Cirrhosis Increases the Rate of Failure of Nonoperative Management in Blunt Liver Injuries

Pre-existing cirrhosis is associated with increased mortality in blunt liver injury. Despite widespread use of nonoperative management (NOM) for blunt liver injury, there is a relative paucity of data regarding how pre-existing cirrhosis impacts the success of NOM. Herein, we perform a retrospective cohort study using ACS TQIP 2017-2020 data to assess the relationship between cirrhosis and failure of NOM for adult patients with blunt liver injury. 37,176 patients were included (342 cirrhosis and 36,834 without cirrhosis). After propensity-score matching, patients with pre-existing cirrhosis had higher rates of failure of NOM (32.2 vs 14.1%, p < 0.01) and in-hospital mortality (36.3 vs 10.8%, p < 0.01) than patients without cirrhosis. Hesitancy to operate on patients with pre-existing cirrhosis and trauma, as well as significant underlying coagulopathy, may explain these findings.

Patient outcomes and cost in robotic emergency general surgery

The use of robotic technology in general surgery continues to increase, though its utility for emergency general surgery remains under-studied. This study explores the current trends in patient outcomes and cost of robotic emergency general surgery (REGS). The Florida Agency for Healthcare Administration database (2018-2020) was queried for adult patients undergoing intra-abdominal emergency general surgery within 24 h of admission and linked to CMS Cost Reports/Hospital Compare, American Hospital Association, and Rand Corporation Hospital datasets. Patients from the four most common REGS procedures were propensity matched to laparoscopic equivalents for hospital cost analysis. A telephone survey was performed with the top 10 REGS hospitals to identify key qualities for successful REGS programs. 181 hospitals (119 REGS, 62 non-REGS) performed 60,733 emergency surgeries. Six-percent were REGS. The most common REGS were cholecystectomy, appendectomy, inguinal and ventral hernia repairs. Before and after propensity matching, total cost for these four procedures were significantly higher than their laparoscopic equivalents, which was due to higher surgical cost as the non-operative costs did not differ. There were no differences in mortality, individual complications, or length of stay for most of the four procedures. REGS volume significantly increased each year. The survey found that 8/10 hospitals have robotic-trained staff available 24/7. Although REGS volume is increasing in Florida, cost remains significantly higher than laparoscopy. Given higher costs and lack of significantly improved outcomes, further study should be undertaken to better inform which specific patient populations would benefit from REGS.

COVID, the Gut, and Nutritional Implications

Purpose of Review

The purpose of this review is to provide an overview of the current literature, recommendations, and practice guidelines on the nutritional management of and implications associated with COVID-19 infection.

Recent Findings

Particular attention should be paid to the screening, prevention, and treatment of malnutrition in critically ill individuals with COVID-19 infection given the significant risk for complications and poor outcomes. Extrapolation of existing literature for the nutritional support in the critically ill patient has demonstrated early enteral nutrition is safe and well-tolerated in patients with severe COVID-19 infection.

Summary

Futures studies should focus on the long-term nutritional outcomes for patients who have suffered COVID-19 infection, nutritional outcomes/recommendations for special populations with COVID-19, nutritional outcomes based on the current recommendations and guidelines for nutrition therapy, and the role for micronutrient supplementation in COVID-19 infection.

Laparoscopic-guided versus transincisional rectus sheath block for pediatric single-incision laparoscopic cholecystectomy: A randomized controlled trial

PURPOSE

The purpose of our study was to compare the effectiveness of transincisional (TI) versus laparoscopic-guided (LG) rectus sheath block (RSB) for pain control following pediatric single-incision laparoscopic cholecystectomy (SILC).

