Predicting the post-operative length of stay for the orthopaedic trauma patient

Investigating Length of Stay Patterns and Its Predictors in the South Wales Trauma Network

Background

Length of stay (LOS) is frequently employed as a performance metric for trauma care. Following the establishment of the trauma network worldwide, the assessment and prediction of LOS in different levels of trauma centres have been extensively studied. However, assessing the total patient length of stay from a whole trauma network perspective is unclear. The objective of this study was to systematically analyse the overall Length of Stay (LOS) pattern within the SWTN before its establishment and in the immediate time after its foundation and, secondly, to assess the association between relevant impact factors and LOS.

Methodology

A retrospective secondary analysis based on the trauma admission dataset from Trauma Audit and Research Network(TARN) dataset was conducted. The studied sample covered around 18000 patients admitted to trauma centres from South Wales Major trauma network between January 2012 and October 2021. The primary outcome is the total length of stay in the trauma network. Statistical tests were applied to examine the difference between normal and outlier LOS. Data visualisation was utilised to demonstrate the LOS patterns and potential association between LOS and relevant demographic and clinical predictors.

Results

The distribution of length of stay in SWTN follows a right-skewed distribution with a median of 10 (IQR, 5-18) and a mean of 15.92 days. There were 1520 patients with outliers for LOS. A significant difference (p¡ 0.05) was found between the normal and outlier groups of LOS based on demographic (age, gender and residential information) and clinical characteristics(ward type, maximum of anatomically-based injury severity score(AIS) and probability of survival). Age group, maximum AIS score on specific injured region, ward type and its interaction effect with the number of admissions may associated with the LOS. Specifically, patients admitted to the geriatric ward exhibited notably prolonged LOS, and individuals with more than 2 admissions to long-term care and recovery-related wards such as neurosurgical rehabilitation, spinal injuries and burns wards also displayed elevated LOS.

Conclusion

Our finding supports prior evidence indicating elderly people are vulnerable to longer stays. Moreover, concerning the types of admission wards, patients admitted to rehabilitation wards who underwent more than 2 hospitalisations also faced an increased risk of prolonged stay. Based on these results, policymakers and healthcare providers should contemplate expanding the allocation of medical resources to this demographic to mitigate the length of stay and optimise associated healthcare costs.

Development and validation of a multivariable preoperative prediction model for postoperative length of stay in a broad inpatient surgical population

BACKGROUND

Postoperative length of stay is a meaningful patient-centered outcome and an important determinant of healthcare costs. The Surgical Risk Preoperative Assessment System preoperatively predicts 12 postoperative adverse events using 8 preoperative variables, but its ability to predict postoperative length of stay has not been assessed. We aimed to determine whether the Surgical Risk Preoperative Assessment System variables could accurately predict postoperative length of stay up to 30 days in a broad inpatient surgical population.

METHODS

This was a retrospective analysis of the American College of Surgeons' National Surgical Quality Improvement Program adult database from 2012 to 2018. A model using the Surgical Risk Preoperative Assessment System variables and a 28-variable "full" model, incorporating all available American College of Surgeons' National Surgical Quality Improvement Program preoperative nonlaboratory variables, were fit to the analytical cohort (2012-2018) using multiple linear regression and compared using model performance metrics. Internal chronological validation of the Surgical Risk Preoperative Assessment System model was conducted using training (2012-2017) and test (2018) datasets.

RESULTS

We analyzed 3,295,028 procedures. The adjusted R2 for the Surgical Risk Preoperative Assessment System model fit to this cohort was 93.3% of that for the full model (0.347 vs 0.372). In the internal chronological validation of the Surgical Risk Preoperative Assessment System model, the adjusted R2 for the test dataset was 97.1% of that for the training dataset (0.3389 vs 0.3489).

CONCLUSION

The parsimonious Surgical Risk Preoperative Assessment System model can preoperatively predict postoperative length of stay up to 30 days for inpatient surgical procedures almost as accurately as a model using all 28 American College of Surgeons' National Surgical Quality Improvement Program preoperative nonlaboratory variables and has shown acceptable internal chronological validation.

