State-Level Analysis of Intimate Partner Violence, Abortion Access, and Peripartum Homicide: Call for Screening and Violence Interventions for Pregnant Patients

BACKGROUND

Despite representing 4% of the global population, the US has the fifth highest number of intentional homicides in the world. Peripartum people represent a unique and vulnerable subset of homicide victims. This study aimed to understand the risk factors for peripartum homicide.

STUDY DESIGN

We used data from the 2018 to 2020 National Violent Death Reporting System to compare homicide rates of peripartum and nonperipartum people capable of becoming pregnant (12 to 50 years of age). Peripartum was defined as currently pregnant or within 1-year postpartum. We additionally compared state-level peripartum homicide rates between states categorized as restrictive, neutral, or protective of abortion. Pearson's chi-square and Wilcoxon rank-sum tests were used.

RESULTS

There were 496 peripartum compared with 8,644 nonperipartum homicide victims. The peripartum group was younger (27.4 ± 71 vs 33.0 ± 9.6, p < 0.001). Intimate partner violence causing the homicide was more common in the peripartum group (39.9% vs 26.4%, p < 0.001). Firearms were used in 63.4% of homicides among the peripartum group compared with 49.5% in the comparison (p < 0.001). A significant difference was observed in peripartum homicide between states based on policies regarding abortion access (protective 0.37, neutral 0.45, restrictive 0.64; p < 0.01); the same trend was not seen with male homicides.

CONCLUSIONS

Compared with nonperipartum peers, peripartum people are at increased risk for homicide due to intimate partner violence, specifically due to firearm violence. Increasing rates of peripartum homicide occur in states with policies that are restrictive to abortion access. There is a dire need for universal screening and interventions for peripartum patients. Research and policies to reduce violence against pregnant people must also consider the important role that abortion access plays in protecting safety.

When Equality Is Not Equity: The Ethics of Access to Trauma Care A Surgical Perspective

OBJECTIVE

The purpose of this surgical perspective is to describe the trauma care needs of the South Side of Chicago and the creation of an adult trauma center at the University of Chicago Medicine and associated hospital-based violence intervention program.

SUMMARY BACKGROUND DATA

Traumatic injury is a leading cause of death and disability in the US. Disparities across the continuum of trauma care exist, which are often rooted in the social determinants of health. Trauma center distribution is critical to timely treatment and should be based on the trauma needs of the area. The previous trauma ecosystem of Chicago was incongruent with the concentration of violent injuries on the south and west sides of the city leading to a fallacy of distributive justice.

METHODS

A descriptive analysis of community partners, trauma program leadership, trauma surgeons and the violence intervention program director was performed.

RESULTS

The UCM trauma center opened in May 2018 and has since been one of the busiest trauma centers in the country with a 40% penetrating trauma rate. There have been significant reductions in patient transport time on the South Side up to 8.9 minutes (P<0.001). The violence intervention program employs credible messengers with lived experience representing the community and has engaged over 8000 patients since 2018 developing both community-based and medical legal partnerships.

CONCLUSIONS

The persistent efforts of the community and key stakeholders led to a system change improving trauma care for the South Side of Chicago.

Trauma surgical skill sustainment at the University of Chicago AMEDD Military-Civilian Trauma Team Training Site: an observation report

Background

The Army Medical Department (AMEDD) Military-Civilian Trauma Team Training (AMCT3) Program was developed to enhance the trauma competency and capability of the medical force by embedding providers at busy civilian trauma centers. Few reports have been published on the outcomes of this program since its implementation.

Methods

The medical and billing records for the two AMCT3 embedded trauma surgeons at the single medical center were retrospectively reviewed for care provided during August 2021 through July 2022. Abstracted data included tasks met under the Army's Individual Critical Task List (ICTL) for general surgeons. The Knowledge, Skills, and Abilities (KSA) score was estimated based on previously reported point values for procedures. To assess for successful integration of the embedded surgeons, data were also abstracted for two newly hired civilian trauma surgeons.

Results

The annual clinical activity for the first AMCT3 surgeon included 444 trauma evaluations and 185 operative cases. The operative cases included 80 laparotomies, 15 thoracotomies, and 15 vascular exposures. The operative volume resulted in a KSA score of 21 998 points. The annual clinical activity for the second AMCT3 surgeon included 424 trauma evaluations and 194 operative cases. The operative cases included 92 laparotomies, 8 thoracotomies, and 25 vascular exposures. The operative volume resulted in a KSA score of 22 799 points. The first civilian surgeon's annual clinical activity included 453 trauma evaluations and 151 operative cases, resulting in a KSA score of 16 738 points. The second civilian surgeon's annual clinical activity included 206 trauma evaluations and 96 operative cases, resulting in a KSA score of 11 156 points.

Conclusion

The AMCT3 partnership at this single center greatly exceeds the minimum deployment readiness metrics established in the ICTLs and KSAs for deploying general surgeons. The AMEDD experience provided a deployment-relevant case mix with an emphasis on complex vascular injury repairs.

Social Vulnerability and Firearm Violence: Geospatial Analysis of 5 US Cities

BACKGROUND

Firearm violence is now endemic to certain US neighborhoods. Understanding factors that impact a neighborhood's susceptibility to firearm violence is crucial for prevention. Using a nationally standardized measure to characterize community-level firearm violence risk has not been broadly studied but could enhance prevention efforts. Thus, we sought to examine the association between firearm violence and the social, structural, and geospatial determinants of health, as defined by the Social Vulnerability Index (SVI).

STUDY DESIGN

In this cross-sectional study, we merged 2018 SVI data on census tract with shooting incidents between 2015 and 2021 from Baltimore, Chicago, Los Angeles, New York City, and Philadelphia. We used negative binomial regression to associate the SVI with shooting incidents per 1,000 people in a census tract. Moran's I statistics and spatial lag models were used for geospatial analysis.

RESULTS

We evaluated 71,296 shooting incidents across 4,415 census tracts. Fifty-five percent of shootings occurred in 9.4% of census tracts. In all cities combined, a decile rise in SVI resulted in a 37% increase in shooting incidents (p < 0.001). A similar relationship existed in each city: 30% increase in Baltimore (p < 0.001), 50% in Chicago (p < 0.001), 28% in Los Angeles (p < 0.001), 34% in New York City (p < 0.001), and 41% in Philadelphia (p < 0.001). Shootings were highly clustered within the most vulnerable neighborhoods.

CONCLUSIONS

In 5 major US cities, firearm violence was concentrated in neighborhoods with high social vulnerability. A tool such as the SVI could be used to inform prevention efforts by directing resources to communities most in need and identifying factors on which to focus these programs and policies.