METHODS

Forty-eight patients 10-21 years old presenting to a single institution for SILC from 2015 to 2018 were randomized to TI or LG RSB. Apart from RSB technique, perioperative care protocols were identical between groups. Pain scores were assessed with validated measures upon arrival in the postanesthesia care unit (PACU) and at regular intervals until discharge. The patients and those assessing them were blinded to RSB technique. The primary outcome was pain score 60 min after PACU arrival. Secondary outcomes included pain scores throughout the PACU stay, opioids (reported as morphine milligram equivalents (MME) per kg bodyweight) administered in PACU, length of stay, outpatient pain scores and opioid use, and adverse events. Groups were compared on outcomes using t test and generalized estimating equations for continuous variables and Fisher's exact test for categorical variables with significance at α = 0.05.

RESULTS

Mean age of the 48 subjects was 15 years (range = 11-20). The majority (79%) were female. Indications for surgery included symptomatic cholelithiasis (n = 41), acute cholecystitis (n = 4), gallstone pancreatitis (n = 2) and choledocholithiasis (n = 1). Mean (standard deviation) operative time was 61 (±23) min overall. No statistically significant differences in demographics, indication, operative time, or intraoperative analgesia were observed between TI (n = 24) and LG (n = 24) groups. The mean 60-min pain score was 3.4 (±2.6) in the LG group versus 3.8 (±2.1) in the TI group (p = 0.573). No significant differences were detected between groups in overall PACU or outpatient pain scores, PACU or outpatient opioid use, length of stay, or incidence of complications. Overall, mean opioid use was 0.1 MME/kg in the PACU and 0.5 MME/kg in the outpatient setting. Mean postoperative length of stay was 0.2 day. There were no major complications.

CONCLUSION

Laparoscopic-guided rectus sheath block is not superior to transincisional rectus sheath block for pain control following pediatric single-incision laparoscopic cholecystectomy. The single-incision laparoscopic approach combined with rectus sheath block resulted in effective pain control, low opioid use, and expedited length of stay with no major complications.

LEVEL OF EVIDENCE

Level I, treatment study, randomized controlled trial.

Same-day Discharge after Appendectomy Results in Cost Savings and Improved Efficiency

Appendectomy incurs significant costs for the healthcare system. There is evidence that patients can be safely discharged the same day after appendectomy. The purpose of this study was to develop an evidence-based protocol for same-day discharge after appendectomy. A fast-track surgery protocol was developed for same-day discharge after appendectomy. This was prospectively applied to all patients presenting for appendectomy from July 2012 to June 2013. Demographics, clinical measures, and outcomes were measured. Of 206 patients eligible for same-day discharge, 185 (90%) were successfully discharged according to the protocol. The mean length of stay after appendectomy was 3.1 ± 1.4 hours. Protocol implementation reduced inpatient use from 99 to 53 per cent. Patient transfers were reduced, resulting in 40 per cent fewer handoffs. The decreased use of hospital resources resulted in a median reduction of hospital charges of $4111 per patient. The complication rate for patients discharged the same day was 2.7 per cent. Appendectomy for acute appendicitis or interval appendectomy can be performed safely as same-day surgery. Implementation of this protocol resulted in optimization of resource use by reducing inpatient admissions, decreasing handoffs, and reducing hospital costs.

Antibiotic Powder Reduces Surgical Site Infections in Children After Single-Incision Laparoscopic Appendectomy for Acute Appendicitis

BACKGROUND

Single-incision laparoscopic appendectomy (SILA) has a higher rate of wound infection than the multiport technique. The purpose of this project was to determine whether the use of topical antibiotic powder reduces surgical site infections (SSIs) in pediatric patients who undergo SILA.

METHODS

Patients aged 0-21 years who underwent SILA for acute appendicitis from April 2015 to November 2016 were included in this quality improvement initiative. Cefoxitin powder was placed in the umbilical wound before skin closure. Data were prospectively collected and outcome measures were compared with a historical cohort who underwent SILA before the implementation of antibiotic powder.