Predictive analysis of lower limb fractures in the orthopedic complex operative unit using artificial intelligence: the case study of AOU Ruggi

The length of stay (LOS) in hospital is one of the main parameters for evaluating the management of a health facility, of its departments in relation to the different specializations. Healthcare costs are in fact closely linked to this parameter as well as the profit margin. In the orthopedic field, the provision of this parameter is increasingly complex and of fundamental importance in order to be able to evaluate the planning of resources, the waiting times for any scheduled interventions and the management of the department and related surgical interventions. The purpose of this work is to predict and evaluate the LOS value using machine learning methods and applying multiple linear regression, starting from clinical data of patients hospitalized with lower limb fractures. The data were collected at the "San Giovanni di Dio e Ruggi d'Aragona" hospital in Salerno (Italy).

Which Factors Predict 30-Day Readmission After Total Hip and Knee Replacement Surgery?

Background

The Centers for Medicare and Medicaid Services enacted the Hospital Readmissions Reduction Program to impose penalties for diagnoses with high readmission rates. Despite several elective orthopedic procedures being included in this program, readmission rates have not declined, and associated costs have reached critical levels for total knee and total hip arthroplasty. Readmissions drastically impact patient outcomes. There are many known contributors to patient readmission rates, including infection, pain, and hematomas. However, evidence is inconclusive regarding other aspects, such as demographics, insurance, and discharge disposition. The purpose of this manuscript is to 1) measure hospital readmission rates for total knee and total hip arthroplasty, 2) evaluate the causes of readmissions, and 3) provide a predictive profile of risk factors associated with hospital readmissions.

Methods

Patients who underwent total knee or total hip arthroplasty were identified through a retrospective database review. An electronic chart review extracted data concerning patient demographics, comorbidities, surgical information, 30-day outcomes, and reasons for 30-day readmissions. Continuous and categorical variables were assessed with the Wilcoxon rank-sum test and the Chi-square test, respectively.

Results

A total of 6,065 patients were included, with 269 (4.4%) having at least one surgery-related 30-day readmission. No differences in readmission were noted with age, sex, or ethnicity; however, differences were found in weight and body mass index. Statistically significant comorbidities were heart failure, chronic obstructive pulmonary disease, dialysis, and alcohol use or abuse.

Conclusion

Our research indicated that surgery type, length of stay, and heart failure most significantly impacted 30-day readmission rates. By assessing readmission rates, we can take steps to optimize care for non-elective surgeries that will improve patient outcomes and cost-effectiveness.

Regular pre-admission urate-lowering therapy and serum urate testing are associated with a shorter hospital length of stay in people with gout: A nation-wide population-based cohort study

OBJECTIVE

This study aims to explore the association between inpatient gout flare-related variables and the length of stay (LOS) in hospitalized people with comorbid gout.

METHODS

Using data from the Aotearoa/New Zealand national data collections, this cohort study included adults with comorbid gout who were admitted to publicly funded hospitals during 2017 for reasons other than gout. The primary outcome was LOS. Association between 20 variables and the LOS was explored using two generalized linear models. Directed acyclic graph (DAG) was constructed to evaluate the causal relationship between pre-admission urate lowering therapy (ULT) and LOS.

RESULTS

The cohort included 36 047 admissions. We identified five variables associated with shorter LOS (pre-admission regular urate-lowering therapy (ULT), serum urate testing, male gender, Māori ethnicity and low-dose aspirin) and seven variables associated with longer LOS (M3 multimorbidity index, acute admission, operation, loop diuretics, potassium-sparing diuretics, NSAIDs, and age). Regular ULT had the strongest impact on shorter LOS (10% shorter). The model estimated an additional four days of hospitalization if the patient had multiple variables associated with longer LOS. DAG suggested a causal relationship between regular ULT and LOS under the condition that all unobserved confounders affected only ULT use, with no impact on in-hospital gout flares and/or LOS except through its influence on ULT use or as mediator of confounders that were observed.

