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Background: Postoperative respiratory failure (PRF) is associated with increased hospital charges and worse patient outcomes. Reliable prediction models can help to guide postoperative planning to optimize care, to guide resource allocation, and to foster shared decision-making with patients., Research Question: Can a predictive model be developed to accurately identify patients at high risk of PRF?, Study Design and Methods: In this single-site proof-of-concept study, we used structured query language to extract, transform, and load electronic health record data from 23,999 consecutive adult patients admitted for elective surgery (2014-2021). Our primary outcome was PRF, defined as mechanical ventilation after surgery of > 48 h. Predictors of interest included demographics, comorbidities, and intraoperative factors. We used logistic regression to build a predictive model and the least absolute shrinkage and selection operator procedure to select variables and to estimate model coefficients. We evaluated model performance using optimism-corrected area under the receiver operating curve and area under the precision-recall curve and calculated sensitivity, specificity, positive and negative predictive values, and Brier scores., Results: Two hundred twenty-five patients (0.94%) demonstrated PRF. The 18-variable predictive model included: operations on the cardiovascular, nervous, digestive, urinary, or musculoskeletal system; surgical specialty orthopedic (nonspine); Medicare or Medicaid (as the primary payer); race unknown; American Society of Anesthesiologists class ≥ III; BMI of 30 to 34.9 kg/m 2 ; anesthesia duration (per hour); net fluid at end of the operation (per liter); median intraoperative FIO 2 , end title CO 2 , heart rate, and tidal volume; and intraoperative vasopressor medications. The optimism-corrected area under the receiver operating curve was 0.835 (95% CI,0.808-0.862) and the area under the precision-recall curve was 0.156 (95% CI, 0.105-0.203)., Interpretation: This single-center proof-of-concept study demonstrated that a structured query language extract, transform, and load process, based on readily available patient and intraoperative variables, can be used to develop a prediction model for PRF. This PRF prediction model is scalable for multicenter research. Clinical applications include decision support to guide postoperative level of care admission and treatment decisions.

