1
|
Syamal S, Tran AH, Huang CC, Badrinathan A, Bassiri A, Ho VP, Towe CW. Outcomes of Trauma "Walk-Ins" in the American College of Surgeons Trauma Quality Program Database. Am Surg 2024; 90:1037-1044. [PMID: 38085592 DOI: 10.1177/00031348231220597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
BACKGROUND Outcomes of trauma "walk-in" patients (using private vehicles or on foot) are understudied. We compared outcomes of ground ambulance vs walk-ins, hypothesizing that delayed resuscitation and uncoordinated care may worsen walk-in outcomes. METHODS A retrospective analysis 2020 American College of Surgeons Trauma Quality Programs (ACS-TQP) databases compared outcomes between ambulance vs "walk-ins." The primary outcome was in-hospital mortality, excluding external facility transfers and air transports. Data was analyzed with descriptive statistics, bivariate, multivariable logistic regression, including an Inverse Probability Weighted Regression Adjustment with adjustments for injury severity and vital signs. The primary outcome for the 2019 (pre-COVID-19 pandemic) data was similarly analyzed. RESULTS In 2020, 707,899 patients were analyzed, 556,361 (78.59%) used ambulance, and 151,538 (21.41%) were walk-ins. We observed differences in demographics, hospital attributes, medical comorbidities, and injury mechanism. Ambulance patients had more chronic conditions and severe injuries. Walk-ins had lower in-hospital mortality (850 (.56%) vs 23,131 (4.16%)) and arrived with better vital signs. Multivariable logistic regression models (inverse probability weighting for regression adjustment), adjusting for injury severity, demographics, injury mechanism, and vital signs, confirmed that walk-in status had lower odds of mortality. For the 2019 (pre-COVID-19 pandemic) database, walk-ins also had lower in-hospital mortality. DISCUSSION Our results demonstrate better survival rates for walk-ins before and during COVID-19 pandemic. Despite limitations of patient selection bias, this study highlights the need for further research into transportation modes, geographic and socioeconomic factors affecting patient transport, and tailoring management strategies based on their mode of arrival.
Collapse
Affiliation(s)
- Sujata Syamal
- Department of Surgery, The MetroHealth System and Case Western Reserve University, Cleveland, OH, USA
| | - Andrew H Tran
- Department of Surgery, The MetroHealth System and Case Western Reserve University, Cleveland, OH, USA
| | - Chi-Ching Huang
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Avanti Badrinathan
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Aria Bassiri
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Vanessa P Ho
- Department of Surgery, The MetroHealth System and Case Western Reserve University, Cleveland, OH, USA
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH, USA
- Center for Health Equity Engagement, Education, and Research, Population Health and Equity Research Institute, The MetroHealth System and Case Western Reserve University, Cleveland, OH, USA
- Trauma Recovery Center, Institute for H.O.P.E, The MetroHealth System, Cleveland, OH, USA
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| |
Collapse
|
2
|
Ladha P, Curry CW, Badrinathan A, Imbroane MR, Bhamre RV, Como JJ, Tseng ES, Ho VP. Pediatric Trauma Care Disparities: Association of Race and Sex With High Acuity Trauma Hospital Admissions. J Surg Res 2024; 296:751-758. [PMID: 38377701 DOI: 10.1016/j.jss.2023.12.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 12/20/2023] [Accepted: 12/30/2023] [Indexed: 02/22/2024]
Abstract
INTRODUCTION For adult trauma patients, the likelihood of receiving treatment at a hospital properly equipped for trauma care can vary by race and sex. This study examines whether a pediatric patient's race/ethnicity and sex are associated with treatment at a high acuity trauma hospital (HATH). MATERIALS AND METHODS Using the 2017 National Inpatient Sample, we identified pediatric trauma patients ( ≤16 y) using International Classification of Diseases-10 codes. Because trauma centers are not defined in National Inpatient Sample, we defined HATHs as hospitals which transferred 0% of pediatric neurotrauma. We used logistic regression to examine associations between race/ethnicity, sex, age, and treatment at a HATH, adjusted for factors including Injury Severity Score, mechanism of injury, and region. RESULTS Of 18,085 injured children (median Injury Severity Score 3 [IQR 1-8]), 67% were admitted to a HATH. Compared to White patients, Hispanic (odds ratio [OR] 0.85 [95% confidence interval [CI] 0.79-0.93]) and other race/ethnicity patients (OR 0.85 [95% CI 0.78-0.93]) had a significantly lower odds of treatment at a HATH. Children aged 2-11 (OR 1.36 [95% CI 1.27-1.46]) were more likely to be treated at a HATH compared to adolescents (age 12-16). After adjustment for other factors, sex was not associated with treatment at a HATH. CONCLUSIONS Our study demonstrated racial and ethnic disparities in access to HATHs for pediatric trauma patients. Hispanic and other race/ethnicity pediatric trauma patients have lower odds of treatment at HATHs. Further research is needed to study the root causes of these disparities to ensure that all children with injuries receive equitable and high-quality care.
Collapse
Affiliation(s)
- Prerna Ladha
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio.
| | - Caleb W Curry
- School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | | | - Marisa R Imbroane
- School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Rasika V Bhamre
- Department of Pediatrics, MetroHealth Medical Center, Cleveland, Ohio
| | - John J Como
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio
| | - Esther S Tseng
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio
| | - Vanessa P Ho
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio; Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio
| |
Collapse
|
3
|
Mahajan A, Egodage T, Ho VP. Exploring the implications of direct oral anticoagulants in trauma. Trauma Surg Acute Care Open 2024; 9:e001360. [PMID: 38420607 PMCID: PMC10900312 DOI: 10.1136/tsaco-2024-001360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024] Open
Affiliation(s)
- Arnav Mahajan
- Surgery, The MetroHealth System, Cleveland, Ohio, USA
- Case Western Reserve University, Cleveland, Ohio, USA
| | - Tanya Egodage
- Surgery, Cooper University Health Care, Camden, New Jersey, USA
| | - Vanessa P Ho
- Surgery, The MetroHealth System, Cleveland, Ohio, USA
- Case Western Reserve University, Cleveland, Ohio, USA
| |
Collapse
|
4
|
Meizoso JP, Byrne J, Ho VP, Neal MD, Stein DM, Haut ER. Advanced and alternative research methods for the acute care surgeon scientist. Trauma Surg Acute Care Open 2024; 9:e001320. [PMID: 38390469 PMCID: PMC10882373 DOI: 10.1136/tsaco-2023-001320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 11/20/2023] [Indexed: 02/24/2024] Open
Abstract
Clinical research has evolved significantly over the last few decades to include many advanced and alternative study designs to answer unique questions. Recognizing a potential knowledge gap, the AAST Associate Member Council and Educational Development Committee created a research course at the 2022 Annual Meeting in Chicago to introduce junior researchers to these methodologies. This manuscript presents a summary of this AAST Annual Meeting session, and reviews topics including hierarchical modeling, geospatial analysis, patient-centered outcomes research, mixed methods designs, and negotiating complex issues in multicenter trials.
Collapse
Affiliation(s)
- Jonathan P Meizoso
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
| | - James Byrne
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Vanessa P Ho
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio, USA
| | - Matthew D Neal
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Deborah M Stein
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
- R. Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
| | - Elliott R Haut
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
5
|
Gasnick A, Sarode AL, Badrinathan A, Ho VP, Tisch DJ, Towe CW. Speed kills? Quantifying the association between police traffic stops, types of stops, and motor vehicle collisions. Injury 2024; 55:111241. [PMID: 38041924 DOI: 10.1016/j.injury.2023.111241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 11/15/2023] [Accepted: 11/24/2023] [Indexed: 12/04/2023]
Abstract
BACKGROUND Motor vehicle crashes (MVCs) are a leading cause of traumatic death and injury. Police traffic stops (PTS) are a common approach to enforcing motor vehicle laws intended to prevent MVCs. However, it is unclear which types of PTS are most effective. This study examined the relationship of PTS subtypes among municipal police patrols on non-interstate roads and MVCs and MVC-related deaths. METHODS PTS subtype data were characterized from six North Carolina cities: Charlotte, Durham, Fayetteville, Greensboro, Raleigh, and Winston-Salem. The primary outcomes of this study were yearly non-interstate MVC and MVC-related death rates per 100 population. The data were analyzed as balanced time-series cross-sectional data. The statistical analysis accounted for time-dependent and city-dependent confounding. We used a two-way fixed effects model to analyze the relationship between PTS and MVC or MVC-related deaths. We also utilized the difference in difference (DID) analysis to analyze if the reduction of PTS following a 2012 policing administrative change in Fayetteville had an association with MVC or MVC-related deaths. RESULTS We found no significant overall association between non-interstate PTS and MVCs (Coeff: -0.00006; p = 0.43) or MVC-related deaths (Coeff: -0.00011; p = 0.15). Panel regression suggested no significant relationship between MVCs and MVC-related deaths and PTS related to driving while impaired (p = 0.36), safe movement violation (p = 0.43), or seatbelt violations (p = 0.17). However, speed limit violations (Coeff: -0.00025; p = 0.032) and stop-light/sign violations (Coeff: -0.00147; p = 0.017) related to PTS significantly reduced MVC-related deaths. The DID regression showed no significant impact on MVCs (p = 0.924) or MVC-related deaths (0.706) before and after the police reform period. CONCLUSIONS The evidence regarding the absence of an overall association and any association with most PTS subtypes suggest that PTS are not effective for MVC death prevention. Policymakers may proceed with exploring modifications to policing efforts without detriments to public safety as defined by MVC and MVC-related deaths. LEVEL OF EVIDENCE Retrospective epidemiological study, level IV.
Collapse
Affiliation(s)
- Allison Gasnick
- Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Anuja L Sarode
- Research in Surgical Outcomes and Effectiveness, University Hospitals Cleveland Medical Center (UH-RISES), Cleveland, OH, United States
| | - Avanti Badrinathan
- Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106-5011, United States
| | - Vanessa P Ho
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, MetroHealth Medical Center, Cleveland, OH, United States; Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH, United States
| | - Daniel J Tisch
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH, United States
| | - Christopher W Towe
- Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106-5011, United States.
| |
Collapse
|
6
|
Kloos J, Bassiri A, Ho VP, Sinopoli J, Vargas LT, Linden PA, Towe CW. Frailty is associated with 90-day mortality in urgent thoracic surgery conditions. JTCVS Open 2024; 17:336-343. [PMID: 38420542 PMCID: PMC10897653 DOI: 10.1016/j.xjon.2023.10.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 10/15/2023] [Accepted: 10/17/2023] [Indexed: 03/02/2024]
Abstract
Objective In patients undergoing elective thoracic surgery, frailty is associated with worse outcomes. However, the magnitude by which frailty influences outcomes of urgent thoracic surgery (UTS) is unknown. Methods We identified patients admitted with a UTS condition from January to September 2017 in the National Readmissions Database. UTS conditions were classified as esophageal perforation, hemo/pneumothorax, rib fracture, and obstructed hiatal hernia. Outcome of interest was mortality within 90 days of index admission. Frailty score was calculated using a deficit accumulation method. Cox proportional hazard modeling was used to calculate a hazard ratio for each combination of UTS disease type and frailty score, adjusted for sex, insurance payor, hospital size, and hospital and patient location, and was compared with the effect of frailty on elective lung lobectomy. Results We identified 107,487 patients with a UTS condition. Among UTS conditions overall, increasing frailty elements were associated with increased mortality (hazard ratio, 2270; 95% CI, 1463-3523; P < .001). Compared with patients without frailty undergoing elective lobectomy, increasing frailty demonstrated trending toward increased mortality in all diagnoses. The magnitude of the effect of frailty on 90-day mortality differed depending on the disease and level of frailty. Conclusions The effect of frailty on 90-day mortality after admission for urgent thoracic surgery conditions varies by disease type and level of frailty. Among UTS disease types, increasing frailty was associated with a higher 90-day risk of mortality. These findings suggest a valuable role for frailty evaluation in both clinical settings and administrative data for risk assessment.
Collapse
Affiliation(s)
- Jacqueline Kloos
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Aria Bassiri
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Vanessa P Ho
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, MetroHealth Medical Center, Cleveland, Ohio
| | - Jillian Sinopoli
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Leonidas Tapias Vargas
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Philip A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| |
Collapse
|
7
|
Towe CW, Bachman KC, Ho VP, Pieracci F, Worrell SG, Moorman ML, Linden PA, Badrinathan A. Early Repair of Rib Fractures Is Associated with Superior Length of Stay and Total Hospital Cost: A Propensity Matched Analysis of the National Inpatient Sample. Medicina (Kaunas) 2024; 60:153. [PMID: 38256413 PMCID: PMC10819862 DOI: 10.3390/medicina60010153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 11/01/2023] [Accepted: 01/02/2024] [Indexed: 01/24/2024]
Abstract
Background and Objectives: Previous studies have suggested that early scheduling of the surgical stabilization of rib fractures (SSRF) is associated with superior outcomes. It is unclear if these data are reproducible at other institutions. We hypothesized that early SSRF would be associated with decreased morbidity, length of stay, and total charges. Materials and Methods: Adult patients who underwent SSRF for multiple rib fractures or flail chest were identified in the National Inpatient Sample (NIS) by ICD-10 code from the fourth quarter of 2015 to 2016. Patients were excluded for traumatic brain injury and missing study variables. Procedures occurring after hospital day 10 were excluded to remove possible confounding. Early fixation was defined as procedures which occurred on hospital day 0 or 1, and late fixation was defined as procedures which occurred on hospital days 2 through 10. The primary outcome was a composite outcome of death, pneumonia, tracheostomy, or discharge to a short-term hospital, as determined by NIS coding. Secondary outcomes were length of hospitalization (LOS) and total cost. Chi-square and Wilcoxon rank-sum testing were performed to determine differences in outcomes between the groups. One-to-one propensity matching was performed using covariates known to affect the outcome of rib fractures. Stuart-Maxwell marginal homogeneity and Wilcoxon signed rank matched pair testing was performed on the propensity-matched cohort. Results: Of the 474 patients who met the inclusion criteria, 148 (31.2%) received early repair and 326 (68.8%) received late repair. In unmatched analysis, the composite adverse outcome was lower among early fixation (16.2% vs. 40.2%, p < 0.001), total hospital cost was less (USD114k vs. USD215k, p < 0.001), and length of stay was shorter (6 days vs. 12 days) among early SSRF patients. Propensity matching identified 131 matched pairs of early and late SSRF. Composite adverse outcomes were less common among early SSRF (18.3% vs. 32.8%, p = 0.011). The LOS was shorter among early SSRF (6 days vs. 10 days, p < 0.001), and total hospital cost was also lower among early SSRF patients (USD118k vs. USD183k late, p = 0.001). Conclusion: In a large administrative database, early SSRF was associated with reduced adverse outcomes, as well as improved hospital length of stay and total cost. These data corroborate other research and suggest that early SSRF is preferred. Studies of outcomes after SSRF should stratify analyses by timing of procedure.
