Level of Comfort With Pediatric Trauma Transports: Survey of Prehospital Providers.

BACKGROUND: Unintentional injury is the leading cause of death in pediatric patients. Despite a heavy burden of pediatric trauma, prehospital transport and triage of pediatric trauma patients are not standardized. Prehospital providers report anxiety and a lack of confidence in transport, triage, and care of pediatric trauma patients. MATERIALS AND METHODS: Prehospital transport providers with 3 organizations across southeast Georgia and northeast Florida were contacted via email (n = 146) and asked to complete 2 Web-based surveys to evaluate their comfort level with performing tasks in the transport of pediatric and adult trauma patients. Bivariate statistics and qualitative thematic analyses were performed to assess comfort with pediatric trauma transports. RESULTS: Survey 1 (N = 35) showed that mean comfort levels of prehospital providers were significantly lower for pediatric patients than adult trauma patients in 7 out of 9 tasks queried, including airway management and interpreting children's physiology. The following themes emerged from survey 2 (N = 14) responses: additional clinical knowledge resources would be beneficial when caring for pediatric trauma patients, pediatric medication administration is a source of uncertainty, prehospital transport teams would benefit from additional pediatric trauma training, infrequent transport of pediatric trauma patients affects provider comfort level, and pediatric trauma generates higher levels of anxiety among providers. DISCUSSION: Prehospital transport of pediatric trauma patients is infrequent and a source of anxiety for prehospital providers. Rigs should be equipped with a reference tool addressing crucial tasks and deficiencies in training.

Pediatric Safety Restraint Use in Motor Vehicle Crashes at a Level I Safety-Net Trauma Center.

BACKGROUND: Adherence to child passenger safety recommendations is essential to prevent death and injury in children involved in motor vehicle crashes. Parents may not undertake the proper safety measures, which can lead to increase injury. METHODS: A safety net, level I trauma center's database was used to identify admitted children (age<15 y/o) involved in motor vehicle crashes over a 2-y period to investigate safety restraint device use and compliance with state recommendations. Variables evaluated were crash characteristics, presence and method of passenger restraint, demographics, Glasgow Coma Scale, and Injury Severity Score. Excluded were patients where restraint characteristics could not be identified and those discharged from the trauma center. RESULTS: Eighty patients met inclusion criteria. Thirty-two (40%) children were unrestrained. Safety restraint device was noted in 48 (60%) children with 13 (27.1%) patients improperly restrained. The most common method of improper restraint (6, 46.2%) was traveling in the front seat before the age state law recommends. With respect to proper, improper, and no restraint, age (7.31 ± 14.26, 5.76 ± 3.24, P = 0.36), female sex (17, 8, 13, P = 0.32), low-income status (14, 5, 24, P = 0.28), and race (P = 0.08) did not differ between the groups. The unrestrained children had statistically lower initial Glasgow Coma Scale and higher Injury Severity Score and were more often involved in high-risk mechanism of Injury motor vehicle crashes. CONCLUSIONS: Despite recommendations and regulations regarding child passenger safety measures, there are a significant number of children that remain suboptimally restrained who are admitted to a safety-net trauma center. Further research is needed to understand the barriers to increase the compliance with recommendations along with targeted educational campaigns in low-compliance populations.

Applying Pediatric Brain Injury Guidelines at a Level I Adult/Pediatric Safety-Net Trauma Center.

