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BackgroundSurgical pancreatic necrosectomy (SPN) is an option for the management of infected pancreatic necrosis. The literature indicates that an escalating, combined endoscopic, interventional radiology and minimally invasive surgery "step-up" approach, such as video-assisted retroperitoneal debridement, may reduce the number of required SPNs and ICU complications, such as multiple organ failure. We hypothesized that complications for surgically treated severe necrotizing pancreatitis patients decreased during the period of adoption of the "step-up" approach.MethodsThe American college of surgeons national surgery quality improvement program database (ACS-NSQIP) was used to find SPN cases from 2007 to 2019 in ACS-NSQIP submitting hospitals. Mortality and Clavien-Dindo class 4 (CD4) ICU complications were collected. Predictors of outcomes were identified by univariate and multivariate analyses.ResultsThere were 2457 SPN cases. SPN cases decreased from 0.09% in 2007 to 0.01% in 2019 of NSQIP operative cases (p

BackgroundCurrent guidelines recommend that patients with choledocholithiasis undergo same-admission cholecystectomy. The compliance with this guideline is poor in elderly patients. We hypothesized that elderly patients treated with endoscopic retrograde cholangiopancreatography (ERCP) alone would have higher complication and readmission rates than the patients treated with cholecystectomy.MethodsThe Nationwide Readmissions Database was queried for all patients aged ≥65 years with admission for choledocholithiasis January to June 2016. The patients were divided based on index treatment received: (1) no intervention; (2) ERCP alone; or (3) cholecystectomy. Multivariate analyses identified predictors of cholecystectomy during index admission and of readmissions.ResultsA total of 16,121 patients with choledocholithiasis were admitted; 38.4% underwent cholecystectomy, 37.6% endoscopic retrograde cholangiopancreatography alone, and 24.0% no intervention. The patients not receiving a cholecystectomy were more likely to be older, female, have a higher Elixhauser score, do-not-resuscitate status, and at a teaching hospital (all P < .001). Emergency readmissions for recurrent biliary disease were lowest in patients undoing a cholecystectomy (2.2% vs 9.2% endoscopic retrograde cholangiopancreatography and 12.4% no intervention, P < .001), as were readmissions for complications (3.6% vs 5.5% and 7.8%, P < .001). Cholecystectomy reduced rates of readmissions for recurrent disease (odds ratio 0.168, P < .001), for complications (odds ratio 0.540, P < .001), and death during readmission (odds ratio 0.503, P = .007); endoscopic retrograde cholangiopancreatography alone reduced only rates of readmissions. Age was not a predictor of readmission or death.ConclusionIndex admission cholecystectomy is associated with a lower risk of readmission for biliary disease or complications, as well as death during readmission, in elderly patients. Age alone is not predictive of outcomes; surgical intervention should be guided by clinical condition, comorbidities, and patient preference.

This observational study assesses the changes in morbidity and mortality of border wall injuries after construction of the 30-ft border wall in San Diego and Imperial Counties, California.

IntroductionPatient outcome prediction models are underused in clinical practice because of lack of integration with real-time patient data. The electronic health record (EHR) has the ability to use machine learning (ML) to develop predictive models. While an EHR ML model has been developed to predict clinical deterioration, it has yet to be validated for use in trauma. We hypothesized that the Epic Deterioration Index (EDI) would predict mortality and unplanned intensive care unit (ICU) admission in trauma patients.MethodsA retrospective analysis of a trauma registry was used to identify patients admitted to a level 1 trauma center for >24 hours from October 2019 to July 2020. We evaluated the performance of the EDI, which is constructed from 125 objective patient measures within the EHR, in predicting mortality and unplanned ICU admissions. We performed a 5 to 1 match on age because it is a major component of EDI, then examined the area under the receiver operating characteristic curve (AUROC), and benchmarked it against Injury Severity Score (ISS) and new injury severity score (NISS).ResultsThe study cohort consisted of 1,325 patients admitted with a mean age of 52.5 years and 91% following blunt injury. The in-hospital mortality rate was 2%, and unplanned ICU admission rate was 2.6%. In predicting mortality, the maximum EDI within 24 hours of admission had an AUROC of 0.98 compared with 0.89 of ISS and 0.91 of NISS. For unplanned ICU admission, the EDI slope within 24 hours of ICU admission had a modest performance with an AUROC of 0.66.ConclusionEpic Deterioration Index appears to perform strongly in predicting in-patient mortality similarly to ISS and NISS. In addition, it can be used to predict unplanned ICU admissions. This study helps validate the use of this real-time EHR ML-based tool, suggesting that EDI should be incorporated into the daily care of trauma patients.Level of evidencePrognostic, level III.

