75.06 Speaking Up For Patient Safety: Comparison Of Surgical And Pediatric Residents

Posted on December 22, 2014

Z. Alawadi3,4, L. R. Putnam3,4, R. Landgren5, J. Etchegaray2,5, E. Thomas1,2, K. Tsao3,4, L. Kao3,4  1University Of Texas Health Science Center At Houston,Department Of Internal Medicine,Houston, TX, USA 2The University Of Texas At Houston-Memorial Hermann Center For Healthcare Quality And Safety,Houston, Texas, USA 3University Of Texas Health Science Center At Houston,Department Of General Surgery,Houston, TX, USA 4Center For Surgical Trials And Evidence-based Practice, University Of Texas Medical School At Houston,Houston, TX, USA 5University Of Texas Medical School At Houston,Hosuton, TX, USA

Introduction: Communication breakdown is a major threat to patient safety. Studies show that surgical, compared to non-surgical, residents are less likely to speak up when there is a patient safety concern. We hypothesized that surgery residents have worse perceptions of safety culture and different reasons for not speaking up than pediatric residents.

Methods: Surgery (SR) and Pediatric residents (PR) at the University of Texas-Houston were asked to complete a 2 part web-based survey. The first part consisted of a validated survey evaluating 5 domains of safety culture within their work environment. Data are presented as the percent of respondents who slightly or strongly agreed with the items within each domain. Negatively-worded questions are reverse coded.  Chi-square analysis was used to compare responses. The second part was an open-ended question asking residents to list 3 reasons that would prevent them from speaking up when there is a patient safety concern. Participation was anonymous. Responses were independently analyzed for thematic content by multiple coders. Coding differences were discussed until consensus was reached.

Results: Response rates were 85% and 80% for SR, and 57% and 28% for PR for the first and second parts of the survey, respectively. PR scored significantly higher than SR on all 5 domains of the survey, especially in regard to communication openness (71% vs 8%, Table). However, both groups reported similar barriers to speaking up: fear of consequences/intimidation, hierarchical system, feeling powerless, and lack of confidence in self-decisions. Excessive workload was an additional barrier reported frequently by SR, while lack of adequate training in patient safety and reporting processes was reported more frequently among PR. 

Conclusion: Despite better perceptions of safety culture among pediatric residents, similar reasons prevent residents from speaking up regardless of their specialty. Although changes in safety culture are needed, they may not be sufficient to empower residents to speak up. Effective methods for overcoming communication barriers within the medical hierarchy and for educating residents about patient safety and reporting processes are necessary to provide safer patient care.

74.05 Marginal Ulceration after Pancreaticoduodenectomy: A Systematic Review and Meta-Analysis.

Posted on December 22, 2014

J. R. Butler1, T. Rogers1, K. N. Kaneshiro3, G. J. Eckert2, N. J. Zyromski1  1Indiana University School Of Medicine,Department Of Surgery,Indianapolis, IN, USA 2Indiana University School Of Medicine,Biostatistics,Indianapolis, IN, USA 3Indiana University School Of Medicine,Research Library,Indianapolis, IN, USA

Introduction:  Marginal ulcer is well-described and serious complication of pancreaticoduodenectomy (PD) whose incidence remains unclear. With the advent of gastric antisecretory medications, surgeons may be able to further mediate the risk of marginal ulceration after PD. Despite this potential, the true relationship between antisecretory medication and marginal ulceration after PD is not precisely known.

Methods: The MEDLINE, EMBASE, Cochrane Central Registrar of Controlled Trials and Cochrane Database of Systematic Reviews databases were searched from their inception to November 2013 for abstracts documenting ulceration after pancreaticoduodenectomy. Two reviewers independently graded abstracts for inclusion in this review. Heterogeneity in combining data was assumed prior to pooling. Random-effects meta-analysis was performed to estimate percentages at 95% confidence intervals. 

Results: After a review of 208 abstracts, 65 studies and case series were graded as relevant. These represented a cohort of 209 patients with marginal ulcer after PD. A meta-analysis of studies meeting inclusion criteria shows mean incidence of ulceration after PD of 4.4% with average time to ulceration being 22.2 months post resection. PPPD 3.6%. Classic Cohort 4.8%. Documented use of postoperative antisecretory medication was associated with a reduced rate of 2.1 %.

Conclusion: Although reported incidences of ulceration after PD vary widely across studies, an overall incidence of 4.4% is reported in the literature. This incidence may be demarcated between classic procedures (4.8%) and PPPD procedures (3.6%). Overall median time to ulceration was 22.2 months. Furthermore, the current body of literature reports that the use of prophylactic gastric antisecretory medication after PD is associated with a reduction in ulceration rate by (2.3%).

 

74.06 NSQIP In Colorectal Surgery: A Tool For Decreasing Preventable Morbidity

Posted on December 22, 2014

A. N. Kulaylat1, Z. A. Gregg1, W. Sangster1, G. Ortenzi1, E. Messaris1  1Penn State Hershey Medical Center,Division Of Colon And Rectal Surgery, Department Of Surgery,Hershey, PA, USA

Introduction:  Clinical outcomes data are playing an increasingly important role in reimbursement, provider evaluation and everyday clinical practice. Furthermore, physicians can use the data to improve the quality of the provided care. The objective of this study is to report a single hospital's experience using the National Surgical Quality Improvement Program (NSQIP) as an instrument to improve outcomes after colorectal surgery resections.

Methods:  Raw institutional and national risk adjusted NSQIP data in a tertiary facility were annually reviewed and changes were implemented to improve outcomes. Special bundles were implemented for prevention of urinary tract infections (UTI) and venous thromboembolic events (VTE).  All targeted colectomies and proctectomies from 2011 to 2013 were reviewed and the following outcome measures were recorded: mortality, overall morbidity, urinary tract infections, venous thromboembolic events and surgical site infections (SSI).

