Publications by authors named "Ben Zarzaur"

152 Publications

Preinjury Functional Independence is not Associated with Discharge Location in Older Trauma Patients.

J Surg Res 2021 Jun 4;266:413-420. Epub 2021 Jun 4.

Department of Surgery, University of Wisconsin School of Medicine, Madison, WI.

Background: The purpose of this study was to evaluate the association between pre-injury Katz Index of Independence in Activities of Daily Living (Katz ADL) functional status and discharge to a facility in non-neurologically injured older trauma patients.

Methods: Data were obtained from 207 patients in the Trauma Medical Home study cohort. Multivariable logistic regression was performed to identify factors associated with non-home discharge.

Results: Average patient age was 67.9 (SD 11.1). Patients were predominantly white (89.4%) and female (52.2%) with a median ISS of 11 (IQR 9-14). The most common mechanism of injury was fall (48.3%), followed by motor vehicle crash (41.1%). Nearly all patients (94.7%) reported independence in activities of daily living prior to hospitalization for injury. Discharge disposition varied, 51.7% of patients were discharged home, 37.7% to subacute rehabilitation, 10.1% to acute rehabilitation and 0.5% to long-term acute care. There was no relationship between pre-injury independence and likelihood of discharge home (P = 0.1331). Age (P < 0.0001), BMI (P = 0.0002), Charlson comorbidity score of 3 or greater (P = 0.0187), being single (P = 0.0077), ISS ≥ 16 (P = 0.0075) and being female with self-reported symptoms of anxiety and/or depression over the past two weeks (P = 0.0092) were associated with significantly greater odds of non-home discharge.

Conclusions: Pre-injury Katz ADL is not associated with discharge disposition, though other significantly associated factors were identified. It is imperative that discussions regarding discharge disposition are initiated early during acute hospitalization. Trauma programs could potentially benefit from implementing an inpatient intervention focused on building coping skills for older patients exhibiting symptoms of anxiety or depression.
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http://dx.doi.org/10.1016/j.jss.2021.04.029DOI Listing
June 2021

Treatment of asymptomatic blunt cerebrovascular injury (BCVI): a systematic review.

Trauma Surg Acute Care Open 2021 26;6(1):e000668. Epub 2021 Apr 26.

Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA.

Background: The management of asymptomatic blunt cerebrovascular injury (BCVI) with respect to stroke prevention and vessel healing is challenging.

Objectives: The aim of this systematic review was to determine if a specific treatment results in lower stroke rates and/or improved vessel healing in asymptomatic BCVI.

Data Sources: An electronic literature search of MEDLINE, EMBASE, Cochrane Library, CINAHL, SCOPUS, Web of Science, and ClinicalTrials.gov performed from inception to March 2020.

Study Eligibility Criteria: Studies were included if they reported on a comparison of any treatment for BCVI and stroke and/or vessel healing rates.

Participants And Interventions: Adult patients diagnosed with asymptomatic BCVI(s) who were treated with any preventive medication or procedure.

Study Appraisal And Synthesis Methods: All studies were systematically reviewed and bias was evaluated by the Newcastle-Ottawa Scale. No meta-analysis was performed secondary to significant heterogeneity across studies in patient population, screening protocols, and treatment selection. The main outcomes were stroke and healing rate.

Results: Of 8781 studies reviewed, 19 reported on treatment effects for asymptomatic BCVI and were included for review. Any choice of medical management was better than no treatment, but no specific differences between choice of medical management and stroke outcomes were found. Vessel healing was rare and the majority of healed vessels were following low-grade injuries.

Limitations: Majority of the included studies were retrospective and at high risk of bias.

Conclusions Or Implications Of Key Findings: Asymptomatic BCVI should be treated medically using a consistent, local protocol. High-quality studies on the effect of individual antithrombotic agents on stroke rates and vessel healing for asymptomatic BCVI are required.
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http://dx.doi.org/10.1136/tsaco-2020-000668DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8076921PMC
April 2021

The Relative Impact of Specific Postoperative Complications on Older Patients Undergoing Hip Fracture Repair.

Jt Comm J Qual Patient Saf 2021 Apr 14;47(4):210-216. Epub 2020 Dec 14.

Background: Hip fractures affect a vulnerable population and are associated with high rates of morbidity, mortality, and resource utilization. Although postoperative complications are a known driver of mortality and resource utilization, the comparative impacts of specific complications on outcomes is unknown. This study assessed which complications are associated with the highest effects on mortality and resource utilization for older patients who undergo hip fracture repair.

Methods: Patients ≥ 65 years of age who underwent hip fracture repair during 2016-2017 included in the Hip Fracture Targeted ACS NSQIP (American College of Surgeons National Surgical Quality Improvement Program) database populated the data set. Prolonged hospitalization (≥ 75th percentile) and 30-day mortality and readmission were the primary outcomes. Population attributable fractions (PAFs) were used to quantify the anticipated reduction in the primary outcomes that would result from complete prevention of 10 postoperative complications.

Results: Of 17,755 patients across 117 hospitals, 70.9% were female, 26.0% were over age 90, 22.8% had an American Society of Anesthesiologists (ASA) score of 4-5, and 53.9% presented with an intertrochanteric fracture. Postoperative delirium affected 29.8% of patients and was associated with death (PAF 18.0%; 95% confidence interval [CI] = 13.2-22.5), prolonged hospitalization (PAF 14.3%; 95% CI = 12.7-15.8), and readmission (PAF 15.0%; 95% CI = 11.3-18.6). Pneumonia affected 4.1% of patients and was associated with death (PAF 10.9%; 95% CI = 8.9-12.8), prolonged hospitalization (PAF 4.0%; 95% CI = 3.5-4.5), and readmission (PAF 9.1%; 95% CI = 7.5-10.7). The impact of the other eight complications was comparatively small.

Conclusion: Postoperative delirium and pneumonia are the highest-impact complications for older hip fracture repair patients. These complications should be prioritized in quality improvement efforts that target this patient population.
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http://dx.doi.org/10.1016/j.jcjq.2020.12.005DOI Listing
April 2021

Insights into the association between coagulopathy and inflammation: abnormal clot mechanics are a warning of immunologic dysregulation following major injury.

Ann Transl Med 2020 Dec;8(23):1576

Department of Orthopedics, Indiana University School of Medicine, Indianapolis, Indiana, USA.