BackgroundTrauma registries are used to identify modifiable injury risk factors for trauma prevention efforts. However, these may miss factors useful for prevention of bicycle-automobile collisions, such as vehicle speeds, driver intoxication, street conditions, and neighborhood characteristics. We hypothesize that (GIS) analysis of trauma registry data matched with a traffic accident database could identify risk factors for bicycle-automobile injuries and better inform injury prevention efforts.MethodsThe trauma registry of a US Level I trauma center was used retrospectively to identify bicycle-motor vehicle collision admissions from January 1, 2010, to December 31, 2018. Data collected included demographics, vitals, injury severity scores, toxicology, helmet use, and mortality.Matching with the Statewide Integrated Traffic Records System was done to provide collision, victim and GIS information. The GIS mapping of collisions was done with census tract data including poverty level scoring. Incident hot spot analysis to identify statistically significant incident clusters was done using the Getis Ord Gi* statistic.ResultsOf 25,535 registry admissions, 531 (2.1%) were bicyclists struck by automobiles, 425 (80.0%) were matched to Statewide Integrated Traffic Records System. Younger age (odds ratio [OR], 1.026; 95% confidence interval [CI], 1.013-1.040, p < 0.001), higher census tract poverty level percentage (OR, 0.976; 95% CI, 0.959-0.993, p = 0.007), and high school or less education (OR, 0.60; 95 CI, 0.381-0.968; p = 0.036) were predictive of not wearing a helmet. Higher census tract poverty level percentage (OR, 1.019; 95% CI, 1.004-1.034; p = 0.012) but not educational level was predictive of toxicology positive-bicyclists in automobile collisions. Geographic information systems analysis identified hot spots in the catchment area for toxicology-positive bicyclists and lack of helmet use.ConclusionCombining trauma registry data and matched traffic accident records data with GIS analysis identifies additional risk factors for bicyclist injury. Trauma centers should champion efforts to prospectively link public traffic accident data to their trauma registries.Level of evidencePrognostic and Epidemiological, level III.

BackgroundThe Affordable Care Act (ACA) increased Medicaid coverage of Emergency General Surgery (EGS). We hypothesized that despite the ACA, racial and geographic disparities persisted for EGS admissions.MethodsThe Nationwide Inpatient Sample was queried from 2012 through Q3 of 2015 for Non-Medicare patient EGS admissions. Difference-in-Differences analyses (DID) compared payors, complications, mortality and costs in pre-ACA years (2012-2013) and post-ACA years (2014-2015Q3).ResultsEGS cases fell 9.1% from 1,711,940 to 1,555,033 NIS-weighted cases. Hispanics were still most likely to be uninsured but had improved coverage (OR 0.92, 95% CI: 0.88-0.96, p

INTRODUCTION:Lack of insurance coverage increases complications and mortality from surgical procedures. The 2014 Affordable Care Act (ACA) Open Enrollment (OE) insured more Americans, but it is unknown if this improved outcomes from emergency general surgery (EGS) procedures. This study seeks to determine how ACA OE coverage changes outcomes in EGS. METHODS:This is a retrospective review using the Nationwide Inpatient Sample database from 2012 to 2014. Patients aged 18 to 64 years undergoing EGS procedures were identified by International Classification of Diseases, Ninth Revision, codes. Medicare patients were excluded. Patient demographics, hospital characteristics, and Charlson comorbidity index were obtained. Outcomes were measured by mortality, complications, and calculated costs. Univariate and difference-in-differences multivariate analyses were performed to determine the effect of the ACA OE on EGS outcomes. RESULTS:A total of 304,110 EGS cases were identified. After Medicare patients were excluded, there were 275,425 cases. In 2014, Medicaid admissions increased 18.2% from 18,495 to 22,615 (p < 0.001) and self-pay admissions decreased 33% from 14,938 to 10,630 (p < 0.001). Mortality significantly increased for self-pay patients in 2014 from 0.81% to 1.22% (p < 0.001). Difference-in-differences analysis indicated that, after risk adjustment, the ACA OE was associated with a small reduction in mortality for insured patients (-0.12%, p = 0.034), increased complications (1.4%, p = 0.009), and increased wage-index adjusted mean costs (4.6%, p < 0.001). There was a significant increase in Medicare (+26.5%) and private (+12.2%, p < 0.001) insurance admissions in teaching hospitals, while nonteaching hospitals had fewer EGS admissions with a greater reduction in uninsured EGS admissions. CONCLUSIONS:The ACA OE created a significant reduction in uninsured EGS admissions but did not reduce EGS mortality. Mortality decreased in insured patients but increased in uninsured patients, indicating that the ACA OE primarily insured lower-risk patients. The ACA OE did increase cost and complications in insured admissions. Teaching hospitals saw the majority of the increase in Medicaid and private insurance EGS admissions. A national registry would improve future study of insurance policy on EGS outcomes. LEVEL OF EVIDENCE:Economic analysis, level IV.

ObjectiveTo assess the impact of high-fidelity patient simulation on pharmacy resident knowledge, confidence, and competency with advanced resuscitation algorithms and interventions.DesignAn overview of the institutional cardiopulmonary arrest algorithm and a review of pertinent medications and calculations were presented to postgraduate year 1 (PGY1) pharmacy residents, followed by participation in 3 simulated clinical scenarios using a high-fidelity mannequin.AssessmentAn improvement of pharmacy resident knowledge, confidence, and competency with advanced resuscitation skills was observed. In addition, pharmacy residents demonstrated high performance levels with skills requiring advanced competency and proactive interactions with the cardiac arrest team.ConclusionIncorporating high-fidelity patient simulation into an advanced resuscitation training program can help pharmacy residents achieve competency through the active learning of practical skills.