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OBJECTIVE: To reweight the Agency for Healthcare Research and Quality Patient Safety for Selected Indicators Composite (Patient Safety Indicator [PSI] 90) from weights based solely on the frequency of component PSIs to those that incorporate excess harm reflecting patients' preferences for outcome‐related health states. DATA SOURCES: National administrative and claims data involving hospitalizations in nonfederal, nonrehabilitation, acute care hospitals. STUDY DESIGN: We estimated the average excess aggregate harm associated with the occurrence of each component PSI using a cohort sample for each indicator based on denominator‐eligible records. We used propensity scores to account for potential confounding in the risk models for each PSI and weighted observations to estimate the “average treatment effect in the treated” for those with the PSI event. We fit separate regression models for each harm outcome. Final PSI weights reflected both the disutilities and the frequencies of the harms. DATA COLLECTION/EXTRACTION METHODS: We estimated PSI frequencies from the 2012 Healthcare Cost and Utilization Project State Inpatient Databases with present on admission data and excess harms using 2012–2013 Centers for Medicare & Medicaid Services Medicare Fee‐for‐Service data. PRINCIPAL FINDINGS: Including harms in the weighting scheme changed individual component weights from the original frequency‐based weighting. In the reweighted composite, PSIs 11 (“Postoperative Respiratory Failure”), 13 (“Postoperative Sepsis”), and 12 (“Perioperative Pulmonary Embolism or Deep Vein Thrombosis”) contributed the greatest harm, with weights of 29.7%, 21.1%, and 20.4%, respectively. Regarding reliability, the overall average hospital signal‐to‐noise ratio for the reweighted PSI 90 was 0.7015. Regarding discrimination, among hospitals with greater than median volume, 34% had significantly better PSI 90 performance, and 41% had significantly worse performance than benchmark rates (based on percentiles). CONCLUSIONS: Reformulation of PSI 90 with harm‐based weights is feasible and results in satisfactory reliability and discrimination, with a more clinically meaningful distribution of component weights.

The current national burden of emergency general surgery (EGS) illnesses and the extent of surgeon involvement in the care of these patients remain largely unknown. To inform needs assessments, research, and education, we sought to: (1) translate previously developed International Classification of Diseases (ICD), 9th Revision, Clinical Modification (ICD-9-CM) diagnosis codes representing EGS conditions to ICD 10th Revision, CM (ICD-10-CM) codes and (2) determine the national burden of and assess surgeon involvement across EGS conditions.We converted ICD-9-CM codes to candidate ICD-10-CM codes using General Equivalence Mappings then iteratively refined the code list. We used National Inpatient Sample 2016 to 2017 data to develop a national estimate of the burden of EGS disease. To evaluate surgeon involvement, using Wisconsin Hospital Association discharge data (January 1, 2016 to June 30, 2018), we selected adult urgent/emergent encounters with an EGS condition as the principal diagnosis. Surgeon involvement was defined as a surgeon being either the attending provider or procedural physician.Four hundred and eighty-five ICD-9-CM codes mapped to 1,696 ICD-10-CM codes. The final list contained 985 ICD-10-CM codes. Nationally, there were 2,977,843 adult patient encounters with an ICD-10-CM EGS diagnosis. Of 94,903 EGS patients in the Wisconsin Hospital Association data set, most encounters were inpatient as compared with observation (75,878 [80.0%] vs. 19,025 [20.0%]). There were 57,780 patients (60.9%) that underwent any procedure. Among all Wisconsin EGS patients, most had no surgeon involvement (64.9% [n = 61,616]). Of the seven most common EGS diagnoses, surgeon involvement was highest for appendicitis (96.0%) and biliary tract disease (77.1%). For the other five most common conditions (skin/soft tissue infections, gastrointestinal hemorrhage, intestinal obstruction/ileus, pancreatitis, diverticular disease), surgeons were involved in roughly 20% of patient care episodes.Surgeon involvement for EGS conditions ranges from highly likely (appendicitis) to relatively unlikely (skin/soft tissue infections). The wide range in surgeon involvement underscores the importance of multidisciplinary collaboration in the care of EGS patients.Prognostic/epidemiological, Level III.

Background Postoperative respiratory failure is the most common serious postoperative pulmonary complication, yet little is known about factors that can reduce its incidence. We sought to elucidate modifiable factors associated with respiratory failure that developed within the first 5 d after an elective operation. Materials and Methods Matched case-control study of adults who had an operation at five academic medical centers between October 1, 2012 and September 30, 2015. Cases were identified using administrative data and confirmed via chart review by critical care clinicians. Controls were matched 1:1 to cases based on hospital, age, and surgical procedure. Results Our total sample (n = 638) was 56.4% female, 71.3% white, and had a median age of 62 y (interquartile range 51, 70). Factors associated with early postoperative respiratory failure included male gender (odds ratio [OR] 1.72, 95% confidence interval [CI] 1.12-2.63), American Society of Anesthesiologists class III or greater (OR 2.85, 95% CI 1.74-4.66), greater number of preexisting comorbidities (OR 1.14, 95% CI 1.004-1.30), increased operative duration (OR 1.14, 95% CI 1.06-1.22), increased intraoperative positive end-expiratory pressure (OR 1.23, 95% CI 1.13-1.35) and tidal volume (OR 1.13, 95% CI 1.004-1.27), and greater net fluid balance at 24 h (OR 1.17, 95% CI 1.07-1.28). Conclusions We found greater intraoperative ventilator volume and pressure and 24-h fluid balance to be potentially modifiable factors associated with developing early postoperative respiratory failure. Further studies are warranted to independently verify these risk factors, explore their role in development of early postoperative respiratory failure, and potentially evaluate targeted interventions.

Background Emergency general surgery (EGS) encompasses a heterogeneous population of acutely ill patients, and standardized methods for determining disease severity are essential for comparative effectiveness research and quality improvement initiatives. The American Association for the Surgery of Trauma (AAST) has developed a grading system for the anatomic severity of 16 EGS conditions; however, little is known regarding how well these AAST EGS grades can be approximated by diagnosis codes in administrative databases. Methods We identified adults admitted for 16 common EGS conditions in the 2012 to 2017q3 National Inpatient Sample. Disease severity strata were assigned using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes based on AAST EGS anatomic severity grades. We evaluated whether assigned EGS severity (multiple strata or dichotomized into less versus more complex) were associated with in-hospital mortality, complications, length of stay, discharge disposition, and costs. Analyses were adjusted for age, sex, comorbidities, hospital traits, geography, and year. Results We identified 10,886,822 EGS admissions. The number of anatomic severity strata derived from ICD-9/10-CM codes varied by EGS condition and by year. Four conditions mapped to four strata across all years. Two conditions mapped to four strata with ICD-9-CM codes but only two or three strata with ICD-10-CM codes. Others mapped to three or fewer strata. When dichotomized into less versus more complex disease, patients with more complex disease had worse outcomes across all 16 conditions. The addition of multiple strata beyond a binary measure of complex disease, however, showed inconsistent results. Conclusion Classification of common EGS conditions according to anatomic severity is feasible with International Classification of Diseases codes. No condition mapped to five distinct severity grades, and the relationship between increasing grade and outcomes was not consistent across conditions. However, a standardized measure of severity, even if just dichotomized into less versus more complex, can inform ongoing efforts aimed at optimizing outcomes for EGS patients across the nation. Level of evidence Prognostic, level III.

