An Analysis of Past Surgical Infection Society Award Recipients.

BACKGROUND: The Surgical Infection Society (SIS) through its foundation (FDTN) confers awards to individuals who demonstrate interest in researching infection in the surgical setting. We sought to characterize the research output from prior award recipients and determine the impact of these awards on the individual and the SIS. METHODS: The SIS website was queried for the names of all past award recipients. A MEDLINE search of the recipients was performed. Total number of publications and publications in the society's journal, Surgical Infections (SI), were identified. Gender and leadership positions within SIS were determined. Meeting attendance and participation were assessed. Donations by scholarship recipient to the FDTN were evaluated. RESULTS: Between 1984 and 2012, 116 individuals received an SIS award or scholarship. Of these, 72% were male. There were 101 scholarships awarded, totaling nearly $3 million. Of the 19 new Junior Faculty Scholarships awarded, four were to consecutive recipients (CR). There were 11 clinical evaluative award scholarships awarded, three to CR. There were 100 Resident/Fellow scholarships awarded, and of these, 22 were awarded to CR. Past recipients had multiple publications (median total publications = 27; interquartile range (IQR): Nine to 62) and published multiple papers on the topic for which they received an award (median two; IQR: Zero to four). Recipients did not publish in SI (median SI publications = zero; IQR: Zero to one). There was no substantial difference in the number of publications by gender. Multiple awards (MA) were conferred to 26 (22%) individuals. Six (5.1%) assumed an executive position within SIS, two (1.7%) became SIS president. Those who received MA were more likely to serve as an officer than those who only received one award (15% vs. 2%, p = 0.02). CONCLUSIONS: Scholarships have a large benefit for individual recipients; however, the benefit to the society remains harder to quantify.

Implementation of an image sharing system significantly reduced repeat computed tomographic imaging in a regional trauma system.

BACKGROUND: The practice of repeating computed tomography (re-CT) is common among trauma patients transferred between hospitals incurring additional cost and radiation exposure. This study sought to evaluate the effectiveness of implementing modern cloud-based technology (lifeIMAGE) across a regional trauma system to reduce the incidence of re-CT imaging. METHODS: This is a prospective interventional study to evaluate outcomes after implementation of lifeIMAGE in January 2012. Key outcomes were rates of CT imaging, including the rates and costs of re-CT from January 2009 through December 2012. RESULTS: There were 1,081 trauma patients transferred from participating hospitals during the study period (657 patients before and 425 patients after implementation), with the overall re-CT rate of 20.5%. Rates of any CT imaging at referring hospitals decreased (62% vs. 55%, p < 0.05) and also decreased at the accepting regional Level I center (58% vs. 52%, p < 0.05) following system implementation. There were 639 patients (59%) who had CT imaging performed before transfer (404 patients before and 235 patients after implementation). Of these patients, the overall re-CT rate decreased from 38.4% to 28.1% (p = 0.01). Rates of re-CT of the head (21% vs. 11%, p = 0.002), chest (7% vs. 3%, p = 0.05), as well as abdomen and pelvis (12% vs. 5%, p = 0.007) were significantly reduced following system implementation. The cost of repeat imaging per patient was significantly lower following system implementation (mean charges, $1,046 vs. $589; p < 0.001). These results were more pronounced in a subgroup of patients with an Injury Severity Score (ISS) of greater than 14, with a reduction in overall re-CT rate from 51% to 30% (p = 0.03). CONCLUSION: The implementation of modern cloud-based technology across the regional trauma system resulted in significant reductions in re-CT imaging and cost. LEVEL OF EVIDENCE: Therapeutic/care management study, level IV; economic analysis, level IV.

Functional and long-term outcomes in severe traumatic brain injury following regionalization of a trauma system.