CONCLUSION

We have identified a set of gout flare-related variables found to be associated with LOS in hospitalized people with comorbid gout. Pre-admission ULT may help reduce the LOS in such patients.

Is there a 'weekend effect' in elective lower limb arthroplasty?

INTRODUCTION

The weekend effect has been defined as a real or perceived decline in patient care provided on weekends and that provided on weekdays. The primary aim of this study was to investigate the association between day of surgery and length of stay for patients receiving elective lower limb joint arthroplasty in a large NHS teaching hospital.

MATERIALS AND METHODS

Data were obtained from a prospectively collected database of consecutive patients undergoing elective primary total knee and hip arthroplasty. Patient and clinical variables were collected alongside length of hospital stay. Data were anonymised and analysed using a multiple linear regression model.

RESULTS

A total of 3,544 knee and 3,277 hip replacements were included. No association was found between length of stay and day of surgery for either procedure. A significant association was noted between longer length of stay and increasing age, higher American Society of Anesthesiologists grade and male compared with female gender.

DISCUSSION

No evidence of a weekend effect was identified. Certain patient factors predicted longer hospital stay and focussing additional resources on these patient groups may prove a useful strategy in reducing overall length of stay.

CONCLUSIONS

Length of stay reduced across the time period included in this review while maintaining equality between the days of the week, which represents the successful management of weekend services.

Pressure injuries, obesity and mental health concerns on admission to rehabilitation are associated with increased orthopaedic rehabilitation length of stay

OBJECTIVE

To investigate the association between a set of comprehensive factors across international literature and rehabilitation length of stay.

METHOD

A chart audit of 197 Australian hospital rehabilitation unit orthopaedic inpatients (2016-2018) was conducted. Items significantly associated with length of stay throughout univariate regressions were entered into a subsequent hierarchical multiple regression analysis, where variables were regressed against length of stay in two steps. Items which were relevant prior to admission to the rehabilitation unit, or immediately upon admission, were regressed against length of stay during the first step, while variables which emerged during admission were entered during the second step.

RESULTS

Having pressure injuries during rehabilitation (p < .001), limited compliance in rehabilitation programs (p = .007), mental health concerns on admission to rehabilitation (p = .007), being obese (p < .001), and having significant pain impacting function (p = .03) were all independently significantly associated with an increased length of stay. Higher Functional Independence Measure motor (p < .001) subscale scores on admission to rehabilitation were associated with decreased length of stay. A hierarchical multiple regression analysis found that pressure injuries during rehabilitation (p = .002), being obese (p = .04), having mental health concerns on admission to rehabilitation (p = .03), and Functional Independence Measure subscale scores on admission (p = .04) were significantly associated with length of stay.

CONCLUSION

It is imperative that clinical programs and interventions promoting mental health outcomes, and addressing the distinct needs of obese inpatients, are delivered in the rehabilitation context.

Ability of a Risk Prediction Tool to Stratify Quality and Cost for Older Patients With Tibial Shaft and Plateau Fractures

OBJECTIVES

To determine whether a validated trauma triage tool can identify the middle-aged and geriatric trauma patients with tibial shaft and plateau fractures who are at the risk for costly admissions and poorer hospital quality measures.

DESIGN

Prospective cohort study.

SETTING

Level-1 trauma center.

PATIENTS/PARTICIPANTS

Sixty-four patients older than 55 years hospitalized with isolated tibial shaft or plateau fractures.

INTERVENTION

Patients with either isolated tibial plateau fractures or tibial shaft fractures over a 3-year period were prospectively enrolled in an orthopedic trauma registry. Demographic information, injury severity, and comorbidities were assessed and incorporated into the Score for Trauma Triage in Geriatric and Middle Aged (STTGMA) score, a validated trauma triage score that calculates inpatient mortality risk upon admission. Patients were then grouped into tertiles based on their STTGMA score.

MAIN OUTCOME MEASURES

Length of stay, complications, discharge location, and direct variable costs.

