Increasing the Rate of Venous Thromboembolism Chemoprophylaxis Administration Using the Electronic Medical Record.

Introduction: Venous thromboembolism (VTE) remains a leading cause of preventable harm among hospitalized patients. Pharmacologic VTE prophylaxis reduces the rate of in-hospital VTE by 60%, but medication administration is often missed for various reasons. Electronic medical record (EMR) prompts may be a useful tool to decrease withholding of critical VTE chemoprophylaxis medications. Methods: In August 2021, an EMR prompt was implemented at a tertiary referral academic medical center mandating nursing staff to contact a provider for approval before withholding VTE chemoprophylaxis. A pre-intervention group from August 2020 to August 2021 was compared to a post-intervention group from August 2021 to August 2022. Rates of VTE chemoprophylaxis withholding were compared between the groups with a P < .01 considered significant. Results: A total of 16,395 patients prescribed VTE chemoprophylaxis were reviewed, with 13,395 (81.7%) receiving low molecular weight heparin. Of the 16,395 patients included, 10,701 (65.3%) were medical and 5694 (34.7%) were surgical. Patients in the pre-intervention cohort (n = 8803) and post-intervention cohort (n = 7592) were similar in hospital length of stay and duration of DVT prophylaxis. In the post-intervention group, the frequency of surgical patients with at least one missed dose had increased by 4.2% (P = .002), with the trauma and acute care surgery (TACS) show an increase of 6.6% (P < .001). However, the frequency of medical patients and non-TACS patients with missed doses decreased by 3.1% (P = .002) and 1.0% (<.001), respectively. Conclusions: EMR prompts appear to be a low-cost intervention that increases the rate of VTE prophylaxis administration among medical and elective surgery patients.

Implementation of a novel peer review academy by Surgery and the Association of Women Surgeons.

BACKGROUND: A novel Peer Review Academy was developed as a collaborative effort between the Association of Women Surgeons and the journal Surgery to provide formal training in peer review. We aimed to describe the outcomes of this initiative using a mixed methods approach. METHODS: We developed a year-long curriculum with monthly online didactic sessions. Women surgical trainee mentees were paired 1:1 with rotating women surgical faculty mentors for 3 formal peer review opportunities. We analyzed pre-course and post-course surveys to evaluate mentee perceptions of the academy and assessed changes in mentee review quality over time with blinded scoring of unedited reviews. Semi-structured interviews were conducted upon course completion. RESULTS: Ten women surgical faculty mentors and 10 women surgical trainees from across the United States and Canada successfully completed the Peer Review Academy. There were improvements in the mentees' confidence for all domains of peer review evaluated, including overall confidence in peer review, study novelty, study design, analytic approach, and review formatting (all, P ≤ .02). The mean score of peer review quality increased over time (59.2 ± 10.8 vs 76.5 ± 9.4; P = .02). In semi-structured interviews, important elements were emphasized across the Innovation, Implementation Process, and Individuals Domains, including the values of (1) a comprehensive approach to formal peer review education; (2) mentoring relationships between women faculty and resident surgeons; and (3) increasing diversity in the scientific peer review process. CONCLUSION: Our novel Peer Review Academy was feasible on a national scale, resulting in significant qualitative and quantitative improvements in women surgical trainee skillsets, and has the potential to grow and diversify the existing peer review pool.

Hypofibrinogenemic Massive Transfusion Trauma Patients Experience Worse Outcomes.