BACKGROUND: We previously demonstrated that regionalization of trauma (RT) significantly reduced in-hospital mortality from 19% to 14% in patients with severe traumatic brain injury (sTBI). However, functional and long-term outcomes had not been assessed. We hypothesized that RT would be associated with improved functional and long-term outcomes in sTBI patients. METHODS: All TBI patients older than 14 years with a head Abbreviated Injury Scale (AIS) score of 3 or greater were identified from the RT database and matched to the state death index and the regional TBI rehabilitation (TBIr) database. Data from 2008 through 2012 were analyzed before and after RT in 2010. For patients discharged to the TBIr unit, overall Functional Independence Measure (FIM) scores and FIM score gains were compared before and after RT. RESULTS: A total of 3,496 patients with sTBI were identified in the RT database, 1,359 in the pre-RT and 2,137 in the post-RT period. The mortality rate after discharge decreased significantly after RT from 21% to 16% (p < 0.0001) at 30 days and from 24% to 20% (p = 0.004) at 6 months. Multivariable logistic regression demonstrated RT to be an independent predictor against mortality at 30 days (odds ratio, 0.74; 95% confidence interval, 0.60-0.91; C statistic, 0.84) and 6 months (odds ratio, 0.82; 95% confidence interval, 0.67-0.99; C statistic, 0.82). Discharges to the TBIr unit increased from 117 (9%) in the pre-RT to 297 (14%) in the post-RT period (p < 0.0001), while discharges to home and non-TBIr units remained similar. Injury Severity Score (ISS) and Glasgow Coma Scale (GCS) score for all discharged patients remained similar. FIM admission scores were similar in the pre-RT (median, 54; interquartile range [IQR], 30-65) and post-RT period (median, 48; IQR, 31-61) (p = 0.2) and remained similar at discharge in the pre-RT (median, 92; IQR, 75-102) and post-RT period (median, 89; IQR, 73-100) (p = 0.1). TBIr patients showed similar FIM score gains in the pre-RT (median, 37; IQR, 26-46) and post-RT period (median, 36; IQR, 24-49) (p = 0.6). CONCLUSION: RT was associated with reduced long-term mortality, increased TBIr admissions, and similar FIM score improvements for patients with sTBI. LEVEL OF EVIDENCE: Therapeutic/care management study, level IV.

Decreased mortality in traumatic brain injury following regionalization across hospital systems.

BACKGROUND: The Northern Ohio Trauma System (NOTS) was established to improve outcomes of trauma patients across the region. We hypothesized that mortality in patients with traumatic brain injury (TBI) would improve after regionalization. METHODS: All patients older than 14 years with a TBI were identified from NOTS, a regional trauma system consisting of two large health care systems and regional emergency medical services providers. Data from 2008 through 2012 were analyzed before and after NOTS formation in 2010. Multivariate logistic regression analysis was performed to evaluate independent predictors of survival. RESULTS: A total of 11,220 patients were identified with TBI in the NOTS database, 4,507 (40%) before NOTS and 6,713 (60%) after NOTS formation. Admissions to the regional Level 1 center post-NOTS formation increased from 36% to 46% (p < 0.0001). Injury Severity Scores (ISSs) and Abbreviated Injury Scale (AIS) scores were similar between periods. The mortality rate decreased from 6.2% to 4.9% (p = 0.005) among all TBIs and from 19% to 14% (p < 0.0001) in TBIs with a head AIS score of 3 or greater (n = 3,538). Craniotomy procedures increased from 1.8% to 2.7% (p = 0.003) overall and from 5.9% to 8.1% (p = 0.02) in TBIs with head AIS score of 3 or greater. Logistic regression analysis demonstrated an independent effect on survival for post-NOTS period in all patients (odds ratio, 0.76; 95% confidence interval, 0.62-0.94; C statistic = 0.96) and in TBIs with head AIS score of 3 or greater (odds ratio, 0.72; 95% confidence interval, 0.58-0.89; C statistic = 0.86). CONCLUSION: Regionalization of trauma care across hospital systems is associated with a reduced mortality rate for patients with TBI, particularly for patients with a head AIS score of 3 or greater. Mortality decreased by 24% for all TBIs and by 28% for severe TBIs. These findings support regionalization of trauma care with collaboration and consolidation of care across health care systems. LEVEL OF EVIDENCE: Therapeutic/care management, level IV; epidemiologic study, level III.

Diagnosis of infection after splenectomy for trauma should be based on lack of platelets rather than white blood cell count.

