Not Just Full of Hot Air: Hyperbaric Oxygen Therapy Increases Survival in Cases of Necrotizing Soft Tissue Infections

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 CONCLUSION: At HBOT capable centers, receiving HBOT was associated with a significant survival benefit. HBOT in conjunction with current practices for the treatment of NSTI can be both a cost effective and life saving therapy

Impact of Pre-Injury Warfarin Use Among Medicare Beneficiaries With Head Trauma

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 \u3e2 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 Conclusion: Anticoagulation with warfarin increases risk of mortality after head injury nearly two fold in Medicare beneficiaries even after adjusting for other risk factors. As new, more difficult to reverse, agents are introduced for chronic anticoagulation this problem may be exacerbated. Physicians should exercise caution when initiating chronic anticoagulation in patients over the age of 65

Acute Care Surgery Patterns in the Current Era: Results of a Qualitative Study

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

Quadrimodal Distribution of Death after Trauma: Predictors of Death in the Fourth Peak

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\u3e24hrs) 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

Improving patient notification of solid abdominal viscera incidental findings with a standardized protocol

BACKGROUND: The increasing use of computed tomography (CT) scans in the evaluation of trauma patients has led to increased detection of incidental radiologic findings. Incidental findings (IFs) of the abdominal viscera are among the most commonly discovered lesions and can carry a risk of malignancy. Despite this, patient notification regarding these findings is often inadequate. METHODS: We identified patients who underwent abdominopelvic CTs as part of their trauma evaluation during a recent 1-year period (9/2011-8/2012). Patients with IFs of the kidneys, liver, adrenal glands, pancreas and/or ovaries had their charts reviewed for documentation of the lesion in their discharge paperwork or follow-up. A quality improvement project was initiated where patients with abdominal IFs were verbally informed of the finding, it was noted on their discharge summary and/or were referred to specialists for evaluation. Nine months after the implementation of the IF protocol, a second chart review was performed to determine if the rate of patient notification improved. RESULTS: Of 1,117 trauma patients undergoing abdominopelvic CT scans during the 21 month study period, 239 patients (21.4%) had 292 incidental abdominal findings. Renal lesions were the most common (146 patients, 13% of all patients) followed by hepatic (95/8.4%) and adrenal (38/3.4%) lesions. Pancreatic (10/0.9%) and ovarian lesions (3/0.3%) were uncommon. Post-IF protocol implementation patient notification regarding IFs improved by over 80% (32.4% vs. 17.7% pre-protocol, p = 0.02). CONCLUSION: IFs of the solid abdominal organs are common in trauma patients undergoing abdominopelvic CT scan. Patient notification regarding these lesions is often inadequate. A systematic approach to the documentation and evaluation of incidental radiologic findings can significantly improve the rate of patient notification

Racial Disparities in Emergency Department Mortality and Departure Status among Trauma Patients in Massachusetts

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 Conclusions: Substantial racial disparities in ED mortality and departure status were observed among MA trauma patients. Determinants of the disparities are under investigation in an ongoing study funded by the National Institute on Minority Health and Health Disparities

Risks factors for significant injury after geriatric falls

Elderly falls are a healthcare epidemic. We aimed to identify risk factors of serious falls by linking data on functional status from the Global Longitudinal Study of Osteoporosis in Women (GLOW) and our institutional trauma registry. 124 of 5,091 local women enrolled in GLOW were evaluated by our trauma team for injuries related to a fall during the study period. Median injury severity score was 9. The most common injuries were intertrochanteric femur fracture (n = 25, 9.8%) and skin contusion/hematoma to face (n = 12, 4.7%). Injured women were older than the uninjured cohort (median 80 versus 68 years), more likely to have cardiovascular disease and osteoarthritis, and less likely to have high cholesterol. Prospectively collected Short Form 36 (SF-36) baseline activity status revealed greater limitation in all assessed activities in women evaluated for fall-related injuries in our trauma center. In multivariable analysis, age (per 10 year increase) and two or more self-reported falls in the baseline survey were the strongest predictors of falling (both HR 2.4, p <0.0001 and p<0.001 respectively), followed by history of osteoarthritis (HR 1.6, p= 0.01). Functional status was no longer associated with risk of fall when adjusting for these factors.Functional status appears to be a surrogate marker for frailty. With the aging of the US population and long lifespan of American women, this finding has important implications for both fall prevention strategies and research intended to better understand why aging women fall as burdensome validated metrics may not be the best indicators of fall risk. The authors have no conflict of interests to declare. Funding statement: This work was partially supported by grants from NIH (8KL2TR000160-03), AHRQ (R01HS22694), and PCORI (ME-1310-07682) to HS

Not just full of hot air: hyperbaric oxygen therapy increases survival in cases of necrotizing soft tissue infections.