Background: Severe injury initiates a complex physiologic response encompassing multiple systems and varies phenotypically between patients. Trauma-induced coagulopathy may be an early warning of a poorly coordinated response at the molecular level, including a deleterious immunologic response and worsening of shock states. The onset of trauma-induced coagulopathy (TIC) may be subtle however. In previous work, we identified an early warning sign of coagulopathy from the admission thromboelastogram, called the MAR ratio. We hypothesized that a low MAR ratio would be associated with specific derangements in the inflammatory response.

Methods: In this prospective, observational study, 88 blunt trauma patients admitted to the intensive care unit (ICU) were identified. Concentrations of inflammatory mediators were recorded serially over the course of a week and the MAR ratio was calculated from the admission thromboelastogram. Correlation analysis was used to assess the relationship between MAR and inflammatory mediators. Dynamic network analysis was used to assess coordination of immunologic response.

Results: Seventy-nine percent of patients were male and mean age was 37 years (SD 12). The mean ISS was 30.2 (SD 12) and mortality was 7.2%. CRITICAL patients (MAR ratio ≤14.2) had statistically higher shock volumes at three time points in the first day compared to NORMAL patients (MAR ratio >14.2). CRITICAL patients had significant differences in IL-6 (P=0.0065), IL-8 (P=0.0115), IL-10 (P=0.0316) and MCP-1 (P=0.0039) concentrations compared to NORMAL. Differences in degree of expression and discoordination of immune response continued in CRITICAL patients throughout the first day.

Conclusions: The admission MAR ratio may be the earliest warning signal of a pathologic inflammatory response associated with hypoperfusion and TIC. A low MAR ratio is an early indication of complicated dysfunction of multiple molecular processes following trauma.
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http://dx.doi.org/10.21037/atm-20-3651DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7791215PMC
December 2020

Dissemination of cancer survivorship care plans: who is being left out?

Support Care Cancer 2021 Jan 7. Epub 2021 Jan 7.

Department of Surgery, Division of Surgical Oncology, The Ohio State University, N924 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210, USA.

Objectives: The Institute of Medicine (IOM) and the American College of Surgeons Commission on Cancer (CoC) recommend a clear and effectively explained comprehensive survivorship care plan (SCP) be given to all cancer survivors. The objective of this study is to understand the relationship between social determinants of health (SDOH) and self-reported receipt of SCP by cancer survivors in the USA.

Methods: We analyzed an adult population of cancer survivors in the 2016 Behavioral Risk Factor Surveillance System's (BRFSS) Survivorship modules. Weighted multivariable logistic regression was used to analyze the association of SDOH and reported receipt of SCP.

Results: There were 7061 cancer patients eligible for an SCP. The probability of reporting receipt of SCP decreased with lower educational achievement (high school/some college: AOR = 0.82, 95% CI: 0.70-0.97, p = 0.02; < high school: AOR = 0.68, 95% CI: 0.47-0.97, p = 0.03) compared to those with at least one college degree. Additionally, being widowed/divorced/separated (widowed/divorced/separated: AOR = 0.72, 95% CI: 0.61-0.86, p < 0.01 vs. married/cohabiting) and uninsured (uninsured: AOR = 0.52, 95% CI: 0.0.34-0.80, p < 0.01 vs. insured) increased the odds of not receiving an SCP. Younger patients were more likely to receive an SCP than those over 65 (18-24 years: AOR = 6.62, 95% CI: 1.87-24.49, p < 0.01 vs. 65+ years).

Conclusion: Among cancer survivors, SDOH such as low educational achievement, widowed/divorced/separated marital status, and being uninsured were associated with a lower likelihood of receiving an SCP. Future studies should evaluate how omission of SCP in these patients influences the quality of care during the transition from oncologists to primary care.
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http://dx.doi.org/10.1007/s00520-020-05915-xDOI Listing
January 2021

Perceptions of Equity and Inclusion in Acute Care Surgery: From the #EAST4ALL Survey.

Ann Surg 2020 12;272(6):906-910

Prince George's Hospital Center, University of Maryland School of Medicine, Cheverly, MD.

Objectives And Background: The aim of this study was to characterize equity and inclusion in acute care surgery (ACS) with a survey to examine the demographics of ACS surgeons, the exclusionary or biased behaviors they witnessed and experienced, and where those behaviors happen. A major initiative of the Equity, Quality, and Inclusion in Trauma Surgery Practice Ad Hoc Task Force of the Eastern Association for the Surgery of Trauma was to characterize equity and inclusion in ACS. To do so, a survey was created with the above objectives.

Methods: A cross-sectional, mixed-methods anonymous online survey was sent to all EAST members. Closed-ended questions are reported as percentages with a cutoff of α = 0.05 for significance. Quantitative results were analyzed focusing on mistreatment and bias.

Results: Most respondents identified as white, non-Hispanic and male. In the past 12 months, 57.5% of females witnessed or experienced sexual harassment, whereas 48.6% of surgeons of color witnessed or experienced racial/ethnic discrimination. Sexual harassment, racial/ethnic prejudice, or discrimination based on sexual orientation/sex identity was more frequent in the workplace than at academic conferences or in ACS. Females were more likely than males to report unfair treatment due to age, appearance or sex in the workplace and ACS (P ≤ 0.002). Surgeons of color were more likely than white, non-Hispanics to report unfair treatment in the workplace and ACS due to race/ethnicity (P < 0.001).

Conclusions: This is the first survey of ACS surgeons on equity and inclusion. Perceptions of bias are prevalent. Minorities reported more inequity than their white male counterparts. Behavior in the workplace was worse than at academic conferences or ACS. Ensuring equity and inclusion may help ACS attract and retain the best and brightest without fear of unfair treatment.
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http://dx.doi.org/10.1097/SLA.0000000000004435DOI Listing
December 2020

Early Achievement of Enteral Nutrition Protein Goals by Intensive Care Unit Day 4 is Associated With Fewer Complications in Critically Injured Adults.

Ann Surg 2019 Nov 25. Epub 2019 Nov 25.

*Indiana University Department of Surgery, Indianapolis, IN †Indiana University Health Methodist Hospital, Indianapolis, IN ‡Indiana University School of Medicine, Indianapolis, IN §Indiana University Department of Surgery, Indianapolis, IN ¶University of Wisconsin, Madison, Department of Surgery, Madison, WI 53792-0001 ||Indiana University Department of Surgery (Retired), Edgewater, MD.

: Objective: We hypothesized that failure to achieve protein goals early in the critical care course via enteral nutrition is associated with increased complications.

Background: Although robust randomized controlled trials are lacking, present data suggest that early, adequate nutrition is associated with improved outcomes in critically ill patients. Injured patients are at risk of accumulating significant protein debt due to interrupted feedings and intolerance.