RESULTS

Sixty-four patients met inclusion criteria. Thirty-three patients (51.6%) presented with tibial plateau fractures and 31 (48.4%) with tibial shaft fractures. The mean age was 66.7 ± 10.2 years. Mean length of stay was significantly different between risk groups with a mean of 6.8 ± 4 days (P < 0.001). Although 19 (90.5%) of the minimal risk patients were discharged home, only 7 (33.3%) and 5 (22.7%) of moderate- and high-risk patients were discharged home, respectively (P < 0.001). Higher-risk patients experienced a significantly greater number of complications during hospitalization but had no differences in the need for intensive care unit-level care (P = 0.027 and P = 0.344, respectively). The total cost difference between the lowest- and highest-risk group was nearly 50% ($14,070 ± 8056 vs. $25,147 ± 14,471; mean difference, $11,077; P = 0.022).

CONCLUSION

Application of the STTGMA triage tool allows for the prediction of key hospital quality measures and cost of hospitalization that can improve clinical decision-making.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Who Is the Geriatric Trauma Patient? An Analysis of Patient Characteristics, Hospital Quality Measures, and Inpatient Cost

Purpose:

The purpose of this study was 2-fold: 1) to investigate the age-related frequency, demographics and distribution of the middle-aged and geriatric orthopedic trauma population and 2) to describe the age-related frequency and distribution of hospital quality measure outcomes and inpatient cost.

Methods:

All patients > 55 years of age who required orthopedic, trauma, or neurosurgery consults at 3 hospitals within an academic medical center from 2014 to 2017 were prospectively followed. On initial evaluation, each patient’s demographics, injury severity, and functional status were collected. Patients were grouped into low and high-energy mechanism cohorts and divided into 5 groups based on age. Hospital quality measures including length of stay, complications, discharge location, and cost of care was compared between age groups. Data were analyzed using ANOVA and Chi-square tests.

Results:

A total of 3965 patients were included in this study of which 3268 (82%) sustained low-energy trauma and 697 (18%) sustained high-energy trauma. With increasing age, more patients had more comorbidities, were less likely to be community ambulators, and more likely to use assistive devices (p < 0.05). Patients in older age groups had longer lengths of stay, more complications, were more likely to need ICU level care, and were less likely to be discharged home (p < 0.05). Rates of mortality were also greater in patients of more advanced age in both low and high-energy cohorts, and the calculated risk triage tool (STTGMA) score increased with each age bracket (p < 0.05). Total cost of care differed between age groups in the low-energy cohort (p = 0.003).

Conclusion:

This epidemiological study provides a clear picture of the frequency and distribution of demographic, physiologic characteristics, outcomes, and cost of care in a middle-aged and geriatric orthopedic trauma population as evaluated by the STTGMA risk tool. Risk profiling of geriatric trauma patients allows for the establishment of baseline norms.

Have Venous Thromboembolism Rates Decreased in Total Hip and Knee Arthroplasty?

BACKGROUND

Venous thromboembolism (VTE) is a major cause of morbidity, mortality, and healthcare costs in arthroplasty patients. In an effort to reduce VTEs, numerous strategies and guidelines have been implemented, but their impact remains unclear. The purpose of this study is to compare annual trends in 30-day VTE, deep vein thrombosis (DVT), pulmonary embolism (PE), and all-cause mortality in (1) total hip arthroplasty (THA) and (2) total knee arthroplasty (TKA).

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database identified 363,530 patients who received a TKA or THA from 2008 to 2016. Bivariate analysis was performed to assess the association between the year in which surgery was performed and demographics and comorbidities. Bimodal multivariate logistic regression models for THA and TKA were developed for 2009-2016 using 2008 as a reference.

RESULTS

Overall incidence of VTE, DVT, PE, and mortality for THA were 0.6%, 0.4%, 0.3%, and 0.2%, respectively. Based off of multivariate regression VTE, DVT, PE, and mortality rates have shown no significant (P > .05) change from 2008 to 2016 in THA patients. Overall incidence of VTE, DVT, PE, and mortality for TKA were 1.4%, 0.9%, 0.6%, and 0.1%, respectively. Multivariate regression revealed reductions when compared to 2008 for VTEs and DVTs from 2009 to 2016 (P < .05) for TKA patients. A significant reduction in PEs (P = .002) was discovered for 2016, while no significant change was observed in mortality (P > .05).