Background There is little evidence supporting or refuting clamping trials, a period of clamping thoracostomy tubes prior to removal. We sought to evaluate whether clamping trials reduce the need for subsequent pleural drainage procedures. Methods We conducted a retrospective cohort study of trauma patients who underwent tube thoracostomy during 2009–2015. We compared patients who underwent clamping trials to those who did not, adjusting for confounders. The primary outcome was subsequent ipsilateral pleural drainage within 30 days. Results We evaluated 214 clamping trial and 285 control patients. Only two of 214 patients failed their clamping trial and none developed a tension pneumothorax [0.0% (95% CI 0.0–1.7%)]. Clamping trials were associated with fewer pleural drainage procedures [13 (6%) vs. 33 (12%); adjusted OR 0.41 (95% CI 0.20–0.84)]. Conclusions A clamping trial prior to thoracostomy tube removal seems to be safe and was associated with less likelihood of a subsequent pleural drainage procedure.

Background Administrative data can be used to identify cases of postoperative respiratory failure (PRF). We aimed to determine if recent changes to the Agency for Healthcare Research and Quality Patient Safety Indicator 11 (PSI 11) and adoption of clinical documentation improvement programs have improved the validity of PSI 11. We also analyzed reasons why PSI 11 was falsely triggered. Study design Cross-sectional study of all eligible discharges using health record data from five academic medical centers between October 1, 2012 and September 30, 2015. Results Of 437 flagged records, 434 (99.3%) were accurately coded and 414 (94.7%) represented true clinical PRF. None of the false positive records involved respiratory failure present on admission. Most (78.3%) false positive records required airway protection but did not have respiratory failure. Conclusion The validity of PSI 11 has improved with recent changes to the code criterion and adoption of clinical documentation improvement programs.

Background Single-center comparative effectiveness studies evaluating outcomes that can occur posthospitalization may become biased if outcomes diagnosed at other facilities are not ascertained. Administrative datasets that link patients' records across facilities may improve outcome ascertainment. Objective To determine whether use of linked administrative data significantly augments thromboembolic outcome ascertainment. Research design Retrospective cohort study. Subjects Patients with an acute isolated calf deep vein thrombosis (DVT) diagnosed at 1 Californian center during 2010-2013. Measures Proximal DVT or pulmonary embolism (PE) within 180 days. We ascertained outcomes from linked California hospitalization, emergency department, and ambulatory surgery data and compared this information to outcomes previously identified from review of the center's medical records. Results Among 384 patients with an isolated calf DVT, 333 could be linked to longitudinal administrative data records. Ten patients had a possible proximal DVT or PE (4 more clearly so) from administrative data; all were unknown from medical record review. Eleven patients with known outcomes from medical record review had no outcome from administrative data. The adjusted odds ratio of proximal DVT or PE with therapeutic anticoagulation attenuated from 0.33 [95% confidence interval (CI), 0.12-0.87] using only medical record review to 0.64 (95% CI, 0.29-1.40) using both medical record review and possible outcomes from administrative data. Restricting the outcome to diagnoses clearly involving proximal DVT or PE, the adjusted odds ratio was 0.46 (95% CI, 0.19-1.10). Conclusions Use of linked hospital administrative data augmented detection of outcomes but imperfect linkage, nonspecific diagnoses, and documentation/coding errors introduced uncertainty regarding the accuracy of outcome ascertainment.

Background The optimal level of care for hemodynamically stable patients with isolated blunt hepatic, renal, or splenic injuries (solid organ injuries [SOIs]) is unknown. We sought to characterize interhospital variability in intensive care unit (ICU) admission of such patients and to determine whether greater hospital-level ICU use would be associated with improved outcomes. Methods We conducted a retrospective cohort study using the 2015 and 2016 National Trauma Data Bank. We included adult patients with blunt trauma with SOIs with an Abbreviated Injury Scale score of 2 to 4. We excluded patients with other significant injuries, hypotension, or another indication for ICU admission, and hospitals with less than 10 eligible patients. We categorized hospitals into quartiles based on the proportion of eligible patients admitted to an ICU. The primary outcome was a composite of organ failure (cardiac arrest, acute lung injury/acute respiratory failure, or acute kidney injury), infection (sepsis, pneumonia, or catheter-related blood stream infection), or death during hospitalization. Results Among 14,312 patients at 444 facilities, 7,225 (50%), 5,050 (35%), and 3,499 (24%) had splenic, hepatic, and renal injuries, respectively. The median proportion of ICU use was 44% (interquartile range, 27-59%, range 0-95%). The composite outcome occurred in 180 patients (1.3%), with death in 76 (0.5%), organ failure in 97 (0.7%), and infection in 53 (0.4%). Relative to hospitals with the lowest ICU use (quartile 1), greater hospital-level ICU use was not associated with decreased likelihood of the composite outcome (adjusted odds ratios, 1.31; 95% confidence interval [95% CI], 0.88-1.95; 0.81; 95% CI, 0.52-1.26; and 0.94; 95% CI, 0.62-1.43 for quartiles 2-4, respectively) or its components. Unplanned ICU transfer was no more likely with lower hospital-level ICU use. Conclusion Admission location of stable patients with isolated mild to moderate abdominal SOIs is variable across hospitals, but hospitalization at a facility with greater ICU use is not associated with substantially improved outcomes. Level of evidence Therapeutic/care management, Level IV.

BackgroundOlder adults with isolated rib fractures are often admitted to an intensive care unit (ICU) because of presumedly increased morbidity and mortality. However, evidence-based guidelines are limited. We sought to identify characteristics of these patients that predict the need for ICU care.Materials and methodsWe analyzed patients ≥50y old at our center during 2013-2017 whose only indication for ICU admission, if any, was isolated rib fractures. The primary outcome was any critical care intervention (e.g., intubation) or adverse event (e.g., hypoxemia) (CCIE) based on accepted critical care guidelines. We used stepwise logistic regression to identify characteristics that predict CCIEs.ResultsAmong 401 patients, 251 (63%) were admitted to an ICU. Eighty-three patients (33%) admitted to an ICU and 7 (5%) admitted to the ward experienced a CCIE. The most common CCIEs were hypotension (10%), frequent respiratory therapy (9%), and oxygen desaturation (8%). Predictors of CCIEs included incentive spirometry

Background The U.S. prison population has increased substantially in recent years, and violent injury is common among prisoners. We sought to describe injury patterns and other characteristics of prisoners who presented to a trauma center after injury. Because penetrating trauma from an improvised weapon (e.g., shank) is frequent, we also sought to compare characteristics and outcomes of prisoners and non-prisoners who sustained an anterior abdominal stab or shank wound (AASW). Methods We analyzed injured adult prisoners who presented to a Level 1 trauma center between February, 2011, and April, 2017. We described characteristics of the injured prisoners and their hospitalizations. We compared prisoners who sustained an AASW to a random sample of non-prisoners with the same mechanism of injury using the chi-square test, Student's t-test, and logistic and Poisson regression. Results Of 14,461 hospitalized injured adults, 299 (2.0%) were injured while incarcerated. 185 (62%) encounters involved interpersonal violence and 36 prisoners (12%) presented with self-inflicted injuries. 98 (33%) had a psychiatric disorder. Among 33 prisoners and 66 non-prisoners who sustained an AASW, prisoners were less likely to have undergone a laparotomy [14/33 (42%) vs 44/66 (67%); RR 0.64 (95% CI 0.41-0.98)] or sustained an injury requiring operative intervention [2/33 (6%) vs 23/66 (35%); RR 0.17 (95% CI 0.04-0.69)]. Conclusions Many injured prisoners have psychiatric illness, are involved in interpersonal violence, or harm themselves. Among hospitalized patients, abdominal stab/shank wounds sustained in prison are less likely to result in significant injuries or operative intervention than similar wounds in non-prisoners.