Social Vulnerability Index is strongly associated with urban pediatric firearm violence: An analysis of five major US cities

BACKGROUND

Firearm-related injury in children is a public health crisis. The Social Vulnerability Index (SVI) identifies communities at risk for adverse effects due to natural or human-caused crises. We sought to determine if SVI was associated with pediatric firearm-related injury and thus could assist in prevention planning.

METHODS

The Centers for Disease Control and Prevention's 2018 SVI data were merged on census tract with 2015 to 2022 open-access shooting incident data in children 19 years or younger from Baltimore, Chicago, Los Angeles, New York City, and Philadelphia. Regression analyses were performed to uncover associations between firearm violence, SVI, SVI themes, and social factors at the census tract level.

RESULTS

Of 11,654 shooting incidents involving children, 52% occurred in just 6.7% of census tracts, which were on average in the highest quartile of SVI. A decile increase in SVI was associated with a 45% increase in pediatric firearm-related injury in all cities combined (incidence rate ratio, 1.45; 95% confidence interval, 1.41-1.49; p < 0.001). A similar relationship was found in each city: 30% in Baltimore, 51% in Chicago, 29% in Los Angeles, 37% in New York City, and 35% in Philadelphia (all p < 0.001). Socioeconomic status and household composition were SVI themes positively associated with shootings in children, as well as the social factors below poverty, lacking a high school diploma, civilian with a disability, single-parent household, minority, and no vehicle access. Living in areas with multi-unit structures, populations 17 years or younger, and speaking English less than well were negatively associated.

CONCLUSION

Geospatial disparities exist in pediatric firearm-related injury and are significantly associated with neighborhood vulnerability. We demonstrate a strong association between SVI and pediatric shooting incidents in multiple major US cities. Social Vulnerability Index can help identify social and structural factors, as well as geographic areas, to assist in developing meaningful and targeted intervention and prevention efforts.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Strengthening Doctor-Patient Relationships Through Hospital-Based Violence Interventions

PROBLEM

Violence in Chicago has been persistently high in low-income communities of color. Recent attention has focused on how structural inequities weaken protective factors that help keep communities healthy and safe. Spikes in community violence seen in Chicago since the COVID-19 pandemic further expose the lack of social service, health care, economic, and political safety nets in low-income communities and the apparent dearth of faith in those systems.

APPROACH

The authors contend that a comprehensive, collaborative approach to violence prevention that prioritizes treatment and community partnerships is needed to address social determinants of health and structural characteristics that often provide the context for interpersonal violence. One strategy to address decreasing faith in systems like hospitals is foregrounding frontline paraprofessional prevention workers who possess cultural capital based on their experiences navigating interpersonal and structural violence. Hospital-based violence intervention programs help professionalize these prevention workers by providing a framework for patient-centered crisis intervention and assertive case management. The authors describe how the Violence Recovery Program (VRP), a multidisciplinary hospital-based violence intervention model, leverages the cultural capital of credible messengers to use teachable moments to promote trauma-informed care to violently injured patients, assess their immediate risk for reinjury and retaliation, and connect them to wrap-around services to help aid comprehensive recovery.

OUTCOMES

Violence recovery specialists have engaged over 6,000 victims of violence since the program's launch in 2018. Three-quarters of patients expressed social determinants of health needs. Over the past year, specialists have connected over one-third of engaged patients to mental health referrals and community-based social services.

NEXT STEPS

High violence rates in Chicago limited case management opportunities in the emergency room. In fall 2022, the VRP began to establish collaborative agreements with community-based street outreach programs and medical-legal partnerships to address structural determinants of health.

A Novel Machine-Learning Tool to Identify Community Risk for Firearm Violence: The Firearm Violence Vulnerability Index (FVVI)

BACKGROUND

Firearm violence in the U.S. is a public health crisis but accessing accurate firearm assault data to inform prevention strategies is a challenge. Vulnerability indices have been used in other fields to better characterize and identify at-risk populations during crises, but no tool currently exists to predict where rates of firearm violence are highest. We sought to develop and validate a novel machine learning algorithm - the Firearm Violence Vulnerability Index (FVVI) - to forecast community risk for shooting incidents, fill data gaps, and enhance prevention efforts.

METHODS

Open-access 2015-2022 fatal and non-fatal shooting incident data from Baltimore, Boston, Chicago, Cincinnati, Los Angeles, New York City, Philadelphia, and Rochester were merged on census tract with 30 population characteristics derived from the 2020 American Community Survey. The dataset was split into training (80%) and validation (20%) sets; Chicago data was withheld for an unseen test set. XGBoost, a decision tree-based machine learning algorithm, was used to construct the FVVI model, which predicts shooting incident rates within urban census tracts.

RESULTS

A total of 44,073 shooting incidents in 2,967 census tracts were used to build the model; 15,347 shooting incidents in 697 census tracts were in the test set. Historical third grade math scores and having a parent jailed during childhood were population characteristics exhibiting the greatest impact on FVVI's decision making. The model had strong predictive power in the test set, with a goodness of fit (D2) of 0.77.

CONCLUSIONS

FVVI accurately predicts gun violence in urban communities at a granular geographic level based solely on population characteristics. FVVI can fill gaps in currently available firearm violence data, while helping to geographically target and identify social or environmental areas of focus for prevention programs. Dissemination of this standardized risk tool could also enhance firearm violence research and resource allocation.

LEVEL OF EVIDENCE

Level III, Prognostic/Epidemiological.

Capacity Assessment in Emergency Surgery

AbstractInformed consent is a necessary component of the ethical practice of surgery. Ideally, consent is performed in a setting conducive to a robust patient-provider conversation, with careful consideration of risks, benefits, and outcomes. For patients with medical or surgical emergencies, navigating the consent process can be complicated and requires both careful and expedited assessment of decision-making capacity. We present a recent case in which a patient in need of emergency care refused intervention, requiring urgent capacity assessment and a modification to usual care.

Coagulopathy as a Surrogate of Severity of Injury in Penetrating Brain Injury

Penetrating brain injury (PBI) is the most devastating type of traumatic brain injury. Development of coagulopathy in the acute setting of PBI, though common, remains of unclear significance as does its reversal. The aim of this study is to investigate the relationship between coagulopathy and clinical presentation, radiographical features, and outcome in civilian patients with PBI. Eighty-nine adult patients with PBI at a Level I trauma center in Chicago, Illinois who survived acute resuscitation and with available coagulation profile were analyzed. Coagulopathy was defined as international normalized ratio [INR] >1.3, platelet count <100,000 /μL, or partial thromboplastin time >37 sec. Median age (interquartile range; IQR) of our cohort was 27 (21-35) years, and 74 (83%) were male. The intent was assault in 74 cases (83%). The mechanism of PBI was gunshot wound in all patients. Forty patients (45%) were coagulopathic at presentation. In a multiple regression model, coagulopathy was associated with lower Glasgow Coma Scale (GCS)-Motor score (odds ratio [OR], 0.67; confidence interval [CI], 0.48-0.94; p = 0.02) and transfusion of blood products (OR, 3.91; CI, 1.2-12.5; p = 0.02). Effacement of basal cisterns was the only significant radiographical features associated with coagulopathy (OR, 3.34; CI, 1.08-10.37; p = 0.04). Mortality was found to be significantly more common in coagulopathic patients (73% vs. 25%; p < 0.001). However, in our limited sample, reversal of coagulopathy at 24 h was not associated with a statistically significant improvement in outcome. The triad of coagulopathy, low post-resuscitation GCS, and radiographical effacement of basal cisterns identify a particularly ominous phenotype of PBI. The role, and potential reversal of, coagulopathy in this group warrants further investigation.