Methods: Critically injured adults who were unable to be volitionally fed were included in this retrospective review. Data collected included demographics, injury characteristics, number and types of operations, total prescribed and delivered protein and calories during the first 7 days of critical care admission, complications, and outcomes. Group-based trajectory modeling was applied to identify subgroups with similar feeding trajectories in the cohort.

Results: There were 274 patients included (71.2% male). Mean age was 50.56  ± 19.76 years. Group-based trajectory modeling revealed 5 Groups with varying trajectories of protein goal achievement. Group 5 fails to achieve protein goals, includes more patients with digestive tract injuries (33%, P = 0.0002), and the highest mean number of complications (1.52, P = 0.0086). Group 2, who achieves protein goals within 4 days, has the lowest mean number of complications (0.62, P = 0.0086) and operations (0.74, P = 0.001).

Conclusions: There is heterogeneity in the trajectory of protein goal achievement among various injury pattern Groups. There is a sharp decline in complication rates when protein goals are reached within 4 days of critical care admission, calling into question the application of current guidelines to healthy trauma patients to tolerate up to 7 days of nil per os status and further reinforcing recommendations for early enteral nutrition when feasible.
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http://dx.doi.org/10.1097/SLA.0000000000003708DOI Listing
November 2019

A trauma medical home, evaluating collaborative care for the older injured patient: study protocol for a randomized controlled trial.

Trials 2020 Jul 16;21(1):655. Epub 2020 Jul 16.

Department of Surgery, University of Wisconsin School of Medicine and Public Health-Madison, 600 Highland Ave., Madison, WI, 53792, USA.

Background: It is estimated that 55 million adults will be 65 years and older in the USA by 2020. These older adults are at increased risk for injury and their recovery is multi-faceted. A collaborative care model may improve psychological and functional outcomes of the non-neurologically impaired older trauma patient and reduce health care costs.

Methods: This is a randomized controlled trial of 430 patients aged 50 and older who have suffered a non-neurologic injury and are admitted to a level one trauma center in Indianapolis, IN, or Madison, WI. Participants will be assigned to either the Trauma Medical Home (TMH) intervention or usual care. The TMH intervention is a collaborative care model that includes validated protocols addressing the multi-faceted needs of this population, with the help of care coordination software and a mobile office concept. The primary outcome is self-reported physical recovery at 6- and 12-month follow-up. Secondary outcomes include self-reported psychological recovery, acute health care utilization, and cost-effectiveness of the intervention at 6 and 12 months. The TMH collaborative care model will be delivered by a registered nurse care coordinator. The assessments will be completed by trained blinded research assistants.

Discussion: The proposed study will evaluate a collaborative care model to help maximize psychological and functional recovery for non-neurologically injured older patients at four level one trauma centers in the Midwest.

Trial Registration: Clinical Trials. NCT03108820 . Registered on 11 April 2017. Protocol Version 6: Study # 1612690852. April 12, 2019.

Sponsor: Indiana University. Human subjects and IRB contact information: [email protected] Prospectively registered in the WHO ICTRP on 4 June 2017.
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http://dx.doi.org/10.1186/s13063-020-04582-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7364470PMC
July 2020

Evaluation of an augmented reality platform for austere surgical telementoring: a randomized controlled crossover study in cricothyroidotomies.

NPJ Digit Med 2020 21;3:75. Epub 2020 May 21.

School of Industrial Engineering, Purdue University, West Lafayette, IN USA.

Telementoring platforms can help transfer surgical expertise remotely. However, most telementoring platforms are not designed to assist in austere, pre-hospital settings. This paper evaluates the system for telementoring with augmented reality (STAR), a portable and self-contained telementoring platform based on an augmented reality head-mounted display (ARHMD). The system is designed to assist in austere scenarios: a stabilized first-person view of the operating field is sent to a remote expert, who creates surgical instructions that a local first responder wearing the ARHMD can visualize as three-dimensional models projected onto the patient's body. Our hypothesis evaluated whether remote guidance with STAR could lead to performing a surgical procedure better, as opposed to remote audio-only guidance. Remote expert surgeons guided first responders through training cricothyroidotomies in a simulated austere scenario, and on-site surgeons evaluated the participants using standardized evaluation tools. The evaluation comprehended completion time and technique performance of specific cricothyroidotomy steps. The analyses were also performed considering the participants' years of experience as first responders, and their experience performing cricothyroidotomies. A linear mixed model analysis showed that using STAR was associated with higher procedural and non-procedural scores, and overall better performance. Additionally, a binary logistic regression analysis showed that using STAR was associated to safer and more successful executions of cricothyroidotomies. This work demonstrates that remote mentors can use STAR to provide first responders with guidance and surgical knowledge, and represents a first step towards the adoption of ARHMDs to convey clinical expertise remotely in austere scenarios.
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http://dx.doi.org/10.1038/s41746-020-0284-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7242344PMC
May 2020

Opioid exposure after injury in United States trauma centers: A prospective, multicenter observational study.

J Trauma Acute Care Surg 2020 06;88(6):816-824

From the Department of Surgery and the Center for Translational Injury Research (J.A.H., V.T.T.T., C.E.G., C.E.W., L.S.K.), McGovern Medical School, University of Texas, Houston, Texas; Department of Surgery (L.A., J.M.), University of Texas Health Tyler, Tyler, Texas; Department of Surgery (J.J.R., J.N.B.), St. Joseph's Hospital and Medical Center, Phoenix, Arizona; Department of Surgery (P.B.M., B.B.P.-J., B.L.Z.), Indiana University, Indianapolis, Indiana; Department of Surgery (J.R.T., K.WS.), University of Arkansas for Medical Sciences, Little Rock, Arkansas; and Department of Surgery (C.D., T.J.S.), University of Colorado Health Memorial Hospital Central, Colorado Springs, Colorado.

Background: Efforts to reduce opioid use in trauma patients are currently hampered by an incomplete understanding of the baseline opioid exposure and variation in United States. The purpose of this project was to obtain a global estimate of opioid exposure following injury and to quantify the variability of opioid exposure between and within United States trauma centers.

Study Design: Prospective observational study was performed to calculate opioid exposure by converting all sources of opioids to oral morphine milligram equivalents (MMEs). To estimate variation, an intraclass correlation was calculated from a multilevel generalized linear model adjusting for the a priori selected variables Injury Severity Score and prior opioid use.