BACKGROUND: Pediatric brain injuries are common, but current management of patients with mild traumatic intracranial hemorrhage (T-ICH) is suboptimal, often including unnecessary repeat head CT (RHCT) and neurosurgical consultation (NSC). Brain Injury Guidelines (BIG) have been developed to standardize the management of TBI, and recent work suggests they may be applied to children. The aim of this study was to apply BIG to a low-risk pediatric TBI population to further determine whether the framework can be safely applied to children in a way that reduces overutilization of RHCTs and NSC. METHODS: A retrospective chart review of a Level I Adult and Pediatric Trauma Center's pediatric registry over 4 y was performed. BIG was applied to these patients to evaluate the utility of RHCT and need for neurosurgical intervention (NSG-I) in those meeting BIG-1 criteria. Those with minor skull fracture (mSFx) who otherwise met BIG-1 criteria were also included. RESULTS: Twenty-eight patients with low-risk T-ICH met criteria for review. RHCT was performed in seven patients, with only two being prompted by clinical neurologic change/deterioration. NSC occurred in 21 of the cases. Ultimately, no patient identified by BIG-1 ± mSFx required NSG-I. CONCLUSIONS: Application of BIG criteria to children with mild T-ICH appears capable of reducing RHCT and NSC safely. Additionally, those with mSFx that otherwise fulfill BIG-1 criteria can be managed similarly by acute care surgeons. Further prospective studies should evaluate the application of BIG-1 in larger patient populations to support the generalizability of these findings.

An Old Idea is a Novel Concept for Supplemental Funding of Surgical Residency Programs.

Background In July 2014, the Institute of Medicine released a review of the governance of Graduate Medical Education (GME), concluding that changes to GME financing were needed to reward desired performance and to reshape the workforce to meet the nation's needs. In light of the rapid emergence of alternative payment systems, we evaluated the financial value of resident participation in operative surgical care.  Methods The Department of Surgery provided Current Procedural Terminology (CPT) codes for procedures performed by the general surgical service at our institution for the 2011 academic year. For each code, the charge and total instances were provided. CPTs allowing an assistant fee were identified using the Searchable Medicare Physician Fee Schedule. This approach enabled calculation of the potential resident contribution to GME funding. Results A total of 515 unique CPTs were potentially billable for a total of 6,578 procedures, of which 2,552 (39%) were reimbursable. These CPTs would have generated $1,882,854 in assistant charges. The top 50 most frequent CPTs resulted in 4,247 procedures. Within the top 50, 1362 procedures (32% of the top 50, 21% of the total) were reimbursable. Of the total assistant charges, $963,227 (51%) occurred in the top 50 most frequent CPTs. Conclusions Credit for resident participation in operative care as co-surgeon would average $67,244 per resident, compared to our current funding of $142,635 per resident. This type of alternative funding could provide 47% of current educational support. The skew in distribution of procedures also suggests that such a system could provide guidance to a more balanced operative experience. Such performance-based credentialing could be used to ensure appropriate housestaff for a given case; these reimbursements could also be adjusted based on quality metrics to provide for transformational change in patient outcomes.

Two novel resource-based metrics to quantify pediatric trauma severity based on probability of requiring critical care and anesthesia services.

BACKGROUND: Mortality-based metrics like the International Classification of Diseases (ICD) Injury Severity Score (ICISS) may underestimate burden of pediatric traumatic disease due to lower mortality rates in children. The purpose of this study was to develop and validate two resource-based severity of injury (SOI) measures, then compare these measures and the ICISS across a broad age spectrum of injured patients. METHODS: The ICISS and two novel SOI measures, termed ICD Critical Care Severity Score (ICASS) and ICD General Anesthesia Severity Score (IGASS), were derived from Florida state administrative 2012 to 2016 data and validated with 2017 data. The ICASS and IGASS predicted the need for critical care services and anesthesia services, respectively. Logistic regression was used to validate each SOI measure. Distributions of ICISS, ICASS, and IGASS were compared across pediatric (0-15 years), adult (16-64 years), and elderly (65-84 years) age groups. RESULTS: The derivation and validation cohorts consisted of 668,346 and 24,070 emergency admissions, respectively. On logistic regression, ICISS, ICASS, and IGASS were strongly predictive of observed mortality, critical care utilization, and anesthesia utilization, respectively (p < 0.001). The mean ICISS was 10.6 for pediatric and 19.0 for adult patients (ratio, 0.56), indicating that the predicted mortality risk in pediatric patients was slightly over half that of adults. In contrast, the mean ICASS for pediatric and adult patients was 50.2 and 53.2, respectively (ratio, 0.94); indicating predicted critical care utilization in pediatric patients was nearly the same as that of adults. The IGASS comparisons followed comparable patterns. CONCLUSION: When a mortality-based SOI measure is used, the severity of pediatric injury appears much lower than that of adults, but when resource-based measures are used, pediatric and adult burden of injury appear very similar. The ICASS and IGASS are novel and valid resource-based SOI measures that are easily calculated with administrative data. They may complement mortality-based measures in pediatric trauma. LEVEL OF EVIDENCE: Level III, prognostic and epidemiological study.

