Study objective We derive a prediction rule to identify children at very low risk for intra-abdominal injuries undergoing acute intervention and for whom computed tomography (CT) could be obviated. ...Methods We prospectively enrolled children with blunt torso trauma in 20 emergency departments. We used binary recursive partitioning to create a prediction rule to identify children at very low risk of intra-abdominal injuries undergoing acute intervention (therapeutic laparotomy, angiographic embolization, blood transfusion for abdominal hemorrhage, or intravenous fluid for ≥2 nights for pancreatic/gastrointestinal injuries). We considered only historical and physical examination variables with acceptable interrater reliability. Results We enrolled 12,044 children with a median age of 11.1 years (interquartile range 5.8, 15.1 years). Of the 761 (6.3%) children with intra-abdominal injuries, 203 (26.7%) received acute interventions. The prediction rule consisted of (in descending order of importance) no evidence of abdominal wall trauma or seat belt sign, Glasgow Coma Scale score greater than 13, no abdominal tenderness, no evidence of thoracic wall trauma, no complaints of abdominal pain, no decreased breath sounds, and no vomiting. The rule had a negative predictive value of 5,028 of 5,034 (99.9%; 95% confidence interval CI 99.7% to 100%), sensitivity of 197 of 203 (97%; 95% CI 94% to 99%), specificity of 5,028 of 11,841 (42.5%; 95% CI 41.6% to 43.4%), and negative likelihood ratio of 0.07 (95% CI 0.03 to 0.15). Conclusion A prediction rule consisting of 7 patient history and physical examination findings, and without laboratory or ultrasonographic information, identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention. These findings require external validation before implementation.
We hypothesized that general thoracic surgeons (GTS) predominantly perform complex noncardiac thoracic surgery in academic hospitals compared with cardiac surgeons (CS), general surgeons, and ...surgical oncologists.
Fiscal year 2007-2008 to 2009-2010 coding and work relative value unit data from the University Health System Consortium and Association of American Medical Colleges Faculty Practice Solutions Center database, which includes 86 academic institutions, was analyzed. Procedural groups for pneumonectomy, other pulmonary resection (including lobectomy, bilobectomy, segmentectomy, sleeve lobectomy, and video-assisted thoracoscopic surgery lobectomy-segmentectomy), and esophagectomy were evaluated.
Of the 1,989,055.3 total work relative value units generated for complex noncardiac thoracic surgical procedures during the study period, 77.5% were generated by GTS, compared with 9.9% by CS, 8.9% by general surgeons, and 3.7% by surgical oncologists (p<0.001). General thoracic surgeons averaged 2.1 pneumonectomies, 51.1 other pulmonary resections, and 12.2 esophagectomies per year compared with 2.1 pneumonectomies, 9.4 other pulmonary resections, and less than 1 esophagectomy per year for CS. General surgeons and surgical oncologists averaged no more than 1.6 cases per year for all categories (all p<0.001, except for pneumonectomy, in which GTS versus CS was not significantly different). To determine the use of parenchymal-sparing operations, we looked at the ratio of sleeve lobectomy to pneumonectomy and found higher usage of parenchymal-sparing techniques by GTS, relative to pneumonectomy, compared with all other groups (p<0.001). General thoracic surgeons averaged 16.0 video-assisted thoracoscopic surgery lobectomies per year compared with approximately 1 per year for all other groups (p<0.001). General thoracic surgeons had a 47.1% increase in video-assisted thoracoscopic surgery lobectomies per year compared with 27.4% for CS.
In academic hospitals, noncardiac thoracic surgery is performed mostly by GTS, supporting academic GTS as a distinct specialty. These results may help determine hospital referral and credentialing policies, and plan general and cardiothoracic surgery residency curriculum.