RESULTS

There were 108 patients in the historical group (HIST) and 126 in the powder group (POWD). The groups were similar in age (HIST: 11.5 ± 3.6 versus POWD: 12.2 ± 3.7 years, P = .15) and body mass index percentile (HIST: 57.6 ± 30.7 versus POWD: 58.8 ± 27.8, P = .84). Operative time was longer in the powder group (HIST: 26.5 ± 7.5 versus POWD: 29.7 ± 8.9 minutes, P = .004). Length of stay (HIST: 0.2 ± 0.4 versus POWD: 0.1 ± 0.4 days, P = .06), 30-day return to emergency department (HIST: 7% versus POWD: 8%, P = 1.0), and hospital readmissions (HIST: 5% versus POWD: 2%, P = .8) were similar. There was a significantly lower rate of superficial SSIs in the powder group (HIST: 4.6% versus POWD: 0%, P = .02).

CONCLUSIONS

In pediatric patients undergoing SILA for acute appendicitis, the use of cefoxitin powder in the umbilical wound is a simple intervention to reduce the incidence of superficial SSIs.

Enhancing recovery after minimally invasive repair of pectus excavatum

PURPOSE

There are variations in the perioperative management of patients who undergo minimally invasive repair of pectus excavatum (MIRPE). The purpose is to analyze the change in resource utilization after implementation of a standardized practice plan and describe an enhanced recovery pathway.

METHODS

A standardized practice plan was implemented in 2013. A retrospective review of patients who underwent MIRPE from 2012 to 2015 was performed to evaluate the trends in resource utilization. A pain management protocol was implemented and a retrospective review was performed of patients who underwent repair before (2010-2012) and after (2014-2015) implementation.

RESULTS

There were 71 patients included in the review of resource utilization. After implementation, there was a decrease in intensive care unit length of stay (LOS), and laboratory and radiologic studies ordered. There were 64 patients included in the pain protocol analysis. After implementation, postoperative morphine equivalents (3.3 ± 1.4 vs 1.2 ± 0.5 mg/kg, p < 0.01), urinary retention requiring catheterization (33 vs 14%, p = 0.07), and LOS (4 ± 1 vs 2.8 ± 0.8 days, p < 0.01) decreased.

CONCLUSION

The implementation of an enhanced recovery pathway is a feasible and effective way to reduce resource utilization and improve outcomes in pediatric patients who undergo minimally invasive repair of pectus excavatum.

The modified percent depth: Another step toward quantifying severity of pectus excavatum without cross-sectional imaging

INTRODUCTION

Current approaches to quantifying the severity of pectus excavatum require internal measurements based on cross-sectional imaging. This study evaluated the modified percent depth (MPD), a novel index of severity that can be obtained with external measurements, potentially avoiding the need for cross-sectional imaging.

METHODS

Patients undergoing surgical repair of pectus excavatum (pectus group), and those undergoing cross-sectional imaging for unrelated reasons (control group), between 2010 and 2016 were included. The MPD of the deformity was calculated using external (i.e. skin surface to skin surface) measurements from the radiographic images. The same external measurements were taken using chest calipers on a subset of these patients in the outpatient clinic. The optimal threshold for MPD that defined severe pectus deformity was derived from receiver-operator characteristic (ROC) analysis. Sensitivity and specificity of the MPD was compared with that of the Haller Index (HI) and Correction Index (CI).

RESULTS

There were 92 children (49 pectus, 43 controls) included. The median MPD was 20.2% and 4.2% for pectus and control patients, respectively (p<0.0001). An MPD cutoff of 10% optimally discriminated between severe pectus patients and controls by ROC analysis. An MPD of >10% had 98% sensitivity and 98% specificity for severe pectus deformity. Sensitivity and specificity were respectively 93% and 93% for HI >3.25, and 100% and 79% for CI >10.

CONCLUSION

An MPD >10% performs slightly better than the HI and CI in distinguishing patients with severe pectus deformities. This novel measurement approach offers distinct advantages over existing indices, in that it does not require cross-sectional imaging and can be done using chest calipers in the office setting. Further studies with larger sample size are needed to verify reproducibility of the technique.

LEVEL OF EVIDENCE

Level II, Study of Diagnostic Test.