Results: The centers enrolled 1,731 patients. The median opioid exposure among all sites was 45 MMEs per day, equivalent to 30 mg of oxycodone or 45 mg of hydrocodone per day. Variation in opioid exposure was identified both between and within trauma centers with the vast majority of variation (93%) occurring within trauma centers. Opioid exposure increased with injury severity, in male patients, and patients suffering penetrating trauma.

Conclusion: The overall median opioid exposure was 45 MMEs per day. Despite significant differences in opioid exposure between trauma centers, the majority of variation was actually within centers. This suggests that efforts to minimize opioid exposure after injury should focus within trauma centers and not on high-level efforts to affect all trauma centers.

Level Of Evidence: Epidemiological, level III.
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http://dx.doi.org/10.1097/TA.0000000000002679DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7802946PMC
June 2020

Mapping the increasing interest in acute care surgery-Who, why and which fellowship?

J Trauma Acute Care Surg 2020 05;88(5):629-635

From Spectrum Health (B.N.G.), Grand Rapids, Michigan; University of Wisconsin (B.L.Z.), Madison, Wisconsin; Rutgers University (D.H.L.), Camden, New Jersey; University of Maryland (W.C.C., S.A.T.), College Park, Maryland; Yale University (K.A.D.), New Haven, Connecticut; University of Michigan (H.B.A.), Ann Arbor, Michigan; and Stanford University (D.A.S.), Stanford, California.

Background: Interest in acute care surgery (ACS) has increased over the past 10 years as demonstrated by the linear increase in fellowship applicants to the different fellowships leading to ACS careers. It is unclear why interest has increased, whether various fellowship pathways attract different applicants or whether fellowship choice correlates with practice patterns after graduation.

Methods: An online survey was distributed to individuals previously registered with the Surgical critical care and Acute care surgery Fellowship Application Service. Fellowship program directors were also asked to forward the survey to current and former fellows to increase the response rate. Data collected included demographics, clinical interests and motivations, publications, and postfellowship practice patterns. Fisher's exact and Pearson's χ were used to determine significance.

Results: Trauma surgery was the primary clinical interest for all fellowship types (n = 273). Fellowship type had no impact on academic productivity or practice patterns. Most fellows would repeat their own fellowship. The 2-year American Association for the Surgery of Trauma-approved fellowship was nearly uniformly reported as the preferred choice among those who would perform a different fellowship. Career motivations were similar across fellowships and over time though recent trainees were more likely to consider predictability of schedule a significant factor in career choice. Respondents reported graduated progression to full responsibility, further exposure to trauma care and additional operative technical training as benefits of a second fellowship year.

Conclusion: American Association for the Surgery of Trauma-approved 2-year fellows appear to be the most satisfied with their fellowship choice. No differences were noted in academic productivity or practice between fellowships. Future research should focus on variability in trauma training and operative experience during residency and in practice to better inform how a second fellowship year would improve training for ACS careers.

Level Of Evidence: Descriptive, mixed methods, Level IV.
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http://dx.doi.org/10.1097/TA.0000000000002585DOI Listing
May 2020

Blueprint for Restructuring a Department of Surgery in Concert With the Health Care System During a Pandemic: The University of Wisconsin Experience.

JAMA Surg 2020 07;155(7):628-635

Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison.

The current health care environment is complex. Systems often cross US state boundaries to provide care to patients with a wide variety of medical needs. The coronavirus disease 2019 pandemic is challenging health care systems across the globe. Systems face varying levels of complexity as they adapt to the new reality. This pandemic continues to escalate in hot spots nationally and internationally, and the worst strain on health care systems may be yet to come. The purpose of this article is to provide a road map developed from lessons learned from the experience in the Department of Surgery at the University of Wisconsin School of Medicine and Public Health and University of Wisconsin Health, based on past experience with incident command structures in military combat operations and Federal Emergency Management Agency responses. We will discuss administrative restructuring leveraging a team-of-teams approach, provide a framework for deploying the workforce needed to deliver all necessary urgent health care and critical care to patients in the system, and consider implications for the future.
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http://dx.doi.org/10.1001/jamasurg.2020.1386DOI Listing
July 2020

Alternative clinical trial designs.

Trauma Surg Acute Care Open 2020 4;5(1):e000420. Epub 2020 Feb 4.

Surgery, University of Vermont Medical Center, Burlington, Vermont, USA.

High-quality clinical trials are needed to advance the care of injured patients. Traditional randomized clinical trials in trauma have challenges in generating new knowledge due to many issues, including logistical difficulties performing individual randomization, unclear pretrial estimates of treatment effect leading to often unpowered studies, and difficulty assessing the generalizability of an intervention given the heterogeneity of both patients and trauma centers. In this review, we discuss alternative clinical trial designs that can address some of these difficulties. These include pragmatic trials, cluster randomization, cluster randomized stepped wedge designs, factorial trials, and adaptive designs. Additionally, we discuss how Bayesian methods of inference may provide more knowledge to trauma and acute care surgeons compared with traditional, frequentist methods.
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http://dx.doi.org/10.1136/tsaco-2019-000420DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7046952PMC
February 2020

Telementoring in Leg Fasciotomies via Mixed-Reality: Clinical Evaluation of the STAR Platform.

Mil Med 2020 01;185(Suppl 1):513-520

School of Industrial Engineering, Purdue University, 315 N. Grant St., West Lafayette, IN 47907.

Introduction: Point-of-injury (POI) care requires immediate specialized assistance but delays and expertise lapses can lead to complications. In such scenarios, telementoring can benefit health practitioners by transmitting guidance from remote specialists. However, current telementoring systems are not appropriate for POI care. This article clinically evaluates our System for Telementoring with Augmented Reality (STAR), a novel telementoring system based on an augmented reality head-mounted display. The system is portable, self-contained, and displays virtual surgical guidance onto the operating field. These capabilities can facilitate telementoring in POI scenarios while mitigating limitations of conventional telementoring systems.

Methods: Twenty participants performed leg fasciotomies on cadaveric specimens under either one of two experimental conditions: telementoring using STAR; or without telementoring but reviewing the procedure beforehand. An expert surgeon evaluated the participants' performance in terms of completion time, number of errors, and procedure-related scores. Additional metrics included a self-reported confidence score and postexperiment questionnaires.

Results: STAR effectively delivered surgical guidance to nonspecialist health practitioners: participants using STAR performed fewer errors and obtained higher procedure-related scores.

Conclusions: This work validates STAR as a viable surgical telementoring platform, which could be further explored to aid in scenarios where life-saving care must be delivered in a prehospital setting.
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http://dx.doi.org/10.1093/milmed/usz234DOI Listing
January 2020

The electric scooter: A surging new mode of transportation that comes with risk to riders.