Study objective We aimed to determine the association between scalp hematoma characteristics and traumatic brain injuries in young children with blunt head trauma who have no other symptoms or signs ...suggestive of traumatic brain injuries (defined as “isolated scalp hematomas”). Methods This was a secondary analysis of children younger than 24 months with minor blunt head trauma from a prospective cohort study in 25 Pediatric Emergency Care Applied Research Network emergency departments. Treating clinicians completed a structured data form. For children with isolated scalp hematomas, we determined the prevalence of and association between scalp hematoma characteristics and (1) clinically important traumatic brain injury (death, neurosurgery for traumatic brain injury, intubation >24 hours for traumatic brain injury, or positive computed tomography (CT) scan in association with hospitalization ≥2 nights for traumatic brain injury); and (2) traumatic brain injury on CT. Results Of 10,659 patients younger than 24 months were enrolled, 2,998 of 10,463 (28.7%) with complete data had isolated scalp hematomas. Clinically important traumatic brain injuries occurred in 12 patients (0.4%; 95% confidence interval CI 0.2% to 0.7%); none underwent neurosurgery (95% CI 0% to 0.1%). Of 570 patients (19.0%) for whom CTs were obtained, 50 (8.8%; 95% CI 6.6% to 11.4%) had traumatic brain injuries on CT. Younger age, non-frontal scalp hematoma location, increased scalp hematoma size, and severe injury mechanism were independently associated with traumatic brain injury on CT. Conclusion In patients younger than 24 months with isolated scalp hematomas, a minority received CTs. Despite the occasional presence of traumatic brain injuries on CT, the prevalence of clinically important traumatic brain injuries was very low, with no patient requiring neurosurgery. Clinicians should use patient age, scalp hematoma location and size, and injury mechanism to help determine which otherwise asymptomatic children should undergo neuroimaging after minor head trauma.
Background The goal of this study is to determine the clinical value of multiplex polymerase chain reaction (PCR) study for enhancing pathogen detection in patients with suspected septicemia after ...trauma, emergency, and burn surgery. PCR-based pathogen detection quickly reveals occult bloodstream infections in these high-risk patients and may accelerate the initiation of targeted antimicrobial therapy. Methods We conducted a prospective observational study comparing results for 30 trauma and emergency surgery patients to 20 burn patients. Whole-blood samples collected with routine blood cultures (BCs) were tested using a new multiplex, PCR-based, pathogen detection system. PCR results were compared to culture data. Results PCR detected rapidly more pathogens than culture methods. Acute Physiology and Chronic Health Evaluation II (APACHE II), Sequential Organ Failure Assessment (SOFA), and Multiple Organ Dysfunction (MODS) scores were greater in PCR-positive versus PCR-negative trauma and emergency surgery patients ( P ≤ .033). Negative PCR results (odds ratio, 0.194; 95% confidence interval, 0.045–0.840; P = .028) acted as an independent predictor of survival for the combined surgical patient population. Conclusion PCR detected the presence of pathogens more frequently than blood culture. These PCR results were reported faster than blood culture results. Severity scores were significantly greater in PCR-positive trauma and emergency surgery patients. The lack of pathogen DNA as determined by PCR served as a significant predictor of survival in the combined patient population. PCR testing independent of traditional prompts for culturing may have clinical value in burn patients. These results warrant further investigation through interventional trials.
Background Outcomes of surgical resident training are under scrutiny with the changing milieu of surgical education. Few have investigated the effect of surgical resident involvement (SRI) on ...operative parameters. Examining 7 common general surgery procedures, we evaluated the effect of SRI on perioperative morbidity and mortality and operative time (OpT). Study Design The American College of Surgeons National Surgical Quality Improvement Program database (2005 to 2007) was used to identify 7 cases of nonemergent operations. Cases with simultaneous procedures were excluded. Logistic regression was performed across all procedures and within each procedure incorporating SRI, OpT, and risk-stratifying American College of Surgery National Surgical Quality Improvement Program morbidity and mortality probability scores, which incorporate multiple prognostic individual patient factors. Procedure-specific, SRI-stratified OpTs were compared using Wilcoxon rank-sum tests. Results A total of 71.3% of the 37,907 cases had SRI. Absolute 30-day morbidity for all cases with SRI and without SRI were 3.0% and 1.0%, respectively (p < 0.001); absolute 30-day mortality for all cases with SRI and without SRI were 0.1% and 0.08%, respectively (p < 0.001). After multivariate analysis by specific procedure, SRI was not associated with increased morbidity but was associated with decreased mortality during open right colectomy (odds ratio 0.32; p = 0.01). Across all procedures, SRI was associated with increased morbidity (odds ratio 1.14; p = 0.048) but decreased mortality (odds ratio 0.42; p < 0.001). Mean OpT for all procedures was consistently lower for cases without SRI. Conclusions SRI has a measurable impact on both 30-day morbidity and mortality and OpT. These data have implications to the impact associated with surgical graduate medical education. Further studies to identify causes of patient morbidity and prevention strategies in surgical teaching environments are warranted.