Results: A total of 803 cases met our criteria. Our ACS NSQIP overall colorectal UTI and VTE rates for 2011 were 3.6% and 2.8% respectively. After implementation of the new practice parameters both UTI and VTE rates decreased in 2013 to 1.4% and 1.75%, respectively (Figure 1). Furthermore, mortality and overall morbidity improved from 4.68% and 20.8% in 2011 to 1% and 15.4%, respectively. On the contrary, outcomes for which we did not implement practice parameters, such as SSI’s, did not demonstrate any improvement from 2011 (7.4%) to 2013 (9.1%).

Conclusion: 1) NSQIP enabled our institution to identify sources of preventable morbidity. 2) By implementing changes in our clinical practice, we were able to lower our rate of UTI’s and VTE’s. 3) NSQIP should be used as a tool that drives quality improvement and not just quality reporting.
 

74.07 Risk Factors and Implications of Post-Discharge Complications after Bariatric Surgery

Posted on December 22, 2014

S. Y. Chen2, M. Stem1, A. O. Lidor1  1Johns Hopkins University School Of Medicine,Department Of Surgery,Baltimore, MD, USA 2Johns Hopkins University School Of Medicine,Baltimore, MD, USA

Introduction:
Although outcomes during hospitalization for patients undergoing bariatric surgery are well known, little is reported about post-discharge complications (PDC) and their implications in this population. We sought to identify the rate of PDC, associated risk factors, and their influence on the early outcomes after bariatric surgery.

Methods:
This was a retrospective study using American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) data from 2005 through 2012. Patients ≥ 18 years of age who underwent a bariatric surgical procedure (laparoscopic adjustable band, laparoscopic gastric bypass [GBP], open GBP, and sleeve gastrectomy) with a primary diagnosis of morbid/severe obesity and BMI ≥ 35 were included. PDC was the primary outcome, defined as an event for which time interval (days) between bariatric surgery and complication was greater than the interval from the surgery to discharge. Secondary outcomes included readmission and reoperation (only available for 2011-2012). We examined the association between PDC and various factors (including length of stay [LOS] and operative time) using multivariable logistic regression. A subset analysis was performed by procedure type.

Results:
A total of 94,415 patients were identified for whom the overall PDC rate within 30-days post-surgery was 3.1%. The rate of PDC decreased significantly from 2005-6 (4.6%) to 2012 (2.7%) (p<0.001). In comparison to patients who experienced no complication or only a pre-discharge complication (PrDC), PDC patients were older, had higher ASA class, greater BMI, and more comorbidities. On average, PDC occurred 9 days post-operatively, with wound infection, urinary tract infection, shock/sepsis, and organ space surgical site infection being the most common. Open GBP patients had the highest PDC rate (8.5%). Only 3.5% of patients experienced both PrDC and PDC. 46.7% of PDC patients were readmitted, and 41.9% required a reoperation. The factors most strongly associated with an increased odds of PDC were BMI ≥ 50, steroid use, procedure type, PrDC, and prolonged LOS and operative time (Table).

Conclusion:
Although the rate of PDC after bariatric surgery is low, it accounts for a significant number of readmissions. Adoption of best practices for prevention of surgical site infection and catheter-associated urinary tract infection, as well as standardized protocols for outpatient monitoring of patients identified to be at high risk of experiencing PDC, should be considered.
 

74.08 Does Inpatient Screening Reduce Post-Discharge Venous Thromboembolism Rates?

Posted on December 22, 2014

C. N. Holcomb1, A. DeRussy2, J. S. Richman1,2, M. T. Hawn1,2  1University Of Alabama At Birmingham,Gastrointestinal Surgery,Birmingham, AL, USA 2The Center For Surgical, Medical, Acute Care Research And Transitions,Birmingham VA Hospital,Birmingham, AL, USA

Introduction:

Hospital venous thromboembolism (VTE) screening practices, but not adherence to SCIP VTE prophylaxis measures, have been reported to explain variation in hospital VTE rates. We examined the relationship between inpatient VTE screening and post-discharge VTE rates at the hospital level to determine whether more frequent inpatient screening is associated with reduced post-discharge VTE occurrence.  

Methods:

We linked national Veterans Affairs (VA) Surgical Quality Improvement Program outcome data to VA administrative data on patients undergoing inpatient surgery from 2005 to 2009 included in the SCIP VTE measurement population.  Screening was identified using CPT codes for diagnostic VTE imaging.  Relationships for hospital-level screening and VTE rates were assessed with Pearson Correlation Coefficients and post-discharge VTE rate was modeled using multivariable linear regression adjusting for hospital volume, inpatient VTE rate, inpatient screening rate and case mix.

Results:

Of the 25,975 patients at 79 VA facilities, 296 patients (1.4%) experienced a VTE during the index hospitalization and 114 (0.4%) experienced a post-discharge VTE within 30 days of surgery. A positive correlation between inpatient screening and inpatient VTE rates (R=0.33, p=0.003)( Figure A), but no correlation between inpatient screening and neither post-discharge screening (R=0.11, p=0.29) nor post-discharge VTE rates (R=0.03, p=0.76) (Figure B) was observed. In multivariable linear regression modeling of post-discharge hospital VTE rate, only inpatient VTE rate was significant (β=0.13, p=0.05).

Conclusion:

Hospitals with more liberal VTE screening have higher inpatient VTE events, but not decreased post-discharge VTE events.  However, hospitals with higher inpatient VTE rates have higher post-discharge VTE rates, suggesting that screening may be influenced by higher observed rates and not surveillance practices alone.
 