Key Points Question Is a greater hospital-level tendency to admit older patients with rib fractures as an isolated injury to the intensive care unit (ICU) associated with improved outcomes for those patients? Findings In this cohort study of 23 951 patients aged 65 years and older, ICU use per trauma center varied from 0% to 92% of patients with isolated rib fractures. Greater ICU use was associated with a reduction in a composite adverse outcome of death, unplanned intubation, or pneumonia. Meaning These findings suggest that admission to an ICU may improve the outcomes of older patients with isolated chest wall injuries., This cohort study characterizes interhospital variability in intensive care unit vs non–intensive care unit admission of older patients with isolated rib fractures and evaluates whether greater hospital-level use of intensive care units is associated with improved outcomes., Importance The optimal level of care for older patients with rib fractures as an isolated injury is unknown. Objectives To characterize interhospital variability in intensive care unit (ICU) vs non-ICU admission of older patients with isolated rib fractures and to evaluate whether greater hospital-level use of ICU admission is associated with improved outcomes. Design, Setting, and Participants This cohort study included trauma patients aged 65 years and older with isolated rib fractures who were admitted to US trauma centers participating in the National Trauma Data Bank between January 1, 2015, and December 31, 2016. Patients were excluded if they had other significant injuries, were intubated or had assisted respirations in the emergency department (ED), or had a Glasgow Coma Scale (GCS) score of less than 9 in the ED. Hospitals with fewer than 10 eligible patients were excluded. Data analysis was conducted from May 2019 through September 2020. Exposures Admission to the ICU. Main Outcomes and Measures Composite of unplanned intubation, pneumonia, or death during hospitalization. Results Among 23 951 patients (11 066 [46.2%] women; mean [SD] age, 77.0 [7.2] years) at 573 hospitals, the median (interquartile range) proportion of ICU use was 16.7% (7.4%-32.0%), but this varied from a low of 0% to a high of 91.9%. The composite outcome occurred in 787 patients (3.3%), with unplanned intubation in 317 (1.3%), pneumonia in 180 (0.8%), and death in 451 (1.9%). Accounting for the hierarchical nature of the data and adjusting for propensity scores reflecting factors associated with ICU admission, receiving care at a hospital with the greatest ICU use (quartile 4), compared with a hospital with the lowest ICU use, was associated with decreased likelihood of the composite outcome (adjusted odds ratio, 0.71; 95% CI, 0.55-0.92). Conclusions and Relevance In this study, admission location of older patients with isolated rib fractures was variable across hospitals, but hospitalization at a center with greater ICU use was associated with improved outcomes. It may be warranted for hospitals with low ICU use to admit more such patients to an ICU.

Bean bag guns were developed as a nonlethal means for law enforcement personnel to subdue individuals. The large surface area and lower velocities of the bean bag round theoretically result in transfer of most of the energy to the skin/subcutaneous tissue and minimize the likelihood of dermal penetration, thereby ‘stunning’ intended victims without causing injury to deeper structures. However, this technology has been associated with significant intra-abdominal and intrathoracic injuries, skin penetration and death. We present a 59-year-old man who sustained a penetrating thoracic injury from a bean bag gun. Although the bean bag was successfully removed, the patient developed a postoperative empyema requiring operative management. We discuss the unique aspects of thoracic trauma from bean bag ballistics as well as considerations in management of patients with this uncommon mechanism of injury.

Clostridium difficile infection remains a common nosocomial illness with a significant impact on health care delivery. As molecular phenotyping of this organism has changed our understanding of its transmission and virulence, so too have diagnostic methods and treatment strategies evolved in recent years. The burden of this infection falls predominantly on elderly patients with comorbidities who have recently received antibiotics. Oral or enteral vancomycin is now preferred for first-line antimicrobial treatment across the disease spectrum, including mild-moderate initial cases. Fidaxomicin (a novel macrolide antibiotic), bezlotoxumab (a monoclonal antibody against toxin TcdB), and fecal microbiota transplantation expand the therapeutic armamentarium, particularly for recurrent infection. Operative treatment should be reserved for patients with fulminant infection, and early identification of patients who would benefit from an operation remains a challenge. Less invasive surgical options—such as laparoscopic diverting ileostomy with colonic irrigation—may improve survival and other outcomes relative to total abdominal colectomy and represent an attractive alternative particularly for frail patients.

Background Traditionally, clinicians present complications at surgical morbidity and mortality (M&M) conferences, and the AHRQ Patient Safety Indicators (PSIs) use inpatient administrative data to identify certain adverse outcomes. Although both methods are used to identify adverse events and inform quality improvement efforts, these 2 methods might not overlap. Study Design This is a retrospective observational study of all hospitalizations at a single academic department of surgery (including subspecialties) in 2016 involving a PSI-defined event (PSIs 03, 05 to 15) identified by surgery faculty and residents for review by departmental M&M conference or administrative data (according to AHRQ, version 6.0). Pediatric cases were excluded. We analyzed the degree to which these 2 processes captured PSI-defined events and reasons for exclusion by each process. Results Among 6,563 surgical hospitalizations, 647 hospitalizations (9.9%) had at least 1 complication identified by the M&M process or the PSIs (or both). Of these hospitalizations, 116 had at least 1 PSI-defined event (for a total of 149 PSI-defined events) captured by either M&M or the PSIs. Most complications (n = 82 [88.2%]) identified by M&M alone were excluded by PSI criteria (as intended), but 11 true PSI events (ie false negatives) were identified by M&M only. In contrast, pressure ulcers and central venous catheter-related bloodstream infections were detected exclusively by the PSIs and not reported via M&M. There was limited overlap, with 18 events (12.1%) captured by both processes. Conclusions Surgical M&M and the PSIs are complementary approaches to identifying complications. Both case-finding processes should be used to inform quality improvement efforts.

BACKGROUND Patients undergoing emergency general surgery (EGS) procedures are up to eight times more likely to die than patients undergoing the same procedures electively. This excess mortality is often attributed to nonmodifiable patient factors including comorbidities and physiologic derangements at presentation, leaving few targets for quality improvement. Although the hospital-level traits that contribute to EGS outcomes are not well understood, we hypothesized that facilities with lower trauma mortality would have lower EGS mortality. METHODS Using the Nationwide Inpatient Sample (2008-2011), we calculated hospital-level risk-adjusted trauma mortality rates for hospitals with more than 400 trauma admissions. We then calculated hospital-level risk-adjusted EGS mortality rates for hospitals with more than 200 urgent/emergent admissions for seven core EGS procedures (laparotomy, large bowel resection, small bowel resection, lysis of adhesions, operative intervention for ulcer disease, cholecystectomy, and appendectomy). We used univariable and multivariable techniques to assess for associations between hospital-level risk-adjusted EGS mortality and hospital characteristics, patient-mix traits, EGS volume, and trauma mortality quartile. RESULTS Data from 303 hospitals, representing 153,544 admissions, revealed a median hospital-level EGS mortality rate of 1.21% (interquartile range, 0.86%-1.71%). After adjusting for hospital traits, hospital-level EGS mortality was significantly associated with trauma mortality quartile as well as patients' community income-level and race/ethnicity (p < 0.05 for all). Mean risk-adjusted EGS mortality was 1.09% (95% confidence interval, 0.94-1.25%) at hospitals in the lowest quartile for risk-adjusted trauma mortality, and 1.64% (95% confidence interval, 1.48-1.80%) at hospitals in the highest quartile of trauma mortality (p < 0.01). Sensitivity analyses limited to (1) high-mortality procedures and (2) high-volume facilities; both found similar trends (p < 0.01). CONCLUSIONS Patients at hospitals with lower risk-adjusted trauma mortality have a nearly 33% lower risk of mortality after admission for EGS procedures. The structures and processes that improve trauma mortality may also improve EGS mortality. Emergency general surgery-specific systems measures and process measures are needed to better understand drivers of variation in quality of EGS outcomes. LEVEL OF EVIDENCE Epidemiological, level III; Care management, level IV.