Collapse
Affiliation(s)
- Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
| | - Katelynn C Bachman
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
| | - Vanessa P Ho
- MetroHealth Medical Center, Department of Surgery, Division of Trauma, Critical Care, Burns, & Acute Care Surgery, Cleveland, OH 44109, USA
| | - Fredric Pieracci
- Department of Surgery Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO 80045, USA
| | - Stephanie G Worrell
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
| | - Matthew L Moorman
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
| | - Philip A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
| | - Avanti Badrinathan
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
| |
Collapse
|
8
|
Ladha P, Truong EI, Kanuika P, Allan A, Kishawi S, Ho VP, Claridge JA, Brown LR. Diagnostic Adjunct Techniques in the Assessment of Hypovolemia: A Prospective Pilot Project. J Surg Res 2024; 293:1-7. [PMID: 37690381 DOI: 10.1016/j.jss.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 07/21/2023] [Accepted: 08/10/2023] [Indexed: 09/12/2023]
Abstract
INTRODUCTION Measuring the hypovolemic resuscitation end point remains a critical care challenge. Our project compared clinical hypovolemia (CH) with three diagnostic adjuncts: 1) noninvasive cardiac output monitoring (NICOM), 2) ultrasound (US) static IVC collapsibility (US-IVC), and 3) US dynamic carotid upstroke velocity (US-C). We hypothesized US measures would correlate more closely to CH than NICOM. METHODS Adult trauma/surgical intensive care unit patients were prospectively screened for suspected hypovolemia after acute resuscitation, excluding patients with burns, known heart failure, or severe liver/kidney disease. Adjunct measurements were assessed up to twice a day until clinical improvement. Hypovolemia was defined as: 1) NICOM: ≥10% stroke volume variation with passive leg raise, 2) US-IVC: <2.1 cm and >50% collapsibility (nonventilated) or >18% collapsibility (ventilated), 3) US-C: peak systolic velocity increase 15 cm/s with passive leg raise. Previously unknown cardiac dysfunction seen on US was noted. Observation-level data were analyzed with a Cohen's kappa (κ). RESULTS 44 patients (62% male, median age 60) yielded 65 measures. Positive agreement with CH was 47% for NICOM, 37% for US-IVC and 10% for US-C. None of the three adjuncts correlated with CH (κ -0.045 to 0.029). After adjusting for previously unknown cardiac dysfunction present in 10 patients, no adjuncts correlated with CH (κ -0.036 to 0.031). No technique correlated with any other (κ -0.118 to 0.083). CONCLUSIONS None of the adjunct measurements correlated with CH or each other, highlighting that fluid status assessment remains challenging in critical care. US should assess for right ventricular dysfunction prior to resuscitation.
Collapse
Affiliation(s)
- Prerna Ladha
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio
| | - Evelyn I Truong
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Peter Kanuika
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Annie Allan
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio
| | - Sami Kishawi
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Vanessa P Ho
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio; Department of Population Health and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio
| | | | - Laura R Brown
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio.
| |
Collapse
|
9
|
Sun KJ, Zhu KY, Moon TJ, Breslin MA, Ho VP, Vallier HA. Recovery Services for Interpersonal Violence Victims on Healthcare Use at a Trauma Center. J Surg Res 2024; 293:443-450. [PMID: 37812878 DOI: 10.1016/j.jss.2023.08.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 07/19/2023] [Accepted: 08/26/2023] [Indexed: 10/11/2023]
Abstract
INTRODUCTION Treatment of interpersonal violence (IPV) patients is often complicated by social and mental health comorbidities. New American College of Surgeons (ACS) requirements include provision of psychosocial support services for recovery after injury. We aim to describe utilization and patient outcomes after provision of Trauma Recovery Services (TRS) at our institution for the IPV population. These services include assistance with food, housing, criminal justice, and advocacy. METHODS IPV patients were identified between September 6, 2018 and December 20, 2020. Demographic information was collected. TRS utilization and specific services rendered were identified. Primary outcome measures included initial length of stay (LOS), number of subsequent emergency department (ED) visits, and outpatient visits within 1 y after the initial injury. Statistical analyses included t-tests, Chi-squared tests, and multivariate regression analyses. RESULTS A total of 502 patients were included in the final cohort, and 394 patients (78.5%) accepted the utilization of TRS services after initial interaction. Patients were on average 33.4 y old, and 59.4% were females. Patients who were older (P < 0.001) and homeless (P = 0.004) were more likely to use TRS, while victims of sexual assault (P < 0.001) and single patients (P = 0.041) were less likely. Patients who utilized TRS had longer initial LOS (P < 0.001), more ED visits (P < 0.001), and more outpatient visits (P = 0.01) related to the initial complaint, independent of potential confounders on multivariate linear regression. Food and housing service utilization associated with LOS (P = 0.01), ED visits (P < 0.001), and outpatient visits (P < 0.001). Additionally, transportation services were associated with longer LOS (P = 0.01) while patient advocacy services were associated with more ED visits (P = 0.03). CONCLUSIONS TRS was extensively utilized by IPV patients, and associated with more follow-up appointments, ED visits, and longer LOS. Emphasis on injury mechanisms, baseline demographics, and social features may further characterize patients in need who tend toward utilization.
Collapse
Affiliation(s)
- Kristie J Sun
- MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Kevin Y Zhu
- MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Tyler J Moon
- MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Mary A Breslin
- MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Vanessa P Ho
- MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Heather A Vallier
- MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio.
| |
Collapse
|
10
|
Thai AP, Tseng ES, Kishawi SK, Robenstine JC, Ho VP. Prehospital tourniquet application in extremity vascular trauma: Improved functional outcomes. Surgery 2023; 174:1471-1475. [PMID: 37735036 DOI: 10.1016/j.surg.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 07/21/2023] [Accepted: 08/08/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Support for prehospital tourniquet use has increased, with recent data suggesting that tourniquet usage decreases shock without increasing limb complications. We hypothesized that prehospital tourniquet application in extremity vascular trauma, compared with no prehospital tourniquet application, is associated with lower rates of delayed amputation and better functional mobility. METHODS We retrospectively studied adult patients with extremity vascular trauma at an urban civilian Level 1 trauma center (June 2016-May 2021). Outcomes of interest included delayed amputation and mobility at hospital discharge, measured by the Activity Measure for Post-Acute Care "6 Clicks" Basic Mobility Score. The "6 Clicks" Basic Mobility Score was documented by physical therapy; higher scores indicate more independent mobility. Injury mechanism, initial lactate, 24-hour transfusions, mortality, and acute kidney injury were also collected. Comparisons were performed using χ2 analysis and Fisher Exact and Wilcoxon rank-sum tests. RESULTS Of 232 patients, prehospital tourniquet application was not associated with mortality or lactate level (both P > .05). The prehospital tourniquet application group had more transfusions, lower rates of acute kidney injury, and fewer delayed amputations (all P < .05). Ninety-one patients (45 prehospital tourniquet application and 46 without prehospital tourniquet application) were evaluated for "Moving between Bed and Chair" in the "6 Clicks" Basic Mobility Score, with patients in the prehospital tourniquet application group demonstrating higher levels of independence (P = .034). CONCLUSION Prehospital tourniquet application was associated with favorable outcomes, including higher functional mobility and decreased delayed amputation. This suggests that tourniquet use should be encouraged in the civilian setting to improve outcomes and reduce the risk of limb loss.
Collapse
Affiliation(s)
- Anthony P Thai
- Case Western Reserve University, School of Medicine, Cleveland, OH
| | - Esther S Tseng
- Case Western Reserve University, School of Medicine, Cleveland, OH; Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, Department of Surgery, MetroHealth Medical Center, Cleveland, OH
| | - Sami K Kishawi
- Case Western Reserve University, School of Medicine, Cleveland, OH; Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Jacinta C Robenstine
- Case Western Reserve University, School of Medicine, Cleveland, OH; Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, Department of Surgery, MetroHealth Medical Center, Cleveland, OH
| | - Vanessa P Ho
- Case Western Reserve University, School of Medicine, Cleveland, OH; Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, Department of Surgery, MetroHealth Medical Center, Cleveland, OH; Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH.
| |
Collapse
|
11
|
Bassiri A, Badrinathan A, Kishawi S, Sinopoli J, Linden PA, Ho VP, Towe CW. Motor Vehicle Protective Device Usage Associated with Decreased Rate of Flail Chest: A Retrospective Database Analysis. Medicina (Kaunas) 2023; 59:2046. [PMID: 38004095 PMCID: PMC10673139 DOI: 10.3390/medicina59112046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 10/31/2023] [Accepted: 11/16/2023] [Indexed: 11/26/2023]
Abstract
Background and Objectives: Protective equipment, including seatbelts and airbags, have dramatically reduced the morbidity and mortality rates associated with motor vehicle collisions (MVCs). While generally associated with a reduced rate of injury, the effect of motor vehicle protective equipment on patterns of chest wall trauma is unknown. We hypothesized that protective equipment would affect the rate of flail chest after an MVC. Materials and Methods: This study was a retrospective analysis of the 2019 iteration of the American College of Surgeons Trauma Quality Program (ACS-TQIP) database. Rib fracture types were categorized as non-flail chest rib fractures and flail chest using ICD-10 diagnosis coding. The primary outcome was the occurrence of flail chests after motor vehicle collisions. The protective equipment evaluated were seatbelts and airbags. We performed bivariate and multivariate logistic regression to determine the association of flail chest with the utilization of vehicle protective equipment. Results: We identified 25,101 patients with rib fractures after motor vehicle collisions. In bivariate analysis, the severity of the rib fractures was associated with seatbelt type, airbag status, smoking history, and history of cerebrovascular accident (CVA). In multivariate analysis, seatbelt use and airbag deployment (OR 0.76 CI 0.65-0.89) were independently associated with a decreased rate of flail chest. In an interaction analysis, flail chest was only reduced when a lap belt was used in combination with the deployed airbag (OR 0.59 CI 0.43-0.80) when a shoulder belt was used without airbag deployment (0.69 CI 0.49-0.97), or when a shoulder belt was used with airbag deployment (0.57 CI 0.46-0.70). Conclusions: Although motor vehicle protective equipment is associated with a decreased rate of flail chest after a motor vehicle collision, the benefit is only observed when lap belts and airbags are used simultaneously or when a shoulder belt is used. These data highlight the importance of occupant seatbelt compliance and suggest the effect of motor vehicle restraint systems in reducing severe chest wall injuries.
Collapse
Affiliation(s)
- Aria Bassiri
- Department of Surgery, Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA; (A.B.); (A.B.); (S.K.); (J.S.); (P.A.L.)
| | - Avanti Badrinathan
- Department of Surgery, Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA; (A.B.); (A.B.); (S.K.); (J.S.); (P.A.L.)
| | - Sami Kishawi
- Department of Surgery, Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA; (A.B.); (A.B.); (S.K.); (J.S.); (P.A.L.)
| | - Jillian Sinopoli
- Department of Surgery, Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA; (A.B.); (A.B.); (S.K.); (J.S.); (P.A.L.)
| | - Philip A. Linden
- Department of Surgery, Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA; (A.B.); (A.B.); (S.K.); (J.S.); (P.A.L.)
| | - Vanessa P. Ho
- Department of Surgery, Division of Trauma, Critical Care, Burns, and Acute Care Surgery, MetroHealth Medical Center, Cleveland, OH 44109, USA;
| | - Christopher W. Towe
- Department of Surgery, Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA; (A.B.); (A.B.); (S.K.); (J.S.); (P.A.L.)
| |
Collapse
|
12
|
Halkiadakis PN, Mahajan S, Crosby DR, Badrinathan A, Ho VP. A prospective assessment of resilience in trauma patients using the Connor-Davidson Resilience Scale. Surgery 2023; 174:1249-1254. [PMID: 37599193 DOI: 10.1016/j.surg.2023.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 06/01/2023] [Accepted: 07/08/2023] [Indexed: 08/22/2023]
Abstract
BACKGROUND Resilience, or the ability to adapt to difficult or challenging life experiences, may be an important mediator in trauma recovery. The primary aim of this study was to describe resilience levels for trauma patients using the validated Connor-Davidson Resilience Scale. METHODS Adult trauma patients admitted to a Level 1 trauma center (June 2022-August 2022) were surveyed at the time of admission and by phone between 2 weeks and 1 month after the original survey to obtain follow-up scores. We utilized the validated Connor-Davidson Resilience Scale score, a 25-question survey with 5 subfactors (Tenacity, Positive Outlook, Social Support, Problem Solving, and Meaning and Purpose). Each question was scored from 0 to 4 (maximum score 100, representing the highest resilience). Patient factors were collected from the electronic medical record and trauma health registry. Wilcoxon signed-rank test and multivariable linear regression were used to understand associations with Connor-Davidson Resilience Scale scores. RESULTS We enrolled 98 patients. The median age was 50 years (interquartile range 32-67), and 74% were male sex. The baseline median Connor-Davidson Resilience Scale score on admission was 88 (interquartile range 81-94). Follow-up surveys (N = 64) showed a median score of 89.5 (80-90.5) (P = non-significant). No demographic variable was significantly associated with increasing baseline Connor-Davidson Resilience Scale score. Increased length of stay (β = 1.03), insurance (β = -7.50), and unknown race (β = 23.69) were correlated with follow-up Connor-Davidson Resilience Scale scores. The subfactor "Meaning and Purpose" decreased at follow-up but was not statistically significant (P = .05). CONCLUSION Validated tools that can accurately distinguish variability in resilience scores are needed for the trauma patient population to understand its relationship with long-term patient health outcomes.
Collapse
Affiliation(s)
- Penelope N Halkiadakis
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, OH; Case Western Reserve University School of Medicine, Cleveland, OH
| | - Sarisha Mahajan
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, OH; University of Michigan, Ann Arbor, MI
| | - Danyel R Crosby
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, OH; Department of Nutritional Biochemistry and Metabolism, Case Western Reserve University, Cleveland, OH
| | - Avanti Badrinathan
- Department of Surgery, University Hospitals Cleveland Medical Center, OH
| | - Vanessa P Ho
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, OH; Case Western Reserve University School of Medicine, Cleveland, OH; Center for Health Equity Engagement, Education, and Research; Population Health and Equity Research Institute, The MetroHealth System and Case Western Reserve University, Cleveland, OH.
| |
Collapse
|
13
|
Abstract
We present a rare case of traumatic self-enucleation of the bilateral globes resulting in traumatic subarachnoid and intraventricular hemorrhages. This case highlights the critical importance of multidisciplinary trauma care, starting with recognition of the potential for less obvious injuries such as contralateral optic nerve injury in unilateral enucleation, intracranial hemorrhage, and cerebrovascular injuries. We highlight the role of a thorough trauma assessment and workup, especially in the context of highly distracting injuries in patients who may also have severe mental illness. The trauma and acute care surgeon, who also serves as the critical care specialist, should be well prepared to facilitate care between multiple subspecialists including neurosurgeons, interventional radiologists, vascular surgeons, and psychiatrists, with a high index of suspicion for occult trauma in seemingly isolated injuries.