Objective We hypothesized that academic adult cardiac surgeons (CSs) and general thoracic surgeons (GTSs) would have distinct practice patterns of, not just case-mix, but also time devoted to ...outpatient care, involvement in critical care, and work relative value unit (wRVU) generation for the procedures they perform. Methods We queried the University Health System Consortium-Association of American Medical Colleges Faculty Practice Solution Center database for fiscal years 2007-2008, 2008-2009, and 2009-2010 for the frequency of inpatient and outpatient current procedural terminology coding and wRVU data of academic GTSs and CSs. The Faculty Practice Solution Center database is a compilation of productivity and payer data from 86 academic institutions. Results The greatest wRVU generating current procedural terminology codes for CSs were, in order, coronary artery bypass grafting, aortic valve replacement, and mitral valve replacement. In contrast, open lobectomy, video-assisted thoracic surgery wedge, and video-assisted thoracic surgery lobectomy were greatest for GTSs. The 10 greatest wRVU-generating procedures for CSs generated more wRVUs than those for GTSs ( P < .001). Although CSs generated significantly more hospital inpatient evaluation and management (E & M) wRVUs than did GTSs ( P < .001), only 2.5% of the total wRVUs generated by CSs were from E & M codes versus 18.8% for GTSs. Critical care codes were 1.5% of total evaluation and management billing for both CSs and GTSs. Conclusions Academic CSs and GTSs have distinct practice patterns. CSs receive greater reimbursement for services because of the greater wRVUs of the procedures performed compared with GTSs, and evaluation and management coding is a more important wRVU generator for GTSs. The results of our study could guide academic CS and GTS practice structure and time prioritization.
Background The use of an acute care surgical model has been shown to improve patient care and efficiency. We propose that it is possible to apply this model to emergency general surgery patients at a ...nontrauma hospital. With this acute care surgery service, no change in the quality of care will occur, and improvements in quality, cost, and outcomes may be achieved and sustained. Study Design A retrospective review was performed of all emergency surgery operations performed at a tertiary referral community hospital without a trauma service. Data were collected from 1 year before and each year up to 4 years after the implementation of an acute care surgical (ACS) service. Results There were fewer overall complications with ACS (21% to 12%, p < 0.0001), and a shorter length of stay (6.5 days to 5.7 days, p = 0.0016). Hospital costs fell from $12,009 to $8,306 (p < 0.0001). Post-appendectomy complications decreased (13% to 3.7%, p < 0.0001), length of stay was shorter (3.0 to 2.3 days, p < 0.0001), and hospital costs decreased from $9,392 to $5,872 (p < 0.0001). Post-cholecystectomy complications decreased (21% to 9%, p = 0.012), length of stay was shorter (5.3 to 3.8 days, p = 0.0004), and hospital costs decreased from $12,526 to $9,348 (p < 0.0001). Conclusions An acute care surgery service can be successfully implemented at a nontrauma hospital. The improvements seen in outcomes and finances are sustainable over time. This sort of coordinated, consistent care is successful and allows alignment of the goals of surgeons, hospitals, and patients.
Study objective We derive and validate clinical prediction rules to identify adult patients at very low risk for intra-abdominal injuries after blunt torso trauma. Methods We prospectively enrolled ...adult patients (≥18 years old) after blunt torso trauma for whom diagnostic testing for intra-abdominal injury was performed. In the derivation phase, we used binary recursive partitioning to create a rule to identify patients with intra-abdominal injury who were undergoing acute intervention (including therapeutic laparotomy or angiographic embolization) and a separate rule for identifying patients with any intra-abdominal injury present. We considered only clinical variables readily available with acceptable interrater reliability. The prediction rules were then prospectively validated in a separate cohort of patients. Results In the derivation phase, we enrolled 3,435 patients, including 311 (9.1%; 95% confidence interval CI 8.1% to 10.1%) with intra-abdominal injury and 109 (35.0%; 95% CI 29.7% to 40.6%) with intra-abdominal injury requiring acute intervention. In the validation study, we enrolled 1,595 patients, including 143 (9.0%; 95% CI 7.6% to 10.5%) with intra-abdominal injury. The derived rule for patients with intra-abdominal injuries who were undergoing acute intervention consisted of hypotension, Glasgow Coma Scale (GCS) score less than 14, costal margin tenderness, abdominal tenderness, hematuria level greater than or equal to 25 red blood cells/high powered field, and hematocrit level less than 30% and identified all 44 patients in the validation phase with intra-abdominal injury who were undergoing acute intervention (sensitivity 44/44, 100%; 95% CI 93.4% to 100%). The derived rule for the presence of any intra-abdominal injury consisted of GCS score less than 14, costal margin tenderness, abdominal tenderness, femur fracture, hematuria level greater than or equal to 25 red blood cells/high powered field, hematocrit level less than 30%, and abnormal chest radiograph result (pneumothorax or rib fracture). In the validation phase, the rule for any intra-abdominal injury present had the following test performance: sensitivity 137 of 143 (95.8%; 95% CI 91.1% to 98.4%), specificity 434 of 1,452 (29.9%; 95% CI 27.5% to 32.3%), and negative predictive value 434 of 440 (98.6%; 95% CI 97.1% to 99.5%). Conclusion These derived and validated clinical prediction rules can aid physicians in the evaluation of adult patients after blunt torso trauma. Patients without any of these variables are at very low risk for having intra-abdominal injury, particularly intra-abdominal injury requiring acute intervention, and are unlikely to benefit from abdominal computed tomography scanning.