BACKGROUNDPatients managed nonoperatively have been excluded from risk-adjusted benchmarking programs, including the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP). Consequently, optimal performance evaluation is not possible for specialties like emergency g

Background Following transfusion, donor white blood cells (WBCs) can persist long-term in the recipient, a phenomenon termed transfusion-associated microchimerism (TA-MC). Prior studies suggest TA-MC is limited to transfusion following traumatic injury, and is not prevented by leukoreduction. Study design and methods We conducted a prospective cohort study at a major trauma center to evaluate TA-MC following injury. Index samples were collected upon arrival, prior to transfusion. Follow-up samples were collected at intervals up to one year, and beyond for those testing positive for TA-MC. TA-MC was detected by real-time quantitative allele-specific polymerase chain reaction assays at the HLA-DR locus and several polymorphic insertion deletion sites screening for non-recipient alleles. Results A total of 378 trauma patients were enrolled (324 transfused cases and 54 non-transfused controls). Mean age was 42 ± 18 years, 74% were male, and 80% were injured by blunt mechanism. Mean Injury Severity Score was 20 ± 12. Among transfused patients, the median (interquartile range) number of red cell units transfused was 6 (3,12), and median time to first transfusion was 9 (0.8,45) hours. Only one case of long-term TA-MC was confirmed in our cohort. We detected short-term TA-MC in 6.5% of transfused subjects and 5.6% on non-transfused controls. Conclusions In contrast to earlier studies, persistent TA-MC was not observed in our cohort of trauma subjects. Short-term TA-MC was detected, but at a lower frequency than previously observed, and rates were not significantly different than what was observed in non-transfused controls. The reduction in TA-MC occurrence may be attributable to changes in leukoreduction or other blood processing methods.

OBJECTIVE We examine how esophagectomy volume thresholds reflect outcomes relative to patient characteristics. SUMMARY BACKGROUND DATA Esophagectomy outcomes are associated with surgeon and hospital operative volumes, leading the Leapfrog Group to recommend minimum annual volume thresholds of 7 and 20 respectively. METHODS Patients undergoing esophagectomy for cancer were identified from the 2007-2013 New York and Florida Healthcare Cost and Utilization Project's State Inpatient Databases. Logit models adjusted for patient characteristics evaluated in-hospital mortality, complications, and prolonged length of stay (PLOS). Median surgeon and hospital volumes were compared between young-healthy (age 18-57, Elixhauser Comorbidity Index [ECI] 4). RESULTS Of 4330 esophagectomy patients, 3515 (81%) were male, median age was 64 (interquartile range 58-71), and mortality was 4.0%. Patients treated by both low-volume surgeons and hospitals had the greatest mortality risk (5.0%), except in the case of older-sick patients mortality was highest at high-volume hospitals with high-volume surgeons (12%). For mortality

In an effort to improve patient outcomes and shorten hospital length of stay for patients undergoing pulmonary lobectomy, clinicians have focused on standardizing the postoperative management of chest tubes.

The recent implementation of the International Classification of Diseases, 10(th) Revision, Clinical Modification and Procedure Coding System (ICD-10-CM/PCS) provides a robust classification of diagnoses and procedures for hospital systems. As researchers begin using ICD-10-CM/PCS for outcomes research from administrative datasets, it is important to understand ICD-10-CM/PCS, as well as the strengths and challenges of these new classifications. In this review, we describe the development of ICD-10-CM/PCS and summarize how it applies specifically to thoracic surgery patients undergoing pulmonary lobectomy, sublobar resection (segmentectomy or wedge resection) and esophagectomy. This myriad of ICD-10-CM/PCS codes presents challenges and questions for thoracic surgery researchers and medical journal reviewers and editors when evaluating thoracic surgical outcomes research utilizing ICD-10-CM/PCS. Additional work is needed to develop consensus guidelines and uniformity for accurate and coherent research methods to utilize ICD-10-CM/PCS in future outcomes research efforts.

Introduction Over the last 5 years, the American Association for the Surgery of Trauma has developed grading scales for emergency general surgery (EGS) diseases. In a previous validation study using diverticulitis, the grading scales were predictive of complications and length of stay. As EGS encompasses diverse diseases, the purpose of this study was to validate the grading scale concept against a different disease process with a higher associated mortality. We hypothesized that the grading scale would be predictive of complications, length of stay, and mortality in skin and soft-tissue infections (STIs). Methods This multi-institutional trial encompassed 12 centers. Data collected included demographic variables, disease characteristics, and outcomes such as mortality, overall complications, and hospital and ICU length of stay. The EGS scale for STI was used to grade each infection and two surgeons graded each case to evaluate inter-rater reliability. Results 1170 patients were included in this study. Inter-rater reliability was moderate (kappa coefficient 0.472-0.642, with 64-76% agreement). Higher grades (IV and V) corresponded to significantly higher Laboratory Risk Indicator for Necrotizing Fasciitis scores when compared with lower EGS grades. Patients with grade IV and V STI had significantly increased odds of all complications, as well as ICU and overall length of stay. These associations remained significant in logistic regression controlling for age, gender, comorbidities, mental status, and hospital-level volume. Grade V disease was significantly associated with mortality as well. Conclusion This validation effort demonstrates that grade IV and V STI are significantly predictive of complications, hospital length of stay, and mortality. Though predictive ability does not improve linearly with STI grade, this is consistent with the clinical disease process in which lower grades represent cellulitis and abscess and higher grades are invasive infections. This second validation study confirms the EGS grading scale as predictive, and easily used, in disparate disease processes. Level of evidence Prognostic/Epidemiologic retrospective multicenter trial, level III.

BACKGROUND Conflicting data on the microbiology and epidemiology of necrotizing soft tissue infections (NSTIs) appear to stem from the heterogeneity in microbiology observed in regions across the United States. Our goal was to determine current differences in organism prevalence and outcomes for NSTI and non-necrotizing severe soft tissue infections across the United States. We hypothesized that there were geographical differences in organism prevalence that would lead to differences in outcomes. MATERIALS AND METHODS This study was a retrospective multi-institutional trial from centers across the United States and Canada. Demographic, clinical, and outcomes data were collected. Bivariate and multivariable analyses were performed to determine the effects of region and microbiology on outcomes. RESULTS A total of 622 patients were included in this study. Polymicrobial infections (45%) were the most prevalent infections in all regions. On bivariate analysis, Clostridium and polymicrobial infections had higher mean Laboratory Risk Indicator for Necrotizing Fasciitis scores and American Association for the Surgery of Trauma grades (P