Collapse
Affiliation(s)
- James Alford Flippin
- Department of Surgery, Division of Trauma, Critical Care, Burns and Emergency General Surgery, MetroHealth Medical Center, Cleveland, OH, USA
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Evelyn Truong
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Sami Kishawi
- Department of Surgery, Division of Trauma, Critical Care, Burns and Emergency General Surgery, MetroHealth Medical Center, Cleveland, OH, USA
| | - Annie Allan
- Department of Surgery, Division of Trauma, Critical Care, Burns and Emergency General Surgery, MetroHealth Medical Center, Cleveland, OH, USA
| | - Vanessa P. Ho
- Department of Surgery, Division of Trauma, Critical Care, Burns and Emergency General Surgery, MetroHealth Medical Center, Cleveland, OH, USA
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| |
Collapse
|
14
|
Stanley SP, DeMario BS, Beel KT, Lee MS, Petitt JC, Brown LR, Tseng ES, Ho VP. Home Medication Regimens Increase in Complexity After Admission for Fall in the Older Trauma Patient. Am Surg 2023; 89:4438-4444. [PMID: 35848087 PMCID: PMC10829064 DOI: 10.1177/00031348221083958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/06/2023]
Abstract
BACKGROUND Hospitalization for the older trauma patient is an opportunity to assess polypharmacy. We hypothesized that medication regimen complexity (RxCS) and pain medication prescriptions (PRxs) would increase in older home-going patients admitted for a fall. METHODS We retrospectively chart reviewed patients ≥45 years old admitted for a fall at a level 1 trauma center who were discharged home with full medication documentation. RxCS was compared pre-admission and post-discharge with Wilcoxon signed-rank tests; opioid and non-opioid PRxs were compared with Fisher's exact test, α = .05. RESULTS 103 patients met inclusion criteria; 58% were ≥65 years old. RxCS (9 [.5-13] to 11 [4.5-15], P < .01) increased on discharge. Opioid PRx rates increased significantly in all age groups. Non-opioid PRx rates increased significantly for patients <65 but not for patients ≥65. CONCLUSIONS Admission for a fall was associated with increases in RxCS, while PRx changes were age-dependent. Providers should recognize that admissions for older patients who fall after trauma are underutilized opportunities to address polypharmacy in high-risk patients.
Collapse
Affiliation(s)
- Samuel P. Stanley
- Department of Surgery, MetroHealth Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH
| | - Belinda S. DeMario
- Department of Surgery, MetroHealth Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH
| | - Kevin T. Beel
- Department of Surgery, MetroHealth Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH
| | - Michelle S. Lee
- Department of Surgery, MetroHealth Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH
| | - Jordan C. Petitt
- Department of Surgery, MetroHealth Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH
| | - Laura R. Brown
- Department of Surgery, MetroHealth Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH
| | - Esther S. Tseng
- Department of Surgery, MetroHealth Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH
| | - Vanessa P. Ho
- Department of Surgery, MetroHealth Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH
| |
Collapse
|
15
|
Flippin JA, DeMario BS, Adomshick VJ, Stanley SP, Truong EI, Hendrickson S, Kalina MA, Lasinski AM, Ho VP. Post-Trauma Discharge Instructions: Are We Dropping the Ball? Am Surg 2023; 89:4625-4631. [PMID: 36083613 PMCID: PMC10829078 DOI: 10.1177/00031348221111515] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/06/2023]
Abstract
INTRODUCTION Complex follow-up plans for polytrauma patients are compiled at the end of hospitalization into discharge instructions. We sought to identify how often patient discharge instructions incorrectly communicated specialist recommendations. We hypothesized that patients with more complex hospitalizations would have more discharge instruction errors (DI-errors). METHODS We reviewed adult trauma inpatients (March 2017-March 2018), excluding those who left against medical advice or were expected to follow up outside our system. Complex hospitalizations were represented using injury severity (ISS), hospital length of stay (LOS), intensive care unit length of stay (iLOS), and number of consultants (NC). We recorded the type of consultant (surgical or nonsurgical), and consultant recommendations for follow-up. DI-errors were defined as either follow-up necessary but omitted or follow-up not necessary yet present on the instructions. Patients with DI-errors were compared to patients without DI-errors. Groups were compared using Wilcoxon rank sum or chi-square (alpha <.05). RESULTS We included 392 patients (median age 45 [IQR 26-58], ISS 14 [10-21], LOS 6 [3-11]). 55 patients (14%) had DI-errors. Factors associated with DI-errors included the total number of consultants and use of nonsurgical consultants. ISS, LOS, iLOS, were not associated with DI-errors. CONCLUSION Common measures of admission complexity were not associated with DI-errors, although the number and type of consultants were associated with DI-errors. Non-surgical specialty consultant recommendations were more likely to be omitted. It is crucial for patients to receive accurate discharge instructions, and systematic processes are needed to improve communication with the patients at discharge.
Collapse
Affiliation(s)
| | | | | | | | - Evelyn I. Truong
- Department of Surgery, MetroHealth Medical Center, Cleveland, OH
| | - Sarah Hendrickson
- Community Trauma Institute, MetroHealth Medical Center, Cleveland, OH
| | - Mark A. Kalina
- Community Trauma Institute, MetroHealth Medical Center, Cleveland, OH
| | | | - Vanessa P. Ho
- Department of Surgery, MetroHealth Medical Center, Cleveland, OH
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH
| |
Collapse
|
16
|
Kishawi SK, Badrinathan A, Towe CW, Ho VP. Associations Between Psychiatric Diagnoses on Length of Stay and Mortality After Rib Fracture: A Retrospective Analysis. J Surg Res 2023; 291:213-220. [PMID: 37453222 DOI: 10.1016/j.jss.2023.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/02/2023] [Accepted: 05/13/2023] [Indexed: 07/18/2023]
Abstract
INTRODUCTION Concurrent psychiatric diagnoses adversely impact outcomes in surgical patients, but their relationship to patients with rib fracture after trauma is less understood. We hypothesized that psychiatric comorbidity would be associated with increases in hospital length of stay (LOS) and mortality risk after rib fracture. MATERIALS AND METHODS The 2017 National Inpatient Sample was queried for adult patients who were admitted with rib fracture after trauma. Mental health disorders were categorized into 34 psychiatric diagnosis groups (PDGs) using clinical classifications software refined for International Classification of Diseases-10. Outcomes of interest were LOS and mortality. Bivariable analysis determined associations between PDGs, patient demographics, hospital characteristics, and outcomes. Logistic regression was performed to identify adjusted effects on mortality, and linear regression was performed to identify effects on LOS. RESULTS Of 32,801 patients, median age was 61 y (IQR 46-76), and median LOS was 5 d (IQR 3-9). No PDGs were associated with increased odds of mortality. Concurrent diagnosis of schizophrenia spectrum (Coeff. 3.5, 95% CI 2.7-4.4, P < 0.001) or trauma- or stressor-related (Coeff. 1.6, 95% CI 0.9-2.5, P < 0.001) disorders demonstrated the greatest association with prolonged LOS. Increased odds of death and prolonged hospital stay were also associated with male sex, non-White patient race, and surgery occurring at urban and public hospitals. CONCLUSIONS Psychiatric comorbidities are associated with death after rib fracture but are associated with increased LOS. These findings may help promote multidisciplinary patient management in trauma.
Collapse
Affiliation(s)
- Sami K Kishawi
- Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio; Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Avanti Badrinathan
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Christopher W Towe
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Vanessa P Ho
- Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio; Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio.
| |
Collapse
|
17
|
Sartelli M, Barie PS, Coccolini F, Abbas M, Abbo LM, Abdukhalilova GK, Abraham Y, Abubakar S, Abu-Zidan FM, Adebisi YA, Adamou H, Afandiyeva G, Agastra E, Alfouzan WA, Al-Hasan MN, Ali S, Ali SM, Allaw F, Allwell-Brown G, Amir A, Amponsah OKO, Al Omari A, Ansaloni L, Ansari S, Arauz AB, Augustin G, Awazi B, Azfar M, Bah MSB, Bala M, Banagala ASK, Baral S, Bassetti M, Bavestrello L, Beilman G, Bekele K, Benboubker M, Beović B, Bergamasco MD, Bertagnolio S, Biffl WL, Blot S, Boermeester MA, Bonomo RA, Brink A, Brusaferro S, Butemba J, Caínzos MA, Camacho-Ortiz A, Canton R, Cascio A, Cassini A, Cástro-Sanchez E, Catarci M, Catena R, Chamani-Tabriz L, Chandy SJ, Charani E, Cheadle WG, Chebet D, Chikowe I, Chiara F, Cheng VCC, Chioti A, Cocuz ME, Coimbra R, Cortese F, Cui Y, Czepiel J, Dasic M, de Francisco Serpa N, de Jonge SW, Delibegovic S, Dellinger EP, Demetrashvili Z, De Palma A, De Silva D, De Simone B, De Waele J, Dhingra S, Diaz JJ, Dima C, Dirani N, Dodoo CC, Dorj G, Duane TM, Eckmann C, Egyir B, Elmangory MM, Enani MA, Ergonul O, Escalera-Antezana JP, Escandon K, Ettu AWOO, Fadare JO, Fantoni M, Farahbakhsh M, Faro MP, Ferreres A, Flocco G, Foianini E, Fry DE, Garcia AF, Gerardi C, Ghannam W, Giamarellou H, Glushkova N, Gkiokas G, Goff DA, Gomi H, Gottfredsson M, Griffiths EA, Guerra Gronerth RI, Guirao X, Gupta YK, Halle-Ekane G, Hansen S, Haque M, Hardcastle TC, Hayman DTS, Hecker A, Hell M, Ho VP, Hodonou AM, Isik A, Islam S, Itani KMF, Jaidane N, Jammer I, Jenkins DR, Kamara IF, Kanj SS, Jumbam D, Keikha M, Khanna AK, Khanna S, Kapoor G, Kapoor G, Kariuki S, Khamis F, Khokha V, Kiggundu R, Kiguba R, Kim HB, Kim PK, Kirkpatrick AW, Kluger Y, Ko WC, Kok KYY, Kotecha V, Kouma I, Kovacevic B, Krasniqi J, Krutova M, Kryvoruchko I, Kullar R, Labi KA, Labricciosa FM, Lakoh S, Lakatos B, Lansang MAD, Laxminarayan R, Lee YR, Leone M, Leppaniemi A, Hara GL, Litvin A, Lohsiriwat V, Machain GM, Mahomoodally F, Maier RV, Majumder MAA, Malama S, Manasa J, Manchanda V, Manzano-Nunez R, Martínez-Martínez L, Martin-Loeches I, Marwah S, Maseda E, Mathewos M, Maves RC, McNamara D, Memish Z, Mertz D, Mishra SK, Montravers P, Moro ML, Mossialos E, Motta F, Mudenda S, Mugabi P, Mugisha MJM, Mylonakis E, Napolitano LM, Nathwani D, Nkamba L, Nsutebu EF, O’Connor DB, Ogunsola S, Jensen PØ, Ordoñez JM, Ordoñez CA, Ottolino P, Ouedraogo AS, Paiva JA, Palmieri M, Pan A, Pant N, Panyko A, Paolillo C, Patel J, Pea F, Petrone P, Petrosillo N, Pintar T, Plaudis H, Podda M, Ponce-de-Leon A, Powell SL, Puello-Guerrero A, Pulcini C, Rasa K, Regimbeau JM, Rello J, Retamozo-Palacios MR, Reynolds-Campbell G, Ribeiro J, Rickard J, Rocha-Pereira N, Rosenthal VD, Rossolini GM, Rwegerera GM, Rwigamba M, Sabbatucci M, Saladžinskas Ž, Salama RE, Sali T, Salile SS, Sall I, Kafil HS, Sakakushev BE, Sawyer RG, Scatizzi M, Seni J, Septimus EJ, Sganga G, Shabanzadeh DM, Shelat VG, Shibabaw A, Somville F, Souf S, Stefani S, Tacconelli E, Tan BK, Tattevin P, Rodriguez-Taveras C, Telles JP, Téllez-Almenares O, Tessier J, Thang NT, Timmermann C, Timsit JF, Tochie JN, Tolonen M, Trueba G, Tsioutis C, Tumietto F, Tuon FF, Ulrych J, Uranues S, van Dongen M, van Goor H, Velmahos GC, Vereczkei A, Viaggi B, Viale P, Vila J, Voss A, Vraneš J, Watkins RR, Wanjiru-Korir N, Waworuntu O, Wechsler-Fördös A, Yadgarova K, Yahaya M, Yahya AI, Xiao Y, Zakaria AD, Zakrison TL, Zamora Mesia V, Siquini W, Darzi A, Pagani L, Catena F. Ten golden rules for optimal antibiotic use in hospital settings: the WARNING call to action. World J Emerg Surg 2023; 18:50. [PMID: 37845673 PMCID: PMC10580644 DOI: 10.1186/s13017-023-00518-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 09/23/2023] [Indexed: 10/18/2023] Open
Abstract
Antibiotics are recognized widely for their benefits when used appropriately. However, they are often used inappropriately despite the importance of responsible use within good clinical practice. Effective antibiotic treatment is an essential component of universal healthcare, and it is a global responsibility to ensure appropriate use. Currently, pharmaceutical companies have little incentive to develop new antibiotics due to scientific, regulatory, and financial barriers, further emphasizing the importance of appropriate antibiotic use. To address this issue, the Global Alliance for Infections in Surgery established an international multidisciplinary task force of 295 experts from 115 countries with different backgrounds. The task force developed a position statement called WARNING (Worldwide Antimicrobial Resistance National/International Network Group) aimed at raising awareness of antimicrobial resistance and improving antibiotic prescribing practices worldwide. The statement outlined is 10 axioms, or "golden rules," for the appropriate use of antibiotics that all healthcare workers should consistently adhere in clinical practice.
Collapse
|
18
|
Sharpe MG, Crosby DR, Creary J, Badrinathan A, Kishawi SK, Ho VP. Digital learning: The reach of podcasts and YouTube on trauma surgery education. Surgery 2023; 174:535-541. [PMID: 37357094 DOI: 10.1016/j.surg.2023.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 04/17/2023] [Accepted: 05/24/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND Physicians, medical students, and health care professionals are charged with staying current throughout their training. No studies have examined the scope of trauma surgery-related podcasts and videos. Our goal was to characterize and evaluate the growing number of trauma-related podcasts and YouTube channels. METHODS We conducted a search across 3 podcasting platforms (Google Podcasts, Apple Podcasts, and Spotify) and 1 video-sharing site (YouTube) for podcasts published up to November 11, 2022. We queued platforms for "Trauma" and "Trauma Surgery." We included podcasts or video channels in English that focused on trauma surgery or trauma survivorship and recovery. Descriptive analyses were used to determine the characteristics of podcasts and YouTube channels, reported as counts. RESULTS We identified 91 podcasts and 103 YouTube channels dedicated to trauma recovery and/or trauma surgery. The longest running podcast was the "TraumaCast," and the oldest YouTube channel was "TraumaPro." The podcast with the most episodes was "Trauma Therapist," and the YouTube channel with the most episodes was the Arizona Trauma Association. Podcasts were aimed at public audiences, whereas YouTube channels focused on providers. A large proportion of content is not created by licensed professionals. CONCLUSIONS Our study shows that popular trauma-focused podcasts target the general population, not health care professionals. The content creators behind these digital platforms seek to educate the public on the recovery process after traumatic injury. We must better understand the advantages and pitfalls of these ubiquitous resources.
