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Background Delays in the transfers of injured patients are perceived to increase morbidity and mortality and drive initiatives to limit the emergency department length of stay (LOS) at referring facilities (RF). RF LOS >4 hours is used for performance improvement (PI) with a large review burden with few improvement opportunities. Methods A statewide trauma registry 2013-2018 was used. Descriptive and inferential statistics including logistic regression were used to evaluate nongeriatric adult patients with ED LOS Results 13,721 of 56,702 transfer patients were selected. Mortality fell over time in all abbreviated injury score groups. GCS-M and systolic blood pressure (SBP) were correlated with mortality in both prehospital and RF data and highest in patients with abnormal GCS-M or SBP in both settings (38.0%, 30.1%). Examination of mortality over time in the group with abnormal VS showed SBP as the only variable with increasing mortality related to RF LOS. Average HLOS and ICU LOS were longest in patients with abnormal PH and RF SBP and GCS-M. Discussion Support for PI evaluation of RF LOS >4 hours was not identified. Increased survival over time is explained by early transfers of high mortality patients. Our data support existing efficient statewide transfers and recommend PI review of transfer patients with abnormal GCS-M and SBP in a narrower timeframe.

Trauma in pregnancy is a leading cause of poor fetal and obstetric outcomes. Trauma team activation (TTA) criteria include injury with ≥ 20 weeks gestational age (GA). A retrospective analysis was performed on pregnant patients evaluated at a Level 1 trauma center. Patients were characterized by TTA: full, partial, or non-TTA, and TTA criteria independent of pregnancy. Index trauma and delayed delivery hospitalization outcomes were examined. Bivariate analysis, t test, and logistic regression were used when appropriate. From 2010 to 2015, 216 full, 50 partial, and 50 non-TTAs presented. Independent of pregnancy, 79 per cent of patients did not meet the TTA criteria. Fourteen (4%) had a pregnancy-related complication during index hospitalization (eight fetal and two maternal deaths). Nine of ten deaths occurred in patients meeting TTA independent of pregnancy. Delivery complications were greater in the index (52%, 13/25) versus subsequent (5%, 17/155) hospitalizations and were predicted by the respiratory rate ( P = 0.016) and injury severity score ( P < 0.001). Poor delayed delivery outcomes were associated with earlier GA ( P < 0.002) and longer index hospitalization ( P < 0.024). Odds of complication are higher in patients meeting the physiologic and anatomic criteria criteria for TTA versus GA criteria alone, signifying overtriage. Trauma activation protocols should be adapted based on the physiologic and anatomic criteria criteria in pregnant patients.

Background Outcomes of complex pancreatic procedures have been used as an index for quality, and higher volume has been associated with improved outcomes, leading to advocacy for referral to those centers. The aim of the study was to evaluate the outcomes of pancreaticoduodenectomy (PD) at a low-volume referral center. Materials and Methods This retrospective study included patients who had a PD within a 7-year period. Operative performance parameters and outcomes were examined. Results Overall, there were 47 pancreatic resections, of which 38 met the inclusion criteria and were used for analyses. The overall median for blood loss, packed red blood cells units transfused, and postoperative days in hospital was as follows, respectively: 675 mL (interquartile range [IQR] = 500-900), 0 units (IQR = 0-2), 12 days (IQR = 9-18). Demographic characteristics, comorbidities, and complications align with the literature. The 30-day in-hospital mortality rate was 5%. Survival probability for those with pancreatic adenocarcinoma at 1 year was 52% and 7% for years 2 and 3. Discussion As cases increased, significant improvement was noted in process outcomes including blood loss, blood transfusion rates, and length of stay (LOS). Survival was comparable to that in the literature, with limitation of not being adjusted for adjuvant therapy. Outcomes of complex pancreatic procedures, like PD, at a low-volume center with commitment and adequate support systems, can match those at high-volume centers.

Flail chest is used as one of the indicators for rib fixation, which is being performed more frequently. Radiologic and clinical flail chest are not clearly differentiated in published studies and the relationship between radiologic flail chest (RFC) and outcomes are not clearly established. Our study was designed to evaluate the relationship of RFC to outcomes in patients with severe blunt chest injury. Adult patients with severe blunt chest injury admitted between January 1, 2014, and June 30, 2016, were identified retrospectively. Three hundred and eighty-three patients were studied and mortality rate was not significantly different in patients with an RFC diagnosis (5.88%) compared with patients without RFC (3.83%), P = 0.50. Length of stay (LOS) in patients with and without RFC were compared and patients with RFC were found to have a statistically significant increase in both hospital and intensive care unit LOS (P = 0.0178, P < 0.0017). Multivariate analysis confirmed RFC as an independent predictor of increased LOS when compared with the number of rib fractures and displacements. Our study suggests that RFC may drive inappropriate use of rib fixation. This questions the justification of liberal rib fixation based on the perceived high mortality rate of modern flail chest diagnoses.