Percutaneous ultrasound-guided vs. intraoperative rectus sheath block for pediatric umbilical hernia repair: A randomized clinical trial

BACKGROUND

Regional anesthesia is commonly used in children. Our hypothesis was that percutaneous ultrasound-guided (PERC) rectus sheath blocks would result in lower postoperative pain scores compared to intraoperative (IO) rectus sheath blocks following umbilical hernia repair.

METHODS

A single-institution randomized blinded trial was conducted in pediatric patients undergoing elective umbilical hernia repair. The primary outcome was mean postoperative Wong-Baker pain score. Secondary outcomes included narcotic requirements and length of postoperative stay.

RESULTS

Fifty-eight patients were included: 28 PERC and 30 IO. Operating room time was significantly longer in the PERC group (41 vs. 35min, p<0.01). Mean postoperative pain scores (PERC-2.6 vs. IO-3.3, p=0.11), morphine equivalents intraoperatively (PERC-0 vs. IO-0.04mg/kg, p=0.29) and postoperatively (PERC-0.04 vs. IO-0.09mg/kg, p=0.17), time to first postoperative narcotic dose (PERC-30 vs. IO-22min, p=0.33, log-rank test), and postoperative length of stay (PERC-76 vs. IO-80min, p=0.44) were similar.

CONCLUSION

Following umbilical hernia repair in children, percutaneous ultrasound-guided and intraoperative rectus sheath blocks resulted in similar mean postoperative pain scores. There were no differences in secondary outcomes such as time to first narcotic, narcotic requirements, and length of stay. The additional resources required to complete a percutaneous ultrasound-guided rectus sheath block may not be warranted.

TYPE OF STUDY

Randomized controlled trial.

LEVEL OF EVIDENCE

Level I.

The role of chest radiography following pectus bar removal

PURPOSE

Surgical correction of pectus excavatum (PE) via a minimally invasive approach involves placement of a steel bar, which is subsequently removed. The purpose of our study was to evaluate the incidence of pneumothorax and the role for chest radiography (CXR) in patients undergoing pectus bar removal.

METHODS

A retrospective review of 84 patients who underwent pectus bar removal from 2006 to 2014 was performed. Results of postoperative CXR, repeat imaging, need for chest thoracostomy tube placement, and complications were analyzed.

RESULTS

Mean Haller index prior to correction was 4.3 ± 0.9. The mean time between PE repair and bar removal was 2.3 ± 0.6 years. Sixty-one patients (72.6 %) had a postoperative CXR. Thirty-one (50.8 %) had no acute findings, 20 (32.8 %) had findings of atelectasis or subcutaneous emphysema, and 10 (16.4 %) had a pneumothorax. One patient (1.6 %) had a second postoperative CXR for a small pneumothorax and rib fractures. There were two complications (2.4 %). No chest tubes were placed for pneumothorax, and 95 % of patients were discharged the day of surgery.

CONCLUSION

Postoperative CXR following pectus bar removal is unnecessary given the low incidence of postoperative pneumothorax requiring intervention. Patients can be safely discharged the day of surgery without the need for routine postoperative chest imaging.

Obesity and single-incision laparoscopic appendectomy in children

BACKGROUND

Single-incision laparoscopic appendectomy (SILA) has emerged as a less-invasive alternative to conventional laparoscopy. The purpose of this study was to assess the impact of body habitus on outcomes after SILA in the pediatric population.

METHODS

A retrospective review of 413 patients who underwent SILA from 2012 to 2015 was performed. Body mass index (BMI) was calculated, and the BMI percentile was obtained per Center for Disease Control guidelines. Standard definitions for overweight (BMI 85th-94th percentile) and obese (BMI > 95th percentile) were used. General demographic and outcome data were analyzed.