INTRODUCTION: Uncontrolled hemorrhage accounts for up to 40% of trauma-related mortality. Previous reports demonstrate that decreased fibrinogen levels during traumatic hemorrhage are associated with worse outcomes. Cryoprecipitate is used to replace fibrinogen for patients in hemorrhagic shock undergoing massive transfusion (MT), though the optimal ratio of cryoprecipitate to fresh frozen plasma (FFP), packed red blood cells (PRBCs), and platelets remains undefined. The purpose of this study is to investigate the effect of admission fibrinogen level and the use of cryoprecipitate on outcomes in trauma patients undergoing MT. METHODS: A prospective practice management guideline was established to obtain fibrinogen levels on adult trauma patients undergoing MT at a level I trauma center from December 2019 to December 2021. Ten units of cryoprecipitate were administered every other round of MT. Thromboelastography (TEG) was also obtained at the initiation and completion of MT. Patient demographic, injury, transfusion, and outcome data were collected. Hypofibrinogenemic (<200 mg/dL) patients at initiation of MT were compared to patients with a level of 200 mg/dL or greater. RESULTS: A total of 96 out of 130 patients met criteria and underwent MT with a median admission fibrinogen of 170.5 mg/dL. Hypofibrinogenemia was associated with elevated INR (1.26 vs 1.13, P < .001) and abnormal TEG including decreased alpha angle (68.1 vs 73.3, P < .001), increased K time (1.7 vs 1.1, P < .001), and decreased max amplitude (58 vs 66, P < .001). Patients with hypofibrinogenemia received more PRBC (10 vs 7 U, P = .002), FFP (9 vs 6 U, P = .003), and platelets (2 vs 1 U, P = .004) during MT. Hypofibrinogenemic patients demonstrated greater mortality than patients with normal levels (50% vs 23.5%, P = .021). Older age, decreased GCS, and elevated injury severity score (ISS) were risk factors for mortality. Increased fibrinogen was associated with lower odds of mortality (P = .001). Age, ISS, and fibrinogen level remained significantly associated with mortality in a multivariable analysis. Overall, fibrinogen in post-MT survivors showed an increase in median level compared to admission (231 vs 177.5 mg/dL, P < .001). CONCLUSION: Trauma patients undergoing MT with decreased admission fibrinogen demonstrate increased mortality. Other mortality risk factors include older age, decreased GCS, and higher ISS. Patients with increased fibrinogen levels had lower odds of mortality in a multivariable model. Post-MT survivors demonstrated significantly higher fibrinogen levels than pre-MT patients. Hypofibrinogenemic patients also had worse TEG parameters and required more PRBCs, FFP, and platelets during MT. Further studies are needed to assess the optimal volume of fibrinogen replacement with cryoprecipitate during MT to improve trauma patient mortality.

Intraoperative Methadone Reduces Postoperative Opioid Requirements in Nuss Procedure for Pectus Excavatum.

INTRODUCTION: Surgical correction of pectus excavatum by Nuss procedure, commonly referred to as minimally invasive repair of pectus excavatum (MIRPE), often results in significant postoperative pain. This study investigated whether adding intraoperative methadone would reduce the postoperative opioid requirement during admission for patients undergoing MIRPE. METHODS: A retrospective cohort chart review was conducted for 40 MIRPE patients between 2018 and 2020. Patients were stratified into 2 groups: those who received multimodal anesthesia (MM, n = 20) and those who received multimodal anesthesia with the addition of intraoperative methadone (MM + M, n = 20). Data collected included total opioid consumption during hospital stay (morphine milligram equivalents [MMEs]), hospital length of stay (LOS), pain scores, time to ambulation, and time to tolerating solid food. RESULTS: Addition of intraoperative methadone for patients undergoing MIRPE significantly reduced postoperative opioid requirements (MME/kg) during admission (P = .007). On average, patients in the MM group received 1.61 ± .55 MME/kg while patients in the MM + M group received 1.16 ± .44 MME/kg. Hospital opioid (non-methadone) total was also significantly reduced between the MM (1.87 ± .54) and MM + M group (1.37 ± .46), P = .003. There was no significant difference in hospital opioid total MME/kg administered between the groups. There were no significant differences observed in hospital LOS, pain scores, time to ambulation, or time to toleration of solid food. DISCUSSION: Incorporating intraoperative methadone for patients undergoing MIRPE reduced postoperative opioid requirements and hospital opioid (non-methadone) totals without a significant change in pain scores. Patients undergoing the Nuss procedure may benefit from the administration of intraoperative methadone.

Ultrasound may safely replace chest radiograph after tube thoracostomy removal in trauma patients.

