adjacent intersections and on the volume of vehicular traffic. Our approach can be used to predict specific street segments on which the greatest absolute reduction in bicycle crash odds could occur by installing new bicycle lanes.

Comparative Effectiveness of Initial Treatment at Trauma Center vs Neurosurgery-Capable Non-Trauma Center for Severe, Isolated Head Injury

BACKGROUND

Head injury is an increasing contributor to death and disability, particularly among the elderly. Older patients are less likely to be treated at trauma centers, and head injury is the most common severe injury treated at non-trauma centers. We hypothesized that patients initially triaged to trauma centers would have lower rates of mortality and higher rates of discharge home without services than those treated at non-trauma centers.

STUDY DESIGN

We used the State Emergency Department and Inpatient Databases (2011 to 2012) for 6 states to conduct a retrospective cohort study of patients with severe, isolated head injury. Combined, these databases capture all visits to non-federal emergency departments. We compared in-hospital mortality and discharge status for all adults and for the subgroup aged 65 years or older who initially presented to either a trauma center or a neurosurgery-capable non-trauma center. To account for selection bias, we used differential distance from patients' homes to a trauma center as an instrumental variable and performed a multivariable matched analysis.

RESULTS

Of 62,198 patients who presented with severe, isolated head injury, 44.2% presented to non-trauma centers and 55.8% to trauma centers. In multivariable matched instrumental variable analysis, initial presentation to a trauma center was associated with no significant difference in overall mortality (-1.06%; 95% CI -3.36% to 1.19%), but a 5.8% higher rate of discharge home (95% CI 1.7% to 10.0%). Among patients aged 65 years or older, initial presentation to a trauma center was associated with a 3.4% reduction in mortality (95% CI 0.0% to 7.1%).

CONCLUSIONS

Patients with isolated, severe head injury have better outcomes if initially treated in designated trauma centers. As 40% of such patients were triaged to non-trauma centers, there are major opportunities for improving outcomes.

A safe haven for the injured? Urban trauma care at the intersection of healthcare, law enforcement, and race

Patients with traumatic injuries often interact with police before and during hospitalization, particularly when their injuries are due to violence. People of color are at highest risk for violent injuries and have the poorest outcomes after injury. The purpose of this study was to describe how injured, Black patients perceived their interactions with police and what these perceptions reveal about police involvement within trauma care systems. We combined data from two qualitative studies to achieve this aim. The first was ethnographic fieldwork that followed Black trauma patients in the hospital through the physical and emotional aftermath of their injuries. The second was a qualitative, descriptive study of how patients experienced trauma resuscitation in the emergency department (ED). Both studies were conducted between 2012 and 2015 at the Trauma Center at Penn, an academic medical center in Philadelphia, Pennsylvania, United States. The present study includes data from 24 adult, Black participants undergoing treatment for injury. We reanalyzed all interview data related to law enforcement encounters from the scene of injury through inpatient hospitalization and coded data using a constant comparative technique from grounded theory. Participants described law enforcement encounters at the scene of injury and during transport to the hospital, in the ED, and over the course of inpatient care. Injured participants valued police officers' involvement when they perceived that officers provided safety at the scene, speed of transport to the hospital, or support and information after injury. Injured participants also found police questioning to be stressful and, at times, disrespectful or conflicting with clinical care. Communities, trauma centers, and professional societies have the opportunity to enact policies that standardize law enforcement access in trauma centers and balance patients' health, privacy, and legal rights with public safety needs.

Patient Characteristics and Temporal Trends in Police Transport of Blunt Trauma Patients: A Multicenter Retrospective Cohort Study

BACKGROUND

Police transport (PT) of penetrating trauma patients has the potential to decrease prehospital times for patients with life-threatening hemorrhage and is part of official policy in Philadelphia, Pennsylvania. We hypothesized that rates of PT of bluntly injured patients have increased over the past decade.

METHODS

We used Pennsylvania Trauma Outcomes Study registry data from 2006-15 to identify bluntly injured adult patients transported to all 8 trauma centers in Philadelphia. PT was compared to ambulance transport, excluding transfers, burn patients, and private transport. We compared demographics, mechanism, and injury outcomes between PT and ambulance transport patients and used multivariable logistic regression to identify independent predictors of PT. We also identified physiological indicators and injury patterns that might have benefitted from prehospital intervention by EMS.