74.09 Improving Compliance to a Wound Infection Prevention Protocol (WIPP) can reduce SSI.

Posted on December 22, 2014

J. Sharma1, S. Perez1, J. Sweeney1  1Emory University School Of Medicine,Surgery,Atlanta, GA, USA

Introduction:
In 2009, ACS-NSQIP was subscribed at our institution and surgical site infection (SSI) was identified as an area of needed improvement.  A multidisciplinary Wound Infection Group (WIG) was tasked to reduce SSI rates and a wound infection prevention process (WIPP) was developed with a focus on colorectal surgery.

Methods:
Between June’2011 and June’2014, NSQIP semiannual reports were queried for O/E ratios for SSI rates.  Compliance was measured for 15 elements in WIPP at initiation and then at 12 months in 711 patients.  Compliance to each element was reported in 3 categories; Good (>80% of patients), Fair (31-79%) and Poor (<30%).  Elements in WIPP were glycemic control; antibiotics timing, re-dosing and appropriateness; skin prep; MRSA screening and treatment; hospital scrubs; double-gloving; use of hair clippers; and patient temperature.

Results:
O/E ratios for SSI in colorectal surgery improved from 1.61 to 0.78; and SSI rates were reduced from 18.2% to 8.2% (p=0.032).  Initial measure of compliance to elements in WIPP was 8/15, 5/15 and 2/15 in Good, Fair and Poor categories, respectively; and in 3 elements compliance was in >90% of patients.  At 12 months, compliance was 11/15, 3/15 and 1/15 in their respective categories; and in 6 elements compliance was in >90% of patients. Areas with lowest compliance were glycemic control and patient temperature.

Conclusion:
Utilizing ACS-NSQIP, identifying areas of quality improvement, organizing multidisciplinary groups such as WIG, and then developing an institutional best practice such as WIPP can be effective in reducing SSI.  Elements with poor compliance can serve as targets of focused quality improvement.
 

74.10 The Diagnostic Pathway For Solid Pancreatic Neoplasms: Are We Applying Too Many Tests?

Posted on December 22, 2014

M. Driedger1, E. Dixon1, F. Sutherland1, O. Bathe1, C. Ball1  1University Of Calgary,Department Of Surgery,Calgary, AB, Canada

Introduction:  The single best diagnostic and staging test for pancreatic cancer remains a contrast enhanced computed tomography (CT) scan. It is frequently the only imaging test required prior to surgical resection for solid pancreatic lesions. Unfortunately, many patients undergo additional testing that often delays definitive care.

Methods:  A retrospective review of all patients with solid pancreatic lesions concerning for adenocarcinoma referred to a high volume HepatoPancreatoBiliary (HPB) service over 4 years (2008 – 2012) was completed. The time intervals between the initial imaging test and both consultation with HPB surgery and operative intervention, as well as the number of additional tests, were evaluated. Standard statistical methodology was employed (p<0.05).

Results:  Among 130 patients with solid pancreatic lesions, the index imaging modality was ultrasound and CT for 75 (58%) and 52 (40%) respectively. Patients underwent a mean of 1.3 diagnostic tests following the index study and prior to consultation with HPB surgery (range: 0–5). There was a significant increase in time to HPB consultation and operative intervention with an increasing number of interval imaging tests (Fig. 1). The mean time to surgical consultation and operation if 0 interval diagnostic tests were performed was 15.9 and 45.4 days respectively. If 4 interval tests were conducted, the mean was 69.4 and 122.6 days respectively. Sixty-two (48%) patients were initially referred to a non-surgical service. The mean time to surgical consultation and operation if an intervening referral occurred was 36.6 and 66.8 days respectively. This compares to 19.8 and 48.1 days respectively in cases of direct referral to an HPB surgeon. The mean number of diagnostic tests performed prior to HPB consultation if a non-surgical referral occurred was 2.1 (vs. 0.7 if direct HPB surgeon referral).

Conclusion:  Despite a relatively simple algorithm for the workup of solid pancreatic lesions, considerable heterogeneity remains in how these patients are investigated prior to referral to HPB surgery. As the number of investigations increases following the index imaging test, there is increasing delay to both surgical consultation and definitive intervention. Initial referral to a non-surgeon also resulted in a 3-fold increase in diagnostic tests and a delay in time to surgery. Education is required to expedite care and mitigate excess diagnostic tests. 

 

73.07 Socioeconomic Disparities in Pediatric Reduction Mammaplasty

Posted on December 22, 2014

T. A. Evans1, T. Soleimani1, R. Sood1, I. Hadad1, J. Socas1, R. L. Flores1, S. S. Tholpady1  1Indiana University School Of Medicine,Division Of Plastic Surgery,Indianapolis, IN, USA

Introduction:   Pediatric breast reduction mammaplasty is a commonly performed procedure in children with excess breast tissue, back pain, and social anxiety.  Although technical aspects of the procedure are no different between adults and children, minimal information exists regarding patient-related factors influencing outcomes in adolescents.  As healthcare reform progresses, it is essential to investigate the socioeconomic factors that affect surgical outcomes. This study was designed to explore the socioeconomic and geographic disparities and their effects on hospital length of stay.

Methods: The Kids Inpatient Database (KID) was utilized from years 2000-2009.  All patients with an ICD-9 diagnosis code of macromastia and procedure code of reduction mammaplasty 20 and under were included.  Demographic data including age, sex, race, payer mix, location of operation, and ZIPINC-quartile were collected.  Significant independent variables associated with complications and length of stay were generated using multivariate analysis.

Results: A total of 1345 patients between the ages of 12 to 20 were evaluated.  The majority of the patients were white (64.04%), from a zip-code with highest (fourth quartile) income (35.93%), and having private insurance as their primary payer (75.4%).  Most of the surgeries were performed in large (58.08%), teaching (65.04%), private-not for profit (84.71%) hospitals located in urban areas.  The most frequent region reductions were performed was the Northeast (37.11%).  Overall comorbidity and complication rates were 30% and 1.64%, respectively.  Hemorrhage/hematoma/seroma and having at least one complication were both associated with having other procedures and with the region of hospital.  Mean length of stay (LOS) was 1.1 days.  African-American race, Medicaid/government payer source, low income, having comcominant procedures/complications and Southern hospitals were significantly associated with increased LOS. 

