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Background: Understanding racial inequities in emergency medical care for traumatic injuries is important to policy considerations. Methods: We analyzed data on the first emergency department (ED) visit for trauma treatment among patients in the Massachusetts (MA) Statewide Trauma Registry. This Registry collects information on all trauma patients who die in the ED, or are dead on arrival, or who are transferred between hospitals in MA. This analysis included ED visits among MA residents aged 15 years and older from 2008 through 2010. Those who died on arrival were excluded. Patients were grouped as non-Hispanic white, non-Hispanic black, Hispanic, Asian, and other or unknown races. We compared injury severity, departure status and ED mortality among the 5 groups while adjusting for severity, sex and age. Results: The 27,453 patients averaged 57.3 years of age, and included 44.9% women, 83.4% whites, 5.4% blacks, 6.8% Hispanics, 1.3% Asians, and 3.1% other or unknown races. In total, 534 (1.95%) died in ED. There was no clinically significant difference in injury severity among race groups. Compared to whites, blacks and other race group had higher mortality (OR=1.62, p=0.006 and OR=2.30, p

Introduction: The effect of warfarin on outcomes of head injured patients remains controversial. Yet more than 2 million Americans, many of them elderly, are started on warfarin annually. Meanwhile, with the aging US population, elderly Americans are becoming an increasingly large proportion of head injured patients. We studied a national cohort of Medicare beneficiaries with head injuries to determine the effects of pre-injury warfarin on outcomes. Methods: A retrospective review of a 5% random sample of Medicare claims data (2009-2010) was performed for enrollees with at least 1 year of Medicare eligibility. Head injury cases were identified using ICD-9 codes for intracranial hemorrhage with or without accompanying skull fractures. Using Part D prescription drug claims, warfarin exposure was defined as >2 warfarin prescriptions filled within 60 days prior to injury. Characteristics and outcomes (mortality, length of stay (LOS), ICU LOS) between warfarin users and patients not on warfarin (non-users) were compared using univariate tests of association. Multivariable models adjusting for patient characteristics, concomitant torso injuries/long-bone fractures, and need for ICU care were conducted to measure the independent effect of warfarin on in-hospital mortality. Results: We identified 3,420 head injured patients,6.6% of whom were treated with warfarin. Warfarin users were more likely to be female (74.2%vs.65.6%, p

Introduction: Patterns of death after trauma are changing due to diagnostic and treatment advances. We examined mortality in critically injured patients at risk of death after discharge. Methods: We reviewed all critically injured (Injury Severity Score≥25 AND death in Emergency Room , death within 24hrs, OR ICU admission>24hrs) adults (age≥18) admitted to a Level 1 trauma center (01/01/2000-12/31/2010) and determined death post-discharge (Social Security Death Index) of patients discharged alive. We compared demographics, injury data, and critical care resource utilization between those who died during follow-up and survivors using univariate tests and Cox proportional hazards models. Results: Of 1,695 critically injured patients, 1135 (67%) were discharged alive. As of 05/1/2012, 977 (58%) index survivors were alive (median follow-up 62mos (IQR35,96)). Of 158 deaths post-discharge, 75 (47%) occurred within the first year. Patients who died post-discharge had longer hospital (24dys (IQR13,38) vs. 17dys (IQR10,27)) and ICU LOS (17dys (IQR6,29) vs. 8dys (IQR4,19)) and were more likely to undergo tracheostomies (36.1% vs. 15.6%, p16dys increased risk of death at one year (HR1.94 (1.22,3.06)) and by the end of follow-up (HR2.19 (1.58,3.04)) compared to shorter ICU stays. Conclusion: We propose the first year after discharge as the fourth peak of trauma related mortality. Duration of ICU LOS during index hospitalization is associated with post-discharge mortality.

Introduction: Since Acute Care Surgery (ACS) was first conceptualized as a specialty a decade ago, ACS teams have been widely adopted. Little is known about the structure and function of these teams. Methods: We conducted 18 open-ended interviews with ACS leaders (1 interview/center representing geographic [New England, Northeast, Mid-Atlantic, South, West, Midwest] and practice [Public/Charity, Community, University] variations). Two independent reviewers analyzed transcribed interviews using an inductive approach to determine major themes in practice variation (NVivo qualitative analysis software). Results: All respondents described ACS as a specialty treating "time sensitive surgical disease" including trauma, emergency general surgery (EGS), and surgical critical care (SCC). 11/18 combined trauma and EGS into a single clinical team; 6/18 included elective general surgery. Emergency orthopedics, neurosurgery, and triage for all surgical services were rare (1/18 each). 11/18 had blocked OR time. All had a core group of trauma and SCC surgeons; 8/18 shared EGS due to volume, manpower, or competition for EGS call. Many (12/18) had formal morning signout rounds; few (2/18) had prospective EGS data registries. Streamlined access to EGS, evidence-based EGS protocols, and improved communication were considered strengths of ACS. ACS was described as the "last great surgical service" reinvigorated to provide "timely," cost-effective EGS by experts in "resuscitation and critical care" and to attract "young, talented, eager surgeons" to trauma and SCC; however, there was concern that it might become the "waste basket for everything that happens at inconvenient times." Conclusion: Despite rapid adoption of ACS, its implementation varies widely. Standardization of scope of practice, continuity of care, and registry development may improve EGS outcomes and allow the specialty to thrive.

INTRODUCTION: The utility of hyperbaric oxygen therapy (HBOT) in the treatment for necrotizing soft tissue infections (NSTI) has not been proven. Previous studies have been subject to significant selection bias since HBOT is not universally available at all medical centers and there is often considerable delay associated with its initiation. We examined the utility of HBOT for the treatment of NSTI in the modern era by isolating centers that have their own HBOT facilities. METHODS: We queried all centers in the University Health Consortium (UHC) database from 2008 to 2010 that have their own HBOT facilities (N=14). Cases of NSTI were identified by ICD-9 diagnosis codes, which included Fournier’s gangrene (608.83), necrotizing fascitis (728.86), and gas gangrene (040.0). HBOT treatment status was identified by the presence (HBOT) or absence (CONTROL) of ICD-9 procedure code (93.95). We then risk stratified and matched our cohort by UHC’s validated severity of illness (SOI) score. Comparisons were then made using univariate tests of association and multivariable logistic regression. RESULTS: There were 1,583 NSTI cases at the 14 HBOT-capable centers. 117 (7%) cases were treated with HBOT. Risk stratified univariate outcomes are summarized in the table. There was no difference between HBOT and CONTROL groups in hospital length of stay (LOS), direct cost, complications, and mortality across the three less severe SOI classes (minor, moderate, and major). However, for extreme SOI the HBOT group had fewer complications (45% vs. 66%; p