RESULTS

Of 28 897 bluntly injured patients, 339 (1.2%) were transported by police and 28 558 (98.8%) by ambulance. Blunt trauma accounted for 11% of PT and penetrating trauma for 89%. PT patients were younger, more likely to be male, and more likely to be African American or Asian and were more often injured by assault or motor vehicle crash. There were no significant differences presenting physiology between PT and EMS patients. In multivariable logistic regression analysis, male sex (OR 1.89, 95%CI 1.40-2.55), African American race (OR 1.71 95%CI 1.34-2.18), and Asian race (OR 2.25, 95%CI 1.22-4.14) were independently associated with PT. Controlling for injury severity and physiology, there was no significant difference in mortality between PT and EMS. Overall, 64% of PT patients had a condition that might have benefited from prehospital intervention such as supplemental oxygen for brain injury or spine stabilization for vertebral fractures.

CONCLUSIONS

PT affects a small minority of blunt trauma patients, and did not appear associated with higher mortality. However, PT patients included many who might have benefited from proven, prehospital intervention. Clinicians, EMS providers, and law enforcement should collaborate to optimize use of PT within the trauma system.

Patient Experiences of Trauma Resuscitation

Importance

Patient satisfaction is an increasingly common feature of quality measurement, and patient-centered care is a key aspect of high-quality clinical care. Incorporating patient preferences in an acute context, such as trauma resuscitation, presents distinct challenges; however, to our knowledge, patients' experiences of trauma resuscitation have not been explored.

Objectives

To describe patient experiences of trauma resuscitation and to identify opportunities to improve patient experience without compromising speed or thoroughness.

Design, Setting, and Participants

This qualitative, descriptive study was conducted at an urban, academic, level I trauma center. Semistructured interviews and video observations were conducted from May to December 2015. Interview participants were adult English-speaking patients who had experienced trauma resuscitation and were clinically stable with no alteration in consciousness. We recruited interview participants and conducted video observations until thematic saturation was reached, resulting in 30 interviews and 20 observations. Video observation patients did not overlap with interview participants. The purposive sample included equal numbers of violently and nonviolently injured patients. Data were analyzed for thematic content from June 2015 to April 2016.

Main Outcomes and Measures

The main outcomes reported are themes of patient experience.

Results

Of 30 interview participants, 25 were men (83.3%), and 21 were black (70.0%). Of 20 video observation patients, 16 were men (80.0%), and 17 were black (85.0%). Salient aspects of patient experience of trauma resuscitation included emotional responses, physical experience, nonclinical concerns, treatment and procedures, trauma team members' interactions, communication, and comfort. Participants drew satisfaction from trauma team members' demeanor, expertise, and efficiency and valued clear clinical communication, as well as words of reassurance. Dissatisfaction stemmed from the perceived absence of these attributes and from participants' emotional or physical discomfort. Observation data added insight into the components of care that may have contributed to participants' responses and those aspects of care that were not salient to participants.

Conclusions and Relevance

Although the urgency of trauma care limits explicit discussion and consideration of patient priorities, we found that patient concerns corresponded well with trauma team goals. Patients perceived trauma team members as competent, efficient, and caring. Focusing on patient communication could further improve patient-centeredness in this setting.

Factors associated with hospital admission after an emergency department treat and release visit for older adults with injuries

INTRODUCTION

Emergency Department (ED) visits for injury often precede hospital admissions in older adults, but risk factors for these admissions are poorly characterized. We sought to determine the incidence and risk factors for hospitalization shortly following discharge home from an ED visit for traumatic injury in older adults. We hypothesized higher risk for admission in those with increased age, discharged home after falls, with increased comorbidity burden, and who live in poor neighborhoods.

METHODS

We identified all community-dwelling patients ≥65years old treated and released for traumatic injury at non-federal EDs in Florida using the 2011 State Inpatient Database and State ED Database of the Agency for Healthcare Research and Quality. Outcome measures were hospitalization within 9 and 30days of discharge from the ED. Multivariable logistic regression was used to establish independent risk factors for hospital admission.

RESULTS

Of 163,851 index ED injury visits, 6298 (3.8%) resulted in inpatient admissions within 9days and 12,938 (7.9%) within 30days. Factors associated with increased odds of admission within 9days included: each additional comorbidity, ≥moderate injury to abdomen or pelvis/extremities, and median neighborhood income<$39,000. Additional factors associated with increased odds of admission within 30days included: lack of private insurance supplement and median neighborhood income<$48,000.