INTRODUCTION: A chest radiograph (CXR) is routinely obtained in trauma patients following tube thoracostomy (TT) removal to assess for residual pneumothorax (PTX). New literature supports the deference of a radiograph after routine removal procedure. However, many surgeons have hesitated to adopt this practice due to concern for patient welfare and medicolegal implications. Ultrasound (US) is a portable imaging modality which may be performed rapidly, without radiation exposure, and at minimal cost. We hypothesized that transitioning from CXR to US following TT removal in trauma patients would prove safe and provide superior detection of residual PTX. MATERIALS AND METHODS: A practice management guideline was established calling for the performance of a CXR and bedside US 2 h after TT removal in all adult trauma patients diagnosed with PTX at a level 1 trauma center. Surgical interns completed a 30-minute, US training course utilizing a handheld US device. US findings were interpreted and documented by the surgical interns. CXRs were interpreted by staff radiologists blinded to US findings. Data was retrospectively collected and analyzed. RESULTS: Eighty-nine patients met inclusion criteria. Thirteen (15%) post removal PTX were identified on both US and CXR. An additional 11 (12%) PTX were identified on CXR, and 5 (6%) were identified via US, for a total of 29 PTX (33%). One patient required re-intervention; the recurrent PTX was detected by both US and CXR. For all patients, using CXR as the standard, US displayed a sensitivity of 54.2%, specificity of 92.3%, negative predictive value of 84.5%, and positive predictive value of 72.2%. The cost of care for the study cohort may have been reduced over $9,000 should US alone have been employed. CONCLUSION: Bedside US may be an acceptable alternative to CXR to assess for recurrent PTX following trauma TT removal.

Prevention of alcohol withdrawal syndrome in the surgical ICU: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document.

Alcohol withdrawal syndrome is a common and challenging clinical entity present in trauma and surgical intensive care unit (ICU) patients. The screening tools, assessment strategies, and pharmacological methods for preventing alcohol withdrawal have significantly changed during the past 20 years. This Clinical Consensus Document created by the American Association for the Surgery of Trauma Critical Care Committee reviews the best practices for screening, monitoring, and prophylactic treatment of alcohol withdrawal in the surgical ICU.

Analysis of Admission Thromboelastogram Profiles in 1369 Male and Female Trauma Patients.

INTRODUCTION: Recent studies have demonstrated a hypercoagulable thromboelastrogram (TEG) in female trauma patients compared with males, conferring a possible survival advantage. We hypothesized that TEG profiles would reveal a relative hypercoagulable state in female compared with male trauma patients. METHODS: A prospective review was conducted on all adult trauma patients admitted to the trauma service at an American College of Surgeons-verified level I trauma center from December 2019 to June 2021 who, per our institutional protocol, received a thrombelastotgraphy on their initial arrival to the trauma center if classified as a level I or II trauma activation. The thromboelastography values of male and female trauma patients were compared as the primary outcome variables of interest. The secondary outcomes investigated were hospital length of stay, surgical interventions, and ventilatory requirement. RESULTS: A total of 1369 patients met inclusion criteria, with 878 (64.1%) male and 491 (35.9%) female. Female patients had a higher median alpha angle (74.8 versus 72.6°, P < 0.001), maximum amplitude (69.3 versus 66.2 mm, P < 0.001), and shorter median K time (1.0 versus 1.2 s, P < 0.001). Female patients had a shorter hospital length of stay (4 versus 5 d, P < 0.001), had a lower rate of surgical intervention (14.6% versus 25.5%, P < 0.001), and had lower rates of mechanical ventilation (19.3% versus 39.5%, P < 0.001). CONCLUSIONS: Female trauma patients were found to have hypercoagulable indices on TEG at the time of initial trauma evaluation compared with males. Intrinsic differences in sex coagulation profiles should be further investigated to optimize modern resuscitation strategies.

Routine Lower Extremity Screening Ultrasound Protocols in Trauma Patients Are Not Cost Effective.

BACKGROUND: Despite prophylaxis, deep vein thrombosis (DVT) and pulmonary embolism remain dreaded complications following traumatic injury and are associated with significant morbidity and mortality. Screening ultrasound (US) protocols have been employed in trauma centers for early detection of lower extremity (LE) deep venous thrombosis. We hypothesized that screening lower extremity venous duplex US would not prove cost effective in our trauma population who receives early pharmacologic prophylaxis. METHODS: Data was collected for one year on all adult trauma patients admitted to the trauma service from December 2019 to 2020. DVT screening US was obtained at 3 days after admission for patients with long bone or pelvic fracture, spinal cord injury, immobility, and/or spinal fracture requiring surgery. Screening US was obtained at 7 days for all others and repeated weekly until discharge. Data was retrospectively collected and analyzed. RESULTS: Exactly 1365 patients met inclusion criteria with median ISS 12 (IQR, 9-17), median age 56 (IQR, 36-73 years), and with majority blunt injuries (90.7%). A total of 1369 screening US were performed finding 27 DVTs (2%). The total cost of screening for the year analyzed amounted to over $270,000 with 50.7 screening US needed to detect 1 DVT. This resulted in an average screening cost of over $10,000 for the detection of a single DVT. DISCUSSION: In trauma patients receiving early pharmacologic prophylaxis, routine LE screening US protocols to detect LE DVT are not cost effective.