RESULTS

SILA was performed in 413 patients during the study period, of which 66.3% were normal weight, 16% were overweight, and 17.7% were obese. There were no significant differences in age at presentation, time to diagnosis, or intraoperative classification of appendicitis. There were no significant differences in operative time (27.0 ± 9.1 versus 27 ± 9.8 versus 28.4 ± 9.4 min, P = 0.514), postoperative length of stay (0.97 ± 1.65 versus 1.53 ± 4.15 versus 1.14 ± 2.27 d, P = 0.214), 30-d surgical site infections (6.9% versus 12.1% versus 8.2%, P = 0.377), emergency department visits (8.4% versus 10.6% versus 11%, P = 0.726), or readmissions (4.7% versus 4.1% versus 4.5%, P = 0.967) among normal, overweight, and obese groups.

CONCLUSIONS

Our results indicate that obesity does not significantly impact outcomes after SILA. SILA can be performed in overweight and obese children with no significant difference in operative time, length of stay, or incidence of surgical site infection. SILA should continue to be offered to overweight and obese children.

Repeat computed tomography scans after pediatric trauma: results of an institutional effort to minimize radiation exposure

BACKGROUND

Many pediatric trauma patients are initially evaluated at non-pediatric, non-trauma centers where they undergo CT prior to transfer to a pediatric trauma center. The purpose of this study is to quantify the number of repeat CT and assess the risk of delayed or missed injuries.

METHODS

The institutional pediatric trauma registry was queried for patients evaluated from January 2001 to March 2012. All patients who underwent repeat CT within 24 h after transfer were included. General admission, demographic, and outcome data were analyzed.

RESULTS

A total of 6041 patients were transferred from a referring hospital after undergoing CT scans. Five percent of patients underwent repeat CT with a mean age of 6.3 ± 5.7 years. Patients who underwent repeat CT scans had significantly higher Injury Severity Scores and lower Glasgow Coma Scale. CT head was the most commonly repeated. Comparing results of referring CT scans to repeated scans, there was good agreement between results for head CT (κ = 0.69) and moderate agreement for abdominopelvic CT (κ = 0.59). The overall incidence of delayed diagnosis of injuries was 0.7%.

CONCLUSION

The low incidence of missed or delayed injuries justifies limiting additional radiation exposure to pediatric trauma patients based on clinical status.

Impact of Experience on Quality Outcomes in Single-incision Cholecystectomy in Children

Single-incision laparoscopic cholecystectomy (SILC) has been shown to be safe in children; however, factors that impact outcomes are not well understood. We report a retrospective review of 151 patients who underwent SILC between 2009 and 2013. Regression analysis was used to determine inflection of learning curve. Patients were grouped by early cases, late cases, and late case with surgical trainees. Mean age for all patients was 15 ± 3 years (5–20.5 year), and mean weight was 66.5 ± 21.3 kg (15–117 kg). There was a decrease in operative times between the early group (n = 15) and the late group (n = 100) (75.3 vs 56.1 minutes, P < 0.05). Surgical trainees were involved in 36 cases, and their introduction did not significantly increase operative times (56.1 vs 60.4 minutes, P = NS (Non-significant)). No difference in operative times between early cases and cases with trainees was identified (75.3 vs 60.4 minutes, P = NS). The complication was 6 per cent, with no significant differences between the groups. There were five conversions (3.3%). During the adoption of SILC, significantly decreased operative times were achieved after a short learning curve, and these were maintained with surgical trainees. Our results show that SILC can be safely introduced into a pediatric surgical practice.

Impact of Experience on Quality Outcomes in Single-incision Cholecystectomy in Children

Single-incision laparoscopic cholecystectomy (SILC) has been shown to be safe in children; however, factors that impact outcomes are not well understood. We report a retrospective review of 151 patients who underwent SILC between 2009 and 2013. Regression analysis was used to determine inflection of learning curve. Patients were grouped by early cases, late cases, and late case with surgical trainees. Mean age for all patients was 15 ± 3 years (5-20.5 year), and mean weight was 66.5 ± 21.3 kg (15-117 kg). There was a decrease in operative times between the early group (n = 15) and the late group (n = 100) (75.3 vs 56.1 minutes, P < 0.05). Surgical trainees were involved in 36 cases, and their introduction did not significantly increase operative times (56.1 vs 60.4 minutes, P = NS (Non-significant)). No difference in operative times between early cases and cases with trainees was identified (75.3 vs 60.4 minutes, P = NS). The complication was 6 per cent, with no significant differences between the groups. There were five conversions (3.3%). During the adoption of SILC, significantly decreased operative times were achieved after a short learning curve, and these were maintained with surgical trainees. Our results show that SILC can be safely introduced into a pediatric surgical practice.