Background: The implementation of the International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS) has created difficulty in identifying certain procedures, including pancreaticoduodenectomy. We sought to evaluate which combinations of ICD-10-PCS codes best identify pancreaticoduodenectomy., Study Design: We used 2017-2018 Medicare data to identify acute care hospitalization claims of beneficiaries with both ICD-10-PCS and Current Procedural Terminology (CPT) codes available. We developed 12 candidate ICD-10-PCS definitions of pancreaticoduodenectomy and evaluated their test characteristics in identifying hospitalizations involving CPT codes 48150, 48152, 48153, 48154, or 48155 as the criterion standard. We selected one candidate definition with the best balance of test characteristics, then performed decision tree analysis and evaluated the conditional marginal sensitivity and positive predictive value of each individual code to understand which were most informative., Results: Among 964,613 hospitalization claims from 4648 hospitals, 385 claims from 217 hospitals involved a CPT code for pancreaticoduodenectomy. The ICD-10-PCS definition with the best balance had a sensitivity of 92.2% (95% CI: 89.2%-94.4%), specificity of 99.9977% (95% CI: 99.9961%-99.9984%), positive predictive value of 93.7% (95% CI: 90.3%-95.9%), and negative predictive value of 99.9969% (95% CI: 99.9955%-99.9978%). The most informative procedure codes involved open nondiagnostic excision or resection of the duodenum (0DB90ZZ and 0DT90ZZ) and pancreas (0FBG0ZZ and 0FTG0ZZ)., Conclusion: An ICD-10-PCS definition of pancreaticoduodenectomy using codes for (1) open or percutaneous endoscopic excision or resection of the pancreas and (2) similar codes for the duodenum, consistent with coding guidelines, has satisfactory test characteristics. We suggest researchers consider such characteristics in defining pancreaticoduodenectomy using ICD-10-PCS., Competing Interests: The authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Patients with chronic limb-threatening ischemia (CLTI) experience high annual mortality and would benefit from timely palliative care intervention. We sought to better characterize use of palliative care among patients with CLTI in the Medicare population., Methods: Using Medicare data from 2017 to 2018, we identified patients with CLTI, defined as two or more encounters with a CLTI diagnosis code. Palliative care evaluations were identified using ICD-10-CM Z51.5 "Encounter for palliative care." Time intervals between CLTI diagnosis, palliative consultation, and death or end of follow-up were calculated. Associations between patient demographics, comorbidities, and palliative care consultation were assessed., Results: A total of 12,133 Medicare enrollees with complete data were categorized as having CLTI. Of these, 7.4% (894) underwent a palliative care evaluation at a median of 170 days (interquartile range, 45-352 days) from their CLTI diagnosis. Compared with those who did not undergo evaluation, palliative patients were more likely to be dual eligible for Medicaid (45.2% vs 38.1%; P < .001) and had more comorbid conditions (P < .001). After controlling for gender and race, age (odds ratio [OR], 1.03; 95% confidence interval [CI], 1.02-1.04), dual eligibility (OR, 1.40; 95% CI, 1.22-1.62), solid organ malignancy (OR, 2.82; 95% CI, 1.92-4.14), hematologic malignancy (OR, 2.24; 95% CI, 1.27-3.98), congestive heart failure (OR, 1.44; 95% CI, 1.15-1.88), complicated diabetes (OR, 1.35; 95% CI, 1.11-1.65), dementia (OR, 1.32; 95% CI, 1.04-1.66), and severe renal failure (OR, 1.56; 85% CI. 1.24-1.98) were independently associated with palliative care evaluation. During mean follow up of 410 ± 220 days, 16.9% (2044) of patients died at a mean of 268 (±189) days after their CLTI diagnosis. Among living patients, only 3.2% (325) underwent palliative evaluation. Comparatively, 27.8% (569) of patients who died received palliative care at a median of 196 days (interquartile range, 55-362 days) after their diagnosis and 15 days (interquartile range, 5-63 days) prior to death., Conclusions: Despite high mortality, palliative care services were rarely provided to Medicare patients with CLTI. Age, medical complexity, and income status may play a role in the decision to consult palliative care. When obtained, evaluations occurred closer to time of death than to time of CLTI diagnosis, suggesting misuse of palliative care as end-of-life care., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: Estimates of chronic limb-threatening ischemia (CLTI) based on diagnosis codes of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) suggest a prevalence of 0.23%-0.32% and incidence of 0.20%-0.26% among Medicare patients. ICD-10-CM includes 144 CLTI diagnosis codes, allowing improved specificity in identifying affected patients. We sought to use ICD-10-CM diagnosis codes to determine the prevalence of CLTI among Medicare patients and describe the patient cohort affected by this condition., Methods: Using two years of data from Centers for Medicare and Medicaid Services, we identified all patients that had at least one CLTI diagnosis code to determine prevalence and incidence rates. Sensitivity analyses were performed to compare our methodology to prior publications and quantify the extent of missed diagnoses. The number and type of vascular procedures that occurred after diagnosis were tabulated. A cohort of patients with two or more CLTI diagnosis codes were then identified for further descriptive analysis. Associations between patient demographics and survival were analyzed using Cox proportional hazards models., Results: Over 65 million patients were enrolled in Medicare in 2017 to 2018. Of these, 480,227 had diagnosis of CLTI, with a corresponding to a 1-year incidence of 0.33% and a 2-year prevalence of 0.74%. Patients underwent an average of 43.6 vascular procedures per 100 person-years. Sensitivity analyses identified 89,805 additional patients that had a diagnosis code of peripheral arterial disease who underwent revascularization or amputation. Patients with CLTI were predominantly male (56.2%), white (76.4%), and qualified for Medicare due to age (64.0%). Thirty-seven percent were dual-eligible. One-year survival was 77.7%, significantly lower than estimated actuarial survival adjusted for age, sex, and race (95.1%; P < .001). Cox proportional hazards models demonstrate significantly increased mortality for men vs women (hazard ratio, 1.07; 95% confidence interval, 1.04-1.10; P < .001), but no association between race and overall survival (hazard ratio, 0.99; 95% confidence interval, 0.98-1.01; P = .83)., Conclusions: Using ICD-10-CM diagnosis codes, we demonstrated slightly higher incidence and prevalence of CLTI than in published literature, reflecting our more complete methodology. Sensitivity analyses suggest that increased complexity of the highly specific ICD-10-CM coding may diminish capture of CLTI. Inclusion of patients with non-CLTI peripheral arterial disease diagnoses produces moderate increases in incidence and prevalence at the cost of decreased specificity in identifying patients with CLTI. Medicare patients with CLTI are older, and more commonly male, black, and dual eligible compared with the general Medicare population. Observed mid-term survival for patients with CLTI is significantly lower than actuarial estimates, confirming the importance of focused efforts on identifying and aligning goals of care in this complex patient population., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