In 2018, the Leapfrog Group set minimum annual lung cancer surgery hospital and surgeon volume thresholds of 40 and 15, respectively. We examined whether outcomes associated with these Leapfrog Group volume thresholds are comparable for patients at the extremes of age and comorbidities.We assessed lung cancer patients undergoing lobectomy or pneumonectomy in the New York and Florida State Inpatient Databases for 2007 to 2013. Multivariate logit models evaluated in-hospital mortality, complications, and prolonged length of stay. Median surgeon and hospital volumes were compared between "younger-healthier" (age 18-60 years, Elixhauser Comorbidity Index1) and "older-sicker" patients (age77 years, Elixhauser Comorbidity Index3).The 27,841 patients included 13,277 men (48%). The median patient age was 69 years (interquartile range, 61-77), and mortality was 2.1%. Patients treated by both low-volume surgeons (15 annual cases) and at low-volume hospitals (40) had the greatest risk of mortality (2.5%), except for the cohort of younger-healthier patients (mortality2%). Mortality for older-sicker patients was highest for high-volume surgeons (12%), although higher hospital volume was protective. Increasing hospital volume was associated with decreased mortality (odds ratio [OR], 0.997; 95% confidence interval [CI], 0.995-0.998; P = .0103), complications (OR, 0.998; 95% CI, 0.997-0.999; P .001), and prolonged length of stay (OR, 0.998; 95% CI, 0.997-1.00; P = .01); similarly, higher surgeon volume was associated with decreased mortality (OR, 0.997; 95% CI, 0.99-1.00; P = .03), complications (OR, 0.997; 95% CI, 0.994-1.00; P = .02), and prolonged length of stay (OR, 0.991; 95% CI, 0.986-0.995; P .01).Hospital volume has a greater effect on morbidity and mortality than surgeon volume especially for older-sicker patients, suggesting that Leapfrog Group volume guidelines should emphasize hospital volume over surgeon volume and may be less relevant for younger-healthier patients.

Objective To convert the Agency for Healthcare Research and Quality's (AHRQ) Quality Indicators (QIs) from International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) specifications to ICD, 10th Revision, Clinical Modification and Procedure Classification System (ICD-10-CM/PCS) specifications. Data sources ICD-9-CM and ICD-10-CM/PCS classifications, General Equivalence Maps (GEMs). Study design We convened 77 clinicians and coders to evaluate ICD-10-CM/PCS codes mapped from ICD-9-CM using automated GEMs. We reviewed codes to develop "legacy" specifications resembling those in ICD-9-CM and "enhanced" specifications addressing enhanced capabilities of ICD-10-CM/PCS. Data collection/extraction methods We tabulated the numbers of mapped codes, added nonmapped codes, and deleted mapped codes to achieve the specifications. Principal findings Of 212 clinical concepts (sets of codes) that comprise the QI specifications, we either added nonmapped codes to or deleted mapped codes from 115 (54 percent). The legacy and enhanced specifications differed for 46 sets (22 percent), affecting 67 of the 101 QIs (66 percent). Occasionally, concepts that defied conversion required reformulation of indicators. Conclusions Converting the AHRQ QIs to ICD-10-CM/PCS required a detailed, thorough process beyond automated mapping of codes. Differences between the legacy and enhanced versions of the QIs are frequently minor but sometimes substantive.

Background Although thoracic trauma is common, little is known about which factors lead to poor functional outcomes. We sought to determine which characteristics of chest wall injury predict postrecovery pulmonary symptoms or health-related quality of life. Methods We conducted a secondary analysis of data from a randomized trial involving patients with chest wall injuries at a Level I trauma center between December 2007 and July 2012. We evaluated the overall severity of the chest wall injury-characterized primarily by the number of fractured ribs-and rib fracture location (upper, middle, and lower; anterior, lateral, and posterior) as predictors of patient-reported outcomes 60 days after injury: dyspnea burden (0-40), Modified Medical Research Council Dyspnea Scale (MMRC) (0-4), St. George's Respiratory Questionnaire (SGRQ), and normalized Medical Outcomes Study Short-Form 36 (SF-36) scores. Results Of 189 evaluable subjects, the mean (SD) number of fractured ribs was 5 (4). The number of fractured ribs was not associated with dyspnea burden, MMRC, or SGRQ scores. After adjustment for confounders, each additional fractured rib was associated with worse SF-36 Physical Functioning and Bodily Pain scores (-0.6 units [95% confidence interval (CI), -1.1 to 0.0] and -0.8 units [95% CI, -1.3 to -0.2], respectively). Lower rib fractures were associated with worse dyspnea burden (3.4 units; 95% CI, 1.0-5.9), MMRC score (0.4 units; 95% CI, 0.0-0.8), and SF-36 Physical Functioning, Role-Physical, Role-Emotional, and Physical Component Summary scores (-4 units [95% CI, -8 to 0], -5 units [95% CI, -8 to -1], -4 units [95% CI, -8 to 0], and -4 units [95% CI, -7 to -1], respectively). Conclusion The overall anatomic severity of chest wall injuries does not predict worse dyspnea symptoms 60 days after injury, but it does predict increased patient perceptions of pain and physical function limitations. Lower rib fractures predict both persistent respiratory symptoms and perception of decreased overall health. Level of evidence Prognostic/epidemiologic study, level III.

As North Atlantic Treaty Organization (NATO) countries begin troop withdrawal from Afghanistan, military medicine needs programs for combat surgeons to retain the required knowledge and surgical skills. Each military branch runs programs at various Level I academic trauma centers to deliver predeployment training and provide a robust trauma experience for deploying surgeons. Outside of these successful programs, there is no system-wide mechanism for nondeploying military surgeons to care for a high volume of critically ill trauma patients on a regular basis in an educational environment that promotes continued professional development. We hypothesize that fully integrated military-civilian relationship regional Level I trauma centers provide a surgical experience more closely mirroring that seen in a Role III hospital than local Level II and Level III trauma center or medical treatment facilities.We characterized the Level I trauma center practice using the number of trauma resuscitations, operative trauma/acute care surgery procedures, number of work shifts, operative density (defined as the ratio of operative procedures/days worked), and frequency of educational conferences. The same parameters were collected from two NATO Role III hospitals in Afghanistan during the peak of Operation Enduring Freedom. Data for two civilian Level II trauma centers, two civilian Level III trauma centers, and a Continental United States Military Treatment Facility without trauma designation were collected.The number of trauma resuscitations, number of 24-hour shifts, operative density, and educational conferences are shown in the table for the Level I trauma center compared with the different institutions. Civilian center trauma resuscitations and operative density were highest at the Level I trauma center and were only slightly lower than what was seen in Afghanistan. Level II and III trauma centers had lower numbers for both. The Level I trauma center provided the most frequent educational opportunities.In a Level I academic trauma center integrated program, military and civilian surgeons have the same clinical and educational responsibilities: rounding and operating, managing critical care patients, covering trauma/acute care surgery call, and mentoring surgery residents in an integrated residency program. The Level I trauma center experience most closely mimics the combat surgeon experience seen at NATO Role III hospitals in Afghanistan compared with other civilian trauma centers. At high-volume Level I trauma centers, military surgeons will have a comprehensive trauma practice, including dedicated educational opportunities. We recommend integrated programs with Level I academic trauma centers as the primary mechanism for sustaining military combat surgical skills in the future.