COVID-19 Among African Americans: An Action Plan for Mitigating Disparities

As the COVID-19 pandemic has unfolded across the United States, troubling disparities in mortality have emerged between different racial groups, particularly African Americans and Whites. Media reports, a growing body of COVID-19-related literature, and long-standing knowledge of structural racism and its myriad effects on the African American community provide important lenses for understanding and addressing these disparities.However, troubling gaps in knowledge remain, as does a need to act. Using the best available evidence, we present risk- and place-based recommendations for how to effectively address these disparities in the areas of data collection, COVID-19 exposure and testing, health systems collaboration, human capital repurposing, and scarce resource allocation.Our recommendations are supported by an analysis of relevant bioethical principles and public health practices. Additionally, we provide information on the efforts of Chicago, Illinois' mayoral Racial Equity Rapid Response Team to reduce these disparities in a major urban US setting.

Cerebrovascular Complications in Early Survivors of Civilian Penetrating Brain Injury

BACKGROUND

This study investigates the presence of cerebrovascular injuries in a large sample of civilian penetrating brain injury (PBI) patients, determining the prevalence, radiographic characteristics, and impact on short-term outcome.

METHODS

We retrospectively reviewed patients with PBI admitted to our institution over a 2-year period. Computed tomography head scans, computer tomography angiograms and venograms of the intracranial vessels were evaluated to determine the wound trajectory, intracranial injury characteristics, and presence of arterial (AI) and venous sinus (VSI) injuries. Demographics, clinical presentation, and treatment were also reviewed. Discharge disposition was used as surrogate of short-term outcome.

RESULTS

Seventy-two patients were included in the study. The mechanism of injury was gunshot wounds in 71 patients and stab wound in one. Forty-one of the 72 patients (60%) had at least one vascular injury. Twenty-six out of 72 patients suffered an AI (36%), mostly pseudoaneurysms and occlusions, involving the anterior and middle cerebral arteries. Of the 72 patients included, 45 had dedicated computed tomography venograms, and of those 22 had VSI (49%), mainly manifesting as superior sagittal sinus occlusion. In a multivariable regression model, intraventricular hemorrhage at presentation was associated with AI (OR 9.9, p = 0.004). The same was not true for VSI.

CONCLUSION

Acute traumatic cerebrovascular injury is a prevalent complication in civilian PBI, frequently involving both the arterial and venous sinus systems. Although some radiographic features might be associated with presence of vascular injury, assessment of the intracranial vasculature in the acute phase of all PBI is essential for early diagnosis. Treatment of vascular injury remains variable depending on local practice.

Race/Ethnicity and Geographic Access to Urban Trauma Care

IMPORTANCE

Little is known about the distribution of life-saving trauma resources by racial/ethnic composition in US cities, and if racial/ethnic minority populations disproportionately live in US urban trauma deserts.

OBJECTIVE

To examine racial/ethnic differences in geographic access to trauma care in the 3 largest US cities, considering the role of residential segregation and neighborhood poverty.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional, multiple-methods study evaluated census tract data from the 2015 American Community Survey in Chicago, Illinois; Los Angeles (LA), California; and New York City (NYC), New York (N = 3932). These data were paired to geographic coordinates of all adult level I and II trauma centers within an 8.0-km buffer of each city. Between February and September 2018, small-area analyses were conducted to assess trauma desert status as a function of neighborhood racial/ethnic composition, and geospatial analyses were conducted to examine statistically significant trauma desert hot spots.

MAIN OUTCOMES AND MEASURES

In small-area analyses, a trauma desert was defined as travel distance greater than 8.0 km to the nearest adult level I or level II trauma center. In geospatial analyses, relative trauma deserts were identified using travel distance as a continuous measure. Census tracts were classified into (1) racial/ethnic composition categories, based on patterns of residential segregation, including white majority, black majority, Hispanic/Latino majority, and other or integrated; and (2) poverty categories, including nonpoor and poor.

RESULTS

Chicago, LA, and NYC contained 798, 1006, and 2128 census tracts, respectively. A large proportion comprised a black majority population in Chicago (35.1%) and NYC (21.4%), compared with LA (2.7%). In primary analyses, black majority census tracts were more likely than white majority census tracts to be located in a trauma desert in Chicago (odds ratio [OR], 8.48; 95% CI, 5.71-12.59) and LA (OR, 5.11; 95% CI, 1.50-17.39). In NYC, racial/ethnic disparities were not significant in unadjusted models, but were significant in models adjusting for poverty and race-poverty interaction effects (adjusted OR, 1.87; 95% CI, 1.27-2.74). In comparison, Hispanic/Latino majority census tracts were less likely to be located in a trauma desert in NYC (OR, 0.03; 95% CI, 0.01-0.11) and LA (OR, 0.30; 95% CI, 0.22-0.40), but slightly more likely in Chicago (OR, 2.38; 95% CI, 1.56-3.64).

CONCLUSIONS AND RELEVANCE

In this study, black majority census tracts were the only racial/ethnic group that appeared to be associated with disparities in geographic access to trauma centers.

What Is the Institutional Duty of Trauma Systems to Respond to Gun Violence?

In the past, trauma centers have almost exclusively focused on caring for patients who suffer from physical trauma resulting from violence. However, as clinicians' perspectives on violence shift, violence prevention and intervention have been increasingly recognized as integral aspects of trauma care. Hospital-based violence intervention programs are an emerging strategy for ending the cycle of violence by focusing efforts in the trauma center context. These programs, with their multipronged, community-based approach, have shown great potential in reducing trauma recidivism by leveraging the acute experience of violence as an opportunity to introduce services and assess risk of re-injury. In this article, we explore the evolving role of trauma centers and consider their institutional duty to address violence broadly, including prevention.

RACIAL AND GEOGRAPHIC VARIATION IN LEG AMPUTATIONS AMONG TEXANS

BACKGROUND

The existence of racial and ethnic disparities in leg amputations rates is well documented. Despite this, approaches to addressing these alarming disparities have been hampered by the inability to identify at-risk individuals in a region and design targeted interventions. We undertook this study to identify small geographic areas in which efforts focused on high-risk individuals with peripheral artery disease (PAD) could address disparities in leg amputation rates.