CONCLUSION

Approximately 1 in 71 patient undergoing TKA, and 1 in 167 undergoing THA developed a VTE within 30 days after surgery. Our study demonstrated that VTE incidence rates have decreased in TKA, while remaining stable in THA over the past 8 years. Further research to determine the optimal prophylaxis algorithm that would allow for a personalized, efficacious, and safe thromboprophylaxis regimen is needed.

LEVEL OF EVIDENCE

III.

Validating a transnational fracture treatment registry using a standardized method

AIM

Subsequent to a three-month pilot phase, recruiting patients for the newly established BFCC (Baltic Fracture Competence Centre) transnational fracture registry, a validation of the data quality needed to be carried out, applying a standardized method.

METHOD

During the literature research, the method of "adaptive monitoring" fulfilled the requirements of the registry and was applied. It consisted of a three-step audit process; firstly, scoring of the overall data quality, followed by source data verification of a sample size, relative to the scoring result, and finally, feedback to the registry on measures to improve data quality. Statistical methods for scoring of data quality and visualisation of discrepancies between registry data and source data were developed and applied.

RESULTS

Initially, the data quality of the registry scored as medium. During source data verification, missing items in the registry, causing medium data quality, turned out to be absent in the source as well. A subsequent adaptation of the score evaluated the registry's data quality as good. It was suggested to add variables to some items in order to improve the accuracy of the registry.

DISCUSSION

The application of the method of adaptive monitoring has only been published by Jacke et al., with a similar improvement of the scoring result following the audit process. Displaying data from the registry in graphs helped to find missing items and discover issues with data formats. Graphically comparing the degree of agreement between the registry and source data allowed to discover systematic faults.

CONCLUSIONS

The method of adaptive monitoring gives a substantiated guideline for systematically evaluating and monitoring a registry's data quality and is currently second to none. The resulting transparency of the registry's data quality could be helpful in annual reports, as published by most major registries. As the method has been rarely applied, further successive applications in established registries would be desirable.

Regional anaesthesia for surgical repair of proximal humerus fractures: a systematic review and critical appraisal

INTRODUCTION

Regional anaesthesia (RA) is often used in shoulder surgery because it provides adequate postoperative analgesia and may enhance the patient outcome. RA reduces overall opioid consumption and is frequently used in enhanced recovery programs to decrease hospital stay. However, there is very limited literature confirming these advantages in the surgical repair of proximal humerus fractures. This paper reviews the current literature on the use of RA in pain management after surgical repair of these fractures and evaluates the effect of RA on the functional outcome, length of stay in hospital, and health care expenditure.

MATERIALS AND METHODS

The PubMed, Embase, Web of Science, and Cochrane Library databases were searched up to March 1, 2018. Studies investigating the use of RA in the management of proximal humerus fractures were included.

RESULTS

Eleven studies (containing 1872 patients) were eligible for inclusion. The analgesic effect of RA was investigated in eight studies that confirmed its pain-relieving ability. Two studies measured functionality and length of hospitalization and suggested that RA improved function and shortened the stay in hospital. Nine papers mentioned side effects associated with RA while three articles claim that RA decreases the incidence of adverse events associated with general anaesthesia.

CONCLUSIONS

This systematic review suggests that RA is a good option for postoperative analgesia in patients undergoing surgical repair of a proximal humerus fracture and is associated with fewer adverse events, a shorter recovery time, and a better functional outcome than those achieved by general anaesthesia alone. However, given the limited amount of data available, conclusions need to be made with caution and prospective studies are needed in the future.

Venous thromboembolism rates remained unchanged in operative lower extremity orthopaedic trauma patients from 2008 to 2016

BACKGROUND

Venous thromboembolism (VTE) is a serious complication that contributes to morbidity, mortality, and healthcare costs during the surgical care of patient with lower extremity fractures. Despite this, few recommendations on the topic exist and the literature on VTE incidence is incomplete. Therefore, this study will attempt to estimate annual incidence and trends in 30-day thrombotic events and mortality for the following fractures: (1) hip, (2) femur, (3) patella, (4) tibia and/or fibula, and (5) ankle.