Traffic Inj Prev 2020 5;21(2):175-178. Epub 2020 Feb 5.

Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.

The proliferation of electric scooter sharing companies has inundated many municipalities with electric scooters. The primary objective of this study is to characterize the epidemiology of injuries from this new mode of transportation in order to inform injury prevention efforts. A multicenter, retrospective study was conducted at two level 1 trauma centers in an urban setting. Patients seen in the emergency department from September 4, 2018 to November 4, 2018 were included if injury coding and chart review identified a scooter-related injury. Demographics, injury patterns, and other injury related factors were obtained via chart review. Ninety-two patients were identified over the study period in 2018 with electric scooter-related injuries. Of the patients utilizing an electric scooter; none used protective gear and 33% used alcohol prior to presentation. More than 60% of patients required medical intervention including laceration repair (26%), fracture reduction (17%), operative fixation of a fracture (7%), or arterial embolization for an associated arterial injury (1%). Approximately 10% of patients required inpatient admission and one required an admission to the intensive care unit. We found a substantial increase in the number of scooter-related injuries during the first two months of electric scooter legalization. There was a lack of safety equipment utilization and concomitant alcohol utilization was common. These may offer areas of focus for injury prevention efforts. Additionally, standardization of injury coding for electric scooter related injury is critical to future studies and will help better understand the impact of this new mode of transportation.
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http://dx.doi.org/10.1080/15389588.2019.1709176DOI Listing
December 2020

The System for Telementoring with Augmented Reality (STAR): A head-mounted display to improve surgical coaching and confidence in remote areas.

Surgery 2020 04 6;167(4):724-731. Epub 2020 Jan 6.

School of Industrial Engineering, Purdue University, West Lafayette, IN. Electronic address:

Background: The surgical workforce particularly in rural regions needs novel approaches to reinforce the skills and confidence of health practitioners. Although conventional telementoring systems have proven beneficial to address this gap, the benefits of platforms of augmented reality-based telementoring in the coaching and confidence of medical personnel are yet to be evaluated.

Methods: A total of 20 participants were guided by remote expert surgeons to perform leg fasciotomies on cadavers under one of two conditions: (1) telementoring (with our System for Telementoring with Augmented Reality) or (2) independently reviewing the procedure beforehand. Using the Individual Performance Score and the Weighted Individual Performance Score, two on-site, expert surgeons evaluated the participants. Postexperiment metrics included number of errors, procedure completion time, and self-reported confidence scores. A total of six objective measurements were obtained to describe the self-reported confidence scores and the overall quality of the coaching. Additional analyses were performed based on the participants' expertise level.

Results: Participants using the System for Telementoring with Augmented Reality received 10% greater Weighted Individual Performance Score (P = .03) and performed 67% fewer errors (P = .04). Moreover, participants with lower surgical expertise that used the System for Telementoring with Augmented Reality received 17% greater Individual Performance Score (P = .04), 32% greater Weighted Individual Performance Score (P < .01) and performed 92% fewer errors (P < .001). In addition, participants using the System for Telementoring with Augmented Reality reported 25% more confidence in all evaluated aspects (P < .03). On average, participants using the System for Telementoring with Augmented Reality received augmented reality guidance 19 times on average and received guidance for 47% of their total task completion time.

Conclusion: Participants using the System for Telementoring with Augmented Reality performed leg fasciotomies with fewer errors and received better performance scores. In addition, participants using the System for Telementoring with Augmented Reality reported being more confident when performing fasciotomies under telementoring. Augmented Reality Head-Mounted Display-based telementoring successfully provided confidence and coaching to medical personnel.
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http://dx.doi.org/10.1016/j.surg.2019.11.008DOI Listing
April 2020

Perceived loss of social support after non-neurologic injury negatively impacts recovery.

J Trauma Acute Care Surg 2020 01;88(1):113-120

From the Indiana University School of Medicine (B.W.C., S.E.S., T.M.B.), Indianapolis, Indiana; and University of Wisconsin School of Medicine and Public Health (B.L.Z.), Madison, Wisconsin.

Background: Traumatic injury is not only physically devastating, but also psychologically isolating, potentially leading to poor quality of life, depression and posttraumatic stress disorder (PTSD). Perceived social support (PSS) is associated with better outcomes in some populations. What is not known is if changes in PSS influence long-term outcomes following nonneurologic injury. We hypothesized that a single drop in PSS during recovery would be associated with worse quality of life.

Methods: This is a post hoc analysis of a prospectively collected database that included patients 18 years or older admitted to a Level I trauma center with Injury Severity Score (ISS) of 10 or higher, and no traumatic brain or spinal cord injury. Demographic and injury data were collected at the initial hospital admission. Screening for depression, PTSD, and Medical Outcomes Study Short Form 36 Mental Composite Score (MCS) were obtained at the initial hospitalization, 1, 2, 4, and 12 months postinjury. The Multidimensional Scale of Perceived Social Support (MSPSS) was obtained at similar time points. Patients with high MSPSS (>5) at baseline were included and grouped by those that ever reported a score ≤5 (DROP), and those that remained high (STABLE). Outcomes were determined at 4 and 12 months.

Results: Four hundred eleven patients were included with 96 meeting DROP criteria at 4 months, and 97 at 1 years. There were no differences in sex, race, or injury mechanism. The DROP patients were more likely to be single (p = 0.012 at 4 months, p = 0.0006 at 1 year) and unemployed (p = 0.016 at 4 months, and p = 0.026 at 1 year) compared with STABLE patients. At 4 months and 1 year, DROP patients were more likely to have PTSD, depression, and a lower MCS (p = 0.0006, p < 0.0001).

Conclusion: Patients who have a drop in PSS during the first year of recovery have significantly higher odds of poor psychological outcomes. Identifying these socially frail patients provides an opportunity for intervention to positively influence an otherwise poor quality of life.

Level Of Evidence: Therapeutic, Prognostic and Epidemiological, Level III.
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http://dx.doi.org/10.1097/TA.0000000000002515DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6945784PMC
January 2020

Impact of Patient Frailty on Morbidity and Mortality after Common Emergency General Surgery Operations.

J Surg Res 2020 03 29;247:95-102. Epub 2019 Nov 29.

Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin. Electronic address:

Background: Frailty has been increasingly recognized as a modifiable risk factor prior to elective general surgery. There is limited evidence regarding the association of frailty with perioperative outcomes after specific emergency general surgery procedures.