Clavien-Dindo Analysis of NSQIP Data Objectively Measures Patient-Focused Quality.

Current quality measures intended to drive improved clinical performance are perceived as an inappropriate administrative burden. Surgeon-constructed quality measures, including the NSQIP, are more closely aligned with provider performance and relevant outcome. We hypothesized that NSQIP participation would be associated with measurable improvement in surgical outcomes. Elective general surgical cases were compared by case volume and incidence of postoperative adverse events (AEs) from 2014 to 2017. Using the Clavien-Dindo severity scaling system, we summed the grades for each AE and defined the patient population burden of these AEs as this sum divided by case volume. Case volume samples increased 67 per cent from 2014 (n = 526, 30 day complete) to 2017 (n = 878). Ratio of patient burden to case volume improved from 0.92 (2014) to 0.73 (2017). Comparison of AE incidence was not significantly different; however, the majority decreased over time. Analysis of individual AE interval change identified sepsis-related respiratory care as the top priority performance improvement target. These data reflect improved performance for a growing volume of surgical procedures. The impact of perioperative morbidity and their associated burden on affected patients has decreased, demonstrating the value of combining NSQIP with Clavien-Dindo to measure the quality of surgical care in objective and patient-specific terms.

Suspected appendicitis pathway continues to lower CT rates in children two years after implementation.

BACKGROUND: We implemented a protocol to evaluate pediatric patients with suspected appendicitis using ultrasound as the initial imaging modality. CT utilization rates and diagnostic accuracy were evaluated two years after pathway implementation. METHODS: This was a retrospective observational study of patients <18 years evaluated for suspected appendicitis. CT rates were compared before and after implementation of the protocol, and monthly CT rates were calculated to assess trends in CT utilization. RESULTS: CT use decreased significantly following pathway implementation from 94.2% (130/138) to 27.5% (78/284; p < 0.001). Linear regression of monthly CT utilization demonstrated that CT rates continued to trend down two years after pathway implementation. Adherence to the pathway was 89.8% (255/284). Negative appendectomy rate was 2.4% (2/85) in the post-pathway period. CONCLUSIONS: Adherence to a pathway designed to evaluate pediatric patients with suspected appendicitis using ultrasound as the primary imaging modality has led to a sustained decrease in CT use without compromising diagnostic accuracy.

Twenty years of pediatric gunshot wounds in our community: Have we made a difference?

BACKGROUND/PURPOSE: Pediatric gunshot wounds (GSWs) carry significant incidence, mortality, and cost. We evaluated 20 years of GSW demographics at this level 1 trauma center and constructed a risk map triangulating areas of high incidence with risk factors. METHODS: Children 0-18 years suffering a GSW between 1996 and 2016 were identified via our trauma registry. Hospital charges, demographic, socioeconomic, and institutional variables were retrospectively reviewed. Multivariable logistic regression identified predictors of mortality. Geographic information system (GIS) mapping of incident location and residence identified areas of higher incidence. RESULTS: The cohort (n = 898) was 86.4% male. Mean age was 15.6 ±â€¯3.4 years. Median Injury Severity Score (ISS) was 9 (1-75). Procedural and/or operative intervention occurred in 52.9%. Intent included assault (81.5%) and unintentional injury (12.8%). Hospital charges showed significant annual increase. Annual incidence varied without trend (p = 0.89). Mapping revealed significant clustering of GSWs in known lower socioeconomic areas. Yearly and total GSWs were highest in one particular zip code. ISS was a significant predictor of mortality (n = 18) (OR 1.19, 95% CI 1.15-1.22, p < 0.001). CONCLUSIONS: Our impoverished neighborhoods have higher pediatric GSW incidence, unchanged over 20 years. Alternative community-based prevention efforts should involve neighborhood capacity building and economic strengthening. TYPE OF STUDY: Retrospective study. LEVEL OF EVIDENCE: Level IV.