Collapse
Affiliation(s)
- Megan G Sharpe
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Danyel R Crosby
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Justin Creary
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Avanti Badrinathan
- Case Western Reserve University School of Medicine, Cleveland, OH; Department of Surgery, University Hospitals, Cleveland, OH
| | - Sami K Kishawi
- Case Western Reserve University School of Medicine, Cleveland, OH; Department of Surgery, University Hospitals, Cleveland, OH
| | - Vanessa P Ho
- Case Western Reserve University School of Medicine, Cleveland, OH; Department of Surgery, Division of Trauma, Critical Care, Burns, and Acute Care Surgery, MetroHealth Medical Center, Cleveland, OH.
| |
Collapse
|
19
|
Ho VP, Roach MJ, Berg KA, Deverakonda DL, Kanuika P, Arko B, Perzynski AT. In their own words: recovery after emergency general surgery in the older patient. Trauma Surg Acute Care Open 2023; 8:e001138. [PMID: 37342818 PMCID: PMC10277530 DOI: 10.1136/tsaco-2023-001138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 05/11/2023] [Indexed: 06/23/2023] Open
Abstract
Objectives Emergency general surgery (EGS) conditions, such as perforated intestines or complicated hernias, can lead to significant postoperative morbidity and mortality. We sought to understand the recovery experience of older patients at least 1 year after EGS to identify key factors for a successful long-term recovery. Methods We conducted semi-structured interviews to explore recovery experiences of patients and their caregivers after admission for an EGS procedure. We screened patients who were aged 65 years or older at the time of an EGS operation, admitted at least 7 days, and still alive and able to consent at least 1 year postoperatively. We interviewed the patients, their primary caregiver, or both. Interview guides were developed to explore medical decision making, patient goals and expectations surrounding recovery after EGS, and to identify barriers and facilitators of recovery. Interviews were recorded and transcribed, and we used an inductive thematic approach to analysis. Results We performed 15 interviews (11 patients and 4 caregivers). Patients wanted to return to their prior quality of life, or 'get back to normal.' Family was key in providing both instrumental support (eg, for daily tasks such as cooking, driving, wound care) and emotional support. Provision of temporary support was key to the recovery of many patients. Although most patients returned to their prior lifestyle, some also experienced depression, persistent abdominal effects, pain, or decreased stamina. When asked about medical decision making, patients expressed viewing the decision for having an operation not as a choice but, rather, the only rational option to treat a severe symptom or life-threating illness. Conclusions There is an opportunity in healthcare to provide better education for older patients and their caregivers around instrumental and emotional support to bolster successful recovery after emergency surgery. Level of evidence Qualitative study, level II.
Collapse
Affiliation(s)
- Vanessa P Ho
- Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
- Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio, USA
- Population Health Research Institute, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Mary Joan Roach
- Physical Medicine and Rehabilitation, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Kristen A Berg
- Population Health Research Institute, MetroHealth Medical Center, Cleveland, Ohio, USA
| | | | - Peter Kanuika
- Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Brianna Arko
- Respiratory Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Adam T Perzynski
- Population Health Research Institute, MetroHealth Medical Center, Cleveland, Ohio, USA
| |
Collapse
|
20
|
Deverakonda DL, Kishawi SK, Lapinski MF, Adomshick VJ, Siff JE, Brown LR, Ho VP. What If We Do Not Operate? Outcomes of Nonoperatively Managed Emergency General Surgery Patients. J Surg Res 2023; 284:29-36. [PMID: 36529078 PMCID: PMC9911375 DOI: 10.1016/j.jss.2022.11.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 11/18/2022] [Accepted: 11/20/2022] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Although two-thirds of patients with emergency general surgery (EGS) conditions are managed nonoperatively, their long-term outcomes are not well described. We describe outcomes of nonoperative management in a cohort of older EGS patients and estimate the projected risk of operative management using the NSQIP Surgical Risk Calculator (SRC). MATERIALS AND METHODS We studied single-center inpatients aged 65 y and more with an EGS consult who did not undergo an operation (January 2019-December 2020). For each patient, we recorded the surgeon's recommendation as either an operation was "Not Needed" (medical management preferred) or "Not Recommended" (risk outweighed benefits). Our main outcome of interest was mortality at 30 d and 1 y. Our secondary outcome of interest was SRC-projected 30-day postoperative mortality risk (median % [interquartile range]), calculated using hypothetical low-risk and high-risk operations. RESULTS We included 204 patients (60% female, median age 75 y), for whom an operation was "Not Needed" in 81% and "Not Recommended" in 19%. In this cohort, 11% died at 30 d and 23% died at 1 y. Mortality was higher for the "Not Recommended" cohort (37% versus 5% at 30 d and 53% versus 16% at 1 y, P < 0.05). The SRC-projected 30-day postoperative mortality risk was 3.7% (1.3-8.7) for low-risk and 5.8% (2-11.8) for high-risk operations. CONCLUSIONS Nonoperative management in older EGS patients is associated with very high risk of short-term and long-term mortality, particularly if a surgeon advised that risks of surgery outweighed benefits. The SRC may underestimate risk in the highest-risk patients.
Collapse
Affiliation(s)
| | - Sami K Kishawi
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio; Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | | | | | - Jonathan E Siff
- Department of Emergency Medicine and the Center for Clinical Informatics Research and Education, MetroHealth Medical Center, Cleveland, Ohio
| | - Laura R Brown
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio
| | - Vanessa P Ho
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio; Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio.
| |
Collapse
|
21
|
Petitt JC, Stanley S, Kashkoush A, Ahorukomeye P, Potter TO, Ho VP, Kelly ML. Percutaneous vertebral augmentation for acute traumatic vertebral Fractures: A TQIP database study. J Clin Neurosci 2023; 110:19-26. [PMID: 36780782 DOI: 10.1016/j.jocn.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 01/18/2023] [Accepted: 02/02/2023] [Indexed: 02/13/2023]
Abstract
Patients with vertebral fractures may be treated with percutaneous vertebroplasty (VP) and kyphoplasty (KP) for pain relief. Few studies examine the use of VP and KP in the setting of an acute trauma. In this study, we describe the current use of VP/KP in patients with acute traumatic vertebral fractures. All patients in the ACS Trauma Quality Improvement Program (TQIP) 2016 National Trauma Databank with severe spine injury (spine AIS ≥ 3) met inclusion criteria, including patients who underwent PVA. Logistic regression was used to assess patient and hospital factors associated with PVA; odds ratios and 95 % confidence intervals are reported. 20,769 patients met inclusion criteria and 406 patients received PVA. Patients aged 50 or older were up to 6.73 (2.45 - 27.88) times more likely to receive PVA compared to younger age groups and women compared to men (1.55 [1.23-1.95]). Hospitals with a Level II trauma center and with 401-600 beds were more likely to perform PVA (2.07 [1.51-2.83]) and (1.82 [1.04-3.34]) respectively. African American patients (0.41 [0.19-0.77]), isolated trauma (0.64 [0.42-0.96]), neurosurgeon group size > 6 (0.47 [0.30-0.74]), orthopedic group size > 10, and hospitals in the Northeastern and Western regions of the U.S. (0.33 [0.21-0.51] and 0.46 [0.32-0.64]) were less likely to be associated with PVA. Vertebroplasty and kyphoplasty use for acute traumatic vertebral fractures significantly varied across major trauma centers in the United States by multiple patient, hospital, and surgeon demographics. Regional and institutional practice patterns play an important role in the use of these procedures.
Collapse
Affiliation(s)
- Jordan C Petitt
- Department of Neurological Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, OH, United States of America.
| | - Samuel Stanley
- Department of Neurological Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, OH, United States of America.
| | - Ahmed Kashkoush
- Department of Neurological Surgery, Cleveland Clinic Foundation, Cleveland, OH, United States of America.
| | - Peter Ahorukomeye
- Department of Neurological Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, OH, United States of America.
| | - Tamia O Potter
- Department of Neurological Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, OH, United States of America.
| | - Vanessa P Ho
- Department of Trauma Surgery, MetroHealth Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, United States of America.
| | - Michael L Kelly
- Department of Neurological Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, OH, United States of America.
| |
Collapse
|
22
|
Wang N, Bachman KC, Linden PA, Ho VP, Moorman ML, Worrell SG, Argote-Greene LM, Towe CW. Age as a Barrier to Surgical Stabilization of Rib Fractures in Patients with Flail Chest. Am Surg 2023; 89:927-934. [PMID: 34732075 PMCID: PMC9061890 DOI: 10.1177/00031348211047490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Although randomized trials demonstrate a benefit to surgical stabilization of rib fractures (SSRF), SSRF is rarely performed. We hypothesized older patients were less likely to receive SSRF nationally. METHODS The 2016 National Inpatient Sample was used to identify adults with flail chest. Comorbidities and receipt of SSRF were categorized by ICD-10 code. Univariable testing and Multivariable regression were performed to determine the association of demographic characteristics and comorbidities to receipt of SSRF. RESULTS 1021 patients with flail chest were identified, including 244 (23.9%) who received SSRF. Patients ≥70 years were less likely to receive SSRF. (<70 yrs 201/774 [26.0%] vs ≥70 43/247 [17.4%], P = .006) and had higher risk of death (<70 yrs 39/774 [5.0%] vs ≥70 33/247 [13.4%], P < .001) In multivariable modeling, only age ≥70 years was associated with SSRF (OR .591, P = .005). CONCLUSION Despite guideline-based support of SSRF in flail chest, SSRF is performed in <25% of patients. Age ≥70 years is associated with lower rate of SSRF and higher risk of death. Future study should examine barriers to SSRF in older patients.
Collapse
Affiliation(s)
- Naomi Wang
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Katelynn C Bachman
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Philip A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Vanessa P Ho
- Division of Trauma, Critical Care, Burns, & Acute Care Surgery, Department of Surgery, MetroHealth Medical Center, Cleveland, OH, USA
| | - Matthew L Moorman
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Stephanie G Worrell
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Luis M Argote-Greene
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| |
Collapse
|
23
|
Kishawi SK, Adomshick VJ, Halkiadakis PN, Wilson K, Petitt JC, Brown LR, Claridge JA, Ho VP. Development of Imaging Criteria for Geriatric Blunt Trauma Patients. J Surg Res 2023; 283:879-888. [PMID: 36915016 DOI: 10.1016/j.jss.2022.10.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 10/07/2022] [Accepted: 10/18/2022] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Current decision tools to guide trauma computed tomography (CT) imaging were not validated for use in older patients. We hypothesized that specific clinical variables would be predictive of injury and could be used to guide imaging in this population to minimize risk of missed injury. METHODS Blunt trauma patients aged 65 y and more admitted to a Level 1 trauma center intensive care unit from January 2018 to November 2020 were reviewed for histories, physical examination findings, and demographic information known at the time of presentation. Injuries were defined using the patient's final abbreviated injury score codes, obtained from the trauma registry. Abbreviated injury score codes were categorized by corresponding CT body region: Head, Face, Chest, C-Spine, Abdomen/Pelvis, or T/L-Spine. Variable groupings strongly predictive of injury were tested to identify models with high sensitivity and a negative predictive value. RESULTS We included 608 patients. Median age was 77 y (interquartile range, 70-84.5) and 55% were male. Ground-level fall was the most common injury mechanism. The most commonly injured CT body regions were Head (52%) and Chest (42%). Variable groupings predictive of injury were identified in all body regions. We identified models with 97.8% sensitivity for Head and 98.8% for Face injuries. Sensitivities more than 90% were reached for all except C-Spine and Abdomen/Pelvis. CONCLUSIONS Decision aids to guide imaging for older trauma patients are needed to improve consistency and quality of care. We have identified groupings of clinical variables that are predictive of injury to guide CT imaging after geriatric blunt trauma. Further study is needed to refine and validate these models.
Collapse
Affiliation(s)
- Sami K Kishawi
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Victoria J Adomshick
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Penelope N Halkiadakis
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Keira Wilson
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, Ohio; Northeast Ohio Medical University, Rootstown, Ohio
| | - Jordan C Petitt
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Laura R Brown
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Jeffrey A Claridge
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Vanessa P Ho
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio; Case Western Reserve University, Department of Population and Quantitative Health Sciences, Cleveland, Ohio.
| |
Collapse
|
24
|
Badrinathan A, Ho VP, Tinkoff G, Houck O, Vazquez D, Gerrek M, Kessler A, Rushing A. Are we waiting for the sky to fall? Predictors of withdrawal of life-sustaining support in older trauma patients: A retrospective analysis. J Trauma Acute Care Surg 2023; 94:385-391. [PMID: 36449699 PMCID: PMC9974547 DOI: 10.1097/ta.0000000000003844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
BACKGROUND Limited data exist regarding the impact of advanced care planning for injured geriatric patients. We hypothesized that patients with advance directives limiting care (ADLC) compared with those without ADLC are more likely to undergo withdrawal of life-sustaining support (WLSS). METHODS This is a propensity-matched analysis utilizing American College of Surgeons Trauma Quality Improvement Program patients 65 years or older who presented between 2017 and 2018. Patients with and without ADLC on admission were compared. The primary outcome was WLSS and days prior to WLSS. Additional factors examined included hospital length of stay (LOS), unplanned operations, unplanned intensive care unit admissions, and in-hospital cardiac arrests. Prior to matching, logistic regression model assessed factors associated with WLSS. Patients with and without ADLC were matched 1:1 via a propensity score using patient and injury factors as covariates, and matched pair analysis compared differences in WLSS between patients with and without ADLC. RESULTS There were 597,840 patients included: 44,001 patients with an ADLC (7.36%) compared with 553,839 with no ADLC (92.64%). Patients with an ADLC underwent WLSS more often than those with no ADLC (7.68% vs. 2.48%, p < 0.001). In a 1:1 propensity-matched analysis, patients with ADLC were more likely to undergo WLSS (odds ratio [OR], 2.38' 95% confidence interval [CI], 2.22-2.55), although stronger predictors of WLSS included severity of injury (Injury Severity Score, 25+; OR, 23.84; 95% CI, 21.55-26.36), unplanned intensive care unit admissions (OR, 3.30; 95% CI, 2.89-3.75), and in-hospital cardiac arrests (OR, 4.97; 95% CI, 4.02-6.15). CONCLUSION A small proportion of the geriatric trauma population had ADLC on admission. While ADLC was predictive of WLSS, adverse events were more strongly associated with WLSS. To ensure patient-centered care and reduce futile interventions, surgeons should delineate goals of care early regardless of ADLC. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
Collapse
Affiliation(s)
| | - Vanessa P Ho
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, MetroHealth Medical Center, Cleveland, Ohio
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio
| | - Glen Tinkoff
- Department of Surgery, University Hospitals Cleveland Medical Center
- Northern Ohio Trauma System, Brooklyn Heights, Ohio
| | - Olivia Houck
- Northern Ohio Trauma System, Brooklyn Heights, Ohio
| | - Daniel Vazquez
- Division of Trauma, Cleveland Clinic Foundation, Akron General Hospital, Akron, Ohio
| | - Monica Gerrek
- Department of Bioethics, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Center for Biomedical Ethics, The MetroHealth System, Cleveland, OH
| | - Ann Kessler
- Rainbow Babies and Children’s Center for Bioethics, University Hospitals, Cleveland, Ohio
| | - Amy Rushing
- Department of Surgery, University Hospitals Cleveland Medical Center
| |
Collapse
|
25
|
Ho VP, Bensken WP, Flippin JA, Santry HP, Claridge JA, Towe CW, Koroukian SM. Functional Status is Key to Long-term Survival in Emergency General Surgery Conditions. J Surg Res 2023; 283:224-232. [PMID: 36423470 PMCID: PMC9923717 DOI: 10.1016/j.jss.2022.10.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 06/29/2022] [Accepted: 10/17/2022] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Emergency General Surgery (EGS) conditions in older patients constitutes a substantial public health burden due to high morbidity and mortality. We sought to utilize a supervised machine learning method to determine combinations of factors with the greatest influence on long-term survival in older EGS patients. METHODS We identified community dwelling participants admitted for EGS conditions from the Medicare Current Beneficiary Survey linked with claims (1992-2013). We categorized three binary domains of multimorbidity: chronic conditions, functional limitations, and geriatric syndromes (such as vision or hearing impairment, falls, incontinence). We also collected EGS disease type, age, and sex. We created a classification and regression tree (CART) model to identify groups of variables associated with our outcome of interest, three-year survival. We then performed Cox proportional hazards analysis to determine hazard ratios for each group with the lowest risk group as reference. RESULTS We identified 1960 patients (median age 79 [interquartile range [IQR]: 73, 85], 59.5% female). The CART model identified the presence of functional limitations as the primary splitting variable. The lowest risk group were patient aged ≤81 y with biliopancreatic disease and without functional limitations. The highest risk group was men aged ≥75 y with functional limitations (hazard ratio [HR] 11.09 (95% confidence interval [CI] 5.91-20.83)). Notably absent from the CART model were chronic conditions and geriatric syndromes. CONCLUSIONS More than the presence of chronic conditions or geriatric syndromes, functional limitations are an important predictor of long-term survival and must be included in presurgical assessment.