The American Association for the Surgery of Trauma (AAST) recently established a grading system for uniform reporting of anatomic severity of several emergency general surgery (EGS) diseases. There are five grades of severity for each disease, ranging from I (lowest severity) to V (highest severity). However, the grading process requires manual chart review. We sought to evaluate whether International Classification of Diseases, 9th and 10th Revisions, Clinical Modification (ICD-9-CM, ICD-10-CM) codes might allow estimation of AAST grades for EGS diseases. The Patient Assessment and Outcomes Committee of the AAST reviewed all available ICD-9-CM and ICD-10-CM diagnosis codes relevant to 16 EGS diseases with available AAST grades. We then matched grades for each EGS disease with one or more ICD codes. We used the Official Coding Guidelines for ICD-9-CM and ICD-10-CM and the American Hospital Association's "Coding Clinic for ICD-9-CM" for coding guidance. The ICD codes did not allow for matching all five AAST grades of severity for each of the 16 diseases. With ICD-9-CM, six diseases mapped into four categories of severity (instead of five), another six diseases into three categories of severity, and four diseases into only two categories of severity. With ICD-10-CM, five diseases mapped into four categories of severity, seven diseases into three categories, and four diseases into two categories. Two diseases mapped into discontinuous categories of grades (two in ICD-9-CM and one in ICD-10-CM). Although resolution is limited, ICD-9-CM and ICD-10-CM diagnosis codes might have some utility in roughly approximating the severity of the AAST grades in the absence of more precise information. These ICD mappings should be validated and refined before widespread use to characterize EGS disease severity. In the long-term, it may be desirable to develop alternatives to ICD-9-CM and ICD-10-CM codes for routine collection of disease severity characteristics.

Introduction: The objective of this study was to compare long-term neurological outcomes in low-risk patients with traumatic intracranial hemorrhage (tICH) admitted to the ICU (intensive care unit) versus patients admitted to the floor. Methods: This retrospective study was conducted at a Level 1 trauma center from October 1, 2008, to February 1, 2013. We defined low-risk patients as age less than 65 years, isolated head injury, normal admission mental status, and no shift or swelling on initial head CT (computed tomography). Clinical data were abstracted from a trauma registry and linked to a brain injury database. We compared the Extended Glasgow Outcome Scale (GOS-E) score at six months between patients admitted to the ICU and patients admitted to the floor. We did a risk-adjusted analysis of the influence of floor admission on a normal GOS-E. Results: We identified 151 patients; 45 (30%) were admitted to the floor and 106 (70%) to the ICU. Twenty-three (51%; 95% CI [36-66%]) patients admitted to the floor and 55 (52%; 95% CI [42-62%]) patients admitted to the ICU had a normal GOS-E. On adjusted analysis; the odds ratio for floor admission was 0.77 (95% CI [0.36-1.64]) for a normal GOS-E at six months. Conclusion: Long-term neurological outcomes in low-risk patients with tICH were not markedly different between patients admitted to the ICU and those admitted to the floor. However, we were unable to demonstrate non-inferiority on adjusted analysis. Future work aimed at a larger, prospective cohort may better evaluate the relative impacts of admission type on outcomes. [West J Emerg Med. 2015;16(2):284–290.]

BackgroundThe effectiveness of the nonsteroidal anti-inflammatory drug ketorolac in reducing pulmonary morbidity after rib fractures remains largely unknown.MethodsA retrospective cohort study was conducted spanning January 2003 to June 2011 assessing pneumonia within 30 days and potential adverse effects of ketorolac among all patients with rib fractures who received ketorolac

Clinicians place chest tubes approximately 1 million times each year in the United States, but little information is available to guide their management. Specifically, use of the rate of pleural fluid drainage as a criterion for tube removal is not standardized. Absent such tubes, pleural fluid drains primarily through parietal pleural lymphatics at rates approaching 500 mL of fluid per day or more for each hemithorax. Early removal of tubes does not appear to be harmful. A noninferiority randomized trial currently in progress comparing removal without considering the drainage rate to a conservative threshold (2 mL/kg body weight in 24 hours) may better inform tube management.

OBJECTIVE The Agency for Healthcare Research and Quality Patient Safety Indicator (PSI) 10, "Postoperative Physiologic and Metabolic Derangement" (PPMD), uses administrative data to detect postoperative acute kidney injury (AKI) requiring dialysis and diabetes-related complications. We sought to evaluate the indicator's criterion validity. RESEARCH DESIGN We conducted a retrospective cross-sectional study of hospitalization records flagged positive and negative by PSI 10 from a diverse set of 35 hospitals between February 1, 2006 and June 30, 2009. Trained nurse abstractors reviewed medical records. We determined the indicator's sensitivity, specificity, and positive and negative predictive values. RESULTS Of 94 records flagged by PSI 10 (87 for AKI, 7 for diabetic complications, 1 for both), 69 (73%) involved an accurately coded event; 60 (64%; 95% CI, 46%-79%) represented true PPMD from a clinical perspective. Two of 8 records flagged for diabetic complications were true events. Nineteen false positives involved preoperative renal failure. Three of 230 records flagged negative (enriched with questionably negative records) represented true PPMD. The indicator's sensitivity was 66% (20%-94%), specificity 99.9% (99.5%-100%), and negative predictive value 99.9% (99.4%-100%). Considering dialysis access procedures tantamount to dialysis and excluding records with lower urinary tract obstruction might increase the sensitivity and positive predictive value to 98% (87%-100%) and 72% (50%-87%), respectively. CONCLUSIONS PSI 10 mostly concerns AKI and currently has moderate criterion validity, which might improve with increased use of "present on admission" coding, abandonment of the diabetes criteria, and adjustments to the indicator specifications regarding dialysis access and urinary tract obstruction.

Current general surgery residents have limited exposure to open trauma operative cases. Simulation supplements variable rotation volume and provides experience with critical but rarely performed procedures. Open simulation classically focuses on static models with anatomic accuracy but lacks practicality when hemorrhage control is the lifesaving maneuver. We sought to evaluate whether training on a dynamic simulator, while much less expensive than training on a static cadaver, might be at least as effective in training surgery residents to expeditiously place temporary vascular shunts (TVSs).Our research team developed an inexpensive, reusable dynamic simulator with ongoing hemorrhage to instruct trainees in the steps of TVS placement. We enrolled 54 general surgery residents in a noninferiority randomized controlled trial comparing training of TVS placement on the dynamic simulator (n = 28) versus a cadaver arm (n = 26). After standardized video didactics, trainees practiced on either the simulator or cadaver arm. After the trainees achieved competency, they were tested on placing a TVS for a live swine femoral artery injury. Two blinded trauma surgeons evaluated the recorded performances.Residents did not differ in baseline characteristics between groups, and all residents in both groups successfully completed the TVS placement test. Subjects trained on the simulator placed the TVS faster than those trained on a cadaver (584 seconds vs. 751 seconds; difference, +167 seconds faster; 90% confidence interval [CI], +52 to +282 seconds), with a trend toward faster time to hemorrhage control (110 seconds vs. 148 seconds; difference, +38 seconds faster; 90% CI, -8 to +84). There was no significant difference in Objective Structured Assessment of Technical Skills scores (3.72 vs. 3.44; difference, +0.27 units better; 90% CI, -0.04 to +0.59).Training on a dynamic simulator resulted in noninferior time to completion of vascular shunt placement compared with training on a cadaver. The addition of dynamic hemorrhage to simulators might inexpensively augment trauma skills training.

BACKGROUND Trauma and transfusion can both alter immunity, and while transfusions are common among traumatically injured patients, few studies have examined their combined effects on immunity.