Conclusion: The results of this large retrospective database analysis show that breast reduction surgery in the adolescent population has a comparatively low early complication rate and short length of hospital stay.  Socioeconomic and geographic disparities are associated with longer length of stay following pediatric reduction mammaplasty.  Factors causing these demographic and patient-related discrepancies should be furthered assessed to improve surgical outcomes in this population.

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73.08 Progress towards a Better Understanding of the Global Impact of Religion on Organ Transplantation

Posted on December 22, 2014

M. Addis1, E. J. Minja1, R. S. Chamberlain1,2,3  1Saint Barnabas Medical Center,General Surgery,Livingston, NJ, USA 2University Of Medicine And Dentistry Of New Jersey,Newark, NJ, USA 3Saint George’s University,Grenada, Grenada, Grenada

Introduction: Despite numerous global policies and strategies to improve the availability of organs for transplantation from both living and deceased donors, the organ shortage problem remains enormous. Differences in cultures, mythology, and religious beliefs play a significant role in the availability of organs for transplantation. This study examines the impact of religious belief system on organ donation worldwide.  Specifically this report focuses on the impact of religion on kidney and liver donations which comprise the majority of transplant performed worldwide, and for which living donation is possible.

Methods: Organ donation statistics (2009) from countries performing more than 100 kidney and/or liver transplantations per year was analyzed.  Living and deceased kidney transplant donors as well as partial and deceased liver transplant donors were analyzed together and separately based on census date in regards to the primary religion in the unique country.

Results: The overwhelming majority of organ donors, both living and deceased, are from countries where Christianity, Daoism and Hinduism are the main religions. When analyzed for type of donation, Hindus and Muslims overwhelmingly prefer living donation compared to faiths as Christianity, Daoism, Jewish and Buddhism who donate almost equally between living and deceased (Figure 1).

Conclusion: Organ donations arise primarily from a sense of altruism, excluding nations in which donors are paid directly. Different cultures and faiths such as Christianity, Daoism, Judaism and Buddhism appear to be faith systems that both promote and place fewer limitations on the type of organ donation, hence almost equal distribution between living and deceased donations are seen in countries where these religions are predominant.  False or true, perceptions about desecration of a body during procurement may pose as limiting factors in explaining the limited availability of deceased organs from countries in which Islam and Hinduism are primary, although lack of medical infrastructure and lower socioeconomics is a reasonable alternative explanation as well. Additional exploration into the impact of religious belief systems on both the promotion and restriction on organ donation is important, and may be a critical factor underlying the absence of donation in many countries.

 

73.09 National Trends In The Use and Outcomes of Liver Transplant

Posted on December 22, 2014

S. Hirani1, Z. A. Sobani2, A. Jackson1, Z. Hirani1, E. Mortensen1, J. Arenas1, T. M. Pawlik4, O. Hyder3  1University Of Texas Southwestern Medical Center,Dallas, TX, USA 2Maimonides Medical Center,Surgery,Brooklyn, NY, USA 3Massachusetts General Hospital,Anesthesiology,Boston, MA, USA 4Johns Hopkins University School Of Medicine,Surgery,Baltimore, MD, USA

Introduction:  The number of hepatic transplants performed in the US has been gradually increasing. This increase may be attributable to broadening indications, less stringent selection processes and expansion of services. However, as the procedure increases in frequency, comparable literature increases are not noticed, with an absence of large-scale studies reporting nationwide morbidity and mortality of the procedure.

Methods:  In order to address this issue we sampled the Nationwide Inpatient Sample (NIS), a stratified random sample of US hospital discharges for patients undergoing hepatic transplants between the years 2000 and 2010. Outcomes variables considered in the study were in- hospital mortality and LOS, and the data was analyzed in 4 time periods 2000 to 2002; 2003 to 2005; 2006 to 2008; 2009 to 2010. Descriptive statistics and comparisons of patient characteristics and outcomes variables across time periods were performed.

Results: 

During the 11-year period, 12,001 patients underwent liver transplantation. Cirrhosis without mention of alcohol was the most common indication accounting for nearly 40% of cases. The overall in-hospital mortality rate was 5.8%, however it declined from 8.5% in 2000-2002 to 0.2% in 2009-2010. Rural hospitals had a mortality of 20% while urban teaching hospitals had a mortality of 5.8% (p < 0.05).

Conclusion: Although there have been significant advances made in reducing perioperative mortality with liver transplants, the length of stay has not significantly changed over the span of 10 years. Further study is warranted to evaluate for 30 day mortality and long term outcomes. Also, there still exists great disparities depending on race, income, gender and geography.  Potential reasons for these disparities, including limited access to healthcare and less experience with perioperative care of liver transplant patients, need to be further explored.
 

73.10 Demographic Disparities between NY,NJ, and PA Kidney Transplant Recipients Impact the Outcomes

Posted on December 22, 2014

J. Ortiz1, A. Parsikia2, S. Pinto3, P. Chang4, K. Khanmoradi2, S. Campos2, R. Zaki2  1Toledo University Medical Center,Toledo, OH, USA 2Einstein Healthcare Network,Philadelphia, PA, USA 3University Of Illinois Chicago (Metropolitan Group Hospital),Chicago, IL, USA 4Drexel University,Philadelphia, PA, USA

Introduction:

Geographic variations in kidney transplant outcomes are well documented but poorly understood.

Methods:

A retrospective analysis of recipients maintained in a standard database from NJ, NY and PA transplanted at a single center over the last eleven years was conducted.