BACKGROUND: The utility of hyperbaric oxygen therapy (HBOT) in the treatment of necrotizing soft tissue infections (NSTIs) has not been proved. Previous studies have been subject to substantial selection bias because HBOT is not available universally 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 International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes, which included Fournier gangrene (608.83), necrotizing fasciitis (728.86), and gas gangrene (040.0). Status of HBOT was identified by the presence (HBOT) or absence (control) of ICD-9 procedure code 93.95. Our cohort was risk-stratified and matched by UHC\u27s 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. Univariate analysis showed that there was no difference between HBOT and control groups in hospital length of stay, 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 CONCLUSION: At HBOT-capable centers, receiving HBOT was associated with a significant survival benefit. Use of HBOT in conjunction with current practices for the treatment of NSTI can be both a cost-effective and life-saving therapy, in particular for the sickest patients

The dangers of being a weekend warrior : A new call for injury prevention efforts

BACKGROUND: Nonprofessionals routinely perform high-risk home maintenance activities otherwise regulated by the Occupational Health and Safety Administration when professionals perform the same work. Reducing the risks taken by these weekend warriors has not been the focus of injury prevention efforts. This study describes injury patterns and outcomes for nonprofessionals attempting home roof and tree maintenance. METHODS: We queried our trauma registry for all adult patients (age, \u3e/=18 years) with injury codes for fall-from-height or struck-by-tree (2005-present) and reviewed charts to determine injuries sustained during home roof or tree work. Patients injured during occupational duties (indicated by Workman\u27s Compensation) were excluded. Descriptive statistics were used to determine patient demographics, injury patterns, and outcomes. RESULTS: A total of 129 patients were injured performing roof and tree maintenance during the study period. Of these patients, 90 (69.8%) were fall from height and 39 (30.2%) were struck by tree. Mean (SD) age was 45 (14) years. The majority were male (124, 96.1%) and white (116, 89.9%). Nearly half (59, 45.7%) were privately insured; a quarter (32, 24.8%) had no insurance. Mean (SD) Injury Severity Score was 12.7 (9.3). Injury distributions were as follows: head injury, 48.8%; facial fractures, 10.1%; cervical spine fractures, 3.9%; thoracic, lumbar, and sacral spine fractures, 28.1%; rib fractures, 27.3%; intrathoracic injuries, 22.5%; liver/spleen injuries, 6.2%; pelvic fractures, 15.6%; upper-extremity fractures, 27.3%; and lower-extremity fractures, 14.7%. Of the patients, 19 (14.7%) had one or more regions with Abbreviated Injury Scale score of higher than 3. Mean (SD) length of stay was 5.3 (7.6) days. Except for 2 deaths (1.6%), discharge dispositions were as follows: home, 64.2%; home with services, 10.1%; rehabilitation, 17.8%; and skilled nursing, 5.4%. CONCLUSION: Weekend warriors performing home roof and tree maintenance sustain serious injuries with a potential for a long-term disability at young ages. Injury prevention efforts should educate the public about the hazards of high-risk home maintenance, possibly encouraging Occupational Health and Safety Administration-regulated protective measures or deferral to trained professionals. LEVEL OF EVIDENCE: Epidemiologic study, level III

Epidemiology and outcomes of community-acquired Clostridium difficile infections in Medicare beneficiaries

BACKGROUND: The incidence of community-acquired Clostridium difficile (CACD) is increasing in the United States. Many CACD infections occur in the elderly, who are predisposed to poor outcomes. We aimed to describe the epidemiology and outcomes of CACD in a nationally representative sample of Medicare beneficiaries. STUDY DESIGN: We queried a 5% random sample of Medicare beneficiaries (2009-2011 Part A inpatient and Part D prescription drug claims; n = 864,604) for any hospital admission with a primary ICD-9 diagnosis code for C difficile (008.45). We examined patient sociodemographic and clinical characteristics, preadmission exposure to oral antibiotics, earlier treatment with oral vancomycin or metronidazole, inpatient outcomes (eg, colectomy, ICU stay, length of stay, mortality), and subsequent admissions for C difficile. RESULTS: A total of 1,566 (0.18%) patients were admitted with CACD. Of these, 889 (56.8%) received oral antibiotics within 90 days of admission. Few were being treated with oral metronidazole (n = 123 [7.8%]) or vancomycin (n = 13 [0.8%]) at the time of admission. Although 223 (14%) patients required ICU admission, few (n = 15 [1%]) underwent colectomy. Hospital mortality was 9%. Median length of stay among survivors was 5 days (interquartile range 3 to 8 days). One fifth of survivors were readmitted with C difficile, with a median follow-up time of 393 days (interquartile range 129 to 769 days). CONCLUSIONS: Nearly half of the Medicare beneficiaries admitted with CACD have no recent antibiotic exposure. High mortality and readmission rates suggest that the burden of C difficile on patients and the health care system will increase as the US population ages. Additional efforts at primary prevention and eradication might be warranted