Collapse
Affiliation(s)
- Vanessa P Ho
- Department of Surgery, MetroHealth Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio; Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio.
| | - Wyatt P Bensken
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio
| | - J Alford Flippin
- Department of Surgery, MetroHealth Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Heena P Santry
- Department of Surgery, Kettering Hospital, Columbus, Ohio
| | - Jeffrey A Claridge
- Department of Surgery, MetroHealth Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Christopher W Towe
- Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Siran M Koroukian
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio
| |
Collapse
|
26
|
Tatebe LC, Ho VP, Santry HP, Tatebe K. Redefining trauma deserts: novel technique to accurately map prehospital transport time. Trauma Surg Acute Care Open 2023; 8:e001013. [PMID: 36704643 PMCID: PMC9872504 DOI: 10.1136/tsaco-2022-001013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 01/07/2023] [Indexed: 01/25/2023] Open
Abstract
Background Prehospital transport time has been directly related to mortality for hemorrhaging trauma patients. 'Trauma deserts' were previously defined as being outside of a 5-mile radial distance of an urban trauma center. We postulated that the true 'desert' should be based on transport time rather than transport distance. Methods Using the Chicagoland area that was used to describe 'trauma deserts,' a sequential process to query a commercial travel optimization product to map transport times over coordinates that covered the entire urban area at a particular time of day. This produces a heat map representing prehospital transport times. Travel times were then limited to 15 minutes to represent a temporally based map of transport capabilities. This was repeated during high and low traffic times and for centers across the city. Results We demonstrated that the temporally based map for transport to a trauma center in an urban center differs significantly from the radial distance to the trauma center. Primary effects were proximity to highways and the downtown area. Transportation to centers were significantly different when time was considered instead of distance (p<0.001). We were further able to map variations in traffic patterns and thus transport times by time of day. The truly 'closest' trauma center by time changed based on time of day and was not always the closest hospital by distance. Discussion As the crow flies is not how the ambulance drives. This novel technique of dynamically mapping transport times can be used to create accurate trauma deserts in an urban setting with multiple trauma centers. Further, this technique can be used to quantify the potential benefit or detriment of adding or removing firehouses or trauma centers.
Collapse
Affiliation(s)
- Leah C Tatebe
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Vanessa P Ho
- Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA,Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio, USA
| | - Heena P Santry
- Department of Surgery, Kettering Hospital, Columbus, Ohio, USA
| | - Ken Tatebe
- Department of Radiation Oncology, Rush University Medical Center, Chicago, Illinois, USA
| |
Collapse
|
27
|
Ho VP, Ingraham AM, Santry HP. Invited Commentary: Moving the Dial on Outcomes for Unplanned Abdominal Surgery. J Am Coll Surg 2023; 236:218-219. [PMID: 36519919 PMCID: PMC10829075 DOI: 10.1097/xcs.0000000000000430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Vanessa P. Ho
- Acute Care Surgery, MetroHealth Medical Center, Cleveland OH
- Department of Surgery, Case Western Reserve University School of Medicine, Cleveland OH
| | - Angela M. Ingraham
- Department of Surgery, University of Wisconsin School of Medicine, Madison, WI
| | - Heena P. Santry
- Acute Care Surgery, Kettering Medical Center, Kettering OH
- Department of Surgery, Wright State University Boonshoft School of Medicine, Dayton, OH
- NBBJ, LLC, Columbus, OH
| |
Collapse
|
28
|
Lai CK, Towe CW, Patel NJ, Brown LR, Claridge JA, Ho VP. Re-Admission in Patients with Necrotizing Soft Tissue Infections: Continuity of Care Matters. Surg Infect (Larchmt) 2022; 23:866-872. [PMID: 36394462 PMCID: PMC9784599 DOI: 10.1089/sur.2022.243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background: Necrotizing soft tissue infections (NSTIs) are rapidly progressive infections with high mortality and complication rates. The incidence of NSTIs has been increasing steadily whereas mortality has decreased; survivors have a high risk of re-hospitalization. We hypothesized that re-admission to the index hospital where the first admission occurred would be associated with better clinical outcomes compared with re-admission to a non-index hospital. Patients and Methods: We identified patients from the 2017 Nationwide Readmissions Database with an index admission for NSTIs and examined all-cause re-admissions within 90 days of discharge. We noted whether re-admission occurred at the index or a non-index hospital. Survey-weighted logistic regression identified factors associated with death at the first re-admission and re-admission to index hospital. We also compared patient outcomes between patients admitted to index versus non-index hospitals. Results: We identified 27,051 NSTI survivors, of whom 6,954 (25.7%) had an unplanned re-admission within 90 days. A large proportion of re-admission occurred at non-index hospitals (28.3%; n = 1,966). Factors associated with non-index re-admission included prolonged index length of stay, discharge to short-term hospital, and leaving against medical advice. Patients re-admitted to index hospitals had a lower mortality rate (4.7% vs. 6.7%; p = 0.003), lower admission costs (in $1000; 45 [23-88] vs. 50 [24-104]; p = 0.004) and higher discharge rate to home (55.7% vs. 48.6%; p < 0.001). Conclusions: More than one-quarter of re-admissions among NSTI survivors were to non-index hospitals. Continuity of care is important because re-admission to the index hospital was associated with better patient outcomes.
Collapse
Affiliation(s)
- Clara K.N. Lai
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Christopher W. Towe
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Nimitt J. Patel
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Laura R. Brown
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | | | - Vanessa P. Ho
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
- Department of Population and Quantitative Health Sciences, Case Western Reserve School of Medicine, Cleveland, Ohio, USA
| |
Collapse
|
29
|
Kishawi SK, Badrinathan A, Thai AP, Benuska SE, Breslin MA, Hendrickson SB, Ho VP. Are trauma surgical societies adequately addressing mental health after injury? Surgery 2022; 172:1549-1554. [PMID: 35981920 PMCID: PMC9942601 DOI: 10.1016/j.surg.2022.06.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/11/2022] [Accepted: 06/16/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Survivors of physical trauma, their home caregivers, and their medical providers all have an increased risk of developing psychological distress and trauma-related psychiatric disease. The purpose of this study was to describe the frequency and change over time of trauma society research presentations regarding mental health to identify opportunities for growth. METHODS Archives from 2018 to 2020 from the American Association for the Surgery of Trauma, the Eastern Association for the Surgery of Trauma, and the Western Trauma Association were reviewed. The studies that measured mental illness, psychosocial distress, and other psychosocial factors were assessed: for (1) the use of patient-reported outcome measures ; (2) the association of psychosocial variables with outcomes; and (3) the interventions investigated. Change over time was assessed using χ2 analysis. RESULTS Of 1,239 abstracts, 57 (4.6%) addressed at least 1 mental health-related factor. Mental health was more frequently studied over time (2018 [3.2%]; 2019 [3.5%]; 2020 [7.7%]; P = .003). The most frequently measured factors were post-traumatic stress disorder, quality of life, general mental health, and depression. Seventeen (29.8%) abstracts addressed substance abuse, most commonly opioid abuse. Seven (12.3%) abstracts measured mental health in caregivers or medical providers. Patient-reported outcome measures were used in 32 studies (56.1%). Two-thirds of studies reported findings suggesting that mental illness impairs trauma-related outcomes. Only 5 (8.8%) investigated interventions designed to reduce adverse outcomes. CONCLUSION Although academic discussion of mental health after trauma increased from 2018 to 2020, the topic remains a limited component of annual programs, patient-reported outcome measures remain underutilized, and intervention studies are rare.
Collapse
Affiliation(s)
- Sami K Kishawi
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, Ohio; Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio; Case Western Reserve University, School of Medicine, Cleveland, Ohio. http://www.twitter.com/skkishawi
| | - Avanti Badrinathan
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio; Case Western Reserve University, School of Medicine, Cleveland, Ohio
| | - Anthony P Thai
- Case Western Reserve University, School of Medicine, Cleveland, Ohio
| | - Sarah E Benuska
- Department of Psychiatry, MetroHealth Medical Center, Cleveland, Ohio
| | - Mary A Breslin
- Institute for H.O.P.E.(TM), Center for Health Resilience, The MetroHealth System, Cleveland, Ohio. http://www.twitter.com/MaryA_Breslin
| | - Sarah B Hendrickson
- Institute for H.O.P.E.(TM), Center for Health Resilience, The MetroHealth System, Cleveland, Ohio; Department of Counselor Education and Supervision, Ohio University, Athens, Ohio. http://www.twitter.com/SHendricksonCLE
| | - Vanessa P Ho
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, Ohio; Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio.
| |
Collapse
|
30
|
Bensken WP, Schiltz NK, Warner DF, Kim DH, Wei MY, Quiñones AR, Ho VP, Kelley AS, Owusu C, Kent EE, Koroukian SM. Comparing the association between multiple chronic conditions, multimorbidity, frailty, and survival among older patients with cancer. J Geriatr Oncol 2022; 13:1244-1252. [PMID: 35786369 PMCID: PMC9798334 DOI: 10.1016/j.jgo.2022.06.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 06/06/2022] [Accepted: 06/22/2022] [Indexed: 01/01/2023]
Abstract
INTRODUCTION The high prevalence of multiple chronic conditions (MCC), multimorbidity, and frailty may affect treatment and outcomes for older adults with cancer. The goal of this study was to use three conceptually distinct measures of morbidity to examine the association between these measures and mortality. MATERIALS AND METHODS Using Medicare claims data linked with the 2012-2016 Ohio Cancer Incidence Surveillance System we identified older adults with incident primary cancer sites of breast, colorectal, lung, or prostate (n = 29,140). We used claims data to identify their Elixhauser comorbidities, Multimorbidity-Weighted Index (MWI), and Claims Frailty Index (CFI) as measures of MCC, multimorbidity, and frailty, respectively. We used Cox proportional hazard models to examine the association between these measures and survival time since diagnosis. RESULTS Lung cancer patients had the highest levels of MCC, multimorbidity, and frailty. There was a positive association between all three measures and a greater hazard of death after adjusting for age, sex (colorectal and lung only), and stage. Breast cancer patients with 5+ comorbidities had an adjusted hazard ratio (aHR) of 1.63 (95% confidence interval [CI]: 1.38, 1.93), and those with mild frailty had an aHR of 3.38 (95% CI; 2.12, 5.41). The C statistics for breast cancer were 0.79, 0.78, and 0.79 for the MCC, MWI, and CFI respectively. Similarly, lung cancer patients who were moderately or severely frail had an aHR of 1.82 (95% CI: 1.53, 2.18) while prostate cancer patients had an aHR of 3.39 (95% CI: 2.12, 5.41) and colorectal cancer patients had an aHR of 4.51 (95% CI: 3.23, 6.29). Model performance was nearly identical across the MCC, multimorbidity, and frailty models within cancer type. The models performed best for prostate and breast cancer, and notably worse for lung cancer. The frailty models showed the greatest separation in unadjusted survival curves. DISCUSSION The MCC, multimorbidity, and frailty indices performed similarly well in predicting mortality among a large cohort of older cancer patients. However, there were notable differences by cancer type. This work highlights that although model performance is similar, frailty may serve as a clearer indicator in risk stratification of geriatric oncology patients than simple MCCs or multimorbidity.
Collapse
Affiliation(s)
- Wyatt P Bensken
- Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, OH, United States of America; Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH, United States of America.
| | - Nicholas K Schiltz
- Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, OH, United States of America; Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, United States of America
| | - David F Warner
- Department of Sociology, University of Alabama at Birmingham, Birmingham, AL, United States of America; Center for Family & Demographic Research, Bowling Green State University, Bowling Green, OH, United States of America
| | - Dae H Kim
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, United States of America; Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States of America
| | - Melissa Y Wei
- Division of General Internal Medicine and Health Services Research, Department of Internal Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States of America; Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, United States of America
| | - Ana R Quiñones
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, United States of America; OHSU-PSU School of Public Health, Oregon Health & Science University, Portland, OR, United States of America
| | - Vanessa P Ho
- Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, OH, United States of America; Department of Surgery, MetroHealth Medical Center, Cleveland, OH, United States of America
| | - Amy S Kelley
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Cynthia Owusu
- Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH, United States of America; Division of Hematology/Oncology, Department of Medicine, Case Western Reserve University, School of Medicine, Cleveland, OH, United States of America
| | - Erin E Kent
- Gillings School of Global Public Health, Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Siran M Koroukian
- Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, OH, United States of America; Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH, United States of America
| |
Collapse
|
31
|
Ferre AC, Curtis J, Flippin JA, Claridge JA, Tseng ES, Brown LR, Ho VP. Do new trauma centers provide needed or redundant access? A nationwide analysis. J Trauma Acute Care Surg 2022; 93:347-352. [PMID: 35647793 PMCID: PMC9615221 DOI: 10.1097/ta.0000000000003652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Our prior research has demonstrated that increasing the number of trauma centers (TCs) in a state does not reliably improve state-level injury-related mortality. We hypothesized that many new TCs would serve populations already served by existing TCs, rather than in areas without ready TC access. We also hypothesized that new TCs would also be less likely to serve economically disadvantaged populations. METHODS All state-designated adult TCs registered with the American Trauma Society in 2014 and 2019 were mapped using ArcGIS Pro (ESRI Inc., Redlands, CA). Trauma centers were grouped as Level 1 or 2 (Lev12) or Level 3, 4 or 5 (Lev345). We also obtained census tract-level data (73,666 tracts), including population counts and percentage of population below the federal poverty threshold. Thirty-minute drive-time areas were created around each TC. Census tracts were considered "served" if their geographic centers were located within a 30-minute drive-time area to any TC. Data were analyzed at the census tract level. RESULTS A total of 2,140 TCs were identified in 2019, with 256 new TCs and 151 TC closures. Eighty-two percent of new TCs were Levels 3 to 5. Nationwide, coverage increased from 75.3% of tracts served in 2014 to 78.1% in 2019, representing an increased coverage from 76.0% to 79.4% of the population. New TC served 17,532 tracts, of which 87.3% were already served. New Lev12 TCs served 9,100 tracts, of which 91.2% were already served; new Lev345 TCs served 15,728 tracts, of which 85.9% were already served. Of 2,204 newly served tracts, those served by Lev345 TCs had higher mean percentage poverty compared with those served by Lev12 TCs (15.7% vs. 13.2% poverty, p < 0.05). DISCUSSION Overall, access to trauma care has been improving in the United States. However, the majority of new TCs opened in locations with preexisting access to trauma care. Nationwide, Levels 3, 4, and 5 TCs have been responsible for expanding access to underserved populations. LEVEL OF EVIDENCE Prognostic and Epidemiologic; Level IV.