METHODS

We used de-identified Texas state admission data to identify PAD-related admissions associated with an initial revascularization (leg angioplasty or leg bypass) or an primary leg (above-ankle) amputation between from 2004 through 2009.

RESULTS

21,273 major initial procedures were performed in Texas from 2004 through 2009 for PAD-related diagnoses, including 16,898 revascularizations and 4,375 leg amputations. A multivariate logistic regression demonstrated that an initial leg amputations done without revascularization was significantly associated with, among other variables: people categorized as black (odds ratio [OR] 1.79) or Hispanic (OR 1.42); those with Medicaid coverage (OR 1.89); and those treated at low volume hospitals (OR 1.78; p<0.001 for all). Four geographic regions were identified with significantly higher risk-adjusted leg amputation rates. Of the 349 Texas hospitals performing major procedures, 72 (21%) reported no revascularization procedures during the six year period studied.

CONCLUSIONS

Prevention efforts directed at specific geographic areas may be more likely to reach at-risk people with PAD and thereby reduce leg amputations disparities in Texas. Such efforts might also find strategies to direct patients toward higher volume centers with higher revascularization rates.

Surgical referral coordination from a first-level hospital: a prospective case study from rural Nepal

Background

Patients in isolated rural communities typically lack access to surgical care. It is not feasible for most rural first-level hospitals to provide a full suite of surgical specialty services. Comprehensive surgical care thus depends on referral systems. There is minimal literature, however, on the functioning of such systems.

Methods

We undertook a prospective case study of the referral and care coordination process for cardiac, orthopedic, plastic, gynecologic, and general surgical conditions at a district hospital in rural Nepal from 2012 to 2014. We assessed the referral process using the World Health Organization’s Health Systems Framework.

Results

We followed the initial 292 patients referred for surgical services in the program. 152 patients (52%) received surgery and four (1%) suffered a complication (three deaths and one patient reported complication). The three most common types of surgery performed were: orthopedics (43%), general (32%), and plastics (10%). The average direct and indirect cost per patient referred, including food, transportation, lodging, medications, diagnostic examinations, treatments, and human resources was US$840, which was over 1.5 times the local district’s per capita income. We identified and mapped challenges according to the World Health Organization’s Health Systems Framework. Given the requirement of intensive human capital, poor quality control of surgical services, and the overall costs of the program, hospital leadership decided to terminate the referral coordination program and continue to build local surgical capacity.

Conclusion

The results of our case study provide some context into the challenges of rural surgical referral systems. The high relative costs to the system and challenges in accountability rendered the program untenable for the implementing organization.

Electronic supplementary material

The online version of this article (10.1186/s12913-017-2624-2) contains supplementary material, which is available to authorized users.

Comparison of Frailty Measures as Predictors of Outcomes After Orthopedic Surgery

OBJECTIVES

To apply the Frailty Phenotype (FP) and Frailty Index (FI) before major elective orthopedic surgery to categorize frailty status and assess associations with postoperative outcomes.

DESIGN

Prospective cohort study.

SETTING

Two tertiary hospitals in Boston, Massachusetts.

PARTICIPANTS

Individuals aged 70 and older undergoing scheduled orthopedic surgery enrolled in the Successful Aging after Elective Surgery (SAGES) Study (N = 415).

MEASUREMENTS

Preoperative evaluation included assessment of frailty using the FP and FI. The weighted kappa statistic was used to determine concordance between the two frailty measures and multivariable modeling to determine associations between each measure and postoperative complications, postoperative length of stay (LOS) of longer than 5 days, discharge to postacute institutional care (PAC), and 300 day readmission.

RESULTS

Frailty was highly prevalent (FP, 35%; FI, 41%). There was moderate concordance between the FP and FI (κ = 0.42, 95% confidence interval (CI) 0.36-0.49). When using the FP, being prefrail predicted greater risk of complications (relative risk (RR) = 1.6, 95% CI = 1.1-2.1) and discharge to PAC (RR = 1.8, 95% CI = 1.2-2.9) than being robust, and being frail predicted more complications (RR = 1.7, 95% CI = 1.1-2.1), LOS longer than 5 days (RR = 3.1, 95% CI = 1.1-8.8), and discharge to PAC (RR = 2.3 95% CI = 1.4-3.7). When using FI, being prefrail predicted LOS longer than 5 days (RR = 2.1, 95% CI = 1.0-4.8) and discharge to PAC (RR = 1.5, 95% CI = 1.4-2.1), as did being frail (RR = 1.9, 95% CI = 1.4-2.5; RR = 3.1, 95% CI = 1.4-6.8, respectively). The other outcomes were not significantly associated with frailty status.

CONCLUSION

FP and FI predict postoperative outcomes after major elective orthopedic surgery and should be considered for preoperative risk stratification.

Assuring survival of safety-net surgical patients

BACKGROUND

Survival of surgical inpatients is a key quality metric. Patient, surgeon, and system factors all contribute to inpatient mortality, and sophisticated risk adjustment is required to assess outcomes. When the mortality of general surgery patients was determined to be high at a safety-net hospital, a comprehensive approach was undertaken to improve patient survival.

METHODS

General surgical service line mortality was measured in the database of the University HealthSystem Consortium from January 2013 through June 2015. Ten best practices were implemented sequentially to decrease observed and/or increase expected mortality. University HealthSystem Consortium mortality rank, observed, expected, and observed/expected index as well as early deaths were compared with control charts for 30 months.

RESULTS

University HealthSystem Consortium general surgery mortality improved from the bottom decile to the top quartile, while Case Mix Index increased from 2.48 to 2.82 (P < .05). Observed mortality decreased from 3.39 to 2.35%. Expected mortality increased from 1.40 to 2.73% (P < .05). The observed/expected mortality index decreased from 2.43 to 0.86 (P < .05). Early deaths decreased from 0.52 to 0% (P < .05).

CONCLUSION

Risk-adjusted mortality and early deaths decreased significantly over 30 months in general surgery patients. Systematic implementation of quality best practices was associated with improved survival of general surgery patients at a safety-net medical center.

Variations in Oncologist Recommendations for Chemotherapy for Stage IV Lung Cancer: What Is the Role of Performance Status?

PURPOSE

Chemotherapy prolongs survival in patients with advanced non-small-cell lung cancer. However, few studies have included patients with poor performance status. This study examined rates of oncologists' recommendations for chemotherapy by patient performance status and symptoms and how physician characteristics influence chemotherapy recommendations.