Alternative payment models: can (should) trauma care be bundled?

BACKGROUND: Recent legislation repealing the Sustainable Growth Rate mandates gradual replacement of fee for service with alternative payment models (APMs), which will include service bundling. We analyzed the 2 years' experience at our state-designated level I trauma center to determine the feasibility of such an approach for trauma care. METHODS: De-identified data from all injured patients treated by the trauma service during 2014 and 2015 were reviewed to determine individual patient injury profiles. Using these injury profiles we created the 'trauma bundle' by concatenating the highest Abbreviated Injury Scale score for each of the six body regions to produce a single 'signature' of injury by region for every patient. These trauma bundles were analyzed by frequency over 2 years and by each year. The impacts of physiology and resource consumption were evaluated by determination of the correlation of the mean and SD of calculated survival probability (Ps) and intensive care unit length of stay (ICU LOS) for each profile group occurring more than 12 times in 2 years. RESULTS: The 5813 patients treated over 2 years produced 858 distinct injury profiles, only 8% (71) of which occurred more than 12 times in 2 years. Comparison of 2014 and 2015 profiles demonstrated high frequency variation among profiles between the 2 years. Analysis of injury patterns occurring >12 times in 2 years demonstrated an inverse correlation between the mean and SD for Ps (R2=0.68) and a direct correlation for ICU LOS (R2=0.84). DISCUSSION: These data indicate that the disease of injury is too inconsistent a mix of injury pattern and physiologic response to be predictably bundled for an APM. The inverse correlation of increasing SD with increasing ICU LOS and decreasing Ps suggests an opportunity for measurable process improvement. LEVEL OF EVIDENCE: Economic and value-based evaluations, level IV. STUDY TYPE: Economic/decision.

How Safe Is the Safety Net? Comparison of Ivor-Lewis Esophagectomy at a Safety-Net Hospital Using the NSQIP Database.

BACKGROUND: Recent data suggest that surgical outcomes at hospitals caring for low-income, vulnerable populations are suboptimal compared with outcomes from nonsafety-net hospitals. Therefore, the purpose of our study was to compare outcomes for patients who underwent an Ivor-Lewis esophagectomy at a safety-net hospital with the National Surgical Quality Improvement Program (NSQIP) database. STUDY DESIGN: We retrospectively reviewed the medical records of consecutive patients who underwent an Ivor-Lewis esophagectomy, between September 2013 and January 2017, at a single safety-net hospital. Patient characteristics and outcomes were compared with the 2013 to 2015 NSQIP database. Continuous variables were compared using Student's t-test, and categorical variables were analyzed using chi-square tests. Values of p < 0.05 were considered significant. RESULTS: We identified 78 patients from the safety-net hospital and 1,825 patients in the NSQIP database who underwent an Ivor-Lewis esophagectomy. Baseline characteristics were similar, except the safety-net hospital patients were more likely to have COPD (19.2% vs 8.1%; p = 0.001) and be current smokers (42.3% vs 26.0%; p = 0.001); patients in the NSQIP group had a higher BMI (28 kg/m2 vs 26 kg/m2; p = 0.001). There were no differences between groups for mortality, readmission, discharge destination, or mean operative time. Safety-net hospital patients had significantly fewer complications (16.7% vs 33.3%; p = 0.003), fewer reoperations (6.4% vs 14.5%; p = 0.046), and shorter hospital length of stay (10.3 vs 13.1 days; p = 0.001). CONCLUSIONS: Patients who underwent an Ivor-Lewis esophagectomy at a safety-net hospital had fewer complications and reoperations, and a shorter hospital length of stay compared with a national cohort. These findings illustrate the value of clinical pathways in optimizing the patient outcomes at safety-net hospitals and providing excellent care to their vulnerable patient population.

Early unplanned trauma readmissions in a safety net hospital are resource intensive but not due to resource limitations.