Material And Methods: A retrospective cohort study of 57,173 patients older than 40 y of age from 2010 to 2014 American College of Surgeons National Surgical Quality Improvement Program underwent appendectomy, cholecystectomy, large bowel resection, small bowel resection, or nonbowel resection (lysis of adhesion, ileostomy creation) on an emergent basis. Preoperative modified frailty index (mFI) was determined for each patient and was used in a multivariable logistic regression to determine the association with perioperative morbidity, mortality, and discharge destination.

Results: A total of 57,173 patients (46% men, mean [SD] age 60 [13] y) underwent an emergency appendectomy (n = 26,067), cholecystectomy (n = 8138), large bowel resection (n = 12,107), small bowel resection (n = 6503), or nonbowel resection (n = 4358). Among them, 14,300 (25.0%) experienced any perioperative complication, and 12,668 (22.2%) experienced a serious complication with an overall 30-d mortality of 5.1%. Highly frail patients had a 30-d mortality of 19.0% across all five operations. In multivariable analysis, mFI was associated with any complication and 30-d mortality in a step-wise fashion for each emergency operation. Intermediate and high mFI were also inversely associated with discharge home for each operation.

Conclusions: Frailty is associated with increased perioperative morbidity and mortality in common emergency general surgery operations. Frailty should be assessed by surgeons to inform decisions on operative intervention and to inform patients/families on expected outcomes.
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http://dx.doi.org/10.1016/j.jss.2019.10.038DOI Listing
March 2020

Reply to Letter: Organ injury scaling 2018 update: Spleen, liver, and kidney.

J Trauma Acute Care Surg 2019 10;87(4):999

University of Maryland, School of Medicine, Shock Trauma, Baltimore, MD 21201; Univerasity of Maryland, School of Medicine, Shock Trauma, Baltimore, MD.

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http://dx.doi.org/10.1097/TA.0000000000002435DOI Listing
October 2019

Physiologic stress among surgeons who take in-house call.

Am J Surg 2019 12 19;218(6):1181-1184. Epub 2019 Sep 19.

Denver Health Medical Center, University of Colorado School of Medicine, USA. Electronic address:

Introduction: Burnout and depression is higher in trauma surgeons as compared to surgeons in other specialties. Clinical practice for many acute care surgeons (ACS) includes in-house call (IHC). The goal of this study was to quantitate physiologic stress among ACS who take IHC.

Methods: ACS with IHC responsibilities from two Level I trauma centers were studied. Participants wore a fitness and heart rate variability (HRV) device over 3 months. HRV was categorized as normal if 85% of baseline, moderate stress when HRV <85% but >50%, and high stress when HRV< 50%.

Results: 1421 nights were recorded among 17 surgeons (35.3% female; mean age 45.5 years). Excluding IHC, mean HRV = 32.23, and 95.63% of days were consistent with moderate or high stress. Post-call day 2 had significantly highest percentage of high stress (65.82%, p = 0.0495). High and moderate stress levels returned to baseline on post-call day 3.

Conclusions: High and moderate stress beyond IHC is common among ACS. Future study is needed to determine consequences of persistent stress and identify factors which impact recovery after IHC.
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http://dx.doi.org/10.1016/j.amjsurg.2019.08.023DOI Listing
December 2019

Timing of Cholecystectomy after Emergent Endoscopic Retrograde Cholangiopancreatography for Cholangitis.

Am Surg 2019 Aug;85(8):895-899

Debate remains regarding the timing of laparoscopic cholecystectomy after emergent endoscopic retrograde cholangiopancreatography (ERCP) for acute cholangitis. We hypothesized that patients undergoing early laparoscopic cholecystectomy would have fewer operative complications and a lower conversion rate. This study is a retrospective review of an ERCP database from 2012 to 2016 of adults with a diagnosis of cholangitis secondary to choledocholithiasis who underwent ERCP followed by a laparoscopic cholecystectomy. Patient demographics, ERCP details, timing of operation (<72 hours >72 hours after ERCP), complications, and mortality were recorded. Analysis included chi-square, Fisher's exact, and Wilcoxon rank-sum tests, where appropriate. In the 127 patients (65 per cent male; median age, 67 years; 48 (38%) early surgery), there were no differences in demographics, BMI, vital signs, or laboratory values. Patients in the late surgery group were more likely to have a Charlson Comorbidity Index > 3 ( = 0.002), require pre-operative endoscopic sphincterotomy ( < 0.002), need pre-operative insertion of a ductal stent ( < 0.03), and had more postoperative complications ( = 0.04). Patients in the late laparoscopic cholecystectomy group had more comorbidities and suffered more complications.
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August 2019

Better understanding the utilization of damage control laparotomy: A multi-institutional quality improvement project.

J Trauma Acute Care Surg 2019 Jul;87(1):27-34

From the Department of Surgery, the University of Texas McGovern Medical School at Houston (J.A.H., J.B.H.), Houston, Texas; the Department of Surgery, the University of Tennessee Health Science Center (J.P.S., M.A.C.), Memphis, Tennessee; the Department of Surgery, the University of Cincinnati College of Medicine (M.D.G.), Cincinnati, Ohio; the Department of Surgery, Temple University School of Medicine (E.D.D., B.J.M.), Philadelphia, Pennsylvania; the Department of Surgery, Indiana University School of Medicine (R.D.R., B.L.Z.), Indianapolis, Indiana; and the Department of Surgery, MetroHealth System (L.A.K., J.A.C.), Cleveland, Ohio.

Background: Rates of damage control laparotomy (DCL) vary widely and consensus on appropriate indications does not exist. The purposes of this multicenter quality improvement (QI) project were to decrease the use of DCL and to identify indications where consensus exists.

Methods: In 2016, six US Level I trauma centers performed a yearlong, QI project utilizing a single QI tool: audit and feedback. Each emergent trauma laparotomy was prospectively reviewed. Damage control laparotomy cases were adjudicated based on the majority vote of faculty members as being appropriate or potentially, in retrospect, safe for definitive laparotomy. The rate of DCL for 2 years prior (2014 and 2015) was retrospectively collected and used as a control. To account for secular trends of DCL, interrupted time series was used to effectiveness of the QI interventions.

Results: Eight hundred seventy-two emergent laparotomies were performed: 73% definitive laparotomies, 24% DCLs, and 3% intraoperative deaths. Of the 209 DCLs, 162 (78%) were voted appropriate, and 47 (22%) were voted to have been potentially safe for definitive laparotomy. Rates of DCL ranged from 16% to 34%. Common indications for DCL for which consensus existed were packing (103/115 [90%] appropriate) and hemodynamic instability (33/40 [83%] appropriate). The only common indication for which primary closure at the initial laparotomy could have been safely performed was avoiding a planned second look (16/32 [50%] appropriate).