Recent clinical research in patients with blunt chest injury has focused on the benefits of surgical fixation of rib fractures. Noninvasive ventilation (NIV) has been demonstrated to prevent the need for intubation and ventilation in posttraumatic respiratory failure. The preemptive use of NIV in patients with rib fractures has not been extensively studied. Our study evaluated the outcomes of patients with ≥3 rib fractures and hospitalized for ≥ 4 days. Seventy-one patients treated with NIV were compared with 270 patients without NIV. NIV patients were older (65.8 vs 56.5 years) had more rib fractures (6.25 vs 5.32) and a higher body mass index (31 vs 27.8) than the comparison group, P < 0.05, but did not have an increased mortality or incidence of respiratory failure. NIV patients did have a statistically significant increase in length of stay compared to control (12.8 vs 8.8, P < 0.05). In the total sample, worse clinical outcomes were associated with older age, increased number of and bilateral rib fractures, higher Injury Severity Score, lower Glasgow Coma Scale, and higher body mass index. Outcomes in the most severely injured group of patients treated with NIV were comparable to other studies using surgical fixation of rib fractures and epidural pain control.

The aim of this study was to evaluate the impact of prehospital antiplatelet and/or anticoagulant (APAC) use on treatment and outcomes in patients with severe blunt chest injury. Patients with three or more rib fractures and a hospital length of stay (LOS) > three days admitted from 2014 to 2015 were included. Demographics, mortality, complications, injuries, hospital and ICU LOS, use of blood products, and thoracostomy were studied. Of 383 patients, 27.4 per cent were on APAC medication. Patients on APAC were older ( P < 0.0001), had higher Glasgow Coma Score ( P < 0.0001), and had lower Injury Severity Score ( P < 0.0001) and total number of fractures ( P = 0.0013) than the non-APAC group. APAC was not a predictor of mortality with or without age adjustment. In multiple linear regressions, APAC did not predict an increased LOS. APAC patients did not demonstrate an increase in admission diagnosis or complication of hemothorax, blood transfusions, tube thoracostomy, tracheostomy, LOS, or mortality rates. Similar findings are present in the subgroup of patients studied with high kinetic energy mechanism of injury. Our study does not support the perceived morbidity of APAC therapy in patients with severe blunt chest injury.

Trauma in pregnancy is a leading cause of poor fetal and obstetric outcomes. Trauma team activation (TTA) criteria include injury with ≥ 20 weeks gestational age (GA). A retrospective analysis was performed on pregnant patients evaluated at a Level 1 trauma center. Patients were characterized by TTA: full, partial, or non-TTA, and TTA criteria independent of pregnancy. Index trauma and delayed delivery hospitalization outcomes were examined. Bivariate analysis

With quality and public reporting of increasing importance, benchmarks are anticipated to grow in relevance. We studied cholecystectomy in a practice in an urban tertiary care hospital. A total of 1083 cholecystectomies were performed in 2008 and 2009. Laparoscopic cholecystectomy was performed in 97.8 per cent of patients with a 2.2 per cent conversion rate. A planned open procedure was performed in only 2.2 per cent of patients. Approximately half of procedures were urgent and performed during an acute hospitalization. Most patients (74%) were female and most patients were overweight or obese (64.8%). Ages into the tenth decade of life were represented. Comorbidities included hypertension, 28.7 per cent; coronary disease, 15.6 per cent; diabetes mellitus, 13.4 per cent; gastroesophageal reflux disease, 10.7 per cent; and asthma, 5.5 per cent. Of female patients, 98 (12.2%) were postpartum and five (0.6%) were pregnant. Of 137 patients without gallstones, 59.1 per cent had biliary dyskinesia and 27 per cent had acalculous cholecystitis. Preoperative magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography (ERCP) were performed in most patients with suspected choledocholithiasis. Intraoperative cholangiograms were performed in 6.9 per cent of patients, 3.3 per cent for abnormal liver function studies. Postoperative ERCP was used in most patients with positive intraoperative cholangiograms. All-cause mortality was 0.8 per cent and attributable mortality was 0.2 per cent. Complications occurred in 7.5 per cent of patients, including retained common bile duct stones in 1.1 per cent, bile duct leak in 0.3 per cent, and common bile duct injury in 0.1 per cent.