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., (© 2021 Health Research and Educational Trust.)

Background: Few interventions are known to reduce the incidence of respiratory failure that occurs following elective surgery (postoperative respiratory failure; PRF). We previously reported risk factors associated with PRF that occurs within the first 5 days after elective surgery (early PRF; E-PRF); however, PRF that occurs six or more days after elective surgery (late PRF; L-PRF) likely represents a different entity. We hypothesized that L-PRF would be associated with worse outcomes and different risk factors than E-PRF., Methods: This was a retrospective matched case-control study of 59,073 consecutive adult patients admitted for elective non-cardiac and non-pulmonary surgical procedures at one of five University of California academic medical centers between October 2012 and September 2015. We identified patients with L-PRF, confirmed by surgeon and intensivist subject matter expert review, and matched them 1:1 to patients who did not develop PRF (No-PRF) based on hospital, age, and surgical procedure. We then analyzed risk factors and outcomes associated with L-PRF compared to E-PRF and No-PRF., Results: Among 95 patients with L-PRF, 50.5% were female, 71.6% white, 27.4% Hispanic, and 53.7% Medicare recipients; the median age was 63 years (IQR 56, 70). Compared to 95 matched patients with No-PRF and 319 patients who developed E-PRF, L-PRF was associated with higher morbidity and mortality, longer hospital and intensive care unit length of stay, and increased costs. Compared to No-PRF, factors associated with L-PRF included: preexisiting neurologic disease (OR 4.36, 95% CI 1.81-10.46), anesthesia duration per hour (OR 1.22, 95% CI 1.04-1.44), and maximum intraoperative peak inspiratory pressure per cm H 2 0 (OR 1.14, 95% CI 1.06-1.22)., Conclusions: We identified that pre-existing neurologic disease, longer duration of anesthesia, and greater maximum intraoperative peak inspiratory pressures were associated with respiratory failure that developed six or more days after elective surgery in adult patients (L-PRF). Interventions targeting these factors may be worthy of future evaluation., (© 2022. The Author(s).)

Background: The American Association for the Surgery of Trauma (AAST) grading system for intestinal obstruction may be a useful measure of anatomic severity, but its construct validity has not yet been evaluated in patients with either large or small bowel obstruction, using the grade applicable at initial presentation (rather than after definitive management)., Materials and Methods: We conducted a retrospective case series of adult inpatients presenting with intestinal obstruction at our center during 2008-2014. We excluded patients without confirmed intestinal obstruction, those with obstruction secondary to a hernia, those who were treated for >24 hours at another hospital, and those with a previous encounter already included in the study. We measured inter-rater reliability using a weighted kappa coefficient. We used multivariable logistic regression, accounting for sampling weights, to assess the relationship of grades with complications, 30-day mortality, and 30-day readmission., Results: Of 287 patients, 165 (58%) had grade I anatomic severity, 75 (26%) grade II, 23 (8%) grade III, 15 (5%) grade IV, and 9 (3%) grade V. Forty-six (16%) patients had a large bowel obstruction. There was substantial inter-rater agreement in grades [weighted kappa 0.69 (95% CI 0.47-0.91)]. Compared to grade I, grades III-V [OR 12.2 (95% CI 2.26-66.2)] but not grade II [OR 2.04 (95% CI 0.79-5.28)] were associated with increased risk of a complication. grade II [OR 7.92 (95% CI 3.27-19.2)], but not grades III-V [OR 3.56 (95% CI 0.30-42.5)] was associated with increased 30-day mortality. Grades were not associated with increased 30-day readmission., Conclusions: AAST intestinal obstruction grades have predictive validity for some but not all outcomes, and may serve a useful role in the measurement of anatomic disease severity., Competing Interests: None., (© 2022 The Authors.)