BACKGROUND: In an era of decreasing reimbursements, the incentive to decrease readmissions has never been greater. It has been suggested that trauma readmission is an indicator of poor hospital care or fragmented discharge. Even though trauma readmissions are relatively low, readmissions add significant cost, tie up already limited resources and lead to worse outcomes, including mortality. The literature on trauma readmissions is sparse, and the reasons and risk factors for readmission are inconsistent across studies. If readmissions are to serve as useful indicators of quality of care, we must elucidate factors that may predict readmissions. METHODS: We performed a retrospective review of all admissions to our urban Level I trauma center from July 1, 2012, to June 30, 2015. All patients aged 16 years or older who were discharged alive were included. We identified all unplanned readmissions that occurred within 30 days of discharge and performed an extensive chart review to determine the reasons for readmission. We performed univariate and multivariable analyses. RESULTS: We identified 6,026 index trauma admissions, with 158 (2.6%) unplanned readmissions within 30 days of discharge. The most common reasons for readmission were disease/symptom progression (30.2%), wound complications (28.9%), and pain control (11.8%). On multivariate analysis, only Injury Severity Score (odds ratio [OR], 1.02; 95% confidence interval [CI], 1.00-1.05; p=0.016), penetrating injuries (OR, 1.9; 95% CI, 1.12-3.24; p=0.018), and smoking (OR, 1.73; 95% CI, 1.05-2.86; p=0.031) were found to be significant. Hospital length of stay, insurance status, and race were not significant. CONCLUSION: In a resource-limited environment, we expected a lack of access to care would lead to increased trauma readmissions; however, we were still able to achieve similar readmission rates, irrespective of insurance status and race. Our trauma readmission rate is low and consistent with previously published studies. Our results at our Level I trauma center support previously published studies that found Injury Severity Score and penetrating injury to be risk factors for readmission; however, more ubiquitous risk factors, such as hospital length of stay and discharge destination, were not significant. With no consensus on the risk factors for unplanned early trauma readmission, individual trauma centers should evaluate their specific risk factors for readmission to improve patient outcomes and decrease hospital costs. LEVEL OF EVIDENCE: Care management, level IV; Epidemiologic, level IV.

The trauma ecosystem: The impact and economics of new trauma centers on a mature statewide trauma system.

INTRODUCTION: Florida serves as a model for the study of trauma system performance. Between 2010 and 2104, 5 new trauma centers were opened alongside 20 existing centers. The purpose of this study was to explore the impact of trauma system expansion on system triage performance and trauma center patients' profiles. METHODS: A statewide data set was queried for all injury-related discharges from adult acute care hospitals using International Classification of Diseases, Ninth Revision (ICD-9) codes for 2010 and 2014. The data set, inclusion criteria, and definitions of high-risk injury were chosen to match those used by the Florida Department of Health in its trauma registry. Hospitals were classified as existing Level I (E1) or Level II (E2) trauma centers and new E2 (N2) centers. RESULTS: Five N2 centers were established 11.6 to 85.3 miles from existing centers. Field and overall trauma system triage of high-risk patients was less accurate with increased overtriage and no change in undertriage. Annual volume at N2 centers increased but did not change at E1 and E2 centers. In 2014, Patients at E1 and E2 centers were slightly older and less severely injured, while those at N2 centers were substantially younger and more severely injured than in 2010. The injured patient-payer mix changed with a decrease in self-pay and commercial patients and an increase in government-sponsored patients at E1 and E2 centers and an increase in self-pay and commercial patients with a decrease in government-sponsored patients at N2 centers. CONCLUSION: Designation of new trauma centers in a mature system was associated with a change in established trauma center demographics and economics without an improvement in trauma system triage performance. These findings suggest that the health of an entire trauma system network must be considered in the design and implementation of a regional trauma system. LEVEL OF EVIDENCE: Therapeutic/care management study, level IV; epidemiological, level IV.

To nearly come full circle: Nonoperative management of high-grade IV-V blunt splenic trauma is safe using a protocol with routine angioembolization.