Collapse
Affiliation(s)
- Alexandra C. Ferre
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, OH
- Digestive Disease & Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Jacqueline Curtis
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH
| | - J. Alford Flippin
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, OH
| | - Jeffrey A. Claridge
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, OH
| | - Esther S. Tseng
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, OH
| | - Laura R. Brown
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, OH
| | - Vanessa P. Ho
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, OH
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH
| |
Collapse
|
32
|
Villarin S, Flippin JA, Bensken WP, Curfman E, Towe CW, Claridge JA, Ho VP. What if You Need More Than One? More Acute Care Surgery Procedures Are Associated with Mortality. Surg Infect (Larchmt) 2022; 23:525-531. [PMID: 35917385 PMCID: PMC9398479 DOI: 10.1089/sur.2021.309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: It is unknown whether having multiple acute care surgery (ACS) procedures performed in one admission confers additional risk. We hypothesized that having multiple procedures (for example, hernia repair plus bowel resection) would be associated with higher mortality. Patients and Methods: We identified all 2017 National Inpatient Sample admissions with ACS procedures including: colon, small bowel/appendix (SB), hernia, adhesiolysis, peptic ulcer procedures, gallbladder, debridement, other laparotomy, other laparoscopy. The total number of procedures for each admission and common dyad (two-procedure) and triad (three-procedure) combinations were identified. Logistic regression estimated the odds of in-hospital mortality for increasing procedure count and specific dyad and triad combinations, using patients with one procedure as the reference. Results: A total of 216,317 ACS patients (median age, 57, interquartile range [IQR], 43-70; 50.6% female) were included; 2.8% died. Patients with multiple procedures were more likely to die than patients with one procedure (7.4% vs. 1.9%). An increasing number of procedures was associated with higher odds of death (two procedures: odds ratio [OR], 3.0; 95% confidence interval [CI], 2.9-3.2] to six or more procedures, OR, 9.5; 95% CI, 4.9-18.5); having more than three procedures was associated with at least fivefold higher odds of death. Specific dyads/triads were associated with particularly high risk of mortality, including ulcer/laparotomy (OR, 15.5; 95% CI, 13.7-17.5) and laparotomy/SB (OR, 8.31; 95% CI, 5.15-13.40). Conclusions: Multiple ACS procedures in one hospitalization confer increased odds of in-hospital mortality. This knowledge enables the ACS providers to better counsel patients by giving more specific expectations regarding mortality based on the number of procedures required or anticipated during an admission.
Collapse
Affiliation(s)
- Sigfredo Villarin
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - J Alford Flippin
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Wyatt P Bensken
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Eric Curfman
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Christopher W Towe
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | | | - Vanessa P Ho
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA.,Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| |
Collapse
|
33
|
DeMario BS, Stanley SP, Truong EI, Ladhani HA, Brown LR, Ho VP, Kelly ML. Predictors for Withdrawal of Life-Sustaining Therapies in Patients With Traumatic Brain Injury: A Retrospective Trauma Quality Improvement Program Database Study. Neurosurgery 2022; 91:e45-e50. [PMID: 35471648 PMCID: PMC9514740 DOI: 10.1227/neu.0000000000002020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 03/05/2022] [Indexed: 12/21/2022] Open
Abstract
Many patients with severe traumatic brain injuries (TBIs) undergo withdrawal of life-sustaining therapies (WLSTs) or transition to comfort measures, but noninjury factors that influence this decision have not been well characterized. We hypothesized that WLST would be associated with institutional and geographic noninjury factors. All patients with a head Abbreviated Injury Scale score ≥3 were identified from 2016 Trauma Quality Improvement Program data. We analyzed factors that might be associated with WLST, including procedure type, age, sex, race, insurance, Glasgow Coma Scale score, mechanism of injury, geographic region, and institutional size and teaching status. Adjusted logistic regression was performed to examine factors associated with WLST. Sixty-nine thousand fifty-three patients were identified: 66% male, 77% with isolated TBI, and 7.8% had WLST. The median age was 56 years (34-73). A positive correlation was found between increasing age and WLST. Women were less likely to undergo WLST than men (odds ratio 0.91 [0.84-0.98]) and took more time to for WLST (3 vs 2 days, P < .001). African Americans underwent WLST at a significantly lower rate (odds ratio 0.66 [0.58-0.75]). Variations were also discovered based on US region, hospital characteristics, and neurosurgical procedures. WLST in severe TBI is independently associated with noninjury factors such as sex, age, race, hospital characteristics, and geographic region. The effect of noninjury factors on these decisions is poorly understood; further study of WLST patterns can aid health care providers in decision making for patients with severe TBI.
Collapse
Affiliation(s)
| | - Samuel P. Stanley
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Evelyn I. Truong
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Husayn A. Ladhani
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Laura R. Brown
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Vanessa P. Ho
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Michael L. Kelly
- Department of Neurological Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, Ohio, USA
| |
Collapse
|
34
|
Gray KE, Sarode A, Jiang B, Alvarado CE, Sinopoli J, Linden PA, Worrell SG, Ho VP, Argote-Greene LM, Towe CW. Surgical Repair Versus Stent for Esophageal Perforation: A Multi-institutional Database Analysis. Ann Thorac Surg 2022; 115:1378-1384. [PMID: 35921860 DOI: 10.1016/j.athoracsur.2022.07.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 04/17/2022] [Accepted: 07/19/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Endoscopic esophageal stenting is used as an alternative to surgical repair for esophageal perforation. Multi-institutional studies supporting stenting are lacking. The purpose of this study was to compare the outcomes of surgical repair and esophageal stenting in patients with esophageal perforation using a nationally representative database. We hypothesized that mortality between these approaches would not be different. METHODS The Premier Healthcare Database was used to compare adult inpatients with esophageal perforation receiving either surgical repair or esophageal stenting from 2009 to 2019. Patients receiving intervention ≤7 days of admission were included in the analysis. Patients receiving both stent and repair on the same day were excluded. The composite outcome of interest was death or discharge to hospice. Logistic regression was used to evaluate independent predictors of death or hospice, adjusting for comorbidities. RESULTS There were 2543 patients with esophageal perforation identified who received repair (1314 [51.7%]) or stenting (1229 [48.3%]). Stenting increased from 7.0% in 2009 to 78.1% in 2019. Patients receiving repair were more likely to be female and White and had fewer Elixhauser comorbidities. Death or discharge to hospice was more common after stent (134/1314 [10.2%] repair vs 199/1229 [16.2%] stent; P < .001); however, after adjustment for comorbidities, logistic regression suggested that death or hospice discharge was similar between approaches (stent vs repair: odds ratio, 1.074; 95% CI, 0.81-1.42; P = .622). Hospital length of stay was shorter after stenting (stent vs repair coefficient, -4.09; P < .001). CONCLUSIONS In patients with esophageal perforation, the odds for death or discharge to hospice were similar for esophageal stenting compared with surgical repair.
Collapse
Affiliation(s)
- Kelsey E Gray
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio.
| | - Anuja Sarode
- Department of Surgery, University Hospitals Research in Surgical Outcomes and Effectiveness (UH-RISES), University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Boxiang Jiang
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Christine E Alvarado
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Jillian Sinopoli
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Phillip A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Stephanie G Worrell
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Vanessa P Ho
- Division of Trauma, Critical Care, Burns and Acute Care Surgery, Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio
| | - Luis M Argote-Greene
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| |
Collapse
|
35
|
Kishawi SK, Tseng ES, Adomshick VJ, Towe CW, Ho VP. Race and trauma mortality: The effect of hospital-level Black-White patient race distribution. J Trauma Acute Care Surg 2022; 92:958-966. [PMID: 35125445 PMCID: PMC9133009 DOI: 10.1097/ta.0000000000003538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Race-related health disparities have been well documented in the United States. In some settings, Black patients have better outcomes in hospitals that serve high proportions of Black patients. We hypothesized that Black trauma patients would have lower mortality in high Black-serving (H-BS) hospitals. METHODS We identified all adult patients with Black or White race and with an Injury Severity Score of ≥4 from the 2017 National Inpatient Sample. We collected hospital identifier, mechanism, age, sex, comorbidities, urban-rural location, insurance, zip code income quartile, and injury severity calculated from International Classification of Diseases, Tenth Revision, codes. We used a previously published method to group hospitals by proportion of Black patients served: HB-S (top 5%), medium Black serving (5-25%), and low Black serving (L-BS; bottom 75%). Adjusted logistic regression using an interaction variable between race and hospital service rank (reference: White patients in H-BS) was used to identify factors associated with mortality. RESULTS We analyzed 184,080 trauma patients (median age, 72 years [interquartile range, 55-84 years]; Injury Severity Score, 9 [4-10]), of whom 11.7% were Black. Overall mortality was 4%. Of 2,376 hospitals, 126 (5.3%) were H-BS and 469 (19.7%) were medium Black serving. Furthermore, 29.8% of Black and 3.6% of White patients were treated at H-BS hospitals, while 71.7% of White and 23.6% of Black patients were treated at L-BS hospitals (p < 0.001). Black patients had the lowest mortality at H-BS hospitals (odds ratio [OR], 0.76 [0.64-0.92]) and the highest mortality (OR, 1.43 [1.13-1.80]) at L-BS hospitals. White patients had the lowest mortality at L-BS hospitals (OR, 0.76 [0.64-0.92]). CONCLUSION After adjusting for patient and hospital factors, disparities exist such that Black and White patients have the best outcomes in hospitals that treat those patients most frequently, suggesting potential for racial bias at the institutional level. Further efforts must be made to promote equitable treatment at all hospitals and reduce these disparities. LEVEL OF EVIDENCE Prognostic and Epidemiologic; Level IV.
Collapse
Affiliation(s)
- Sami K. Kishawi
- MetroHealth Medical Center, Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, 2500 MetroHealth Drive, Cleveland, OH 44109
- University Hospitals Cleveland Medical Center, Department of Surgery, 11100 Euclid Avenue, Lakeside 7 Floor, Cleveland, OH 44106
- Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH 44106
| | - Esther S. Tseng
- MetroHealth Medical Center, Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, 2500 MetroHealth Drive, Cleveland, OH 44109
- Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH 44106
| | - Victoria J. Adomshick
- Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH 44106
| | - Christopher W. Towe
- University Hospitals Cleveland Medical Center, Department of Surgery, 11100 Euclid Avenue, Lakeside 7 Floor, Cleveland, OH 44106
- Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH 44106
| | - Vanessa P. Ho
- MetroHealth Medical Center, Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, 2500 MetroHealth Drive, Cleveland, OH 44109
- Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH 44106
| |
Collapse
|
36
|
Ho VP, Bensken WP, Warner DF, Claridge JA, Santry HP, Robenstine JC, Towe CW, Koroukian SM. Association of Complex Multimorbidity and Long-term Survival After Emergency General Surgery in Older Patients With Medicare. JAMA Surg 2022; 157:499-506. [PMID: 35476053 PMCID: PMC9047756 DOI: 10.1001/jamasurg.2022.0811] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Importance Although nearly 1 million older patients are admitted for emergency general surgery (EGS) conditions yearly, long-term survival after these acute diseases is not well characterized. Many older patients with EGS conditions have preexisting complex multimorbidity defined as the co-occurrence of at least 2 of 3 key domains: chronic conditions, functional limitations, and geriatric syndromes. The hypothesis was that specific multimorbidity domain combinations are associated with differential long-term mortality after patient admission with EGS conditions. Objective To examine multimorbidity domain combinations associated with increased long-term mortality after patient admission with EGS conditions. Design, Setting, and Participants This cohort study included community-dwelling participants aged 65 years and older from the Medicare Current Beneficiary Survey with linked Medicare data (January 1992 through December 2013) and admissions for diagnoses consistent with EGS conditions. Surveys on health and function from the year before EGS conditions were used to extract the 3 domains: chronic conditions, functional limitations, and geriatric syndromes. The number of domains present were summed to calculate a categorical rank: no multimorbidity (0 or 1), multimorbidity 2 (2 of the 3 domains present), and multimorbidity 3 (all 3 domains present). Whether operative treatment was provided during the admission was also identified. Data were cleaned and analyzed between January 16, 2020, and April 29, 2021. Exposures Mutually exclusive multimorbidity domain combinations (functional limitations and geriatric syndromes; functional limitations and chronic conditions; chronic conditions and geriatric syndromes; or functional limitations, geriatric syndromes, and chronic conditions). Main Outcomes and Measures Time to death (up to 3 years from EGS conditions admission) in patients with multimorbidity combinations was analyzed using a Cox proportional hazards model and compared with those without multimorbidity; hazard ratios (HRs) and 95% CIs are presented. Models were adjusted for age, sex, and operative treatment. Results Of 1960 patients (median [IQR] age, 79 [73-85] years; 1166 [59.5%] women), 383 (19.5%) had no multimorbidity, 829 (42.3%) had 2 multimorbidity domains, and 748 (38.2%) had all 3 domains present. A total of 376 (19.2%) were known to have died in the follow-up period, with a median (IQR) follow-up of 377 (138-621) days. Patients with chronic conditions and geriatric syndromes had a mortality risk similar to those without multimorbidity. However, all domain combinations with functional limitations were associated with significantly increased risk of death: functional limitations and chronic conditions (HR, 1.83; 95% CI, 1.03-3.23); functional limitations and geriatric syndromes (HR, 2.91; 95% CI, 1.37-6.18); and functional limitations, geriatric syndromes, and chronic conditions (HR, 2.08; 95% CI, 1.49-2.89). Conclusions and Relevance Findings of this study suggest that a patient's baseline complex multimorbidity level efficiently identifies risk stratification groups for long-term survival. Functional limitations are rarely considered in risk stratification paradigms for older patients with EGS conditions compared with chronic conditions and geriatric syndromes. However, functional limitations may be the most important risk factor for long-term survival.