Study objective We validate the accuracy of a previously derived clinical prediction rule for the identification of children with intra-abdominal injuries after blunt torso trauma. Methods We ...conducted a prospective observational study of children with blunt torso trauma who were evaluated for intra-abdominal injury with abdominal computed tomography (CT), diagnostic laparoscopy, or laparotomy at a Level I trauma center during a 3-year period to validate a previously derived prediction rule. The emergency physician providing care documented history and physical examination findings on a standardized data collection form before knowledge of the results of diagnostic imaging. The clinical prediction rule being evaluated included 6 “high-risk” variables, the presence of any of which indicated that the child was not at low risk for intra-abdominal injury: low age-adjusted systolic blood pressure, abdominal tenderness, femur fracture, increased liver enzyme levels (serum aspartate aminotransferase concentration >200 U/L or serum alanine aminotransferase concentration >125 U/L), microscopic hematuria (urinalysis >5 RBCs/high powered field), or an initial hematocrit level less than 30%. Results One thousand three hundred twenty-four children with blunt torso trauma were enrolled, and 1,119 (85%) patients had the variables in the decision rule documented by the emergency physician and therefore made up the study sample. The prediction rule had the following test characteristics: sensitivity=149 of 157, 94.9% (95% confidence interval CI 90.2% to 97.7%) and specificity=357 of 962, 37.1% (95% CI 34.0 to 40.3%). Three hundred sixty-five patients tested negative for the rule; thus, strict application would have resulted in a 33% reduction in abdominal CT scanning. Of the 8 patients with intra-abdominal injury not identified by the prediction rule, 1 underwent a laparotomy. This patient had a serosal tear and a mesenteric hematoma at laparotomy, neither of which required specific surgical intervention. Conclusion A clinical prediction rule consisting of 6 variables, easily available to clinicians in the ED, identifies most but not all children with intra-abdominal injury. Application of the prediction rule to this sample would have reduced the number of unnecessary abdominal CT scans performed but would have failed to identify 1 child undergoing (a nontherapeutic) laparotomy. Thus, further refinement of this prediction rule in a large, multicenter cohort is necessary before widespread implementation.
Abstract Objective The objective of this study is to determine the rate of intra-abdominal injury (IAI) in adults with blunt abdominal trauma after a normal abdominal computed tomographic (CT) scan. ...We hypothesize that the risk of subsequent IAI is so low that hospital admission and observation for possible IAI are unnecessary. Methods We conducted a prospective, observational cohort study of adults (>18 years) with blunt trauma who underwent abdominal CT scanning in the emergency department. Computed tomographic scans were obtained with intravenous contrast but no oral contrast. Abnormalities on abdominal CT included all visualized IAIs or any finding suggestive of possible IAI. Patients were followed up to determine the presence or absence of IAI and the need for therapeutic intervention if IAI was identified. Results Of the 3103 patients undergoing abdominal CT, 2734 (88%) had normal CT scans. The median age was 39 years (interquartile range, 26-51 years); and 2141 (78%) were admitted to the hospital. Eight (0.3%; 95% confidence interval, 0.1%-0.6%) were identified with IAIs after normal abdominal CT scans including the following injuries: pancreas (5), liver (4), gastrointestinal (2), and spleen (2). Five underwent therapy at laparotomy. Abdominal CT had a likelihood ratio (+) of 20.9 (95% confidence interval, 17.7-24.8) and likelihood ratio (−) of 0.034 (0.017-0.068). Conclusion Adult patients with blunt torso trauma and normal abdominal CT scans are at low risk for subsequently identified IAI. Thus, hospitalization for evaluation of possible IAI after a normal abdominal CT scan is unnecessary in most cases.
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