INTRODUCTION: Nonoperative management (NOM) of hemodynamically stable high-grade (IV-V) blunt splenic trauma remains controversial given the high failure rates (19%) that persist despite angioembolization (AE) protocols. The NOM protocol was modified in 2011 to include mandatory AE of all grade (IV-V) injuries without contrast blush (CB) along with selective AE of grade (I-V) with CB. The purpose of this study was to determine if this new AE (NAE) protocol significantly lowered the failure rates for grade (IV-V) injuries allowing for safe observation without surgery and if the exclusion of grade III injuries allowed for the prevention of unnecessary angiograms without affecting the overall failure rates. METHODS: The records of patients with blunt splenic trauma from January 2000 to October 2014 at a Level I trauma center were retrospectively reviewed. Patients were divided into two groups and failure of NOM (FNOM) rates compared: NAE protocol (2011-2014) with mandatory AE for all grade (IV-V) injuries without CB and selective AE for grade (I-V) with CB versus old AE (OAE) protocol (2000-2010) with selective AE for grade (I-V) with CB. RESULTS: Seven hundred twelve patients underwent NOM with 522 (73%) in the OAE group and 190 (27%) in the NAE group. Evolving from the OAE to the NAE strategy resulted in a significantly lower FNOM rate for the overall group (grade I-V) (OAE vs. NAE, 4% to 1%, p = 0.04) and the grade (IV-V) group (OAE vs. NAE, 19% vs. 3%, p = 0.01). Angiograms were avoided in 113 grade (I-III) injuries with no CB; these patients had NOM with observation alone and none failed. CONCLUSIONS: A protocol using mandatory AE of all high-grade (IV-V) injuries without CB and selective AE of grade (I-V) with CB may provide for optimum salvage with safe NOM of the high-grade injuries (IV-V) and limited unnecessary angiograms. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Development and validation of a continuously age-adjusted measure of patient condition for hospitalized children using the electronic medical record.

Awareness of a patient's clinical status during hospitalization is a primary responsibility for hospital providers. One tool to assess status is the Rothman Index (RI), a validated measure of patient condition for adults, based on empirically derived relationships between 1-year post-discharge mortality and each of 26 clinical measurements available in the electronic medical record. However, such an approach cannot be used for pediatrics, where the relationships between risk and clinical variables are distinct functions of patient age, and sufficient 1-year mortality data for each age group simply do not exist. We report the development and validation of a new methodology to use adult mortality data to generate continuously age-adjusted acuity scores for pediatrics. Clinical data were extracted from EMRs at three pediatric hospitals covering 105,470 inpatient visits over a 3-year period. The RI input variable set was used as a starting point for the development of the pediatric Rothman Index (pRI). Age-dependence of continuous variables was determined by plotting mean values versus age. For variables determined to be age-dependent, polynomial functions of mean value and mean standard deviation versus age were constructed. Mean values and standard deviations for adult RI excess risk curves were separately estimated. Based on the "find the center of the channel" hypothesis, univariate pediatric risk was then computed by applying a z-score transform to adult mean and standard deviation values based on polynomial pediatric mean and standard deviation functions. Multivariate pediatric risk is estimated as the sum of univariate risk. Other age adjustments for categorical variables were also employed. Age-specific pediatric excess risk functions were compared to age-specific expert-derived functions and to in-hospital mortality. AUC for 24-h mortality and pRI scores prior to unplanned ICU transfers were computed. Age-adjusted risk functions correlated well with similar functions in Bedside PEWS and PAWS. Pediatric nursing data correlated well with risk as measured by mortality odds ratios. AUC for pRI for 24-h mortality was 0.93 (0.92, 0.94), 0.93 (0.93, 0.93) and 0.95 (0.95, 0.95) at the three pediatric hospitals. Unplanned ICU transfers correlated with lower pRI scores. Moreover, pRI scores declined prior to such events. A new methodology to continuously age-adjust patient acuity provides a tool to facilitate timely identification of physiologic deterioration in hospitalized children.

The effects of neoadjuvant therapy on morbidity and mortality of esophagectomy for esophageal cancer: American college of surgeons national surgical quality improvement program (ACS-NSQIP) 2005-2012.