CONCLUSION

Among older adults treated and discharged from the ED for an injury, those who have high comorbidity burdens, have abdominal or orthopedic injuries, and live in poor neighborhoods are at increased risk of hospitalization within 9 or 30days of ED discharge.

Outcomes of hospitalized patients undergoing emergency general surgery remote from admission

BACKGROUND

Emergency general surgery during hospitalization has not been well characterized. We examined emergency operations remote from admission to identify predictors of postoperative 30-day mortality, postoperative duration of stay >30 days, and complications.

METHODS

Patients >18 years in The American College of Surgeons National Surgical Quality Improvement Program (2011-2014) who had 1 of 7 emergency operations between hospital day 3-18 were included. Patients with operations >95th percentile after admission (>18 days; n = 581) were excluded. Exploratory laparotomy only (with no secondary procedure) represented either nontherapeutic or decompressive laparotomy. Multivariable logistic regression was used to identify predictors of study outcomes.

RESULTS

Of 10,093 patients with emergency operations, most were elderly (median 66 years old [interquartile ratio: 53-77 years]), white, and female. Postoperative 30-day mortality was 12.6% (n = 1,275). Almost half the cohort (40.1%) had a complication. A small subset (6.8%) had postoperative duration of stay >30 days. Postoperative mortality after exploratory laparotomy only was particularly high (>40%). In multivariable analysis, an operation on hospital day 11-18 compared with day 3-6 was associated with death (odds ratio 1.6 [1.3-2.0]), postoperative duration of stay >30 days (odds ratio 2.0 [1.6-2.6]), and complications (odds ratio 1.5 [1.3-1.8]). Exploratory laparotomy only also was associated with death (odds ratio 5.4 [2.8-10.4]).

CONCLUSION

Emergency general surgery performed during a hospitalization is associated with high morbidity and mortality. A longer hospital course before an emergency operation is a predictor of poor outcomes, as is undergoing exploratory laparotomy only.

Failure to Rescue after Infectious Complications in a Statewide Trauma System

BACKGROUND

The failure to rescue (FTR) rate, the rate of death after a complication, measures a center's ability to identify and manage complications by "rescuing" vulnerable patients. Infectious complications are common after trauma, but risk factors for death after infection are not established. We hypothesized that risk factors would differ for FTR after infectious complications, development of infections, and for development of and death after non-infectious complications.

PATIENTS AND METHODS

We analyzed trauma registry data for adult patients admitted to all 30 level I and II Pennsylvania trauma centers, 2011-2014. We used multivariable regression to identify risk factors for infection, non-infectious complications, failure to rescue after infection (FTR-I), failure to rescue after non-infectious complications (FTR-N), and death. We compared secondary complication patterns among patients with an index infection.

RESULTS

Of 95,806 admitted patients, at least one complication developed in 11.2%. Among these, 33.6% had an infection as the first complication. Mortality rates were 3.7% overall, 2.8% in patients with no complications, 7.2% after infection, and 13.5% after non-infectious complications. Urinary tract infection was the most common infection (41.7%), followed by pneumonia (37.5%) and wound infection (6.9%). Risk factors for infection included higher injury severity score (ISS), poor admitting physiology, female gender, cirrhosis, dementia, history of stroke, and drug abuse. Factors associated with FTR-I included male gender (odds ratio [OR] 1.6, 95% confidence interval 1.1-1.2), older age (OR 1.04, 1.03-1.05), increased ISS, cirrhosis, chronic renal insufficiency, and use of anticoagulation or steroids.

CONCLUSIONS

Infectious complications are common in trauma patients and are an important component of FTR. Risk factors for infection and FTR-I differ and may help identify patients who may benefit from close surveillance and early intervention. Half of all FTR deaths were preceded by only a single complication, highlighting that management of this index complication, along with any secondary complications, may be a fruitful area for intervention.

State injury prevention policies and variation in death from injury

OBJECTIVES

Death from injury is frequently preventable, but injury remains a leading cause of death in the USA. While evidence-based strategies exist to prevent many types of injuries, effective policies for implementing these strategies at the population level are needed to reduce injury deaths. We identified promising injury prevention policies and evaluated their association with injury death rate (IDR).

METHODS

We identified 11 injury prevention policies and accessed data on 2013 state and county IDRs. States were divided into strong, moderate and weak tertiles based on total number of policies in place. Adjusted regression modelling compared the strength of state prevention policies with IDRs at the state level and then at the county level to account for variability within states.