Objectives: Trauma and acute care surgery (TACS) patients face complex barriers associated with hospitalization discharge that hinder successful recovery. We sought to better understand the challenges in the discharge transition of care, which might suggest interventions that would optimize it., Methods: We conducted a qualitative study of patient and clinician perceptions about the hospital discharge process at an urban level 1 trauma center. We performed semi-structured interviews that we recorded, transcribed, coded both deductively and inductively, and analyzed thematically. We enrolled patients and clinicians until we achieved data saturation., Results: We interviewed 10 patients and 10 clinicians. Most patients (70%) were male, and the mean age was 57±16 years. Clinicians included attending surgeons, residents, nurse practitioners, nurses, and case managers. Three themes emerged. (1) Communication (patient-clinician and clinician-clinician): clinicians understood that the discharge process malfunctions when communication with patients is not clear. Many patients discussed confusion about their discharge plan. Clinicians lamented that poorly written discharge summaries are an inadequate means of communication between inpatient and outpatient clinicians. (2) Discharge teaching and written instructions : patients appreciated discharge teaching but found written discharge instructions to be overwhelming and unhelpful. Clinicians preferred spending more time teaching patients and understood that written instructions contain too much jargon. (3) Outpatient care coordination : patients and clinicians identified difficulties with coordinating ongoing outpatient care. Both identified the patient's primary care physician and insurance coverage as important determinants of the outpatient experience., Conclusion: TACS patients face numerous challenges at hospitalization discharge. Clinicians struggle to effectively help their patients with this stressful transition. Future interventions should focus on improving communication with patients, active communication with a patient's primary care physician, repurposing, and standardizing the discharge summary to serve primarily as a means of care coordination, and assisting the patient with navigating the transition., Level of Evidence: III-descriptive, exploratory study., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

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] <2) and older-sick patients (age ≥71, 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 <1%, annual hospital and surgeon volumes needed were 23 and 8, respectively; mortality rose to 4.2% when volumes dropped to the Leapfrog thresholds of 20 and 7, respectively. Complication rose from 53% to 63% when hospital and surgeon volumes decreased from 28 and 10 to 19 and 7, respectively. PLOS rose from 19% to 27% when annual hospital and surgeon volumes decreased from 27 and 8 to 20 and 7, respectively., Conclusions: Current Leapfrog Group esophagectomy volume guidelines may not predict optimal outcomes for all patients, especially at extremes of age and comorbidities., Competing Interests: The authors report no conflicts of interest., (Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.)

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., (Copyright © 2021. Published by Elsevier Inc.)

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., (Copyright © 2020 Elsevier Inc. All rights reserved.)

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.

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., (Copyright © 2020 Elsevier Inc. All rights reserved.)

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: 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., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: 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., Methods: 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 Index <1) and "older-sicker" patients (age >77 years, Elixhauser Comorbidity Index >3)., Results: 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 (mortality <2%). 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)., Conclusions: 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., (Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

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., (Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2020.)

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.

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: Older 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 Methods: We analyzed patients ≥50 y 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., Results: Among 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 <1 L (OR 4.72, 95% CI 2.14-10.45); use of a walker (OR 2.86, 95% CI 1.29-6.34); increased chest Abbreviated Injury Scale score (AIS 3 OR 5.83, 95% CI 2.34-14.50); age ≥72 y (OR 2.68, 95% CI 1.48-4.86); and active smoking (OR 2.11, 95% CI 1.06-4.20)., Conclusions: Routine ICU admission is not necessary for most older adults with isolated rib fractures. The predictors we identified warrant prospective evaluation for development of a clinical decision rule to preclude unnecessary ICU admissions., (Copyright © 2019 Elsevier Inc. All rights reserved.)

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 < 0.001 for both) than other organisms. Patients in the South were more likely to be uninsured and had worse unadjusted outcomes. In a risk-adjusted model, increasing American Association for the Surgery of Trauma grade was predictive of mortality (OR, 2.3; 95% CI, 1.6-3.1; P < 0.001), as was age ≥ 55 y (OR 2.7, 95% CI 1.3-5.3, P = 0.006), but region and organism type were not associated with mortality., Conclusions: We found important regional differences with respect to organism type and demographics. However, on risk-adjusted models, neither region nor organism type predicted mortality., (Copyright © 2019 Elsevier Inc. All rights reserved.)