Traumatic brain injury patients with platelet inhibition receiving platelet transfusion demonstrate decreased need for neurosurgical intervention and decreased mortality.

BACKGROUND: Platelet dysfunction is known to occur in patients with traumatic brain injury (TBI), and the correction of platelet dysfunction may prevent hemorrhagic progression in TBI. Thromboelastography with platelet mapping (TEG-PM; Haemonetics) evaluates the degree of platelet function inhibition through the adenosine diphosphate (ADP) and arachidonic acid (AA) pathways. We hypothesized that ADP and AA inhibition would improve with the transfusion of platelets in patients with TBI. METHODS: A retrospective review was conducted at a Level I trauma center of all patients presenting with TBI from December 2019 to December 2020. Per a practice management guideline, a platelet mapping assay was obtained on all patients with TBI upon admission. If ADP or AA was found to be inhibited (>60%), the patient was transfused 1 unit of platelets and a repeat platelet mapping assay was ordered. Demographic data, laboratory values, and outcomes were analyzed. RESULTS: Over the 13-month study period, 453 patients with TBI underwent TEG-PM with a protocol adherence rate of 66.5% resulting in a total of 147 patients who received platelets for ADP and/or AA inhibition; of those, 107 underwent repeat TEG-PM after platelets were administered. With the administration of platelets, ADP (p < 0.0001), AA (p < 0.0001), and MA (p = 0.0002) all significantly improved. Of 330 patients with TBI not taking antiplatelet medications, 50.9% showed inhibition in ADP and/or AA. If AA or ADP inhibition was noted on admission, mortality was increased (p = 0.0108). If ADP improved with platelet administration, the need for neurosurgical intervention was noted to decrease (p = 0.0182). CONCLUSION: Patients with TBI and platelet inhibition may benefit from the administration of platelets to correct platelet dysfunction. Thromboelastography with platelet mapping may be implemented in the initial workup of patients presenting with TBI to assess platelet dysfunction and provide prognostic information, which may guide treatment. LEVEL OF EVIDENCE: Therapeutic / Care Management, level III.

Overutilization of Helicopter Emergency Medical Services in Central Gulf Coast Region Results in Unnecessary Expenditure.

INTRODUCTION: When appropriately used, helicopter emergency medical services (HEMSs) allow for timely delivery of severely injured patients to definitive care. Inappropriate utilization of HEMSs results in increased cost to the patient and trauma system. The purpose of this study was to review current HEMS criteria in the central Gulf Coast region and evaluate for potential areas of triage refinement and cost savings. We hypothesized that a significant number of patients received potentially unwarranted HEMS transport. METHODS: A retrospective cohort study of all patients with trauma arriving to a level I trauma center by helicopter over 28 mo was performed; 381 patients with trauma and with HEMS transport from the scene were included. Data were collected from prehospital sources, as well as hospital chart review for each patient. The primary outcome was the rate of unwarranted HEMS transport. RESULTS: A total of 381 adult patients with trauma transported by the HEMS were analyzed, of which 34% were deemed potentially nonwarranted transports. The significant factors correlating with warranted HEMS transport included age, multiple long bone fractures, penetrating mechanism, and vehicle ejection. Insurance demographics did not correlate to transport modality. Many of these patients were transported from a location within the same county or the county adjacent to the trauma center. When comparing patients transported by ground and HEMSs from the same scene, no time savings were identified. Unwarranted transports at the trauma center represented an estimated health care expenditure of over $3 million. CONCLUSIONS: HEMSs may be overused in the central Gulf Coast region, creating the risk for a substantial resource and financial burden to the trauma system. Further collaboration is needed to establish HEMS triage criteria, that is, more appropriate use of resources.

Delineating the Role of Serum Immunoglobulin Titers in Burn Patients at High Risk for Herpes Simplex Virus Infection.