OBJECTIVE: This study used a multi-center database to evaluate the impact of neoadjuvant therapy on the 30-day morbidity and mortality following esophagectomy for esophageal cancer. METHODS: The NSQIP database was queried for 2005-2012 for patients, who had esophagectomy for esophageal cancer. Patients were divided into two groups: neoadjuvant therapy and esophagectomy only. RESULTS: The neoadjuvant group had a lower rates of sepsis (8% vs. 13%, unadjusted P = 0.004) and acute renal failure (0.4% vs. 2%, unadjusted P = 0.01), and a higher rate of pulmonary embolism (PE) (3% vs. 1%, unadjusted P = 0.04). The adjusted odds of PE for patients, who received neoadjuvant therapy were 2.8 times the odds of PE for patients in the esophagectomy group, controlling for BMI. The association with renal failure was not significant, when one adjusted for race. There was no difference in the rates of reoperation, readmission, stroke, cardiac arrest, MI, surgical site and deep organ infections, anastomosis failure, blood transfusions, DVT, septic shock, pneumonia, UTI, respiratory failure, and 30-day mortality between the two groups. CONCLUSIONS: We conclude that neoadjuvant therapy followed by esophagectomy for esophageal cancer does not have a negative impact on 30-day mortality. Neoadjuvant therapy is associated with increased odds of PE. J. Surg. Oncol. 2017;115:296-300. © 2016 Wiley Periodicals, Inc.

National Surgical Quality Improvement Program integration with Morbidity and Mortality conference is essential to success in the march to zero.

BACKGROUND: Morbidity and Mortality conference (M&M) and the National Surgical Quality Improvement Program (NSQIP) are systems to improve surgical care. We evaluated the commonality of adverse events (AEs) and the change in AE rates after integration. METHODS: A single institution's NSQIP and M&M registries were analyzed to determine commonality of AE reported. Causal determinant groups were then created to categorize and standardize AE. Incidence of AE and patient commonality identified by these systems was evaluated over 2 years. RESULTS: The 68 common patients identified in 2012 represented 27% of NSQIP and 43% of M&M patients. Common AE reported by M&M and NSQIP decreased from 16.9% (2013) to 9.6% (2014). Causality code analysis demonstrated significant differences in proportion of issues addressed within each (P < .0001). CONCLUSIONS: Despite standardized coding, M&M focus differed from NSQIP. Low commonality affirms NSQIP as a critical adjunct to voluntary reporting. Combining both may help eliminate preventable AEs.

Restating Surgical Risk: From Patient to Population.

BACKGROUND: Recent federal legislation driving transition from fee-for-service to alternative methods of payment makes risk recognition essential for determination of appropriate payment systems. Because negotiations will include bundled population cohorts, we compared risk and results of an urban safety net teaching hospital's surgical population with state and national cohorts. STUDY DESIGN: Deidentified summary data for 2013 and 2014 were analyzed to compare the safety net teaching hospital with a statewide collaborative and a national cohort from similar academic centers. Incidence of preoperative risk factors were compared, identifying those that were >50% higher than both state and national experiences. These were compared for change in incidence between years. Outcomes were evaluated by 30-day mortality, readmissions, return to operating room, length of stay, and adverse events incidence. RESULTS: For both years, incidence of smoking, ventilator dependence, and CHF within 30 days was >50% higher than in the state and national cohorts. In 2014, septic shock was added to this, along with increased diabetes (14.3% to 19.8%), CHF (1.9% to 2.8%), and hypertension (39.9% to 52.5%). Despite these changes, 30-day mortality, return to operating room, length of stay, and readmissions were within ±5% of state and national results. Unplanned intubation, ventilation longer than 48 hours, and acute renal failure were 10th decile outliers. Median and interquartile range for length of stay were similar for all 3 populations across both years. CONCLUSIONS: The incidence of comorbid conditions defines greater risk in this safety net teaching hospital population. Increased smoking-related pathology reflects local population disease burden, and increased ventilator support defines additional cost for this care. As disease-, procedure-, or population-based payment alternatives evolve, risk recognition, reduction, and resolution will be essential for determination of cost-efficient, optimal, surgical outcomes.