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., (© 2019 AABB.)

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.

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., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

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., (© Health Research and Educational Trust.)

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., (Copyright © 2018 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

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.

Background: Patients 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 general surgery (EGS) where nonoperative management is common. We developed a multi-institutional EGS clinical data registry within ACS NSQIP that includes patients managed nonoperatively to evaluate variability in nonoperative care across hospitals and identify gaps in performance assessment that occur when only operative cases are considered., Methods: Using ACS NSQIP infrastructure and methodology, surgical consultations for acute appendicitis, acute cholecystitis, and small bowel obstruction (SBO) were sampled at 13 hospitals that volunteered to participate in the EGS clinical data registry. Standard NSQIP variables and 16 EGS-specific variables were abstracted with 30-day follow-up. To determine the influence of complications in nonoperative patients, rates of adverse outcomes were identified, and hospitals were ranked by performance with and then without including nonoperative cases., Results: Two thousand ninety-one patients with EGS diagnoses were included, 46.6% with appendicitis, 24.3% with cholecystitis, and 29.1% with SBO. The overall rate of nonoperative management was 27.4%, 6.6% for appendicitis, 16.5% for cholecystitis, and 69.9% for SBO. Despite comprising only 27.4% of patients in the EGS pilot, nonoperative management accounted for 67.7% of deaths, 34.3% of serious morbidities, and 41.8% of hospital readmissions. After adjusting for patient characteristics and hospital diagnosis mix, addition of nonoperative management to hospital performance assessment resulted in 12 of 13 hospitals changing performance rank, with four hospitals changing by three or more positions., Conclusion: This study identifies a gap in performance evaluation when nonoperative patients are excluded from surgical quality assessment and demonstrates the feasibility of incorporating nonoperative care into existing surgical quality initiatives. Broadening the scope of hospital performance assessment to include nonoperative management creates an opportunity to improve the care of all surgical patients, not just those who have an operation., Level of Evidence: Care management, level IV; Epidemiologic, level III.

Importance: The utility of the focused assessment with sonography for trauma (FAST) examination in children is unknown., Objective: To determine if the FAST examination during initial evaluation of injured children improves clinical care., Design, Setting, and Participants: A randomized clinical trial (April 2012-May 2015) that involved 975 hemodynamically stable children and adolescents younger than 18 years treated for blunt torso trauma at the University of California, Davis Medical Center, a level I trauma center., Interventions: Patients were randomly assigned to a standard trauma evaluation with the FAST examination by the treating ED physician or a standard trauma evaluation alone., Main Outcomes and Measures: Coprimary outcomes were rate of abdominal computed tomographic (CT) scans in the ED, missed intra-abdominal injuries, ED length of stay, and hospital charges., Results: Among the 925 patients who were randomized (mean [SD] age, 9.7 [5.3] years; 575 males [62%]), all completed the study. A total of 50 patients (5.4%, 95% CI, 4.0% to 7.1%) were diagnosed with intra-abdominal injuries, including 40 (80%; 95% CI, 66% to 90%) who had intraperitoneal fluid found on an abdominal CT scan, and 9 patients (0.97%; 95% CI, 0.44% to 1.8%) underwent laparotomy. The proportion of patients with abdominal CT scans was 241 of 460 (52.4%) in the FAST group and 254 of 465 (54.6%) in the standard care-only group (difference, -2.2%; 95% CI, -8.7% to 4.2%). One case of missed intra-abdominal injury occurred in a patient in the FAST group and none in the control group (difference, 0.2%; 95% CI, -0.6% to 1.2%). The mean ED length of stay was 6.03 hours in the FAST group and 6.07 hours in the standard care-only group (difference, -0.04 hours; 95% CI, -0.47 to 0.40 hours). Median hospital charges were $46 415 in the FAST group and $47 759 in the standard care-only group (difference, -$1180; 95% CI, -$6651 to $4291)., Conclusions and Relevance: Among hemodynamically stable children treated in an ED following blunt torso trauma, the use of FAST compared with standard care only did not improve clinical care, including use of resources; ED length of stay; missed intra-abdominal injuries; or hospital charges. These findings do not support the routine use of FAST in this setting., Trial Registration: clinicaltrials.gov Identifier: NCT01540318.