METHODS

We surveyed medical oncologists involved in the care of a population-based cohort of patients with lung cancer from the CanCORS (Cancer Care Outcomes Research and Surveillance) study. Physicians were queried about their likelihood to recommend chemotherapy to patients with stage IV lung cancer with varying performance status (Eastern Cooperative Oncology Group performance status 0 [good] v 3 [poor]) and presence or absence of tumor-related pain. Repeated measures logistic regression was used to estimate the independent associations of patients' performance status and symptoms and physicians' demographic and practice characteristics with chemotherapy recommendations.

RESULTS

Nearly all physicians (adjusted rate, 97% to 99%) recommended chemotherapy for patients with good performance status, and approximately half (adjusted rate, 38% to 53%) recommended chemotherapy for patients with poor performance status (P < .001). Compared with patient factors, physician and practice characteristics were less strongly associated with chemotherapy recommendations in adjusted analyses.

CONCLUSION

Strong consensus among oncologists exists for chemotherapy in patients with advanced non-small-cell lung cancer and good performance status. However, the relatively high rate of chemotherapy recommendations for patients with poor performance status despite the unfavorable risk-benefit profile highlights the need for ongoing work to define high-value care in oncology and to implement and evaluate strategies to align incentives for such care.

Effect of Delirium and Other Major Complications on Outcomes After Elective Surgery in Older Adults

IMPORTANCE

Major postoperative complications and delirium contribute independently to adverse outcomes and high resource use in patients who undergo major surgery; however, their interrelationship is not well examined.

OBJECTIVE

To evaluate the association of major postoperative complications and delirium, alone and combined, with adverse outcomes after surgery.

DESIGN, SETTING, AND PARTICIPANTS

Prospective cohort study in 2 large academic medical centers of 566 patients who were 70 years or older without recognized dementia or a history of delirium and underwent elective major orthopedic, vascular, or abdominal surgical procedures with a minimum 3-day hospitalization between June 18, 2010, and August 8, 2013. Data analysis took place from December 13, 2013, through May 1, 2015.

MAIN OUTCOMES AND MEASURES

Major postoperative complications, defined as life-altering or life-threatening events (Accordion Severity grade 2 or higher), were identified by expert-panel adjudication. Delirium was measured daily with the Confusion Assessment Method and a validated medical record review method. The following 4 subgroups were analyzed: (1) no complications or delirium; (2) complications only; (3) delirium only; and (4) complications and delirium. Adverse outcomes included a length of stay (LOS) of more than 5 days, institutional discharge, and rehospitalization within 30 days of discharge.

RESULTS

In the 566 participants, the mean (SD) age was 76.7 (5.2) years, 236 (41.7%) were male, and 523 (92.4%) were white. Forty-seven patients (8.3%) developed major complications and 135 (23.9%) developed delirium. Compared with no complications or delirium as the reference group, major complications only contributed to prolonged LOS only (relative risk [RR], 2.8; 95% CI, 1.9-4.0); by contrast, delirium only significantly increased all adverse outcomes, including prolonged LOS (RR, 1.9; 95% CI, 1.4-2.7), institutional discharge (RR, 1.5; 95% CI, 1.3-1.7), and 30-day readmission (RR, 2.3; 95% CI, 1.4-3.7). The subgroup with complications and delirium had the highest rates of all adverse outcomes, including prolonged LOS (RR, 3.4; 95% CI, 2.3-4.8), institutional discharge (RR, 1.8; 95% CI, 1.4-2.5), and 30-day readmission (RR, 3.0; 95% CI, 1.3-6.8). Delirium exerted the highest attributable risk at the population level (5.8%; 95% CI, 4.7-6.8) compared with all other adverse events (prolonged LOS, institutional discharge, or readmission).

CONCLUSIONS AND RELEVANCE

Major postoperative complications and delirium are separately associated with adverse events and demonstrate a combined effect. Delirium occurs more frequently and has a greater effect at the population level than other major complications.

Differential impact of infection control strategies on rates of resistant hospital-acquired pathogens in critically ill surgical patients

BACKGROUND

There were two major outbreaks of multi-drug resistant Acinetobacter baumannii (MDRA) in our general surgery and trauma intensive care units (ICUs) in 2004 and 2011. Both required aggressive multi-faceted interventions to control. We hypothesized that the infection control response may have had a secondary benefit of reducing rates of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), and Clostridium difficile (C. diff).

METHODS

We analyzed data retrospectively from a prospective infection control database at a major university hospital and calculated the incidence rates of nosocomial MRSA, VRE, and C. diff before and after the two MDRA outbreaks (2004 and 2011) in the general surgery and trauma ICUs, and two unaffected control ICUs: thoracic surgery ICU and medical ICU. We tracked incidence rates in 6 mos segments for 24 mos per outbreak and created a composite variable of "any resistant pathogen" for comparison.

RESULTS

The incidence rates of "any resistant pathogen" were significantly lower in the general surgery ICU after both outbreaks (24 to 11 cases per 1000 patient days in 2004, p=0.045 and 7.7 ->4.0 cases per 1000 patient days in 2011, p=0.04). This did not persist after 6 mos. The trauma ICU's rate of "any resistant pathogen" did not change after either outbreak (16 ->16.5 cases per 1000 patient days in 2004, p=0.44 and 4.6 ->1.9 cases per 1000 patient days in 2011, p=0.41). The rates in the control ICUs were unchanged during the study periods.

CONCLUSIONS

Rates of resistant pathogens were lower in the general surgery ICU after response to MDRA outbreaks in both 2004 and 2011 although the rates increased again with time. There were no changes in rates of resistant pathogens in the trauma ICU after MDRA outbreaks in 2004 and 2011. Outbreak responses may have a differential impact in general surgery ICU versus trauma ICUs.

The Cost of Responding to an Acinetobacter Outbreak in Critically Ill Surgical Patients

BACKGROUND

Our institution had an outbreak of multi-drug-resistant Acinetobacter (MDRA) in 2011. We analyzed the costs of responding to this outbreak from the hospital's perspective.

METHODS

We estimated retrospectively the excess costs associated with an MDRA outbreak response at a major academic medical center, including the costs of staffing, supplies, administrative time, deep cleaning, and environmental testing. Differences in mean costs before and during the 2011 MDRA outbreak were analyzed using the Student t-test.

RESULTS

The overall excess cost incurred during the outbreak response was $371,079 in 2011 U.S. dollars. The largest contributors were the extra resources needed to staff and clean the two intensive care units (ICUs) (78%). In the general surgery ICU, the mean weekly cost of nursing during the outbreak was $13,276 more for regular hours (+15%; p < 0.01) than in the pre-outbreak period and $2,682 more for overtime hours (+86%; p = 0.02). In the trauma ICU, the cost was $20,746 more for regular hours (+24%; p < 0.01) and $3,445 more for overtime hours (+124%; p < 0.01). The costs of supplies ($13,036; +30%; p = 0.03) and gloves ($2,572; +48%; p = 0.01) also were greater during the outbreak. Administrative time, consumables, use of a surge pod, and environmental testing accounted for the remainder of the extra costs.

