IMPORTANCE: Although wait times for hip fracture surgery have been linked to mortality and are being used as quality-of-care indicators worldwide, controversy exists about the duration of the wait ...that leads to complications. OBJECTIVE: To use population-based wait-time data to identify the optimal time window in which to conduct hip fracture surgery before the risk of complications increases. DESIGN, SETTING, AND PARTICIPANTS: Population-based, retrospective cohort study of adults undergoing hip fracture surgery between April 1, 2009, and March 31, 2014, at 72 hospitals in Ontario, Canada. Risk-adjusted restricted cubic splines modeled the probability of each complication according to wait time. The inflection point (in hours) when complications began to increase was used to define early and delayed surgery. To evaluate the robustness of this definition, outcomes among propensity-score matched early and delayed surgical patients were compared using percent absolute risk differences (RDs, with 95% CIs). EXPOSURE: Time elapsed from hospital arrival to surgery (in hours). MAIN OUTCOMES AND MEASURES: Mortality within 30 days. Secondary outcomes included a composite of mortality or other medical complications (myocardial infarction, deep vein thrombosis, pulmonary embolism, and pneumonia). RESULTS: Among 42 230 patients with hip fracture (mean SD age, 80.1 years 10.7, 70.5% women) who met study entry criteria, overall mortality at 30 days was 7.0%. The risk of complications increased when wait times were greater than 24 hours, irrespective of the complication considered. Compared with 13 731 propensity-score matched patients who received surgery earlier, 13 731 patients who received surgery after 24 hours had a significantly higher risk of 30-day mortality (898 6.5% vs 790 5.8%; % absolute RD, 0.79; 95% CI, 0.23-1.35) and the composite outcome (1680 12.2%) vs 1383 10.1%; % absolute RD, 2.16; 95% CI, 1.43-2.89). CONCLUSIONS AND RELEVANCE: Among adults undergoing hip fracture surgery, increased wait time was associated with a greater risk of 30-day mortality and other complications. A wait time of 24 hours may represent a threshold defining higher risk.
This quality improvement study establishes an 8-component framework to assess surgical improvement efforts that are reported to the American College of Surgeons.
IMPORTANCE: Adhesive small-bowel obstruction (aSBO) is a potentially chronic, recurring surgical illness. Although guidelines suggest trials of nonoperative management, the long-term association of ...this approach with recurrence is poorly understood. OBJECTIVE: To compare the incidence of recurrence of aSBO in patients undergoing operative management at their first admission compared with nonoperative management. DESIGN, SETTING, AND PARTICIPANTS: This longitudinal, propensity-matched, retrospective cohort study used health administrative data for the province of Ontario, Canada, for patients treated from April 1, 2005, through March 31, 2014. The study population included adults aged 18 to 80 years who were admitted for their first episode of aSBO. Patients with nonadhesive causes of SBO were excluded. A total of 27 904 patients were included and matched 1:1 by their propensity to undergo surgery. Factors used to calculate propensity included patient age, sex, comorbidity burden, socioeconomic status, and rurality of home residence. Data were analyzed from September 10, 2017, through October 4, 2018. EXPOSURES: Operative vs nonoperative management for aSBO. MAIN OUTCOMES AND MEASURES: The primary outcome was the rate of recurrence of aSBO among those with operative vs nonoperative management. Time-to-event analyses were used to estimate hazard ratios of recurrence while accounting for the competing risk of death. RESULTS: Of 27 904 patients admitted with their first episode of aSBO, 6186 (22.2%) underwent operative management. Mean (SD) patient age was 61.2 (13.6) years, and 51.1% (14 228 of 27 904) were female. Patients undergoing operative management were younger (mean SD age, 60.2 14.3 vs 61.5 13.4 years) with fewer comorbidities (low burden, 382 6.2% vs 912 4.2%). After matching, those with operative management had a lower risk of recurrence (13.0% vs 21.3%; hazard ratio, 0.62; 95% CI, 0.56-0.68; P < .001). The 5-year probability of experiencing another recurrence increased with each episode until surgical intervention, at which point the risk of subsequent recurrence decreased by approximately 50%. CONCLUSIONS AND RELEVANCE: According to this study, operative management of the first episode of aSBO is associated with significantly reduced risk of recurrence. Guidelines advocating trials of nonoperative management for aSBO may assume that surgery increases the risk of recurrence putatively through the formation of additional adhesions. The long-term risk of recurrence of aSBO should be considered in the management of this patient population.