Preprocedural Coagulation Studies in Pediatric Patients Undergoing Percutaneous Intervention for Appendiceal Abscesses

The literature reports poor correlation between coagulation screening and prediction of bleeding risk in children. Our aim is to determine whether there is a role for coagulation studies in children undergoing percutaneous intervention for appendiceal abscesses. A retrospective review of 1805 patients presenting with a diagnosis of appendicitis from September 2008 to September 2013 was performed. Patients presenting with appendiceal abscess who underwent percutaneous intervention were selected for further review (n = 131). A total of 76 patients (58%) had normal coagulation studies, whereas 55 (42%) had elevated values. An international normalized ratio ≥ 1.3 was found in 26 patients. Patients with normal coagulation values had an incidence of bleeding of 1.3 per cent. In the abnormal coagulation group, 8 patients received fresh frozen plasma before intervention, whereas 47 did not. There was one hematoma noted in each group with an incidence of bleeding of 3.6 per cent. The overall incidence of hematoma was 2.3 per cent with no significant difference in bleeding risk between the normal and abnormal coagulation groups. In conclusion, although many patients are found to have elevated coagulation studies, most do not have bleeding complications after intervention. There is poor correlation between coagulation screening and postprocedural outcomes evidenced by the low risk of bleeding.

Preprocedural Coagulation Studies in Pediatric Patients Undergoing Percutaneous Intervention for Appendiceal Abscesses

The literature reports poor correlation between coagulation screening and prediction of bleeding risk in children. Our aim is to determine whether there is a role for coagulation studies in children undergoing percutaneous intervention for appendiceal abscesses. A retrospective review of 1805 patients presenting with a diagnosis of appendicitis from September 2008 to September 2013 was performed. Patients presenting with appendiceal abscess who underwent percutaneous intervention were selected for further review (n = 131). A total of 76 patients (58%) had normal coagulation studies, whereas 55 (42%) had elevated values. An international normalized ratio ≥ 1.3 was found in 26 patients. Patients with normal coagulation values had an incidence of bleeding of 1.3 per cent. In the abnormal coagulation group, 8 patients received fresh frozen plasma before intervention, whereas 47 did not. There was one hematoma noted in each group with an incidence of bleeding of 3.6 per cent. The overall incidence of hematoma was 2.3 per cent with no significant difference in bleeding risk between the normal and abnormal coagulation groups. In conclusion, although many patients are found to have elevated coagulation studies, most do not have bleeding complications after intervention. There is poor correlation between coagulation screening and postprocedural outcomes evidenced by the low risk of bleeding.

Operative Findings Are a Better Predictor of Resource Utilization in Pediatric Appendicitis

PURPOSE

Post-operative management following appendectomy is dependent upon intraoperative assessment. We determined concordance between surgical and histopathologic diagnosis to better predict resource utilization in pediatric patients undergoing appendectomy.

METHODS

A retrospective analysis of 326 patients with operative appendicitis from July 2012 to July 2013 was performed. Based on operative findings, patients were classified as simple appendicitis (SA) or complex appendicitis (CA).

RESULTS

The SA group included 194 (59.5%) patients while the CA group included 132 (40.5%) patients. There were significant differences in WBC, CRP, operative time, length of stay, and 30-day complications. Seventy percent of patients with intra-operative findings of SA were found to have complex pathology while 10.6% with intra-operative findings of CA were found to have simple pathology. There is poor agreement between intra-operative findings and histopathologic findings (κ=0.173). Although 70% of patients with intra-operative findings of SA were labeled as complex pathology, 86% followed a fast track protocol (same day discharge) with a low complication rate (1.7%).