CONCLUSIONS

Our institution incurred $371,079 in excess costs as a result of an MDRA outbreak. This figure does not include the costs related to treatment of the infections, loss of reimbursement because of hospital-acquired infection, legal services, or changes in staff morale, patient satisfaction, or hospital reputation. Strategies to prevent and control such outbreaks better have substantial value.

Hand-hygiene compliance does not predict rates of resistant infections in critically ill surgical patients

BACKGROUND

Our institution had a major outbreak of multi-drug-resistant Acinetobacter (MDRA) in its general surgical and trauma intensive care units (ICUs) in 2011, requiring implementation of an aggressive infection-control response. We hypothesized that poor hand-hygiene compliance (HHC) may have contributed to the outbreak of MDRA. A response to the outbreak including aggressive environmental cleaning, cohorting, and increased hand hygiene compliance monitoring may have led to an increase in HHC after the outbreak and to a consequent decrease in the rates of infection by the nosocomial pathogens methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and Clostridium difficile.

METHODS

Hand-hygiene compliance, tracked in monthly audits by trained and anonymous observers, was abstracted from an infection control database. The incidences of nosocomial MRSA, VRE, and C. difficile were calculated from a separate prospectively collected data base for 6 mo before and 12 mo after the 2011 outbreak of MDRA in the institution's general surgical and trauma ICUs, and data collected prospectively from two unaffected ICUs (the thoracic surgical ICU and medical intensive care unit [MICU]). We created a composite endpoint of "any resistant pathogen," defined as MRSA, VRE, or C. difficile, and compared incidence rates over time, using the Wilcoxon signed rank test and Pearson product-moment correlation coefficient to measure the correlations among these rates.

RESULTS

Rates of HHC before and after the outbreak of MDRA were consistently high in both the general surgical (median rates: 100% before and 97.6% after the outbreak, p=0.93) and trauma ICUs (median rates: 90% before and 96.75% after the outbreak, p=0.14). In none of the ICUs included in the study did the rates of HHC increase in response to the outbreak of MDRA. The incidence of "any resistant pathogen" decreased in the general surgical ICU after the outbreak (from 6.7/1,000 patient-days before the outbreak to 2.7/1,000 patient-days after the outbreak, p=0.04), but this decrease did not correlate with HHC (trauma ICU: Pearson correlation [ρ]=-0.34, p=0.28; general surgical ICU: ρ=0.52, p=0.08).

CONCLUSIONS

The 2011 outbreak of MDRA at our institution occurred despite high rates of HHC. Notwithstanding stable rates of HHC, the rates of infection with MRSA, VRE and C. difficile decreased in the general surgical ICU after the outbreak. This suggests that infection control tactics other than HHC play a crucial role in preventing the transmission of nosocomial pathogens, especially when rates of HHC have been maximized.

Physicians' beliefs about the benefits and risks of adjuvant therapies for stage II and stage III colorectal cancer

BACKGROUND

Adjuvant therapy plays a major role in treating colorectal cancer, and physicians' views of its effectiveness influence treatment decisions. We assessed physicians' views of the relative benefits and risks of adjuvant chemotherapy and radiotherapy for stages II and III colon and rectal cancers.

METHODS

The Cancer Care Outcomes Research and Surveillance Consortium surveyed a geographically dispersed population of medical oncologists, radiation oncologists, and surgeons in the United States about the benefits and risks of adjuvant therapies for colorectal cancer. We used logistic regression to assess the association of physician and practice characteristics with beliefs about adjuvant therapies.

RESULTS

Among 1,296 respondents, > 90% believed the benefits of adjuvant therapies for stage III colorectal cancer outweigh the risks. Only 21.9%, 50%, and 50.4% believed in the net benefit of chemotherapy for stage II colon cancer, chemotherapy for stage II rectal cancer, and radiation for stage II rectal cancer, respectively. Younger physicians were less likely than others to perceive adjuvant therapy for stage II colorectal cancer as beneficial. Medical oncologists were more likely than surgeons and radiation oncologists to endorse the benefits of adjuvant chemotherapy and radiation for stage II rectal cancer, but less likely for stage II colon cancer.

CONCLUSIONS

Physicians largely agreed that the benefits of adjuvant chemotherapy for stage III colon cancer, as well as chemotherapy, and radiation for stage III rectal cancer, outweigh the risks, consistent with strong evidence, but were divided over the net benefit of adjuvant therapies for stage II colorectal cancer, where evidence is inconsistent.

Improving Antibiotic De-Escalation in Suspected Ventilator-Associated Pneumonia: An Observational Study With a Pharmacist-Driven Intervention

BACKGROUND

Recommendations for treatment of ventilator-associated pneumonia (VAP) emphasize early empiric broad-spectrum antibiotics. However, appropriate antibiotic de-escalation is also critical for optimal patient care.

MATERIALS AND METHODS

We examined how often intensivists in our institution appropriately de-escalated antibiotics in cases of suspected VAP, and whether decision support by intensive care unit pharmacists could improve rates of antibiotic targeting and early antibiotic discontinuation in low-risk patients.

MAIN RESULTS

A total of 92 (observation phase = 50; intervention phase = 42) patients with suspected VAP were identified. During the observation phase, 39 cases yielded positive sputum cultures, but in only 23 (59%) were antibiotics targeted to culture results. This rate improved during the intervention phase when 29 (91%) of 32 cases with positive cultures were targeted (P value .003). There were 48 cases in which the risk of pneumonia was considered low. Of the 26 low-risk cases in the observation phase, 5 (19%) had antibiotics discontinued early versus 5 (23%) of the 22 cases in the intervention phase.

CONCLUSIONS

Decision support by clinical pharmacists significantly improved rates of appropriate antibiotic targeting in cases of culture-positive suspected VAP but did not have a significant effect on early antibiotic discontinuation in patients at low risk of true pneumonia.

Diatom assemblages promote ice formation in large lakes

We present evidence for the directed formation of ice by planktonic communities dominated by filamentous diatoms sampled from the ice-covered Laurentian Great Lakes. We hypothesize that ice formation promotes attachment of these non-motile phytoplankton to overlying ice, thereby maintaining a favorable position for the diatoms in the photic zone. However, it is unclear whether the diatoms themselves are responsible for ice nucleation. Scanning electron microscopy revealed associations of bacterial epiphytes with the dominant diatoms of the phytoplankton assemblage, and bacteria isolated from the phytoplankton showed elevated temperatures of crystallization (T(c)) as high as -3 °C. Ice nucleation-active bacteria were identified as belonging to the genus Pseudomonas, but we could not demonstrate that they were sufficiently abundant to incite the observed freezing. Regardless of the source of ice nucleation activity, the resulting production of frazil ice may provide a means for the diatoms to be recruited to the overlying lake ice, thereby increasing their fitness. Bacterial epiphytes are likewise expected to benefit from their association with the diatoms as recipients of organic carbon excreted by their hosts. This novel mechanism illuminates a previously undescribed stage of the life cycle of the meroplanktonic diatoms that bloom in Lake Erie and other Great Lakes during winter and offers a model relevant to aquatic ecosystems having seasonal ice cover around the world.