Herpes simplex virus (HSV) is common in the population and reactivation of latent infection often occurs in times of physiologic stress, including postburn injury. Active HSV infection complicates burn injury recovery and increases morbidity. A retrospective chart review of high-risk burn patients (≥20%TBSA and/or facial burns) who had screening HSV immunoglobulin titers drawn from 2015 to 2018 was conducted. Titer levels and morbidity-related outcomes were compared between patients who developed active infection and those who did not. Fifty-six patients had serum HSV titers measured. Twenty-nine patients (52%) developed clinical signs of HSV infection, almost all of which (97%) suffered facial burns. Titers were ordered on median hospital day 1.5 (0.00-4.0) and infection occurred on day 8.0 (2.0-16). Median HSV-1,2 IgM titers were significantly increased in patients who developed clinically active HSV infection (0.71 [0.44-1.1] vs 0.52 [0.34-0.74], P = .02). Median HSV-1 IgG (P = .65) and HSV-2 IgG titers (P = .97) were not different between groups. Patients who developed active infection had a comparable hospital length of stay (27 [9.5-40] days vs 20 [8.0-28] days, P = .17) and ICU length of stay (26 [13-49] days vs 19 [11-27] days, P = .09) to those who did not develop infection. There was no difference in mortality. Increased HSV-1 and 2 IgM screening levels were associated with an increased risk of developing active HSV infection, and offer a specific screening modality in high-risk patients. Elevated IgM titers warrant further consideration for administration of HSV prophylaxis, as earlier intervention may prevent infection onset and minimize morbidity.

Oral Administration of Injectable Ketamine During Burn Wound Dressing Changes.

Providing adequate analgesia during burn wound care is essential to patient-centered care. Both oral and intravenous (IV) ketamine are often used for analgesia and sedation. Ketamine may improve analgesia and decrease opioid requirements for burn wound care. Oral ketamine wafers and tablets have been used as a safe alternative internationally but are unavailable in the United States. The purpose of this study was to compare opioid usage and patient satisfaction scores in patients with and without the use of oral injectable ketamine for burn wound care, with each patient serving as their own control. Ketamine, opioid, and benzodiazepine dosages recorded during dressing changes were compared to dressing changes without ketamine use that occurred before and after ketamine-associated sessions in each patient. Fourteen patients received oral ketamine at a median (interquartile range [IQR]) dose of 2.5 (2.2-2.7) mg/kg. Ketamine use significantly decreased opioid requirements when compared to wound care sessions that did not use ketamine both before (50 [IQR: 30-75] mg vs 75 [IQR: 46-91] mg median IV morphine equivalents, P = .0097) and after (50 [IQR: 30-75] mg vs 63 [IQR: 50-96] mg median IV morphine equivalents, P = .0042) the ketamine-associated sessions. One patient experienced hallucinations, and no adverse events were observed. Hence, oral administration of injectable ketamine was associated with a decrease in opioid requirements during dressing changes. Additionally, ketamine use improved patient satisfaction (P = .0034). Preliminary data suggest this promising analgesia method is safe and effective for burn wound care.

Intravenous Ketamine as an Adjunct to Procedural Sedation During Burn Wound Care and Dressing Changes.

Little has been published regarding intravenous (IV) ketamine for burn wound care in adult patients. Ketamine may serve as a safe alternative to provide conscious sedation and limit opioid administration to patients. The purpose of this study was to characterize IV ketamine use during burn wound care and establish its potential role as a safe adjunct to opioid and benzodiazepine medications. This is a retrospective review of adult patients admitted to a regional burn center who received IV ketamine for burn wound care. Patient demographics, medications, and ketamine-related adverse effects including hypertension and dysphoric reactions were recorded. Cardiopulmonary complications were also tracked. Thirty-six patients met inclusion criteria; fifty total cases were performed. The median patient age was 37 (interquartile range [IQR]: 28-55] years with a median burn size of 9.5 (IQR: 4.0-52) %TBSA. The median ketamine dose administered was 1.2 (IQR: 0.8-2.1) mg/kg. IV midazolam was administered in almost all cases (98%) at a median dose of 3.0 (IQR: 2.0-5.0) mg. Opioids were administered in 13 of 50 cases (26%) at a median morphine equivalent dose of 10 (IQR: 5.0-18) mg. In 46 cases (92%), patients denied unpleasant recall of medication. Dysphoric reactions were observed in three cases (6%). Ketamine-induced hypertension occurred in three cases (6%) and all immediately responded to IV labetalol. There were no cardiopulmonary complications. These findings suggest that IV ketamine provides a safe analgesia and sedative option for burn wound care. Given these findings, IV ketamine for burn wound care warrants further study.