Results:

PA recipients received a higher proportion of high-risk and HCV-positive donors and were more likely to be African-American, HCV positive and have had prior transplants. PA recipients recorded highest rates of delayed graft function in the immediate post-operative period and highest patient mortality and re-transplantation rates on long-term follow-up. Medium term outcomes (Overall patient survival rates at 1 and 3 years) were not significantly different between NJ (93.81%; 77.14%), NY (92.31%; 78.16%) and PA (88.64%; 70.17%) recipients (p>0.05).

Conclusions:

Higher waitlist times among NY and NJ recipients resulted in earlier transplantation when re-listed in Northern Philadelphia. Despite higher risk clinical profiles among PA patients,1- and 3- year patient and graft survival rates were not significantly different between the three patient categories. This may be indicative of closer follow-up of PA recipients. Nevertheless, long-term outcomes were significantly worse in PA patients. There was a not insignificant number of patients outside PA who were lost to follow-up.

73.11 Does Obesity Affect Outcomes in Adult Burn Patients?

Posted on December 22, 2014

J. J. Ray1, S. S. Satahoo1, C. J. Allen1, J. P. Meizoso1, C. M. Thorson1, L. F. Teisch1, J. E. Sola2, K. G. Proctor1, L. R. Pizano1, N. Namias1, C. I. Schulman1  1University Of Miami,Divisions of Trauma, Surgical Critical Care, and Burns,Miami, FL, USA 2University Of Miami,Division of Pediatric and Adolescent Surgery,Miami, FL, USA

Introduction: It is recognized that negative outcomes are associated with obesity in trauma, but less is known about outcomes in burn patients. We aim to bridge this gap to better understand the association of obesity to clinical and economic outcomes in the burn population. We hypothesize that obesity is an independent predictor of adverse events.

Methods: The National Inpatient Sample was queried for adult patients (age ≥ 18 years) with an “emergency,” “urgent,” or “trauma center” admission from 2005-2009, and ICD-9 codes for burn injury. Patients with isolated injuries to the internal organs and eyes (941-946.5, 948-949.5) were excluded as were those with missing data for total body surface area (TBSA) burn and/or burn degree. Demographics, disease severity, length of stay (LOS), discharge disposition, hospital costs and outcomes were reviewed. Parametric data are represented as mean±standard deviation and non-parametric data as median(interquartile range). Univariate and multivariate analysis logistic regression models were performed.

Results: In 14,602 patients, 3.3% were obese (body mass index>30). The rate of obesity increased significantly over the study period (2005: 1.7%, 2006: 2.0%, 2007: 2.8%, 2008: 4.6%, 2009: 5.2%, p<0.001). On univariate analysis, there were no significant differences between obese and non-obese patients in terms of race, TBSA burn, degree of burn, need for mechanical ventilation, or household income. Significant differences were noted in incidence of wound infection (7.2%vs5.0%), urinary tract infection (UTI) (7.2%vs4.6%), deep vein thrombosis (DVT) in TBSA burn ≥ 10% (3.1 vs 1.1%), pulmonary embolism (PE) in TBSA burn ≥ 10% (2.3%vs0.6%), discharge to home (57.7%vs66.6%), high disease severity (91.8%vs73.5%), LOS [6(8) vs 5(9)] and hospital costs [$10,122.12($19,825.21) vs $7892.07($17.191.96)] (all p <0.05). Significant predictors of adverse events (UTI, wound infection, DVT, or PE) included: obesity (15.2%vs10.1%), TBSA ≥ 20% (14.6%vs9.6%), age (53±20y vs 45±18y) and black race (13.0%vs9.9%). These remained significant on multivariate analysis using a logistic regression model (area under receiver operator curve= 0.703) (Table).

Conclusion: In burn patients, obesity is an independent predictor of adverse events along with TBSA ≥ 20, age, and black race. Our findings highlight the potential clinical and economic impact of the obesity epidemic on burn patients nationwide.

 

73.12 Cultural Divergence: Trauma Mechanisms and Outcomes Transcend Racial Similarities

Posted on December 22, 2014

N. Kamagate1, T. Wood1, U. Pandya1, M. S. O’Mara1  1Grant Medical Center/Ohio University,Trauma And Acute Care Surgery/Ohio University Heritage College Of Osteopathic Medicine,Columbus, OHIO, USA

Introduction:   Race has been associated with outcomes in trauma patients. However, growing populations of 1st and 2nd generation African immigrants has brought up questions as to whether it is culture or race that influences these outcomes.   We hypothesize that the cultural background of patients instead of racial type, impacts cause, course and outcomes in trauma patients.

Methods:   25470 patients admitted to a level one trauma center over an 8-year period were retrospectively evaluated. Patients were separated into 3 groups: 1) Caucasian, 2) non-immigrant African Americans, and 3) African first or second generation immigrants.  Demographic, injury mechanism and severity, and outcome variables were evaluated.

Results:  Patient demographics and injury severity were not different.  The mechanism of injury in the immigrant population was different (see table), with immigrant patients having a majority of motor vehicle collisions.  MVCs were the most frequent in the nonimmigrant and Caucasian groups as well, but those two groups had much higher incidence of penetrating injury (non-immigrant African Americans) and falls (Caucasians).  There was also a decreased mortality in the immigrant group (2.8%), which was significantly (p < 0.0001) lower than both the non-immigrant (4.4%) and Caucasian groups (3.1%).

Conclusion:  There is more to trauma outcomes than race.  Cultural background is a significant predictor of injury cause and of survival in trauma patients.