METHODS

We identified 120,521 operative lower extremity orthopaedic trauma patients from 2008 to 2016 using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. To evaluate the relationship between the year in which surgery was performed and comorbidities and demographic information bivariate analysis was performed. Bivariate analysis was also performed for the outcomes of interest and year in which the surgery was performed to assess for change. Additionally, bimodal multivariate logistic regression models for hip, femur, and ankle fractures were built, comparing the years 2009 to 2016 using 2008 as a baseline.

RESULTS

Overall incidence for VTE over the study period was 1.7% for hip fractures, 2.4% for femur fractures, 0.9% for patella fractures, 1.1% in tibia and/or fibula fractures, and 0.6% in ankle fractures. Over the study period VTE incidence saw a significant decrease (p < 0.05) in hip and femur fractures, but not for patella, tibia and/or fibula, and ankle fractures. After adjusting for confounding factors with multivariate analysis, the change in hip and femur fractures was no longer significant, while no significant decrease was again found for ankle fractures (p > 0.05).

CONCLUSION

Our study demonstrates that VTE rates have remained unchanged in operative lower extremity orthopaedic trauma from 2008 to 2016. This highlights the need for higher quality evidence on this important topic in orthopaedic trauma, including a reevaluation on the necessity of thromboprophylaxis guidelines.

LEVEL OF EVIDENCE

III.

Using Trauma Triage Score to Risk-Stratify Inpatient Triage, Hospital Quality Measures, and Cost in Middle-Aged and Geriatric Orthopaedic Trauma Patients

OBJECTIVES

To investigate the efficacy of a novel geriatric trauma risk assessment tool [Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA)] designed to predict inpatient mortality to risk-stratify measures of hospital quality and cost of care in middle-aged and geriatric orthopaedic trauma patients.

DESIGN

Prospective cohort study.

SETTING

Academic medical center.

PATIENTS

One thousand five hundred ninety-two patients 55 years of age and older who were evaluated by orthopaedic surgery in the emergency department between October 1, 2014, and September 30, 2016.

INTERVENTION

Calculation of the inpatient mortality risk score (STTGMA) using each patient's demographics, injury severity, and functional status. Patients were stratified into minimal-, low-, moderate-, and high-risk cohort groups based on risk of <0.9%, 0.9%-1.9%, 1.9%-5%, and >5%.

MAIN OUTCOME MEASUREMENTS

Length of stay, complications, disposition, readmission, and cost.

RESULTS

One thousand two hundred seventy-eight patients (80.3%) sustained low-energy injuries and 314 patients (19.7%) sustained high-energy injuries. The average age was 73.8 ± 11.8 years. The mean length of hospital stay was 5.2 days with a significant difference between the STTGMA risk groups. This risk stratification between groups was also seen in complication rate, need for Intensive Care Unit/Step Down Unit care, percentage of patients discharged, and readmission within 30-days. The mean total cost of admission for the minimal-risk group was less than one-third that of the high-risk cohort.

CONCLUSIONS

The STTGMA tool is able to risk-stratify hospital quality outcome measures and cost. Thus, it is a valuable clinical tool for health care providers in identifying high-risk patients in efforts to continue to provide high-quality resource conscious care to orthopaedic trauma patients.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

The Incremental Hospitalization Cost of Significant Transport-Related Traumatic Brain Injury

AIM

This study aims to determine the incremental cost of acute hospitalization for traumatic brain injury (TBI) compared with matched controls. A second purpose is to identify the factors contributing to this hospital costs.

METHODOLOGY

Analyses were performed on administrative data for injured patients, hospitalized in Belgium between 2009 and 2011 following a road traffic accident. Cases were matched to a control with similar injuries but without TBI. The incremental hospitalization cost of TBI and the factors contributing to the hospital costs were determined using multivariable regression modeling with gamma distribution and log link.