Conclusion: A single faceted QI intervention failed to decrease the rate of DCL at six US Level I trauma centers. However, opportunities for improvement in safely decreasing the rate of DCL were present. Second look laparotomy appears to lack consensus as an indication for DCL and may represent a target to decrease the rate of DCL after injury.

Level Of Evidence: Epidemiological study with one negative criterion, level III.
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http://dx.doi.org/10.1097/TA.0000000000002288DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6771434PMC
July 2019

Financial toxicity is associated with worse physical and emotional long-term outcomes after traumatic injury.

J Trauma Acute Care Surg 2019 11;87(5):1189-1196

From the Department of Surgery (P.T.M., S.Se., S.O.-G., L.R.T., B.L.Z.), Indiana University School of Medicine, Indianapolis, Indiana; and Department of Surgery (S.Sa.), University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.

Background: Increasing health care costs and high deductible insurance plans have shifted more responsibility for medical costs to patients. After serious illnesses, financial responsibilities may result in lost wages, forced unemployment, and other financial burdens, collectively described as financial toxicity. Following cancer treatments, financial toxicity is associated with worse long-term health-related quality of life (HRQoL) outcomes. The purpose of this study was to determine the incidence of financial toxicity following injury, factors associated with financial toxicity, and the impact of financial toxicity on long-term HRQoL.

Methods: Adult patients with an Injury Severity Score of 10 or greater and without head or spinal cord injury were prospectively followed for 1 year. The Short-Form-36 was used to determine overall quality of life at 1 month, 2 months, 4 months, and 12 months. Screens for depression and posttraumatic stress syndrome were administered. The primary outcome was any financial toxicity. A multivariable generalized estimating equation was used to account for variability over time.

Results: Five hundred patients were enrolled, and 88% suffered financial toxicity during the year following injury (64% reduced income, 58% unemployment, 85% experienced stress due to financial burden). Financial toxicity remained stable over follow-up (80-85%). Factors independently associated with financial toxicity were lower age (odds ratio [OR], 0.96 [0.94-0.98]), lack of health insurance (OR, 0.28 [0.14-0.56]), and larger household size (OR, 1.37 [1.06-1.77]). After risk adjustment, patients with financial toxicity had worse HRQoL, and more depression and posttraumatic stress syndrome in a stepwise fashion based on severity of financial toxicity.

Conclusion: Financial toxicity following injury is extremely common and is associated with worse psychological and physical outcomes. Age, lack of insurance, and large household size are associated with financial toxicity. Patients at risk for financial toxicity can be identified, and interventions to counteract the negative effects should be developed to improve long-term outcomes.

Level Of Evidence: Prognostic/epidemiologic study, level III.
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http://dx.doi.org/10.1097/TA.0000000000002409DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6815224PMC
November 2019

To Sleep, Perchance to Dream: Acute and Chronic Sleep Deprivation in Acute Care Surgeons.

J Am Coll Surg 2019 08 6;229(2):166-174. Epub 2019 Apr 6.

Department of Surgery, University of Maryland School of Medicine, Baltimore, MD.

Background: Acute and chronic sleep deprivation are significantly associated with depressive symptoms and are thought to be contributors to the development of burnout. In-house call inherently includes frequent periods of disrupted sleep and is common among acute care surgeons. The relationship between in-house call and sleep deprivation among acute care surgeons has not been previously studied. The goal of this study was to determine prevalence and patterns of sleep deprivation in acute care surgeons.

Study Design: A prospective study of acute care surgeons with in-house call responsibilities from 2 level I trauma centers was performed. Participants wore a sleep-tracking device continuously over a 3-month period. Data collected included age, sex, schedule of in-house call, hours and pattern of each sleep stage (light, slow wave, and rapid eye movement [REM]), and total hours of sleep. Sleep patterns were analyzed for each night, excluding in-house call, and categorized as normal, acute sleep deprivation, or chronic sleep deprivation.

Results: There were 1,421 nights recorded among 17 acute care surgeons (35.3% female; ages 37 to 65 years, mean 45.5 years). Excluding in-house call, the average amount of sleep was 6.54 hours, with 64.8% of sleep patterns categorized as acute sleep deprivation or chronic sleep deprivation. Average amount of sleep was significantly higher on post-call day 1 (6.96 hours, p = 0.0016), but decreased significantly on post-call day 2 (6.33 hours, p = 0.0006). Sleep patterns with acute and chronic sleep deprivation peaked on post-call day 2, and returned to baseline on post-call day 3 (p = 0.046).

Conclusions: Sleep patterns consistent with acute and chronic sleep deprivation are common among acute care surgeons and worsen on post-call day 2. Baseline sleep patterns were not recovered until post-call day 3. Future study is needed to identify factors that affect physiologic recovery after in-house call and further elucidate the relationship between sleep deprivation and burnout.
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http://dx.doi.org/10.1016/j.jamcollsurg.2019.03.019DOI Listing
August 2019

Effect of damage control laparotomy on major abdominal complications and lengths of stay: A propensity score matching and Bayesian analysis.

J Trauma Acute Care Surg 2019 08;87(2):282-288

From the Department of Surgery, The University of Texas McGovern Medical School at Houston (J.A.H., J.B.H.), Houston, Texas; The Department of Surgery, The University of Tennessee Health Science Center (J.P.S., M.A.C.), Memphis, Tennessee; The Department of Surgery, The University of Cincinnati College of Medicine(M.D.G., T.A.P.), Cincinnati, Ohio; The Department of Surgery, Temple University School of Medicine (E.D.D., B.J.M.), Philadelphia, Pennsylvania; the Department of Surgery, Indiana University School of Medicine (R.D.R., B.L.Z.), Indianapolis, Indiana; and The Department of Surgery, MetroHealth System (L.A.K., J.A.C.), Cleveland, Ohio.

Background: In patients for whom surgical equipoise exists for damage control laparotomy (DCL) and definitive laparotomy (DEF), the effect of DCL and its associated resource utilization are unknown. We hypothesized that DEF would be associated with fewer abdominal complications and less resource utilization.

Methods: In 2016, six US Level I trauma centers performed a yearlong, prospective, quality improvement project with the primary aim to safely decrease the use of DCL. From this cohort of patients undergoing emergent trauma laparotomy, those who underwent DCL but were judged by majority faculty vote at each center to have been candidates for potential DEF (pDEF) were prospectively identified. These pDEF patients were matched 1:1 using propensity scoring to the DEF patients. The primary outcome was the incidence of major abdominal complications (MAC). Deaths within 5 days were excluded. Outcomes were assessed using both Bayesian generalized linear modeling and negative binomial regression.