This 14-state study compared mortality rates at hospitals with a level 1 trauma center and hospitals without a trauma center among patients with moderate-to-severe injuries. After adjustment for ...baseline differences in patients' characteristics, the one-year mortality rate was significantly lower at trauma centers than at non–trauma centers (10 percent vs. 14 percent).
This 14-state study compared mortality rates at hospitals with a level 1 trauma center and hospitals without a trauma center among patients with moderate-to-severe injuries. The one-year mortality rate was significantly lower at trauma centers than at non–trauma centers (10 percent vs. 14 percent).
In 1976, the American College of Surgeons Committee on Trauma published criteria for categorizing hospitals according to the resources required to provide various levels of care for traumatic injuries.
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Increasingly, states are using these criteria as a basis for designating trauma centers as part of a regionalized approach to trauma care.
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However, this process has not been uniform. There is substantial variation across states in the number and geographic distribution of trauma centers,
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owing in part to the lack of strong evidence of the effectiveness of trauma centers coupled with high costs of verifying their capabilities.
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The existing evidence . . .
Although existing guidelines support the utilization of intracranial pressure (ICP) monitoring in patients with traumatic brain injury (TBI), the evidence suggesting benefit is limited. To evaluate ...the impact on outcome, we determined the relationship between ICP monitoring and mortality in centers participating in the American College of Surgeons Trauma Quality Improvement Program (TQIP). Data on 10,628 adults with severe TBI were derived from 155 TQIP centers over 2009-2011. Random-intercept multilevel modeling was used to evaluate the association between ICP monitoring and mortality after adjusting for important confounders. We evaluated this relationship at the patient level and at the institutional level. Overall mortality (n=3769) was 35%. Only 1874 (17.6%) patients underwent ICP monitoring, with a mortality of 32%. The adjusted odds ratio (OR) for mortality was 0.44 95% confidence interval (CI), 0.31-0.63, when comparing patients with ICP monitoring to those without. It is plausible that patients receiving ICP monitoring were selected because of an anticipated favorable outcome. To overcome this limitation, we stratified hospitals into quartiles based on ICP monitoring utilization. Hospitals with higher rates of ICP monitoring use were associated with lower mortality: The adjusted OR of death was 0.52 (95% CI, 0.35-0.78) in the quartile of hospitals with highest use, compared to the lowest. ICP monitoring utilization rates explained only 9.9% of variation in mortality across centers. Results were comparable irrespective of the method of case-mix adjustment. In this observational study, ICP monitoring utilization was associated with lower mortality. However, variability in ICP monitoring rates contributed only modestly to variability in institutional mortality rates. Identifying other institutional practices that impact on mortality is an important area for future research.