RESULTS

A descriptive comparison of cases and controls shows clear differences in healthcare utilization and costs. The presence of a TBI increases the cost by a factor between 1.66 (95% confidence interval: 1.52-1.82) and 2.08 (95% confidence interval: 1.72-2.51). Regarding healthcare utilization, the most important determinants of hospital costs are surgical complexity, use of magnetic resonance imaging, intensive care unit admission, and mechanical ventilation.

DISCUSSION

To our knowledge, this is the first matched-control study calculating the incremental hospitalization cost of TBI. The insights provided by this study are relevant in the context of prospective payments and can be an incentive for investments in prevention policies and extramural care.

New Trends in Terrorism-Related Injury Mechanisms: Is There a Difference in Injury Severity?

STUDY OBJECTIVE

The latest wave of terrorism worldwide has seen significant use by terrorists of mundane, "low-technology" weapons, such as utility knives and civilian vehicles. How do the injuries they produce compare with that of more conventional terrorism mechanisms, such as use of firearms and explosives? We compare injury patterns of the most frequent terrorism-related injury mechanisms in an Israeli data set.

METHODS

This was a retrospective study of 1,858 patients hospitalized because of terrorism events, which were recorded in the Israeli National Trauma Registry between January 1997 and December 2016. The events were divided into 4 groups based on weapon used: explosions, shootings, stabbings, and vehicular attacks. The groups were compared in terms of injuries sustained, use of hospital resources, and clinical outcomes.

RESULTS

Explosion-related and vehicular terrorism resulted in a higher proportion of multiple injuries, whereas stabbings and shootings mostly led to isolated injuries. Victims of vehicular attacks had a high proportion of severe head injuries, whereas stabbing victims had a high volume of vascular injuries. All mechanisms involved significant damage to extremities; however, among stabbing victims injury was mainly to the upper extremities, whereas among vehicular attack victims it was mostly to the lower extremities. The overall injury severity of the compared groups was similar, leading to comparable levels of intensive care use and inhospital mortality. Certain similarities in victims' characteristics were observed between the shootings and stabbings and between explosions and vehicular attacks.

CONCLUSION

Despite differences between various terrorist attack mechanisms, the resulting injury severity and inhospital mortality are very similar, with stabbings and vehicular attacks causing injuries as serious as those caused by conventional weapons.

The American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator Has a Role in Predicting Discharge to Post-Acute Care in Total Joint Arthroplasty

BACKGROUND

Patient demand and increasing cost awareness have led to the creation of surgical risk calculators that attempt to predict the likelihood of adverse events and to facilitate risk mitigation. The American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator is an online tool available for a wide variety of surgical procedures, and has not yet been fully evaluated in total joint arthroplasty.

METHODS

A single-center, retrospective review was performed on 909 patients receiving a unilateral primary total knee (496) or hip (413) arthroplasty between January 2012 and December 2014. Patient characteristics were entered into the risk calculator, and predicted outcomes were compared with observed results. Discrimination was evaluated using the receiver-operator area under the curve (AUC) for 90-day readmission, return to operating room (OR), discharge to skilled nursing facility (SNF)/rehab, deep venous thrombosis (DVT), and periprosthetic joint infection (PJI).

RESULTS

The risk calculator demonstrated adequate performance in predicting discharge to SNF/rehab (AUC 0.72). Discrimination was relatively limited for DVT (AUC 0.70, P = .2), 90-day readmission (AUC 0.63), PJI (AUC 0.67), and return to OR (AUC 0.59). Risk score differences between those who did and did not experience discharge to SNF/rehab, 90-day readmission, and PJI reached significance (P < .01). Predicted length of stay performed adequately, only overestimating by 0.2 days on average (rho = 0.25, P < .001).

CONCLUSION

The American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator has fair utility in predicting discharge to SNF/rehab, but limited usefulness for 90-day readmission, return to OR, DVT, and PJI. Although length of stay predictions are similar to actual outcomes, statistical correlation remains relatively weak.