Importance: Deep vein thrombosis (DVT) isolated to the calf veins (distal to the popliteal vein) is frequently detected with duplex ultrasonography and may result in proximal thrombosis or pulmonary embolism (PE)., Objective: To evaluate whether therapeutic anticoagulation is associated with a decreased risk for proximal DVT or PE after diagnosis of an isolated calf DVT., Design, Setting, and Participants: All adult patients with ultrasonographic detection of an isolated calf DVT from January 1, 2010, to December 31, 2013, at the Vascular Laboratory of the University of California, Davis, Medical Center were included. Patients already receiving therapeutic anticoagulation and those with a chronic calf DVT, a contraindication to anticoagulation, prior venous thromboembolism within 180 days, or diagnosis of a PE suspected at the time of calf DVT diagnosis were excluded. Data were analyzed from August 18, 2015, to February 14, 2016., Exposures: Intention to administer therapeutic anticoagulation., Main Outcomes and Measures: Proximal DVT or PE within 180 days of the diagnosis of the isolated calf DVT., Results: From 14 056 lower-extremity venous duplex studies, we identified 697 patients with an isolated calf DVT and excluded 313 of these. The remaining 384 patients were available for analysis (222 men [57.8%]; 162 women [42.2%]; mean [SD] age, 60 [16] years). The calf DVT involved an axial vein (anterior tibial, posterior tibial, or peroneal) in 243 patients (63.2%) and a muscular branch (soleus or gastrocnemius) in 215 (56.0%). Physicians attempted to administer therapeutic anticoagulation in 243 patients (63.3%), leaving 141 control participants. Proximal DVT occurred in 7 controls (5.0%) and 4 anticoagulation recipients (1.6%); PE, in 6 controls (4.3%) and 4 anticoagulation recipients (1.6%). Therapeutic anticoagulation was associated with a decreased risk for proximal DVT or PE at 180 days (odds ratio [OR], 0.34; 95% CI, 0.14-0.83) but an increased risk for bleeding (OR, 4.35; 95% CI, 1.27-14.9), findings that persisted after adjustment for confounding factors (ORs, 0.33 [95% CI, 0.12-0.87] and 4.87 [95% CI, 1.37-17.3], respectively) and sensitivity analyses., Conclusions and Relevance: Rates of proximal DVT or PE are low after isolated calf DVT. Therapeutic anticoagulation is associated with a reduction of these outcomes but an increase in bleeding.

Background: 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)., Methods: 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., Results: 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)., Conclusion: 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: 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.

In 2008, we conducted a retrospective cross-sectional study to determine the test characteristics of the Agency for Healthcare Research and Quality patient safety indicator (PSI) for hospital-acquired pressure ulcer (PU). We sampled 1,995 inpatient records that met PSI 3 criteria and 4,007 records assigned to 14 DRGs with the highest empirical rates of PSI 3, which did not meet PSI 3 criteria, from 32 U.S. academic hospitals. We estimated the positive predictive value (PPV), sensitivity, and specificity of PSI 3 using both the software version contemporary to the hospitalizations (v3.1) and an approximation of the current version (v4.4). Of records that met PSI 3 version 3.1 criteria, 572 (PPV 28.3%; 95% CI 23.6-32.9%) were true positive. PU that was present on admission (POA) accounted for 76% of the false-positive records. Estimated sensitivity was 48.2% (95% CI 41.0-55.3%) and specificity 71.4% (95% CI 68.3-74.5%). Reclassifying records based on reported POA information and PU stage to approximate version 4.4 of PSI 3 improved sensitivity (78.6%; 95% CI 62.7-94.5%) and specificity (98.0; 95% CI 97.1-98.9%). In conclusion, accounting for POA information and PU staging to approximate newer versions of the PSI software (v4.3) moderately improves validity.

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.

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.