 

73.13 Failure-to-Rescue from Complication after Blunt Traumatic Injury: Is Socioeconomic Status a Factor?

Posted on December 22, 2014

M. Arafeh1, S. Selvarajah1, E. B. Schneider1, J. Canner1, C. K. Zogg1, A. H. Haider1  1Johns Hopkins University School Of Medicine,Center For Surgical Trials And Outcomes Research, Department Of Surgery,Baltimore, MD, USA

Introduction:  Variations in in-hospital mortality rates by socioeconomic status (SES) following trauma have been consistently demonstrated, but mechanisms underlying this disparity are poorly understood. We sought to evaluate the impact of SES on the occurrence of post-traumatic complications and subsequent failure-to-rescue (FTR). 

Methods:  A retrospective analysis of the 2006-2011 Nationwide Emergency Department Sample (NEDS) was performed. Patients aged 18-64 years presenting to Level I or II trauma centers with blunt traumatic injury were identified. SES was determined using a pre-defined NEDS variable classifying patients into quartiles of median household income by zip code. A nationally representative weighted population subset was used, approximating a 20% stratified sample of U.S. hospital-based emergency departments. [t1] Complications associated with FTR as defined by the Agency for Healthcare Research & Quality (AHRQ) were identified using ICD-9 diagnosis codes. Multivariable logistic regression was performed to determine the odds of FTR (defined as mortality following a specified complication) comparing patients from the lowest SES (Q1) with patients from the highest SES (Q4), adjusting for age, gender, insurance status, injury severity, comorbidities,  trauma level, and teaching status. 

 

Results: Of 412,534 cases that met inclusion criteria, 22,398 (5.4%) patients had one or more complication. Overall, proportionally more patients in Q1 (n=13,964; 5.8%) developed complications compared with patients in Q4 (n=8,474; 5.0%), p=0.002. Of patients who developed complications, the average patient age was 44 years (SE=0.252); 76.8% were males with equal distribution between Q1 and Q4 (p=0.799). FTR was proportionally more common among patients in Q1 compared to Q4 (19.5% vs. 15.4%; p=0.004). After adjusting for relevant covariates, the odds of FTR were 31% higher among patients in Q1 compared to Q4 (AOR=1.31 [95% CI=1.067-1.620], p=0.012). 

 

Conclusion: Among patients who develop complications, FTR is significantly increased following blunt traumatic injury in the lowest SES quartile (Q1) compared to the wealthiest patients (Q4). Further research will be necessary to discern factors associated with higher complication and greater FTR rates among patients with low SES.
 

73.14 A National Estimation of LGB Patients Seeking Surgical Care in the ED

Posted on December 22, 2014

R. Y. Shields1, N. Nagarajan1, B. Lau1, C. Zogg1, L. Kodadek1, A. Robinson2, D. German2, A. Ranjit1, S. Peterson1, A. Haider1  1Johns Hopkins University School Of Medicine,Baltimore, MD, USA 2Johns Hopkins Bloomberg School Of Public Health,Baltimore, MD, USA

Introduction:

Widespread health and healthcare disparities for lesbian, gay, and bisexual (LGB) patients have been well documented in a variety of ambulatory settings. However, no information of specific treatments, outcomes, or risks in the emergency department (ED) or surgical settings exists for this population. Using the ED as a point of entry, we aimed to estimate the number of LGB patients who seek emergent surgical care annually by extrapolating from existing population data.

 

Methods:

A review was done to find studies that surveyed sexual orientation. We searched MEDLINE/PubMed, Embase, CINAHL, and Scopus using controlled vocabulary and relevant free text which included: LGB*, homosexual*, health care. We included studies that reported proportion of LGB individuals, conducted within the United States, and published between 1980-2013. Studies that reported sexual behavior or attraction, did not use standardized question formats, or had high rates of missing data were not included. We extracted relevant data from these studies to determine estimated LGB proportions in the general population. Using national estimates of ED visits from the HCUP National Emergency Department Sample (NEDS) and ICD-9 codes to identify patients needing surgical consultations, we calculated a nationally-representative number (and corresponding 95% CI) of LGB individuals seeking surgical care in the ED.

Results:

We reviewed 405 potentially relevant papers, of which 3 satisfied our inclusion criteria (Table). Combining their results, we estimated that 2.78% (95% CI: 2.73-2.84) of the U.S. population identify as LGB. Data from the 2011 NEDS estimated a total of 131,048,605 ED visits. Of the 131 million ED visits, 14 million required emergent surgical care. Assuming that 2.78% of the ED visits were by self-identifying LGB individuals, there were approximately 3.64 million (95% CI: 3.57 – 3.72 million) encounters with LGB patients in the ED in 2011. Of these, 389,200 (95% CI: 382,200 – 397,600) required a surgical consult.

Conclusion:

Every year, millions of patients who self-identify as LGB seek care in EDs across the country, a significant proportion of whom require surgical care. It is likely that this is a conservative estimate given widespread underreporting of LGB status. It is impossible to further examine potential disparities facing LGB patients seeking surgical care without routine collection of sexual orientation information, a priority for the Institute of Medicine and The Joint Commission. Additional research is needed to develop effective education and training for surgeons and surgical residents to address LGB patients. 

73.15 Perioperative Complications of Traumatic Open Femur Fracture ORIF in the Elderly

Posted on December 22, 2014

N. N. Branch1,2, A. Obirieze2, R. H. Wilson1,2  1Howard University College Of Medicine,Washington, DC, USA 2Howard University Hospital,Surgery,Washington, DC, USA

Introduction: Elderly patients 65 years and older represent an increasing proportion of the population, and they are typically more susceptible to open femoral fractures.  However, factors such as bone quality, nutritional status and comorbidites may affect treatment approaches and outcomes.  We aim to assess 30 day perioperative complications associated with open reduction and internal fixation of open femoral fractures in the elderly.