CONCLUSIONS

Pathology findings that overestimate the severity of disease correlate poorly with the post-operative outcomes for appendicitis. We conclude that operative findings are more predictive of clinical course than histopathologic results. This can have an impact on resource utilization planning.

Impact of experience on quality outcomes in single-incision laparoscopy for simple and complex appendicitis in children

BACKGROUND

Single-incision laparoscopic appendectomy (SILA) is an effective treatment for appendicitis in children. We report our experience with SILA, focusing on how surgeon experience may impact quality outcomes.

METHODS

A retrospective review of patients who underwent SILA from August 2009 to November 2013 was performed. Patients were grouped by early experience, late experience without surgical trainees, and late experience with trainees and further stratified into simple and complex appendicitis.

RESULTS

SILA was performed on 703 patients with a mean age of 11.8±3.9years. Four hundred eleven (58.5%) patients were diagnosed with simple and 292 (41.5%) with complex appendicitis. There was a significant decrease in operative time between early and late groups for both simple and complex appendicitis. Following the introduction of surgical trainees, there was a significant increase in operative time compared to the late group for simple appendicitis. There were no significant differences in complication rates between any of the groups.

CONCLUSION

The adoption of SILA requires a significant learning curve even for the experienced laparoscopist with the potential for decreased operative times with experience. While there may be an increase in operative time with the introduction of trainees, this does not impact quality outcomes.

Admission patterns in pediatric trauma patients with isolated injuries

BACKGROUND

Pediatric trauma patients presenting with stable, isolated injuries are often admitted to the trauma service for initial management. The purpose of this study was to evaluate admission patterns in trauma patients with isolated injuries and compare outcomes based on admitting service.

METHODS

The institutional trauma registry was retrospectively reviewed for patients presenting from January 2007-December 2012. A total of 3417 patients were admitted to a surgical service and further reviewed. Patients with isolated injuries were further stratified by admission to the general trauma service (GTS, n = 738) versus admission to the subspecialty surgical trauma service (STS, n = 2251).

RESULTS

When compared to patients admitted to GTS, patients admitted to STS with isolated injuries were significantly younger, were more likely to present with injury severity scores ranging from 9-14, Glasgow coma scale ≥ 13, had shorter emergency room length of stay, were more likely to undergo surgery within 24 h, and had fewer computed tomography scans performed. There were no missed injuries in patients with isolated injuries admitted to STS (with 5% having a GTS consult) compared with one missed injury in those admitted to GTS. Patients with isolated injuries admitted to an STS were found to have significantly lower complication rates (0.6% versus 2.2%, P < 0.01).

CONCLUSIONS

Pediatric trauma patients presenting with stable, isolated injuries may be efficiently and safely managed by nontrauma services without an increase in missed injuries or complications.

Same-day discharge after appendectomy results in cost savings and improved efficiency

Appendectomy incurs significant costs for the healthcare system. There is evidence that patients can be safely discharged the same day after appendectomy. The purpose of this study was to develop an evidence-based protocol for same-day discharge after appendectomy. A fast-track surgery protocol was developed for same-day discharge after appendectomy. This was prospectively applied to all patients presenting for appendectomy from July 2012 to June 2013. Demographics, clinical measures, and outcomes were measured. Of 206 patients eligible for same-day discharge, 185 (90%) were successfully discharged according to the protocol. The mean length of stay after appendectomy was 3.1 ± 1.4 hours. Protocol implementation reduced inpatient use from 99 to 53 per cent. Patient transfers were reduced, resulting in 40 per cent fewer handoffs. The decreased use of hospital resources resulted in a median reduction of hospital charges of $4111 per patient. The complication rate for patients discharged the same day was 2.7 per cent. Appendectomy for acute appendicitis or interval appendectomy can be performed safely as same-day surgery. Implementation of this protocol resulted in optimization of resource use by reducing inpatient admissions, decreasing handoffs, and reducing hospital costs.