Collapse
Affiliation(s)
- Vanessa P Ho
- Division of Trauma, Critical Care, Burn, and Acute Care Surgery, Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio.,Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio
| | - Wyatt P Bensken
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio
| | - David F Warner
- Department of Sociology, University of Alabama at Birmingham, Birmingham.,Center for Family & Demographic Research, Bowling Green State University, Bowling Green, Ohio
| | - Jeffrey A Claridge
- Division of Trauma, Critical Care, Burn, and Acute Care Surgery, Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio
| | - Heena P Santry
- Department of Surgery, Kettering Health, Kettering, Ohio.,NBBJ Design, Columbus, Ohio
| | - Jacinta C Robenstine
- Division of Trauma, Critical Care, Burn, and Acute Care Surgery, Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio
| | - Christopher W Towe
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Siran M Koroukian
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio
| |
Collapse
|
37
|
Ho VP, Bensken WP, Santry HP, Towe CW, Warner DF, Connors AF, Koroukian SM. Heath status, frailty, and multimorbidity in patients with emergency general surgery conditions. Surgery 2022; 172:446-452. [DOI: 10.1016/j.surg.2022.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 02/02/2022] [Accepted: 02/20/2022] [Indexed: 10/18/2022]
|
38
|
Ferre AC, Ho VP, Lasinski A, Claridge JA. Content and Accessibility of Surgical Critical Care Fellowship Websites in the United States. Am Surg 2022:31348221074233. [PMID: 35113674 PMCID: PMC10167647 DOI: 10.1177/00031348221074233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Resident physicians are using the Internet to gather information about graduate medical education programs. The content of fellowship websites has been demonstrated to influence applicants' decisions. The purpose of this study was to evaluate the content of the surgical critical care fellowship (SCCF) program websites. METHODS A list of Eastern Association for the Surgery of Trauma (EAST) and American Association for the Surgery of Trauma (AAST) SCCF programs was obtained, and compared to the Accreditation Council for Graduate Medical Education (ACGME) list of accredited programs. The accessibility of each website was assessed through Google®. Content areas were assessed for each SCCF website. RESULTS At the time of this study, 76 SCCF were listed on the EAST website and an additional 14 were supplied by the AAST database. 125 programs were listed in the ACGME database. Of the 76 SCCF listed by EAST, 44 (58%), 32 (42%), and 7 (9%) of SCCF programs had an EAST listing that was 3, 5, or 10 years or more out of date, respectively. Of the 90 SCCF programs listed on EAST or AAST sites, 36 programs (40%) had an inaccurate PD named on their listing. One hundred and nineteen of the 125 (95%) SCCF programs had websites accessible through Google®. Only 25 (20%) programs had a website containing a program description, faculty list, curriculum, and current/past fellows list. CONCLUSIONS Many SCCF websites lacked information regarding program specifics. Valuable information for potential applicants was inadequate across SCCF websites.
Collapse
Affiliation(s)
| | - Vanessa P Ho
- Department of General Surgery, Trauma and Surgical Critical Care, 2559Metro Health Medical Center, Cleveland, OH, USA
| | - Alaina Lasinski
- Department of General Surgery, Trauma and Surgical Critical Care, 2559Metro Health Medical Center, Cleveland, OH, USA
| | - Jeffrey A Claridge
- Department of General Surgery, Trauma and Surgical Critical Care, 2559Metro Health Medical Center, Cleveland, OH, USA
| |
Collapse
|
39
|
Coffey MR, Bachman KC, Ho VP, Worrell SG, Moorman ML, Linden PA, Towe CW. Iatrogenic rib fractures and the associated risks of mortality. Eur J Trauma Emerg Surg 2022; 48:231-241. [PMID: 33496799 PMCID: PMC8310895 DOI: 10.1007/s00068-020-01598-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 12/27/2020] [Indexed: 02/03/2023]
Abstract
PURPOSE Rib fractures, though typically associated with blunt trauma, can also result from complications of medical or surgical care, including cardiopulmonary resuscitation. The purpose of this study is to describe the demographics and outcomes of iatrogenic rib fractures. METHODS Patients with rib fractures were identified in the 2016 National Inpatient Sample. Mechanism of injury was defined as blunt traumatic rib fracture (BTRF) or iatrogenic rib fracture (IRF). IRF was identified as fractures from the following mechanisms: complications of care, drowning, suffocation, and poisoning. Differences between BTRF and IRF were compared using rank-sum test, Chi-square test, and multivariable regression. RESULTS 34,644 patients were identified: 33,464 BTRF and 1180 IRF. IRF patients were older and had higher rates of many comorbid medical disorders. IRF patients were more likely to have flail chest (6.1% versus 3.1%, p < 0.001). IRF patients were more likely to have in-hospital death (20.7% versus 4.2%, p < 0.001) and longer length of hospitalization (11.8 versus 6.9 days, p < 0.001). IRF patients had higher rates of tracheostomy (30.2% versus 9.1%, p < 0.001). In a multivariable logistic regression of all rib fractures, IRF was independently associated with death (OR 3.13, p < 0.001). A propensity matched analysis of IRF and BTRF groups corroborated these findings. CONCLUSION IRF injuries are sustained in a subset of extremely ill patients. Relative to BTRF, IRF is associated with greater mortality and other adverse outcomes. This population is understudied. The etiology of worse outcomes in IRF compared to BTRF is unclear. Further study of this population could address this disparity.
Collapse
Affiliation(s)
- Max R. Coffey
- Case Western Reserve University School of Medicine, Cleveland, OH, United States,University Hospitals Cleveland Medical Center, Department of Surgery, Cleveland, OH, United States
| | - Katelynn C. Bachman
- Case Western Reserve University School of Medicine, Cleveland, OH, United States,University Hospitals Cleveland Medical Center, Department of Surgery, Cleveland, OH, United States
| | - Vanessa P. Ho
- Case Western Reserve University School of Medicine, Cleveland, OH, United States,MetroHealth Medical Center, Department of Surgery, Division of Trauma, Critical Care, Burns, & Acute Care Surgery, Cleveland, OH, United States
| | - Stephanie G. Worrell
- Case Western Reserve University School of Medicine, Cleveland, OH, United States,University Hospitals Cleveland Medical Center, Department of Surgery, Cleveland, OH, United States
| | - Matthew L. Moorman
- Case Western Reserve University School of Medicine, Cleveland, OH, United States,University Hospitals Cleveland Medical Center, Department of Surgery, Cleveland, OH, United States
| | - Philip A. Linden
- Case Western Reserve University School of Medicine, Cleveland, OH, United States,University Hospitals Cleveland Medical Center, Department of Surgery, Cleveland, OH, United States
| | - Christopher W. Towe
- Case Western Reserve University School of Medicine, Cleveland, OH, United States,University Hospitals Cleveland Medical Center, Department of Surgery, Cleveland, OH, United States
| |
Collapse
|
40
|
Ferre AC, DeMario BS, Ho VP. Narrative review of palliative care in trauma and emergency general surgery. Ann Palliat Med 2022; 11:936-946. [PMID: 34551577 PMCID: PMC8901564 DOI: 10.21037/apm-20-2428] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 08/23/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The purpose of this article is to discuss the goals of palliative care with regards to acute care surgery patients and review the literature regarding administration and implementation of palliative programs. BACKGROUND For patients who experience unexpected and sometimes catastrophic life changes related to trauma or emergency general surgery, palliative care is a crucial adjunct that can help ensure the provision of optimal symptom management, communication, and goal-concordant care provided. METHODS Palliative care is medical specialty with a philosophy of care focused on improving the quality of life for patients with serious injury or illness and their loved ones. Palliative care provides significant benefit across the entire spectrum of illness and injury, regardless of prognosis. We will discuss palliative care topics related to trauma and emergency general surgery patients, including symptom management, goal setting, end of life care, communication strategies, addressing implicit/explicit bias, trauma-specific and emergency general surgery-specific considerations, and implementation strategies to reduce barriers for utilization of palliative care. CONCLUSIONS Unfortunately, palliative care is often underutilized in the trauma and emergency general surgery population. Acute care surgeons should be familiar with principles of primary palliative care, as well as understand the added benefits that be provided by consultant palliative care specialists.
Collapse
Affiliation(s)
- Alexandra C. Ferre
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | | | - Vanessa P. Ho
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA;,Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| |
Collapse
|
41
|
Kashkoush A, Petitt JC, Ladhani H, Ho VP, Kelly ML. Predictors of Mortality, Withdrawal of Life-Sustaining Measures, and Discharge Disposition in Octogenarians with Subdural Hematomas. World Neurosurg 2022; 157:e179-e187. [PMID: 34626845 PMCID: PMC8692425 DOI: 10.1016/j.wneu.2021.09.121] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 09/27/2021] [Accepted: 09/28/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Risk factors for mortality in patients with subdural hematoma (SDH) include poor Glasgow Coma Scale (GCS) score, pupil nonreactivity, and hemodynamic instability on presentation. Little is published regarding prognosticators of SDH in the elderly. This study aims to examine risk factors for hospital mortality and withdrawal of life-sustaining measures in an octogenarian population presenting with SDH. METHODS A prospectively collected multicenter database of 3279 traumatic brain injury admissions to 45 different U.S. trauma centers between 2017 and 2019 was queried to identify patients aged >79 years old presenting with SDH. Factors collected included baseline demographic data, past medical history, antiplatelet/anticoagulant use, and clinical presentation (GCS, pupil reactivity, injury severity scale [ISS]). Primary outcome data included hospital mortality/discharge to hospice care and withdrawal of life-sustaining measures. Multivariate logistic regression analyses were used to identify factors independently associated with primary outcome variables. RESULTS A total of 695 patients were isolated for analysis. Of the total cohort, the rate of hospital mortality or discharge to hospice care was 22% (n = 150) and the rate of withdrawal of life-sustaining measures was 10% (n = 66). A multivariate logistic regression model identified GCS <13, pupil nonreactivity, increasing ISS, intraventricular hemorrhage, and neurosurgical intervention as factors independently associated with hospital mortality/hospice. Congestive heart failure (CHF), hypotension, GCS <13, and neurosurgical intervention were independently associated with withdrawal of life-sustaining measures. CONCLUSIONS Poor GCS, pupil nonreactivity, ISS, and intraventricular hemorrhage are independently associated with hospital mortality or discharge to hospice care in patients >80 years with SDH. Pre-existing CHF may further predict withdrawal of life-sustaining measures.
Collapse
Affiliation(s)
- Ahmed Kashkoush
- Department of Neurological Surgery, Cleveland Clinic Foundation, Cleveland, OH, United States of America. (9500 Euclid Ave, Cleveland, OH 44195)
| | - Jordan C. Petitt
- Department of Neurological Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, Ohio, USA. (2500 MetroHealth Drive Cleveland, Ohio 44109)
| | - Husayn Ladhani
- Department of Neurological Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, Ohio, USA. (2500 MetroHealth Drive Cleveland, Ohio 44109)
| | - Vanessa P. Ho
- Division of Trauma and Acute Care Surgery, Department of Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, Ohio, USA. (2500 MetroHealth Drive Cleveland, Ohio 44109)
| | - Michael L. Kelly
- Department of Neurological Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, Ohio, USA. (2500 MetroHealth Drive Cleveland, Ohio 44109)
| | | |
Collapse
|
42
|
DeMario B, Robenstine J, Tseng ES, Douglass F, Como JJ, Claridge JA, Ho VP. "What Are My Injuries?" Health Literacy and Patient Comprehension of Trauma Care and Injuries. J Surg Res 2021; 268:105-111. [PMID: 34298209 PMCID: PMC10877543 DOI: 10.1016/j.jss.2021.06.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/03/2021] [Accepted: 06/08/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Trauma patients often have complex injuries treated by multidisciplinary providers with wide-ranging expertise. We hypothesized that trauma patients would frequently incorrectly identify both their injuries and care teams. We also hypothesized that low health literacy level would be correlated with low levels of comprehension about injuries or care teams. MATERIALS AND METHODS We performed a prospective study of adult trauma inpatients >18 years. Participants were surveyed to report on 1) injured body regions 2) their care teams, and 3) health literacy via a validated survey. Self-reported injuries and care teams were compared to the patient's medical record. We also studied whether health literacy was associated with patient knowledge of injuries and care teams. RESULTS Fifty participants were surveyed; thirty-two percent could not identify ≥50% of their injuries. Patients reliably identified injuries to the head, but injuries to other body areas were often misidentified. Forty-two percent of patients were not able to identify ≥50% of their medical teams, and 28% could not identify ≥75% of their medical teams. Patients often did not recognize teams such as nutrition, physical/occupationalt, or social work as part of their care. Thirteen participants reported adequate health literacy. Health literacy was not related to participant knowledge of injuries or care teams (both P = 0.9). CONCLUSION Many trauma inpatients were unable to correctly identify their injuries and care teams despite a range of self-reported health literacy scores.
Collapse
Affiliation(s)
- Belinda DeMario
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio
| | - Jacinta Robenstine
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio
| | - Esther S Tseng
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio
| | - Francisca Douglass
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio
| | - John J Como
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio
| | - Jeffrey A Claridge
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio
| | - Vanessa P Ho
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio; Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio.
| |
Collapse
|
43
|
Linden PA, Towe CW, Worrell SG, Jiang B, Ho VP, Argote-Greene L, Bachman K, Perry Y. Drain Amylase: A Simple and Versatile Method of Detecting Esophageal Anastomotic Leaks. Ann Thorac Surg 2021; 113:1794-1800. [PMID: 34437855 DOI: 10.1016/j.athoracsur.2021.07.062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 06/15/2021] [Accepted: 07/19/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Anastomotic leak following esophagectomy is a significant cause of morbidity. Perianastomotic drain amylase is accurate in detecting leaks, but it is unclear whether its accuracy is affected by comorbid conditions, anastomotic method, or anastomotic location. We hypothesized that drain amylase would accurately discriminate leak in a variety of settings. METHODS We reviewed 290 consecutive patients undergoing esophagectomy with gastric conduit reconstruction. Patient comorbidities, operative variables, and drain amylase were collected. The diagnosis of a leak was based on the level of intervention required, and was characterized as "clinically significant" if it required wound opening, endoscopic or surgical intervention. Receiver operating characteristic curves analysis was performed to determine the accuracy of amylase to detect leak for each patient variable. RESULTS 53/290 (18.3%) esophagectomies had an anastomotic leak, of which 33/290 (11.4%) were clinically significant. Drain amylase was a strong predictor of anastomotic leak on postoperative days 3-7, regardless of patient comorbidities, location of anastomosis, or technique of anastomosis, but was less accurate in the diagnosis of leak in current smokers (AUC 0.530 vs 0.752, p= 0.006). A maximum drain amylase value no higher than 35 on postoperative 3, 4 or 5 was 88% sensitive in detecting leak at any point postoperatively. A value >=150 was 88% specific in diagnosing leak CONCLUSIONS: Drain amylase is a versatile method for early detection of anastomotic leaks. Its accuracy is unaffected by neoadjuvant treatment, location or type of anastomosis or patient comorbidities, but may be less accurate in active smokers.
Collapse
Affiliation(s)
- Philip A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, OH.
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, OH
| | - Stephanie G Worrell
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, OH
| | - Boxiang Jiang
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, OH
| | - Vanessa P Ho
- Department of Surgery, Metrohealth Hospital and Case Western Reserve School of Medicine, Cleveland, OH
| | - Luis Argote-Greene
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, OH
| | - Katelynn Bachman
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, OH
| | - Yaron Perry
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, OH
| |
Collapse
|
44
|
Haines LK, Cook AC, Hatchimonji JS, Ho VP, Kalbfell EL, O'Connell KM, Robenstine JC, Schlögl M, Toevs CC, Jones CA, Krouse RS, Martin ND. Top Ten Tips Palliative Care Clinicians Should Know About Trauma and Emergency Surgery. J Palliat Med 2021; 24:1072-1077. [PMID: 34128716 DOI: 10.1089/jpm.2021.0158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
There is growing interest in, and need for, integrating palliative care (PC) into the care of patients undergoing emergency surgery and those with traumatic injury. Thus, PC consults for these populations will likely grow in the coming years. Understanding the nuances and unique characteristics of these two acutely ill populations will improve the care that PC clinicians can provide. Using a modified Delphi technique, this article offers 10 tips that experts in the field, based on their broad clinical experience, believe PC clinicians should know about the care of trauma and emergency surgery patients.