Methods: A retrospective analysis of the National Trauma Data Bank (NTDB) from 2007-2010 utilizing ICD-9 codes was conducted.  Cases ≥ 18 years old, who underwent open reduction and internal fixation (ORIF) of the femur at a level I or level II trauma center were included.  Patients were then stratified by age, with those 18-24 years serving as the reference group. Univariate, bivariate, and multivariate analyses were performed.

Results: 9,406 patients met the inclusion criteria, with the majority being white (61%), males (73%), between 25-44 years old (41%) with a mean age of 29 years.  Patient with private insurance (25%) and injury via motor vehicle collisions (34%) were most common. Elderly patients comprised 9.5% of the total population of which 85% were White and 62% were female. Elderly patients were 85% more likely to have fixation after hospital day 2 (OR: 1.85 CI: 1.49-2.29 p<0.001), 94% more likely to have an organ/space surgical site infection (OR: 1.94 CI: 1.32-2.37 p=0.001), and more than seven times more likely to die (OR: 7.58 CI: 3.71-15.49 p<0.001). All patients were over three times more likely to die if they had at least one perioperative complication (OR: 3.6 CI: 2.48-5.24 p<0.001).  All age groups were more likely to have at least one perioperative complication compared to those 18-24 years with the elderly having the greatest odds at 67% (OR: 1.67 CI: 1.25-2.21 p<0.001), followed by ages 45-64 (OR: 1.47 CI: 1.22-1.78 p<0.001), and ages 25-44 (OR: 1.30 CI: 1.10-1.55 p=0.002).

Conclusion: While the elderly represent a small proportion of open femoral fracture cases they are more likely to have a perioperative complication including infections.  Moreover elderly patients are the group most likely to suffer the most profound complication of all; perioperative death as compared to their younger counterparts.  While direct causality cannot be identified with this study, it is probable that a reduction of overall complications in this patient population could improve perioperative mortality.

73.16 PEDESTRIAN CRASH INJURIES IN LAS VEGAS: ALCOHOL USE AND OTHER FACTORS INCREASE RISK OF INJURY

Posted on December 22, 2014

D. R. Fraser1, N. D. Fulkerson1, A. A. Chavez1, N. K. Ingalls1, E. A. Snavely2, B. S. Penalosa1, J. J. Fildes1, D. A. Kuhls1  2University Medical Center,Trauma,Las Vegas, NV, USA 1University Of Nevada School Of Medicine,Surgery/Trauma,Las Vegas, NV, USA

Introduction: Las Vegas is ranked the13th most dangerous metropolitan area for walking, according to Transportation for America. Approximately 5,000 pedestrians die each year on U.S. roadways, creating a public health concern for pedestrian safety. To effectively target injury prevention, we analyzed demographic, environmental, temporal and alcohol consumption factors associated with being struck by a vehicle while navigating the streets of Las Vegas on foot.

Methods: We conducted a retrospective analysis of injuries resulting from auto pedestrian crashes (APC) at our Level I Trauma Center in Las Vegas from 2009-2013 (n=1126). Demographic, injury, environmental and hospital utilization data were analyzed in SPSS 22 using chi square, Mann Whitney U and logistic regression tests with significance set at p<0.05.

Results: Overall, 29% of injured pedestrians were labeled as having suspected alcohol use on admission; this did not vary by racial groups and was reported higher during the weekdays. These patients with suspected alcohol use were 4.3 times more likely to be admitted at night and experienced a longer hospital length of stay (HLOS). Injury severity did not vary with the time of day or day of the week but injury patterns varied: severe extremity injury (Abbreviated Injury Scale (AIS) of 3+) occurred during weekdays (p<0.001) and more severe facial injuries occurred at night. Additionally, patients admitted at night had a lower Glasgow Coma Scale (GCS) and Revised Trauma Score (RTS) compared to those admitted during the day. Seasonal variation included more night admissions for spring, summer and fall. During the summer, APC patients were 2.2 times more likely to occur at night. Friday pedestrian injuries were higher compared to Sunday, Monday and Tuesday. Predictors of low GCS (3-8) included increased age, Asian and Other race groups. Compared to the White group, Asian and Other groups were 2.46 and 3.6 times more likely to have a low admission GCS. Older age, New Injury Severity Score (NISS) and suspected alcohol use were significant predictors of HLOS.

Conclusion: In Las Vegas, there are demographic, temporal and social factors that contribute to APCs. Pedestrians who engage in alcohol use during the summer months have an increased likelihood of being involved in a crash at night and during the weekdays. Patients injured during the night had a decreased Revised Trauma Score (RTS), indicating an initial assessment of more serious injury. Age, NISS and suspected alcohol use were associated with increased HLOS. Increased incidence of pedestrian injuries occurred on Friday compared with earlier days in the week. Injury prevention efforts should focus on alcohol consumption, seasonal and diurnal variations that contribute to pedestrian safety. A prospective study that analyzes pedestrian behaviors and other factors may help elucidate other factors that place pedestrians at risk and contribute to high rate of APCs in Las Vegas.

73.17 Contemporary National Outcomes of Carotid Endarterectomy – Safe, but with a Persistent Gender Bias

Posted on December 22, 2014

R. S. Turley1, K. McGinigle1, C. K. Shortell1, L. Mureebe1  1Duke University Medical Center,Vascular Surgery,Durham, NC, USA

Introduction:  Although evidence supports carotid endarterectomy (CEA) to reduce stroke risk in symptomatic and asymptomatic patients, evolution of medical therapy and carotid stenting have sparked controversy over the validity of these 20 year old trials. Furthermore, subset analyses from these trials suggested that women might not see the same stroke risk reduction after CEA as compared to men. The objective of this study is to estimate contemporary outcomes of CEA and compare these to older values and investigate potential gender bias in patient selection and outcomes of CEA.