IMPORTANCE: Trauma is the leading cause of death among US children. Whether pediatric trauma centers (PTCs), mixed trauma centers (MTCs), or adult trauma centers (ATCs) offer a survival benefit ...compared with one another when treating injured children is controversial. Ascertaining the optimal care environment will better inform quality improvement initiatives and accreditation standards. OBJECTIVE: To evaluate the association between type of trauma center (PTC, MTC, or ATC) and in-hospital mortality among young children (5 years and younger), older children (aged 6-11 years), and adolescents (aged 12-18 years). DESIGN, SETTING, AND PARTICIPANTS: In this retrospective cohort study, injured children aged 18 years or younger who were hospitalized in the United States from January 1, 2010, to December 31, 2013, were observed for the duration of their admission until discharge or death. We included patients with an Abbreviated Injury Score of 2 or greater in at least 1 body region. Random-intercept multilevel regression was used to evaluate the association between center type and in-hospital mortality after adjusting for confounders. Stratified analyses in young children, older children, and adolescents were performed. We conducted secondary analyses limited to patients with severe injuries (Injury Severity Score ≥25). Both analyses were performed between January 1 and August 31, 2014. Data were derived from 252 US level I and II trauma centers voluntarily participating in the American College of Surgeons adult or pediatric Trauma Quality Improvement Program. MAIN OUTCOME AND MEASURE: In-hospital mortality. RESULTS: We identified 175 585 injured children. Crude mortality rates were 2.3% for children treated at ATCs, 1.8% for children treated at MTCs, and 0.6% for children treated at PTCs. After adjustment, children had higher odds of dying when treated at ATCs (odds ratio OR, 1.57; 95% CI, 1.15-2.14) and MTCs (OR, 1.45; 95% CI, 1.05-2.01) compared with those treated at PTCs. In stratified analyses, young children had higher odds of death when treated at ATCs vs PTCs (OR, 1.78; 95% CI, 1.05-3.40), but there was no association between center type and mortality among older children (OR, 1.17; 95% CI, 0.65-2.11) and adolescents (OR, 1.23; 95% CI, 0.82-1.85). Results were similar in analyses of severely injured children: those treated at ATCs (OR, 1.75; 95% CI, 1.25-2.44) and MTCs (OR, 1.62; 95% CI, 1.15-2.29) had higher odds of death when compared with those treated at PTCs. CONCLUSIONS AND RELEVANCE: Injured children treated at ATCs and MTCs had higher in-hospital mortality compared with those treated at PTCs. This association was most evident in younger children and remained significant in severely injured children. Quality improvement initiatives geared toward ATCs and MTCs are required to provide optimal care to injured children.
Evidence-based guidelines for managing patients with intra-abdominal infection were prepared by an Expert Panel of the Surgical Infection Society and the Infectious Diseases Society of America. These ...updated guidelines replace those previously published in 2002 and 2003. The guidelines are intended for treating patients who either have these infections or may be at risk for them. New information, based on publications from the period 2003–2008, is incorporated into this guideline document. The panel has also added recommendations for managing intra-abdominal infection in children, particularly where such management differs from that of adults; for appendicitis in patients of all ages; and for necrotizing enterocolitis in neonates.
Background Patients with severe traumatic brain injury (sTBI) are at high risk for developing venous thromboembolism (VTE). Nonetheless, pharmacologic VTE prophylaxis is often delayed out of concern ...for precipitating extension of intracranial hemorrhage (ICH). The purpose of this study was to compare the effectiveness of early vs late VTE prophylaxis in patients with sTBI, and to characterize the risk of subsequent ICH-related complication. Study Design Adults with isolated sTBI (head Abbreviated Injury Scale score ≥3 and total Glasgow Coma Scale score ≤8) who received VTE prophylaxis with low-molecular-weight or unfractionated heparin were derived from the American College of Surgeons Trauma Quality Improvement Program (2012 to 2014). Patients were divided into EP (<72 hours) or LP (≥72 hours) groups. Propensity score matching was used to minimize selection bias. The primary end point was VTE (pulmonary embolism or deep vein thrombosis). Secondary outcomes were defined as late neurosurgical intervention (≥72 hours) or death. Results We identified 3,634 patients with sTBI. Early prophylaxis was given in 43% of patients. Higher head injury severity, presence of ICH, and early neurosurgery were associated with late prophylaxis. Propensity score matching yielded a well-balanced cohort of 2,468 patients. Early prophylaxis was associated with lower rates of both pulmonary embolism (odds ratio = 0.48; 95% CI, 0.25–0.91) and deep vein thrombosis (odds ratio = 0.51; 95% CI, 0.36–0.72), but no increase in risk of late neurosurgical intervention or death. Conclusions In this observational study of patients with sTBI, early initiation of VTE prophylaxis was associated with decreased risk of pulmonary embolism and deep vein thrombosis, but no increase in risk of late neurosurgical intervention or death. Early prophylaxis may be safe and should be the goal for each patient in the context of appropriate risk stratification.
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