Background The American Association for the Surgery of Trauma (AAST) has developed a new grading system for uniform description of anatomic severity of emergency general surgery (EGS) diseases, ranging from Grade I (mild) to Grade V (severe). The purpose of this study was to determine the relationship of AAST grades for acute colonic diverticulitis with patient outcomes. A secondary purpose was to propose an EGS quality improvement program using risk-adjusted center outcomes, similar to National Surgical Quality Improvement Program and Trauma Quality Improvement Program methodologies. Methods This was a retrospective study of 1,105 patients (one death) from 13 centers. At each center, two reviewers (blinded to each other's assignments) assigned AAST grades. Interrater reliability was measured using κ coefficient. Relationship between AAST grade and clinical events (complications, intensive care unit use, surgical intervention, and 30-day readmission) as well as length of stay was measured using regression analyses to control for age, comorbidities, and physiologic status at the time of admission. Final model was also used to calculate observed-to-expected (O-E) ratios for adverse outcomes (death, complications, readmissions) for each center. Results Median age was 54 years, 52% were males, 43% were minorities, and 22% required a surgical intervention. Almost two thirds had Grade I or II disease. There was a high level of agreement for grades between reviewers (κ = 0.81). Adverse events increased from 13% for Grade I, to 18% for Grade II, 28% for Grade III, 44% for Grade IV, and 50% for Grade V. Regression analysis showed that higher disease grades were independently associated with all clinical events and length of stay, after adjusting for age, comorbidities, and physiology. O-E ratios showed statistically insignificant variations in risk of death, complications, or readmissions. Conclusion AAST grades for acute colonic diverticulitis are independently associated with clinical outcomes and resource use. EGS quality improvement program methodology that incorporates AAST grade, age, comorbidities, and physiologic status may be used for measuring quality of EGS care. High-quality EGS registries are essential for developing meaningful quality metrics. Level of evidence Prognostic study, level V.

Background The Agency for Healthcare Research and Quality Patient Safety Indicator postoperative respiratory failure (PRF) uses administrative data to screen for potentially preventable respiratory failure after elective surgery based on a respiratory failure diagnosis or an intubation or ventilation procedure code. Data on PRF accuracy in identifying true events is scant; a recent study using University HealthSystem Consortium data found a positive predictive value (PPV) of 83%. We examined the indicator's PPV in the Veterans Health Administration. Study Design We applied the Patient Safety Indicator software (v.3.1a) to fiscal year 2003–2007 VA discharge data. Trained abstractors reviewed medical records of 112 software-flagged PRF cases. We calculated the PPV and examined false positives to determine reasons for incorrect identification and true positives to determine clinical consequences and potential risk factors of PRF. Results Seventy-five cases were true positive (PPV 67%; 95% CI, 57–76%); 13% were identified by a diagnosis code, 53% by a procedure code, 33% by both. Of false positives, 19% represented coding errors, 76% represented nonelective admissions. Of true positives, 28% of patients died, 56% had an American Society of Anesthesiologists level higher than II. Of associated index procedures, 53% were abdominal/pelvic, and 56% lasted >3 hours. Conclusions Based on our and University HealthSystem Consortium's findings, PRF should continue to be used as a screen for potential patient-safety events. Its PPV could be substantially improved in the Veterans Health Administration through introduction of an admission status code. Many PRF-identified cases appeared to be at high risk, based on patient and procedure-related factors. The degree to which such cases are truly preventable events requires additional assessment.

Measurement of peripheral blood cytokines and other immunomodulatory proteins is a useful and popular tool for assessing human immune responses to a wide range of assaults. A common challenge in this work is obtaining fresh, high-quality samples and limiting the time between blood collection and the separation of plasma or serum from cells. In this study we sought to determine the effect of sample age at the time of processing on the measured levels of 41 soluble immune mediators. Two cohorts were examined: healthy lab donors and trauma patients, who have significant immune perturbation. Whole-blood samples were aliquoted, and plasma was isolated, at days 0, 1, 2, and 3 after collection. Multiplexing techniques were used to measure protein concentrations, and general estimating equations were used to determine if there was a significant change over time. Over the 3-day period examined, only 15 of the 41 proteins showed no significant change in either cohort. Among the remaining proteins both increases and decreases were observed, with changes ranging from 2.4% per day to 325% per day. Proteins with significant changes in one cohort did not always show significant changes in the other group. These results support the need to separate plasma or serum from whole blood as quickly as possible and/or to standardize the length of time to processing within a given study of peripheral blood protein concentrations. When this is not possible, care should be taken to account for differences due to sample age.

Anemia is recognized as a possible cause of secondary injury following traumatic brain injury (TBI). Cogent arguments can be made for both liberal and restrictive blood transfusion practices in this setting. In this narrative review, we summarize available knowledge regarding the risks of anemia and transfusion in patients with TBI. Laboratory studies using animal models and healthy human subjects suggest that anemia below a hemoglobin (Hb) concentration of 7 g/dL results in impaired brain function and below 10 g/dL may be detrimental to recovery from TBI. Clinical studies that have evaluated the association of anemia with clinical outcomes have not consistently demonstrated harm, but they generally have important methodological weaknesses. Alternatively, studies that have analyzed transfusion as a predictor of worse outcome have consistently identified such an association, but these studies may involve residual confounding. What little information exists from randomized trials that have included patients with TBI and evaluated liberal versus restrictive transfusion strategies is inconclusive. Since anemia in the setting of TBI is relatively common and there is considerable variation in transfusion preferences, greater study of this topic - preferably with one or more rigorous, adequately powered, non-inferiority randomized trials - is desirable.

Hospital administrative data are being used to identify hospitals with hospital-acquired complications such as iatrogenic pneumothorax. This was a retrospective cross-sectional study of hospitalization records to estimate the positive predictive value (PPV) of the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicator for iatrogenic pneumothorax. A probability sample of inpatient medical records from 2006 to 2007 was reviewed in a national sample of 28 volunteer hospitals. Among the 200 flagged cases, the PPV was 78% (95% confidence interval = 73%-82%). False positive cases were mostly a result of exclusionary conditions (11%) and pneumothoraxes that were present on admission (7%). About 44% of events followed attempted central venous catheter (CVC) placement. Of the 69 CVC-associated events, only 5 occurred with ultrasound guidance. AHRQ's iatrogenic pneumothorax indicator can serve in quality of care improvement. At least 1725 hospital-acquired pneumothoraxes could have been prevented in 2004 through universal use of ultrasound guidance during internal jugular cannulation.

Hospital administrative data are being used to identify patients with postoperative venous thromboembolism (VTE), either pulmonary embolism (PE) or deep-vein thrombosis (DVT). However, few studies have evaluated the accuracy of these ICD-9-CM codes across multiple hospitals.The Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicator (PSI)-12 was used to identify cases with postoperative VTE in 80 hospitals that volunteered for either an AHRQ or University HealthSystem Consortium (UHC) validation project. Trained abstractors using a standardized tool and guidelines retrospectively verified all coded VTE events.In the combined samples, the positive predictive value of the set of prespecified VTE codes for any acute VTE at any time during the hospitalization was 451 of 573 = 79% (95% CI: 75%-82%). However, the positive predictive value for acute lower extremity DVT or PE diagnosed after an operation was 209 of 452 = 44% (95% CI: 37%-51%) in the UHC sample and 58 of 121 = 48% (95% CI: 42-67%) in the AHRQ sample. Fourteen percent of all cases had an acute upper extremity DVT, 6% had superficial vein thrombosis and 21% had no acute VTE, however, 61% of the latter had a documented prior/chronic VTE. In the UHC cohort, the sensitivity for any acute VTE was 95.5% (95% CI: 86.4%-100%); the specificity was 99.5% (95% CI: 99.4%-99.7%).Current PSI 12 criteria do not accurately identify patients with acute postoperative lower extremity DVT or PE. Modification of the ICD-9-CM codes and implementation of "present on admission" flags should improve the predictive value for clinically important VTE events.