RESULTS

The strength of state prevention policies (tertile) was not significantly associated with IDR in US states. However, counties in strong policy states had a 11.8-point lower IDR compared with those in weak policy states (p=0.001).

CONCLUSIONS

States with more injury prevention policies in place have lower rates of death from injury, particularly when evaluated at the county level. Implementing recommended prevention policies holds potential to prevent injury death in the USA.

Variation in intensive care unit utilization and mortality after blunt splenic injury

BACKGROUND

Although trauma patients are frequently cared for in the intensive care unit (ICU), admission triage criteria are unclear and may vary among providers and institutions. The benefits of close monitoring must be weighed against the economic and opportunity costs of an ICU admission.

MATERIALS AND METHODS

We conducted a retrospective cohort study of patients treated for blunt splenic injuries from 2011-2014 at 30 level I and II Pennsylvania trauma centers. We used multivariable logistic regression to assess the relationship between ICU admission and mortality, adjusting for patient characteristics, injury characteristics, and physiology. We calculated center-level observed-to-expected ratios for ICU utilization and mortality and evaluated correlations with Spearman's rho. We compared the proportion of patients receiving critical care procedures, such as mechanical ventilation or central line placement between high and low-ICU-utilization centers.

RESULTS

Of 2587 patients with blunt splenic injuries, 63.9% (1654) were admitted to the ICU. Median injury severity score was 17 overall, 13 for non-ICU patients and 17 for ICU patients (P < 0.001). In multivariable logistic regression, ICU admission was not significantly associated with mortality. Center-level risk-adjusted ICU admission rates ranged from 17.9%-87.3%. Risk-adjusted mortality rates ranged from 1.2%-9.6%. There was no correlation between observed-to-expected ratios for ICU utilization and mortality (Spearman's rho = -0.2595, P = 0.2103). Proportionately fewer ICU patients received critical care procedures at high-utilization centers than at low-utilization centers.

CONCLUSIONS

Risk-adjusted ICU utilization rates for splenic trauma varied widely among trauma centers, with no clear relationship to mortality. Standardizing ICU admission criteria could improve resource utilization without increasing mortality.

Impact of State Ignition Interlock Laws on Alcohol-Involved Crash Deaths in the United States

OBJECTIVES

To investigate the impact on alcohol-involved crash deaths of universal ignition interlock requirements, which aim to prevent people convicted of driving under the influence of alcohol from driving while intoxicated.

METHODS

We used data from the National Highway Traffic Safety Administration for 1999 to 2013. From 2004 to 2013, 18 states made interlocks mandatory for all drunk-driving convictions. We compared alcohol-involved crash deaths between 18 states with and 32 states without universal interlock requirements, accounting for state and year effects, and for clustering within states.

RESULTS

Policy impact was apparent 3 years after implementation. The adjusted rate of alcohol-involved crash deaths was 4.7 (95% confidence interval [CI] = 4.0, 5.4) per 100,000 in states with the universal interlock requirement, compared with 5.5 (95% CI = 5.48, 5.53) in states without, an absolute reduction of 0.8 (95% CI = 0.1, 1.5) deaths per 100,000 per year.

CONCLUSIONS

Requiring ignition interlocks for all drunk-driving convictions was associated with 15% fewer alcohol-involved crash deaths, compared with states with less-stringent requirements. Interlocks are a life-saving technology that merit wider use.

Behind-the-counter status and availability of emergency contraception

OBJECTIVE

The objective of the study was to determine whether the 2006 Food and Drug Administration approval of Plan B for behind-the-counter status increased availability.

STUDY DESIGN

We conducted a survey in 2005 and 2007 of pharmacies listed in Atlanta, GA, Boston, MA, and Philadelphia, PA. We measured ability to dispense Plan B within 24 hours. Also measured were reasons for lack of availability and cost of Plan B.

RESULTS

Pharmacists were interviewed at 1087 pharmacies (75% response rate) in 2005 and 795 pharmacies (82% response rate) in 2007. In 2007, 8% of pharmacies were unable to provide Plan B within 24 hours, compared with 23% of pharmacies in 2005 (P < .001). The total refusal rate in 2007 was half the rate of 2005 (2% vs 4%, P = .004). The average cost of Plan B was $43.

CONCLUSION

Availability of Plan B in Atlanta and Philadelphia increased after it was awarded behind-the-counter status.