BACKGROUND: There is a lack of evidence-based criteria to assist the diagnosis of infection following trauma splenectomy (TS). However, the literature suggests that white blood cell count (WBC) is associated with infection in patients who undergo TS. We sought to find whether there exist key differences in laboratory and clinical parameters that can assist the diagnosis of infection after TS. METHODS: We evaluated all consecutive trauma patients who had undergone TS at a Level 1 trauma center from 2005 to 2011 for the development of infection. To do this, we compared the values of demographic, laboratory, and clinical variables of infected and non-infected patients on odd post-operative days (POD) in the period from 1-15 days after TS. RESULTS: Of 127 patients who underwent TS, 25 died within 48 h after the procedure and were excluded from our analysis, leaving, 102 patients for investigation. In the 41 (40%) patients who developed an infection, the mean day for the first infectious episode was POD 7 (range, POD 4-14). The three most common infections were pneumonia (51%), urinary tract infection (24%), and bacteremia (20%). An evaluation of laboratory and clinical parameters showed no differences in the WBC of the patients who did and did not develop infections at any time in the 15 d after TS. However, the platelet count was statistically significantly higher in non-infected patients on POD 3-9 and on POD 13, and maximal body temperature was statistically significantly higher in the infected group of patients during the first week after TS. Differences in laboratory and clinical values of the infected and non-infected patients were greatest on POD 5. CONCLUSIONS: Patients who undergo TS have high rates of infectious complications. The WBC is not a reliable predictor of infection in these patients in the 2 wks following TS. However, patients who do not develop infection after TS have statistically significantly higher absolute platelet counts and rates of change in their daily platelet counts than those who develop infection.

Where's the difference? Presentation of nosocomial infection in critically ill trauma versus general surgery patients.

BACKGROUND: Diagnosing infection efficiently is integral to managing critically ill patients. Knowing if and how trauma and general surgery patients differ in their presentation of new infectious complications could be useful. We hypothesized these populations would differ in presentation in the intensive care unit (ICU). METHODS: We analyzed data collected prospectively from all 1,657 trauma and general surgery patients admitted to the surgical and trauma ICU (STICU) over a 21-month period. Clinical data from the first day of a newly diagnosed infection were compared for trauma (82% of the series) and general surgery (18%) patients. RESULTS: A total of 10,424 STICU days were included, and 267 nosocomial infections were diagnosed. Trauma patients were younger (50 vs. 62 years; p<0.001) and more likely to be male (78% vs. 46%; p<0.001) than were general surgery patients. Similar percentages of the two groups were infected (11% and 13%, respectively), and infections occurred after a similar number of days in the STICU. The mean maximum temperature on the day prior to diagnosis was higher in trauma patients (38.4°C vs. 37.7°C; p<0.001), and the mean leukocyte count was lower (13,500 vs. 15,800 10(6)/L; p=0.013). General surgery patients were more likely to be hypotensive (13% vs. 2%; p=0.002) and to have a positive fluid balance >2 L on the first day of infection (27% vs. 13%; p=0.02). Respiratory infections were more common in trauma patients (40% vs. 7%; p<0.001), and urinary tract infections were less common (19% vs. 36%; p=0.011). CONCLUSION: Differences exist in how new infections manifest in trauma and general surgery patients in the ICU. General surgery patients appeared sicker on their first day of infection, as evidenced by a higher leukocyte count, lower blood pressure, and substantial positive fluid balance. Intensivists may need differing thresholds for triggering infection workups when employed in a mixed unit.

Bacterial species-specific hospital mortality rate for intra-abdominal infections.

BACKGROUND: Intra-abdominal infections (IAIs) are a major cause of morbidity and death. We hypothesized that the involvement of specific organisms would predict death independently. PATIENTS AND METHODS: All patients with IAIs treated at an academic tertiary-care facility over eight years (June 1999-June 2007) were included. The data collected were demographics, co-morbidities, source of infection, intra-abdominal culture results, type of infection (community-acquired vs. nosocomial), type of intervention (operative vs. percutaneous drainage), and outcome. The Charlson Comorbidity Index and multiple organ dysfunction score (MODS) were used in the analysis. RESULTS: A total of 389 patients were admitted for 452 infection episodes (IEs) during the study period. None of the 129 patients with appendiceal-related infections died, and these patients were excluded from further analysis. Thus, 323 non-appendiceal IEs were evaluated. The overall mortality rate was 8.7%. The mean age of the patients was 54 y, and 50% of them were male. Intra-abdominal cultures were obtained from 303 IEs (93.8%). The most common cause of IAI was post-operative infection (44%). There were 49 distinct species isolated. The most common were Enterococcus (105), Escherichia coli (75), Streptococcus (62), Staphylococcus (51), and Bacteroides (46). Bivariable analysis revealed multiple risk factors associated with death. Logistic regression demonstrated that independent risk factors for death were age ≥65 years (odds ratio [OR] 3.92), cardiac event (OR=8.17), catheter-related blood stream infection (OR=6.16), and growth of Clostridium (OR=13.03). The growth of Streptococcus was predictive of survival. The C statistic was 0.89. CONCLUSIONS: In addition to age and intrinsic patient factors, the presence of specific bacterial organisms independently predicts death in patients with non-appendiceal IAI.