Results: Eight hundred seventy-two total patients were enrolled, 639 (73%) DEF and 209 (24%) DCL. Of the 209 DCLs, 44 survived 5 days and were judged to be patients who could have safely been closed at the primary laparotomy. Thirty-nine pDEF patients were matched to 39 DEF patients. There were no differences in demographics, mechanism of injury, Injury Severity Score, prehospital/emergency department/operating room vital signs, laboratory values, resuscitation, or procedures performed during laparotomy. There was no difference in MAC between the two groups (31% DEF vs. 21% pDEF, relative risk 0.99, 95% credible interval 0.60-1.54, posterior probability 56%). Definitive laparotomy was associated with a 72%, 77%, and 72% posterior probability of more hospital-free, intensive care unit-free, and ventilator-free days, respectively.

Conclusion: In patients for whom surgeons have equipoise for DCL versus definitive surgery, definitive abdominal closure was associated with a similar probability of MAC, but a high probability of fewer hospital-free, intensive care unit-free, and ventilator-free days.

Level Of Evidence: Therapeutic/care management, level III.
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http://dx.doi.org/10.1097/TA.0000000000002285DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6660375PMC
August 2019

The conference effect: National surgery meetings are associated with increased mortality at trauma centers without American College of Surgeons verification.

PLoS One 2019 26;14(3):e0214020. Epub 2019 Mar 26.

Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, United States of America.

Background: Thousands of physicians attend scientific conferences each year. While recent data indicate that variation in staffing during such meetings impacts survival of non-surgical patients, the association between treatment during conferences and outcomes of a surgical population remain unknown. The purpose of this study was to examine mortality resulting from traumatic injuries and the influence of hospital admission during national surgery meetings.

Study Design: Retrospective analysis of in-hospital mortality using data from the Trauma Quality Improvement Program (2010-2011). Identified patients admitted during four annual meetings and compared their mortality with that of patients admitted during non-conference periods. Analysis included 155 hospitals with 12,256 patients admitted on 42 conference days and 82,399 patients admitted on 270 non-conference days. Multivariate analysis performed separately for hospitals with different levels of trauma center verification by state and American College of Surgeons (ACS) criteria.

Results: Patient characteristics were similar between meeting and non-meeting dates. At ACS level I and level II trauma centers during conference versus non-conference dates, adjusted mortality was not significantly different. However, adjusted mortality increased significantly for patients admitted to trauma centers that lacked ACS trauma verification during conferences versus non-conference days (OR 1.2, p = 0.008), particularly for patients with penetrating injuries, whose mortality rose from 11.6% to 15.9% (p = 0.006).

Conclusions: Trauma mortality increased during surgery conferences compared to non-conference dates for patients admitted to hospitals that lacked ACS trauma level verification. The mortality difference at those hospitals was greatest for patients who presented with penetrating injuries.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0214020PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6435237PMC
December 2019

Augmented Reality as a Medium for Improved Telementoring.

Mil Med 2019 03;184(Suppl 1):57-64

School of Industrial Engineering, Purdue University, 315N. Grant St., West Lafayette, IN.

Combat trauma injuries require urgent and specialized care. When patient evacuation is infeasible, critical life-saving care must be given at the point of injury in real-time and under austere conditions associated to forward operating bases. Surgical telementoring allows local generalists to receive remote instruction from specialists thousands of miles away. However, current telementoring systems have limited annotation capabilities and lack of direct visualization of the future result of the surgical actions by the specialist. The System for Telementoring with Augmented Reality (STAR) is a surgical telementoring platform that improves the transfer of medical expertise by integrating a full-size interaction table for mentors to create graphical annotations, with augmented reality (AR) devices to display surgical annotations directly onto the generalist's field of view. Along with the explanation of the system's features, this paper provides results of user studies that validate STAR as a comprehensive AR surgical telementoring platform. In addition, potential future applications of STAR are discussed, which are desired features that state-of-the-art AR medical telementoring platforms should have when combat trauma scenarios are in the spotlight of such technologies.
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http://dx.doi.org/10.1093/milmed/usy300DOI Listing
March 2019

What's in a Name? Provider Perception of Injured John Doe Patients.

J Surg Res 2019 06 14;238:218-223. Epub 2019 Feb 14.

Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana.

Background: We previously demonstrated that unidentified aliased patients, John Doe's (DOEs), are one of the highest risk and most medically fragile populations of injured patients. Aliasing can result in misplaced information and confusion that must be overcome by health care professionals. DOE alias use is institutionally dependent and not uniform, which may lead to significant variation in perception of confusion and error. We sought to determine if health care practitioners experience confusion that may result in compromised care when caring for injured DOE patients.

Methods: After obtaining institutional review board approval, we surveyed critical care nurses, nurse practitioners, resident physicians, and surgeons who care for DOE patients at two academic level I trauma centers with separate DOE alias practices. Surveys asked whether caring for DOE patients created possible or actual confusion and possible or actual patient care errors. In one institution (Selective DOE), only unidentified patients were given an alias that was reconciled when information became available. At the other institution (All DOE), all trauma patients were admitted with an alias that was reconciled within 24 h. Respondents were invited to complete an anonymous questionnaire regarding the care for DOE patients. Results were analyzed with Wilcoxon rank-sum tests, and significance was assessed at a level of 0.05.

Results: Of 176 total respondents, 120 (68.2%) reported from Selective DOE and 56 (31.8%) from All DOE. Overall 53.1% reported that DOE use can cause serious confusion. Specifically, 31.3% reported experiencing actual confusion, although only 4% reported actual errors. Nurses had significantly higher perceived risk of confusion in the system of All DOE versus Selective DOE assignment (17.9% versus 4.2%, P < 0.01). Resident physicians reported significantly more frequent actual mistakes within the All DOE versus Selective DOE (24.1% versus 6.6%, P < 0.01), despite finding no significant difference in resident perception of confusion (21.4% versus 12.5%, respectively, P = 0.18).

Conclusions: Our study sheds light on clinical consequences of EMR use and aliases for end users. We show that nurses perceive that there are greater potential complications associated with DOE aliases use, and this varies depending on the system used for managing unidentified patients. Minimizing DOE alias use may help to minimize provider confusion, risk for error, and patient safety.
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http://dx.doi.org/10.1016/j.jss.2019.01.027DOI Listing
June 2019