Methods:  The American College of Surgeons National Surgical Quality Improvement Program was used to evaluate post-operative complication rates after CEA form 2010 – 2011 (Cohort2). Data from 2006-2007 (Cohort1) was used for comparison. Primary study endpoints were postoperative stroke and a composite of stroke, peripheral nerve injury, myocardial infarction and surgical complications. Univariate comparisons were conducted using Pearson's chi-square test for categorical variables and Wilcoxon rank-sum tests for continuous variables.

Results: A total of 27,014 procedures were available for analysis. 5.15% of study population were in Cohort1. The postoperative stroke rate for Cohort1 was 1.57 %, and 1.43% for Cohort2 (p = 0.36). The composite outcome rate was 7.94% for Cohort1 and 6.39% for Cohort2 (p < 0.001). Within each cohort, there was no difference in composite outcome based on gender (Table1). However, in the more recent procedures (Cohort2), there is a small but significant increase in the postoperative stroke risk for women (1.67%) as compared to men (1.27%, p = 0.03). This coincides with a differential in the indication for procedure. Multivariate analysis revealed significant contributors to the composite outcome: history of chronic obstructive pulmonary disease, congestive heart failure, recent weight loss, and ASA class. Neither gender nor symptomatic status proved to be a contributor to either postoperative stroke or to the composite outcome.

Conclusion: Complications following CEA have improved from prior large multicenter randomized trials, as well as over the last few years. Although best medical therapy has also improved, our analysis suggests outcomes after CEA have similarly evolved such that we should continue to aggressively pursue CEA for patients who meet established criteria. Gender should not be a factor in recommendation for CEA, and more weight should be placed on other identified pre-operative factors.

73.18 Is the Amputation Rate Higher for Individuals Over 70 Years Old?

Posted on December 22, 2014

C. Rivera1, N. J. Gargiulo1  1North Shore University And Long Island Jewish Medical Center,Vascular Surgery,Manhasset, NY, USA

Introduction:   As average life expectancy has risen, a patients age has become an important factor in the management and outcome of many pathological processes.  This study was done to determine if age plays a role in presentation, management and outcome of peripheral arterial disease i.e. critical limb ischemia (CLI).

Methods:  
This is a prospective review of all patients that presented to our institution with CLI from January 1, 2007 to December 31, 2007. CLI was defined as ischemic rest pain, non-healing ulceration or gangrene (Rutherford Class 4 and 5). All patients underwent conventional arteriography and if possible an endovascular, open or hybrid procedure for limb salvage. Data was analyzed to determine any significant differences in presentation and outcomes in the group of patients under seventy years of age compared to those over seventy years of age. Data points included in the analysis were: Rutherford class, TransAtlantic InterSociety Consensus II (TASC II) classification, types of intervention (open, endovascular or hybrid), in hospital mortality, one-year amputation free survival and rate on re-intervention.

Results:  One hundred and forty eight patients presented with CLI over this one year period. Of these, 82 (55%) were under seventy years old and 66 (45%) were older. The two groups had similar demographics. Patients in the older group were more likely to present with Rutherford class 5 lesions. Both groups had similar rates of TASC II D iliac disease, however older patients had a higher prevalence of TASC II D femoropopliteal disease (56% vs. 37%) and a higher prevalence of TASC II D infrapopliteal disease (66% vs. 52%). Patients in the older group were more likely to be treated with open procedure and had higher postoperative mortality (6.45% vs. 1.21%). One year amputation rate was significantly higher in the older population (15% vs. 6%).  Average primary patency rates in both groups were about 24 months. Rate of re-interventions was similar in both groups (17% vs. 15%).

Conclusion:  Patients over seventy years of age are more likely to present with more severe TASC II D femoropopliteal and infrapopliteal disease. This may be attributed to higher one year amputation rates in this group. Postoperative mortality is also higher in older population. Primary patency and re-intervention rates do not depend on patients’ age. 

 

73.19 Geographical Location and Lack of Seasonality Determines Incidence of Acute Appendicitis

Posted on December 22, 2014

D. F. Nino1,3, J. S. Barajas-Gamboa4, S. W. Bickler2, J. A. Nino3  1Johns Hopkins University School Of Medicine,Pediatric Surgery / Surgery,Baltimore, MD, USA 2University Of California – San Diego,Pediatric Surgery / Surgery,San Diego, CA, USA 3Universidad Nacional De Colombia,Pediatric Surgery / Surgery,Bogota, CUNDINAMARCA, Colombia 4Universidad Autonoma De Bucaramanga,Surgery,Bucaramanga, SANTANDER, Colombia

Introduction:  Incidence of acute appendicitis (AA) varies by geographical region, season, race, sex and age. We have determined the incidence of AA and perforation rate at a referral teaching hospital located in Colombia. We hypothesize that due to geographical location and lack of distinct seasons there is no variability in the incidence of AA throughout the year.

Methods:  Under IRB approval, a retrospective review of a prospectively maintained database of all surgical cases was carried out. The number of appendectomies was determined for a 5-year period and analyzed per month. Multivariate analyses included age, sex and perforation rate. A two-way ANOVA, p<0.05 was considered significant. Multivariate linear regressions were used to determine correlation between independent variables, incidence and perforation rate. 

Results: Between 01/2008 and 12/2012 we identified 3921 cases of AA, 60.8% male and average age 9-years-old (range 2–16). The number of cases per month for the five years analyzed averaged 65 (range 40–83 cases/month). The incidence of AA remained constant throughout the different months (p = 0.1178) and did not vary per year analyzed (p = 0.6805). Multivariate regression analysis demonstrated no effects of age and sex in the total incidence. Perforation rate averaged 34.3% (23.5 – 45%) without variation per-month or per-year. 

Conclusion: Our study indicates that the geographical location of our country and subsequent lack of seasonality have an impact on the incidence of AA. Contrary to current literature we found no seasonal variation. More studies are warranted to determine the cause or lack thereof of variation in the incidence of AA.

 

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