Patient Safety Indicator (PSI) 15, or "Accidental Puncture or Laceration" (APL), of the US Agency for Healthcare Research and Quality was recently endorsed as a consensus standard for quality of care by the National Quality Forum. We sought to determine the positive predictive value (PPV) of this indicator.We conducted a retrospective cross-sectional study of hospitalization records that met PSI 15 criteria. We sampled cases from 32 geographically diverse hospitals, including both teaching and nonteaching hospitals, between October 1, 2005 and March 31, 2007. Trained abstractors from each center reviewed randomly sampled medical records, using a standard instrument. We determined the PPV of the indicator and conducted descriptive analyses of the cases.Of the 249 cases that met PSI 15 criteria, 226 (91%; 95% CI: 88%-94%) represented true APL. Fifty-six of the true APL cases (24%) represented injuries that generally would be expected to heal without repair, yielding, from the standpoint of clinical relevance, a PPV of 68% (95% CI: 62%-74%). True positive cases that would typically warrant repair (n=170) were most likely to involve the gastrointestinal tract (30%), bladder (25%), dura (19%), or an important blood vessel (16%). In 97 of the true APL cases (43%), adhesions or other scar tissue were thought to have contributed to the complication. The 23 false-positive cases involved no apparent event other than normal operative conduct (n=7), a complication other than APL (bleeding, infection, dislodgement of a gastrostomy tube, or fracture) (7), an APL present on admission (5), or a disease-related lesion (4).Although PSI 15 is highly predictive of APL from a coding perspective, the indicator is less predictive of APL that could be considered clinically important. A significant proportion of cases represent relatively inconsequential injuries or injuries for which the risk may have been acceptable relative to the goals of the procedure.

The clinical effects of methamphetamines (MA) may complicate medical management, potentially increasing resource utilization and hospital costs out of proportion to the patient's severity of injury. We hypothesize that minimally injured (MI) patients testing positive for MA consume more resources than patients testing negative for MA.Adult trauma patients were identified from 4 years of registry data, which was linked to cost data from our center's financial department. Patients were classified as MI (Injury Severity Score9) or severely injured (Injury Severity Score9). Primary outcome was total direct costs for the inpatient hospital stay. Secondary outcomes included direct costs by cost center, contribution margin, and hospital length of stay.Sixty-five percent (n = 6,193) of the 10,663 adult patients during the study period were admitted with MI. Nine percent (n = 557) of those tested were positive for MA. Total direct costs were higher in MI MA patients compared to nonusers ($2,998 vs. $2,667, p0.001), and users consumed more resources in all 10 cost centers. The same multivariate model showed marginally increased costs with MI alcohol users, but not with MI cocaine users or severely injured MA users.MI MA patients consume more resources than patients testing negative for MA. Although MA use complicates the initial evaluation of patients, resource consumption was increased for all cost centers representing the entirety of a patients hospital stay, suggesting that the influence of MA is not limited to the initial diagnostic workup. Centers with high proportions of MA users may realize significant losses if compensation contracts are inadequate.

The objective of this study was to determine whether elderly acutely injured patients take longer to be transferred from referring hospitals to a regional trauma center than younger patients. We reviewed all trauma patients transferred urgently to a regional trauma center over 2 years. We considered age ≥ 65 years to be elderly. We performed multivariable linear regression to determine the extra time spent at the referring hospital attributable to elderly status, after adjustment for confounders. For 371 transfers, mean Injury Severity Score was 12, and 12% of patients had hypotension before transfer. Mean time spent at the referring hospital was 233 ± 110 min. After adjustment for confounders, including Injury Severity Score and computed tomography (CT) scanning before transfer, elderly patients spent 32 min more at referring hospitals than non-elderly patients (95% confidence interval 1–63 min). We conclude that interhospital transfer of elderly acutely injured trauma patients takes longer than for younger patients. Providers may be less aggressive in treating elderly trauma patients.

✓Patients with Chiari malformation (CM) Type I typically experience chronic, slowly progressive symptoms. Rarely, however, do they suffer acute neurological deterioration following an iatrogenic decrease in caudal cerebrospinal fluid pressure due to, for example, a lumbar puncture. To our knowledge, acute neurological deterioration following missile spinal injury in CM has not been previously described. The authors report on a 16-year-old girl who was shot in the abdomen and lumbar spine. Although neurologically intact on initial workup, she developed precipitous quadriplegia and apnea in a delayed fashion. Tonsillar herniation with medullary compression and cerebellar infarction was diagnosed on magnetic resonance imaging. Suboccipital decompression resulted in significant neurological improvement. Well-formed tonsillar ectopia diagnosed at surgery suggested a preexisting CM. The authors conclude that missile spinal trauma can precipitate medullary compression and acute neurological decline, especially in patients with preexisting tonsillar ectopia. Immediate operative decompression to relieve impaction at the cervicomedullary junction can result in significant neurological recovery.

Microchimerism, the stable persistence of an allogeneic cell population, can result from allogeneic exposures including blood transfusion. Transfusion-associated microchimerism (TA-MC) appears to be a common but newly recognized complication of blood transfusion. Thus far TA-MC has been detected when severely injured patients are transfused. Injury induces an immunosuppressive and inflammatory milieu in which fresh blood products with replication-competent leukocytes can sometimes cause TA-MC. TA-MC is present in approximately half of transfused severely injured patients at hospital discharge and is not affected by leukoreduction. In approximately 10% of patients, the chimerism from a single blood donor may increase in magnitude over months to years, reaching as much as 2% to 5% of all circulating leukocytes. In this review, we discuss recent studies of TA-MC in the civilian trauma population and the potential for study of TA-MC in the military population, where the severity of injury and freshness of blood products suggest that TA-MC may be even more prominent. We also discuss the need for future studies to address the immunology of TA-MC, its stem cell biology, and its clinical manifestations that have the potential to be either pathologic (autoimmunity, graft-versus-host disease) or therapeutic (tolerance induction, various cell and gene therapies).

Metabolic acidosis has been implicated in the development of coagulopathy, although the specific mechanisms have not been well characterized. We sought to explore whether resuscitation of injured patients with a balanced crystalloid solution affects coagulation, as measured by endogenous thrombin potential (ETP) and thromboelastography (TEG). We performed an exploratory analysis of a subset of subjects enrolled in a randomized trial comparing the effect of resuscitation with isotonic saline versus Plasma-Lyte A (PLA) on acidosis and electrolyte abnormalities. We collected plasma at admission and 6 h later for subsequent ETP and TEG analysis and compared subjects receiving isotonic saline to those receiving PLA. Among 18 evaluated subjects, baseline characteristics, including ETP and TEG parameters, were similar between the two arms. At 6 h, subjects receiving isotonic saline were more acidemic. At 6 h, there were no differences in ETP parameters between groups; however, TEG results showed the time from initial clot formation to an amplitude of 20 mm (K) was shorter (3.8 ± 2.1 vs. 7.2 ± 2.8 s) and the rapidity of fibrin build-up and cross-linking (α angle) was significantly greater (41 ± 8 vs. 24 ± 15 deg) for the PLA group than in the isotonic saline group. Relative to PLA, isotonic saline does not alter thrombin generation, but isotonic saline and PLA may differentially impact clotting factor availability. The shorter time to reach prespecified clot amplitude and the increased rate of fibrin generation imply faster amplification of clotting factors with PLA without effect on latency time or clot strength.