Preoperative hyponatremia and perioperative complications

BACKGROUND

Although hyponatremia has been linked to increased morbidity and mortality in a variety of medical conditions, its association with perioperative outcomes remains uncertain.

METHODS

To determine whether preoperative hyponatremia is a predictor of 30-day perioperative morbidity and mortality, we conducted a cohort study using the American College of Surgeons National Surgical Quality Improvement Program database to identify 964 263 adults undergoing major surgery from more than 200 hospitals (from January 1, 2005, to December 31, 2010) and observed them for 30-day perioperative outcomes. We used multivariable logistic regression to estimate relative risks for death, major coronary events, wound infections, and pneumonia occurring within 30 days of surgery and quantile regression to estimate differences in average length of hospital stay.

RESULTS

A total of 75 423 patients with preoperative hyponatremia (sodium level <135 mEq/L [to convert to millimoles per liter, multiply by 1.0]) were compared with 888 840 patients with normal baseline sodium levels (135-144 mEq/L). Preoperative hyponatremia was associated with a higher risk of 30-day mortality (5.2% vs 1.3%; adjusted odds ratio [aOR], 1.44; 95% CI, 1.38-1.50), and this finding was consistent in all the subgroups. This association was particularly marked in patients undergoing nonemergency surgery (aOR, 1.59; 95% CI, 1.50-1.69; P < .001 for interaction) and American Society of Anesthesiologists class 1 and 2 patients (aOR, 1.93; 95% CI, 1.57-2.36; P < .001 for interaction). Furthermore, hyponatremia was associated with a greater risk of perioperative major coronary events (1.8% vs 0.7%; aOR, 1.21; 95% CI, 1.14-1.29), wound infections (7.4% vs 4.6%; 1.24; 1.20-1.28), and pneumonia (3.7% vs 1.5%; 1.17; 1.12-1.22) and prolonged median lengths of stay by approximately 1 day.

CONCLUSION

Preoperative hyponatremia is a prognostic marker for perioperative 30-day morbidity and mortality.

Novel risk markers and long-term outcomes of delirium: the successful aging after elective surgery (SAGES) study design and methods

OBJECTIVES

Delirium, a costly, life-threatening, and potentially preventable condition, is a common complication for older adults following major surgery. Although the basic epidemiology of delirium after surgery has been defined, the contribution of delirium to long term outcomes remains uncertain, and novel biomarkers from plasma and neuroimaging have yet to be examined. This program project was designed to contribute to our understanding of the complex multifactorial syndrome of delirium.

DESIGN

Long term prospective cohort study.

SETTING

Three academic medical centers (2 hospitals and 1 coordinating center).

PARTICIPANTS

Patients without recognized dementia (targeted cohort= 550 patients) age 70 and older scheduled to undergo elective major surgery are assessed at baseline before surgery, daily during their hospital stay, and for 18 to 36 months after discharge.

MEASUREMENTS

The Successful Aging after Elective Surgery (SAGES) study is an innovative, interdisciplinary study that includes biomarkers, neuroimaging, cognitive reserve markers, and serial neuropsychological testing to examine the contribution of delirium to long term cognitive and functional decline. The primary goal is to examine the contribution of delirium to long term cognitive and functional decline. In addition, novel risk markers for delirium are being examined, including plasma biomarkers (eg, cytokines, proteomics), advanced neuroimaging markers (eg, volumetric, white matter hyperintensity, noncontrast blood flow, and diffusion tensor measures), and cognitive reserve markers (eg, education, occupation, lifetime activities).

CONCLUSION

Results from this study will contribute to a fuller understanding of the etiology and prognosis of delirium. Ultimately, we hope this project will provide the groundwork for future development of prevention and treatment strategies for delirium, designed to minimize the long term negative impact of delirium in older adults.

Disaster triage after the Haitian earthquake

In the aftermath of the devastating Haitian earthquake, we became the primary relief service for a large group of severely injured earthquake victims. Finding ourselves virtually isolated with extremely limited facilities and a group of critically injured patients whose needs vastly outstripped the available resources we employed a disaster triage system to organize their clinical care. This report describes the specific injury profile of this group of patients, their clinical course, and the management philosophy that we employed. It provides useful lessons for similar situations in the future.

Preinjury beta blocker usage does not affect the heart rate response to initial trauma resuscitation

BACKGROUND

The effect of preinjury beta blockade on heart rate during initial trauma resuscitation is unclear. We hypothesized that preinjury beta blockade does not affect the heart rate response to initial trauma resuscitation.

METHODS

A case-control study of patients admitted to a level I trauma center was conducted. Medical records were reviewed for demographics, medications, injury information, and hemodynamic profiles. Logistic regression identified correlations between preinjury beta blockade and hemodynamics during initial trauma resuscitation and in-hospital mortality.

RESULTS

There were 76 deaths (cases) and 304 survivors (controls). Mean pre-resuscitation heart rate was 83 in patients on beta blocker and 89 in patients not on beta blocker (p=0.007). Mean post-resuscitation heart rate was 80 in patients on beta blocker and 85 in patients not on beta blocker (p=0.02). Tachycardia was present in 14.3% with preinjury beta blocker and 29.7% without (p=0.009). Bradycardia was present in 7.1% with preinjury beta blocker and 2.3% without (p=0.035). Of all patients who presented with an abnormal heart rate, 46% of patients on beta blocker attained a normal heart rate after resuscitation vs. 53% of patients not on beta blocker (p=not significant).

CONCLUSION

Preinjury beta blockade is associated with a slower presenting heart rate, more bradycardia, less tachycardia, but no difference in mortality or ability to achieve a normal heart rate with resuscitation.