Trauma recidivists: surprisingly better outcomes than initially injured trauma patients.

BACKGROUND: The purpose of this study was to determine if there was a difference in hospital outcomes between trauma recidivists (RCID) and nonrecidivists (NRCID). METHODS: Outcomes of RCID and NRCID were compared. A recidivist was defined as a patient with a history of hospital evaluation for injury within the prior 5 years. Patients with good functional status had a Glasgow Outcome Score of 4 to 5. RESULTS: Of the 2,127 patients admitted, 466 (22%) were RCID. NRCID were more likely to have Injury Severity Score >25 (12% vs 8.6%; P = .04) than RCID. Eighty-eight percent of RCID were discharged with a good functional status compared with 83% of RCID (P = .02). NRCID were more likely to be admitted to a critical care unit (43% vs 36%; P = .01), but there was no significant difference in hospital mortality. CONCLUSION: RCID were less severely injured and had better hospital outcomes than NRCID.

Trauma center variation in splenic artery embolization and spleen salvage: a multicenter analysis.

BACKGROUND: This study aimed to evaluate if variation in management of blunt splenic injury (BSI) among Level I trauma centers is associated with different outcomes related to the use of splenic artery embolization (SAE). METHODS: All adult patients admitted for BSI from 2008 to 2010 at 4 Level I trauma centers were reviewed. Use of SAE was determined, and outcomes of spleen salvage and nonoperative management (NOM) failure were evaluated. A priori, a 10% SAE rate was used to group centers into high- or low-use groups. RESULTS: There were 1,275 BSI patients. There were intercenter differences in age, injury severity, and grade of spleen injury (Spleen Injury Scale [SIS]). Mortality was similar by center; however, BSI treatment varied significantly by center. Overall, SAE use was highest at center A compared with B, C, and D (19%, 11%, 1%, and 4%, respectively; p < 0.01). High SAE use centers had significantly higher spleen salvage rates and fewer NOM failures. Differences in the use of SAE (25% vs. 2%, p < 0.01) and salvage rate (67% vs. 56%, p = 0.03) were most dramatic between high- and low-use SAE centers for Grade 3 and 4 injured spleens. In patients who received initial NOM, multivariate logistic regression analysis showed that SAE was an independent predictor of spleen salvage (odds ratio, 5; 95% confidence interval, 1.8-13.5; p < 0.01) as were lower age, lower SIS, and Injury Severity Score (ISS). Patients treated at high SAE use centers were more likely to leave the hospital with their spleen in situ (odds ratio, 3; 95% confidence interval, 1.7-6.3; p < 0.01). CONCLUSION: Significant practice variation exists in the use of SAE in treating BSI at Level I trauma centers. Centers with higher rates of SAE use have higher spleen salvage and less NOM failure. SAE was shown to be an independent predictor of spleen salvage. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Anterior abdominal stab injury: a comparison of self-inflicted and intentional third-party stabbings.

BACKGROUND: There is minimal literature comparing self-inflicted (SI) with non-self-inflicted (NSI) anterior abdominal stab wounds (AASW). METHODS: Adult patients treated at a level 1 trauma center from 2006 through 2011 with an AASW were reviewed. RESULTS: There were 215 patients with an AASW; 20% were SI. NSI patients had more nonabdominal injuries (47% vs 16%, P < .01) and disposition directly to the operating room (45% vs 26%, P = .02). Intra-abdominal injury rates were similar. One hundred twenty-eight patients had isolated AASWs; 28% were SI. SI patients had higher admission rates (86% vs 63%, P = .01). One hundred three patients had isolated stable/asymptomatic AASWs; 31% were SI. SI patients had more admissions (84% vs 52%, P < .01), had higher intensive care unit admission rates (23% vs 5%, P = .01), longer LOS (3.2 vs 1.4, P < .01), and higher hospital charges ($18,000 vs $11,000, P < .01). The rates of intra-abdominal injury were again similar. CONCLUSIONS: Controlling for extra-abdominal injuries, SI AASW patients have similar rates of intra-abdominal injury but use more resources.