Collapse
Affiliation(s)
- Lindsay K Haines
- Department of Medicine and the Palliative and Advanced Illness Research Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Allyson C Cook
- Department of Medicine and University of California San Francisco, San Francisco, California, USA.,Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Justin S Hatchimonji
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Vanessa P Ho
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA.,Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Elle L Kalbfell
- Department of Surgery, University of Wisconsin-Madison, Wisconsin, USA
| | - Kathleen M O'Connell
- Department of Surgery, University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - Jacinta C Robenstine
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Mathias Schlögl
- Centre on Aging and Mobility, University Hospital Zurich and City Hospital Waid Zurich, Zurich, Switzerland.,University Clinic for Acute Geriatric Care, City Hospital Waid Zurich, Zurich, Switzerland
| | - Christine C Toevs
- Department of Surgery, Terre Haute Regional Hospital, Indiana University School of Medicine, Terre Haute, Indiana, USA
| | | | - Robert S Krouse
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania and the Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
| | - Niels D Martin
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| |
Collapse
|
45
|
Truong EI, Kishawi SK, Ho VP, Tadi RS, Warner DF, Claridge JA, Tseng ES. Opioids and Injury Deaths: A population-based analysis of the United States from 2006 to 2017. Injury 2021; 52:2194-2198. [PMID: 33814132 PMCID: PMC8487056 DOI: 10.1016/j.injury.2021.03.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 02/23/2021] [Accepted: 03/06/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION In the United States, the opioid epidemic claims over 130 lives per day due to overdoses. While the use of opioids in trauma patients has been well-described in the literature, it is unknown whether prescription opioid use is associated with mortality after trauma. We hypothesized that legally obtained prescription opioid consumption would be positively associated with injury-related deaths in the United States. METHODS Cross-sectional time-series data was compiled using state-level mortality data from the Centers for Disease Control and Prevention Multiple Causes of Death database and prescription opioid shipping data to each state using the US Department of Justice Automated Reports and Consolidated Ordering System Retail Drug Summary reports from 2006 to 2017, with opioids shipped used as a proxy for local opioid consumption. Oxycodone and hydrocodone amounts were converted to morphine equivalent doses (MEDs). Our primary outcome was an association between MEDs and injury mortality rates at the state-level. We analyzed total injury-related deaths and subgroups of unintentional deaths, suicides, and homicides. We modeled the data using fixed effects regression to reduce bias from unmeasured differences between states. RESULTS Data were available for all states and the District of Columbia. Opioid deliveries increased through 2012 and then declined. Total injury-related mortalities have been increasing steadily since 2012. Opioid MEDs did not show a consistent or statistically significant relationship with injury-related mortality, including with any subgroups of unintentional deaths, suicides, and homicides. CONCLUSION In every state examined, there was no consistent relationship between the amount of prescription opioids delivered and total injury-related mortality or any subgroups, suggesting that there is not a direct association between prescription opioids and injury-related mortality. This is the first study to combine national mortality and opioid data to investigate the relationship between legally obtained opioids and injury-related mortality. The US opioid epidemic remains a significant challenge that requires ongoing attention from all stakeholders in our medical and public health systems.
Collapse
Affiliation(s)
- Evelyn I Truong
- Case Western Reserve University School of Medicine, 9501 Euclid Ave, Cleveland, OH, 44106, United States
| | - Sami K Kishawi
- Department of Surgery, MetroHealth Medical Center, 2500 MetroHealth Dr., Cleveland, OH, 44109, United States
| | - V P Ho
- Department of Surgery, MetroHealth Medical Center, 2500 MetroHealth Dr., Cleveland, OH, 44109, United States; Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, 10900 Euclid Ave, Cleveland, OH, 44106, United States
| | - Roshan S Tadi
- American University of Antigua College of Medicine, St. John's, Osbourn, Antigua and Barbuda
| | - David F Warner
- University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - Jeffrey A Claridge
- Department of Surgery, MetroHealth Medical Center, 2500 MetroHealth Dr., Cleveland, OH, 44109, United States
| | - Esther S Tseng
- Department of Surgery, MetroHealth Medical Center, 2500 MetroHealth Dr., Cleveland, OH, 44109, United States.
| |
Collapse
|
46
|
Abstract
Background: Standardized and concise data presentation forms the base for subsequent analysis and interpretation. This article reviews types of data, data properties and distributions, and both numerical and graphical methods of data presentation. Methods: For the purposes of illustration, the National Inpatient Sample was queried to categorize patients as having either emergency general surgery or non-emergency general surgery admissions. Results: Variables are categorized as either categorical or numerical. Within the former, there are ordinal and or nominal subtypes; within the latter, there are ratio and interval subtypes. Categorical data are typically displayed as number (%). Numerical data must be assessed for normality as normally distributed data behave in certain patterns that allow for specific statistical tests to be used. Several properties exist for numerical data, including measurements of central tendency (mean, median, and mode), as well as standard deviation, range, and interquartile range. The best initial assessment of the distribution of numerical data is graphical with both histograms and box plots. Conclusion: Knowledge of the types, distribution, and properties of data is essential to move forward with hypothesis testing.
Collapse
Affiliation(s)
- Wyatt P Bensken
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Fredric M Pieracci
- Department of Surgery, Denver Health Medical Center, Denver, Colorado, USA
| | - Vanessa P Ho
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| |
Collapse
|
47
|
Abstract
Background: Comparison of parameters between two or more groups forms the basis of hypothesis testing. Statistical tests (and statistical significance) are designed to report the likelihood the observed results are caused by chance alone, given that the null hypothesis is true. Methods: To demonstrate the concepts described, we utilized the Nationwide Inpatient Sample for patients admitted for emergency general surgery (EGS) and those admitted with non-EGS diagnoses. Depending on the type and distribution of individual variables, appropriate statistical tests were applied. Results: Comparison of numerical variables between two groups is begun with a simple correlation, depicted graphically in a scatterplot, and assessed statistically with either a Pearson or Spearman correlation coefficient. Normality of numerical variables is then assessed and in the case of normality, a t-test is applied when comparing two groups, and an analysis of variance (ANOVA) when comparing three or more groups. For data that are not distributed normally, a Wilcoxon rank sum (Mann-Whitney U) test may be used. For categorical variables, the χ2 test is used, unless cell counts are less than five, in which case the Fisher exact test is used. Importantly, both the ANOVA and χ2 test are used to assess for overall differences between two or more groups. Individual pair comparison tests, as well as adjusting for multiple comparisons must be used to identify differences between two specific groups when there are more than two groups. Conclusion: A basic understanding of statistical significance, and the type and distribution of variables is necessary to select the appropriate statistical test to compare data. Failure to understand these concepts may result in spurious conclusions.
Collapse
Affiliation(s)
- Wyatt P Bensken
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Vanessa P Ho
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Fredric M Pieracci
- Department of Surgery, Denver Health Medical Center, Denver, Colorado, USA
| |
Collapse
|
48
|
Ladhani HA, Ho VP, Charbonnet CC, Sperry JL, Guyette FX, Brown JB, Daley BJ, Miller RS, Harbrecht BG, Phelan HA, Claridge JA. Dose-dependent association between blood transfusion and nosocomial infections in trauma patients: A secondary analysis of patients from the PAMPer trial. J Trauma Acute Care Surg 2021; 91:272-278. [PMID: 34397951 PMCID: PMC8664092 DOI: 10.1097/ta.0000000000003251] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The Prehospital Air Medical Plasma (PAMPer) trial demonstrated a survival benefit to trauma patients who received thawed plasma as part of early resuscitation. The objective of our study was to examine the association between blood transfusion and nosocomial infections among trauma patients who participated in the PAMPer trial. We hypothesized that transfusion of blood products will be associated with the development of nosocomial infections in a dose-dependent fashion. METHODS We performed a secondary analysis of prospectively collected data of patients in the PAMPer trial with hospital length of stay of at least 3 days. Demographics, injury characteristics, and number of blood products transfused were obtained to evaluate outcomes. Bivariate analysis was performed to identify differences between patients with and without nosocomial infections. Two logistic regression models were created to evaluate the association between nosocomial infections and (1) any transfusion of blood products, and (2) quantity of blood products. Both models were adjusted for age, sex, and Injury Severity Score. RESULTS A total of 399 patients were included: age, 46 years (interquartile range, 29-59 years); Injury Severity Score, 22 (interquartile range, 12-29); 73% male; 80% blunt mechanism; and 40 (10%) deaths. Ninety-three (27%) developed nosocomial infections, including pneumonia (n = 67), bloodstream infections (n = 14), catheter-associated urinary tract infection (n = 10), skin and soft tissue infection (n = 8), Clostridium difficile colitis (n = 7), empyema (n = 6), and complicated intra-abdominal infections (n = 3). Nearly 80% (n = 307) of patients received packed red blood cells (PRBCs); 12% received cryoprecipitate, 69% received plasma, and 27% received platelets. Patients who received any PRBCs had more than a twofold increase in nosocomial infections (odds ratio, 2.15; 95% confidence interval, 1.01-4.58; p = 0.047). The number of PRBCs given was also associated with the development of nosocomial infection (odds ratio, 1.10; 95% confidence interval, 1.05-1.16; p < 0.001). CONCLUSION Trauma patients in the PAMPer trial who received a transfusion of at least 1 U of PRBCs incurred a twofold increased risk of nosocomial infection, and the risk of infection was dose dependent. LEVEL OF EVIDENCE Therapeutic/care management, level IV.
Collapse
Affiliation(s)
- Husayn A Ladhani
- From the Division of Trauma, Critical Care, Burns, and Acute Care Surgery, Department of Surgery (H.A.L., V.P.H., C.C.C., J.A.C.), MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio; Department of Surgery and Critical Care Medicine (J.L.S., J.B.B.), Department of Emergency Medicine (F.X.G.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Surgery (B.J.D.), University of Tennessee Health Science Center, Knoxville; Department of Surgery, John Peter Smith Hospital (R.S.M.), Fort Worth, Texas; Department of Surgery (B.G.H.), University of Louisville, Louisville, Kentucky; and Department of Surgery (H.A.P.), Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
49
|
Ho VP, Adams SD, O'Connell KM, Cocanour CS, Arbabi S, Powelson EB, Cooper Z, Stein DM. Making your geriatric and palliative programs a strength: TQIP guideline implementation and the VRC perspective. Trauma Surg Acute Care Open 2021; 6:e000677. [PMID: 34337156 PMCID: PMC8286789 DOI: 10.1136/tsaco-2021-000677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 06/05/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Older patients compose approximately 30% of trauma patients treated in the USA but make up nearly 50% of deaths from trauma. To help standardize and elevate care of these patients, the American College of Surgeons (ACS) Trauma Quality Improvement Program's best practice guidelines for geriatric trauma management was published in 2013 and that for palliative care was published in 2017. Here, we discuss how palliative care and geriatrics quality metrics can be tracked and used for performance improvement and leveraged as a strength for trauma verification. METHODS We discuss the viewpoint of the ACS Verification, Review, and Consultation and three case studies, with practical tips and takeaways, of how these measures have been implemented at different institutions. RESULTS We describe the use of (1) targeted educational initiatives, (2) development of a consultation tool based on institutional resources, and (3) application of a nurse-led frailty screen. DISCUSSION Specialized care and attention to these vulnerable populations is recommended, but the implementation of these programs can take many shapes.Level of evidence V.
Collapse
Affiliation(s)
- Vanessa P Ho
- Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Sasha D Adams
- Department of Surgery, University of Texas McGovern Medical School, Houston, Texas, USA
| | | | | | - Saman Arbabi
- Surgery, University of Washington, Seattle, Washington, USA
| | - Elisabeth B Powelson
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA
| | - Zara Cooper
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Deborah M Stein
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
| |
Collapse
|
50
|
Tseng ES, Zolin SJ, Young BT, Claridge JA, Conrad-Schnetz KJ, Curfman ET, Wise NL, Lemaitre VC, Ho VP. Can educational videos reduce opioid consumption in trauma inpatients? A cluster-randomized pilot study. J Trauma Acute Care Surg 2021; 91:212-218. [PMID: 33797489 PMCID: PMC8487055 DOI: 10.1097/ta.0000000000003174] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Opioids are often used to treat pain after traumatic injury, but patient education on safe use of opioids is not standard. To address this gap, we created a video-based opioid education program for patients. We hypothesized that video viewing would lead to a decrease in overall opioid use and morphine equivalent doses (MEDs) on their penultimate hospital day. Our secondary aim was to study barriers to video implementation. METHODS We performed a prospective pragmatic cluster-randomized pilot study of video education for trauma floor patients. One of two equivalent trauma floors was selected as the intervention group; patients were equally likely to be admitted to either floor. Nursing staff were to show videos to English-speaking or Spanish-literate patients within 1 day of floor arrival, excluding patients with Glasgow Coma Scale score less than 15. Opioid use and MEDs taken on the day before discharge were compared. Intention to treat (ITT) (intervention vs. control) and per-protocol groups (video viewers vs. nonviewers) were compared (α = 0.05). Protocol compliance was also assessed. RESULTS In intention to treat analysis, there was no difference in percent of patients using opioids or MEDs on the day before discharge. In per-protocol analysis, there was no different in percent of patients using opioids on the day before discharge. However, video viewers still on opioids took significantly fewer MEDs than patients who did not see the video (26 vs. 38, p < 0.05). Protocol compliance was poor; only 46% of the intervention group saw the videos. CONCLUSION Video-based education did not reduce inpatient opioid consumption, although there may be benefits in specific subgroups. Implementation was hindered by staffing and workflow limitations, and staff bias may have limited the effect of randomization. We must continue to establish effective methods to educate patients about safe pain management and translate these into standard practices. LEVEL OF EVIDENCE Therapeutic, Level IV.
Collapse
Affiliation(s)
- Esther S. Tseng
- Division of Trauma, Critical Care, Burns, and Emergency General Surgery, MetroHealth Medical Center, Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, OH
| | | | - Brian T. Young
- Division of Trauma, Critical Care, Burns, and Emergency General Surgery, MetroHealth Medical Center, Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Jeffrey A. Claridge
- Division of Trauma, Critical Care, Burns, and Emergency General Surgery, MetroHealth Medical Center, Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, OH
| | | | - Eric T. Curfman
- Division of Trauma, Critical Care, Burns, and Emergency General Surgery, MetroHealth Medical Center, Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Nicole L. Wise
- Division of Trauma, Critical Care, Burns, and Emergency General Surgery, MetroHealth Medical Center, Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Vetrica C. Lemaitre
- Division of Trauma, Critical Care, Burns, and Emergency General Surgery, MetroHealth Medical Center, Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Vanessa P. Ho
- Division of Trauma, Critical Care, Burns, and Emergency General Surgery, MetroHealth Medical Center, Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, OH
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH
| |
Collapse
|