Non-operative management of malarial splenic rupture: the Khartoum experience and an international review

Malarial splenic rupture (MSR) occurs in a subset of patients and can be an acute surgical emergency. MSR is a well-known entity for more than 100 years, yet there are no well-structured studies in the literature that systematically evaluate this complication. While it has become increasingly recognized that splenic salvage can be vital to the long term immunity and health of these patients, there are few data to guide a safe approach to non-operative management of these patients. Current knowledge of spontaneous rupture of the spleen has been gained largely though reported cases. We present 2 cases of MSR and a review of the literature of the management of MSR. We present an algorithm for the management of MSR. Of the 60 cases of MSR in the literature 31 were managed with splenectomy, 21 were managed non-operatively, and 8 early deaths occurred during initial presentation. The most common presenting symptoms were fever (67%) and abdominal pain (51%). Seventy-two percent of patients were hypotensive and tachycardic on presentation. Fifteen (71%) of 21 patients had successful non-operative management for MSR. Of the six patients that failed non-operative treatment, 4 patients eventually needed splenectomy, and 2 patients died without operation. We recommend that patients presenting with fever, abdominal pain, hypotension, and spenomegaly receive urgent resuscitation, ultrasonography (where available) to evaluate for blood in the abdomen, and surgical consultation. Patients who are hemodynamically stable before or after resuscitation can be selectively chosen for non-operative management.

Graduate medical education in trauma/critical care and acute care surgery: defining goals for a new workforce

The increasing need for skilled emergency surgical providers, coupled with decreasing experience in emergency surgery among trainees, has led to significant shortages in the availability of such surgeons. In response to this crisis, surgical leaders have developed a comprehensive curriculum and a set of professional standards to guide the training of a new specialist: the acute care surgeon. This article reviews the development and goals for Fellowship training of this new specialty.

Can hospitals "game the system" by avoiding high-risk patients?

BACKGROUND

It has been suggested that implementation of quality-improvement benchmarking programs can lead to risk-avoidance behaviors in some physicians and hospitals in an attempt to improve their rankings, potentially denying patients needed treatment. We hypothesize that avoidance of high-risk patients will not change risk-adjusted rankings.

STUDY DESIGN

We conducted a simulation analysis of 6 complex operations in the Nationwide Inpatient Sample, including abdominal aortic aneurysm repair, aortic valve replacement, coronary artery bypass grafting, percutaneous coronary intervention, esophagectomy, and pancreatic resection. Primary outcomes included in-hospital mortality. Hospitals were ranked into quintiles based on observed-to-expected (O/E) mortality ratios, with their expected mortalities calculated based on models generated from the previous 3 years. Half of the hospitals were then randomly selected to undergo risk avoidance by avoiding 25% of patients with higher than median risks (ie, Charlson, Elixhauser, age, minority, or uninsured status). Their new O/E ratios and hospital-rank categories were compared with their original values.

RESULTS

A total of 2,235,298 patients were analyzed, with an overall observed mortality rate of 1.9%. Median change in O/E ratios across all simulations was zero, and O/E ratios did not change in 97.5% to 99.3% of the hospitals, depending on the risk definitions. Additionally, 70.5% to 98.0% of hospital rankings remained unchanged, 1.3% to 13.1% of hospital rankings improved, and 0.7% to 14.3% of hospital rankings worsened after risk avoidance.

CONCLUSIONS

Risk-adjusted rankings of hospitals likely cannot be changed by simply avoiding high-risk patients. In the minority of scenarios in which risk-adjusted rankings changed, they were as likely to improve as worsen after risk avoidance.

Can universal coverage eliminate health disparities? Reversal of disparate injury outcomes in elderly insured minorities

BACKGROUND

Health outcome disparities in racial minorities are well documented. However, it is unknown whether such disparities exist among elderly injured patients. We hypothesized that such disparities might be reduced in the elderly owing to insurance coverage under Medicare. We investigated this issue by comparing the trauma outcomes in young and elderly patients in California.

METHODS

A retrospective analysis of the California Office of Statewide Health Planning and Development hospital discharge database was performed for all publicly available years from 1995 to 2008. Trauma admissions were identified by International Classification of Disease, Ninth Revision, primary diagnosis codes from 800 to 959, with certain exclusions. Multivariate analysis examined the adjusted risk of in-hospital mortality in young (<65 y) and elderly (≥65 y) patients, controlling for age, gender, injury severity as measured by the survival risk ratio, Charlson comorbidity index, insurance status, calendar year, and teaching hospital status.

RESULTS

A total of 1,577,323 trauma patients were identified. Among the young patients, the adjusted odds ratio of death relative to non-Hispanic whites for blacks, Hispanics, Asians, and Native Americans/others was 1.2, 1.2, 0.90, and 0.78, respectively. The corresponding adjusted odds ratios of death for elderly patients were 0.78, 0.87, 0.92, and 0.61.

CONCLUSIONS

Young black and Hispanic trauma patients had greater mortality risks relative to non-Hispanic white patients. Interestingly, elderly black and Hispanic patients had lower mortality risks compared with non-Hispanic whites.

Tale of two sites: capillary versus arterial blood glucose testing in the operating room

INTRODUCTION

Pre- and intraoperative glycemic control has been identified as a putative target to improve outcomes of surgical patients. Glycemic control requires frequent monitoring of blood glucose levels with appropriate adjustments. However, monitoring standards have been called into question, especially in cases in which capillary samples are used. Point-of-care testing (POCT) using capillary samples and glucometers has been noted to give relatively accurate results for critically ill patients. However, the package inserts of most glucometers warn that they should not be used for patients in shock. This has led clinicians to doubt their accuracy in the operating room. The accuracy of capillary samples when tested in patients undergoing surgical procedures has not been proven. This study aims to determine the accuracy of intraoperative blood glucose values using capillary samples relative to arterial samples.

METHODS

A prospective study was conducted by collecting paired capillary and arterial samples of patients undergoing major operations at a tertiary medical center from August 2009 to May 2011. Subjects were a convenience sample of patients who had arterial lines and needed glucose testing while undergoing the procedure. Precision Xceed Pro (Abbott) handheld glucometers were used to obtain the blood glucose values. Our primary outcome of interest was the degree of correlation between capillary and arterial blood glucose values or the degree to which arterial glucose levels can be predicted by capillary glucose samples. We used linear regression and the Student t tests for statistical analyses.

RESULTS

Seventy-two-paired samples were collected. Of the cases, 54% were major abdominal operations, whereas 24% were vascular operations. The mean values ± standard deviation for glucose levels were 146 ± 35 mg/dL (capillary) and 147 ± 36 mg/dL (arterial). The mean time ± standard deviation between the collection of both samples was 3.5 ± 1.3 minutes. The regression coefficient showed a strong positive correlation of .91 between capillary glucose values and arterial values (P < .001) although correlation was less stringent at the hyperglycemic range of values. The R(2) statistic was 84%. Differences in values between capillary and arterial samples would not have altered the diagnosis of hypo- and hyperglycemia using typical thresholds.

CONCLUSIONS

Capillary samples collected intraoperatively are strongly correlated with arterial samples. Glucose monitoring in the operating room can be safely performed by collecting capillary samples for POCT. However, clinicians should still be cautious when interpreting glucose levels that are high, either by repeating the blood glucose test or by having samples sent to the laboratory.