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Conference Highlights: ACS 2016

Conference Highlights: ACS 2016

Assessing Early Discontinuation of Opiates After Trauma The inappropriate use of prescription opiates  is a significant public health issue throughout the United States, but little is known about patterns of use and factors associated with discontinuation of these drugs after major trauma. For a study, investigators sought to identify predictors of opiate discontinuation in patients who were discharged after experiencing a trauma. At 3 months, more than 90% had discontinued opiate use. Advanced age, marital status, and low socioeconomic status appeared to be significantly associated with a lower likelihood of discontinuation of opiates after a trauma whereas race, injury severity, and comorbid anxiety or depression were not. The findings may help surgeons identify high-risk patients and manage them accordingly. —————————————————————-   Monitoring Functional Recovery at Home Few studied have explored the feasibility of wearable, real-time, wireless monitoring devices and their effect on functional recovery and patient-centered outcomes after surgery. For a study, researchers had major abdominal surgery patients wear wristband pedometers that tracked their steps 3 to 7 days before their operation, during their hospitalization, and for 2 weeks after they were discharged. Web-based, self-reported symptoms and quality of life (QOL) were obtained throughout the study. Adherence rates for wearing the pedometer were above 80% before and after discharge. More than 75% of symptom and QOL assessments were completed by about 63% and 74% of patients, respectively. Patient satisfaction scores were 4 out of 5. —————————————————————-   Predicting ICU Readmission for Surgical Patients ICU readmission within 72 hours is an established quality measure of postoperative care, but research is lacking on predictors of these readmissions following various types of...
Domestic Violence Among Trauma Patients

Domestic Violence Among Trauma Patients

Domestic violence encompasses a wide variety of maltreatment, including neglect, abandonment, and emotional, physical, sexual, and verbal abuse. The problem remains a significant healthcare burden throughout the United States, with recent national estimates showing that 1.5 million women and 830,000 men experience domestic violence each year. Data from the United States Department of Health and Human Services also show that four children die each day as a result of child abuse. In addition, about 14% of older adults experience some kind of physical, psychological, and sexual abuse each year. Trauma surgeons and emergency physicians are often at the forefront of the domestic violence problem. They are among the first who can identify and intervene in these challenging situations. “Recent studies suggest that few trauma surgeons and emergency physicians know the true incidence of this problem,” says Bellal Joseph, MD. To address this research gap, Dr. Joseph and colleagues had a study published in JAMA Surgery that assessed the national prevalence and trends of domestic violence among trauma patients.   Analyzing Trends For the investigation, the study team retrospectively analyzed prospective data from the National Trauma Data Bank on patients who presented to trauma from 2007 to 2012. Over 6 years, the authors identified trauma patients who experienced domestic violence using several diagnosis codes and stratified patients by age into three groups: Children (aged 18 or younger) Adults (aged 19 to 54). Elderly aged 55 and older).   Researchers identified 16,575 trauma patients who experienced domestic violence and the vast majority of cases involved children (61.7%) and adults (33.2%). The average age of trauma patients who experienced domestic violence was...
Assessing Quality in Acute Care Surgery

Assessing Quality in Acute Care Surgery

Emergency and trauma surgeries are increasingly being performed by the same providers, often using the same resources. It has been implied that improvements in care for one of these populations could enhance the care of the other, but few analyses have compared the quality of care provided to each type of surgery group. New Research In the Archives of Surgery, my colleagues and I had a study published that evaluated the relationship between trauma and elective general surgery (ELGS) and emergency general surgery (EMGS) care. Our hypothesis was that there would be similarities in mortality and serious morbidity outcomes because of the crossover in providers and resources used. We compared performance among 46 hospitals to determine how well these institutions performed across populations with regard to outcomes. Our findings indicated that there were no significant relationships between trauma and EMGS mortality or between trauma and ELGS mortality. We also didn’t observe any significant relationships between trauma and EMGS morbidity or between trauma and ELGS morbidity. Furthermore, no hospital had consistently good or poor outcomes across the surgical populations assessed in the analysis. Examining Implications Based on our findings, research and quality improvement efforts should focus on how to improve EMGS care. Many performance improvement measures have been devoted to trauma surgery, but few have focused on EMGS patients. The National Trauma Databank contains records on more than 2 million patients. The American College of Surgeons has established the Trauma Quality Improvement Program for benchmarking trauma centers. Similar data banks and benchmarking efforts that focus on quality of care provided to EMGS patients are in the early stages of development...
Examining a Protocol for Transfusing Plasma to Severely Injured Patients

Examining a Protocol for Transfusing Plasma to Severely Injured Patients

Patients with a trauma-induced coagulopathy account for more than half of hemorrhagic deaths in the United States. About 25% of severely injured patients are already coagulopathic and thrombocytopenic upon arrival to trauma centers. Mortality rates have been shown to decrease in these patients when they receive higher ratios of plasma and platelets. “Early transfusion of red blood cells (RBCs) has been established as a core element of trauma resuscitation,” says Bryan A. Cotton, MD, MPH. “Most trauma centers store RBCs in their EDs, but few store plasma in their EDs. This makes it challenging to achieve high plasma-RBC ratios early during care, which in turn can worsen coagulopathy and increase patient mortality.” Expediting Plasma Delivery Over the past several years, more and more trauma centers have implemented massive transfusion (MT) protocols to ensure that severely injured patients receive higher plasma-RBC ratios early. “This was shown to markedly reduce the time to release of plasma, but the time to transfusion was still excessively long,” Dr. Cotton says. In an effort to expedite the delivery of plasma for patients requiring MT, some medical centers began keeping thawed plasma (TP) in their blood banks (BBs).   MT protocols vary throughout trauma centers in the U.S., but those reporting the most marked changes in survival are the ones that have implemented concurrent TP programs. Furthermore, trauma centers that develop TP programs concurrent with MT protocols have shown that they can reduce the time to first plasma transfusion and the overall number of blood components transfused. Testing a New Thawed Plasma Protocol In 2006, Dr. Cotton and colleagues began a TP program in their...
Wide Variation in Blood Transfusion Use

Wide Variation in Blood Transfusion Use

Current clinical guidelines from three medical societies suggest that the hemoglobin threshold for blood transfusions during surgery should be 7 g/dl or 8 g/dl. These guidelines also note that patients don’t need a transfusion when hemoglobin levels are above 10 g/dl. However, when hemoglobin levels fall between these thresholds, there is little consensus on the best course of action. Although four landmark studies published over the past 5 years suggest that it’s safe to wait until hemoglobin levels fall to 7 g/dl or 8 g/dl before transfusing, wide variation and excessive use of blood transfusions have been reported. Advances in viral testing in recent years have made blood transfusion safer, but risks still exist for these patients, including lung injury, immune suppression, and viral transmission. Blood is also in scarce supply and expensive. Wide Variation of Hemoglobin Thresholds In an issue of Anesthesiology, my colleagues and I had a study published that sought to confirm the wide range of hemoglobin thresholds used by surgeons and anesthesiologists. Over 18 months, we collected data on more than 48,000 surgical patients at Johns Hopkins Hospital. Within the institution, there was a variation of up to 3 g/dl in hemoglobin thresholds among surgeons and anesthesiologists, when compared with their peers. Virtually all providers used thresholds above the ones recommended in guidelines, and none used thresholds below the recommended range. Surprisingly, sicker patients—generally those under-going cardiac surgeries—had the lowest hemoglobin thresholds, whereas those undergoing surgery for pancreatic cancer, orthopedic issues, and aortic aneurysms received blood transfusions at higher thresholds. The amount of blood transfused did not correlate with how sick the patients were or...
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