A different form of injury prevention: Successful screening and referral for human immunodeficiency virus and hepatitis C virus in a trauma population.

BACKGROUND: In the United States, millions of patients are living with human immunodeficiency virus (HIV) and hepatitis C virus (HCV) (0.44% and 1.5%) and many are currently undiagnosed. Because highly effective treatments are now available, early identification of these patients is extremely important to achieve improved clinical outcomes. Prior data and trauma-associated risk factors suggest a higher prevalence of both diseases in the trauma population. We hypothesized that a screening program could be successfully initiated among trauma activation patients and that a referral and linkage-to-care program could be developed. METHODS: Hepatitis C virus and HIV screening tests were added to standard trauma activation laboratory orders at an academic Level I Trauma Center. Confirmatory viral load was sent when indicated. Patients with positive results were educated about their disease and referred to disease-specific follow-up. Data were collected prospectively from January 1, 2016, until June 30, 2017. Total and new diagnosis, referral rates, and linkage-to-care rates were analyzed. RESULTS: One thousand eight hundred ninety-eight patients arrived as trauma activations. One thousand two hundred seventeen (64.1%) patients were screened (Level A, 75.6%; Level B, 60.2%). Seven percent of the screened patients were initially positive, and 5.5% were confirmed positive. Rates of both HIV (1.1%) and HCV (4.4%) were almost triple the national average. Overall, 3.3% screened positive for a new diagnosis. For HCV, the rate of new diagnosis was twice the national average (3%). Over 85% of all cases were referred for follow-up, and the combined linkage-to-care rate was 43.3%. CONCLUSION: The majority of patients were screened and referred for follow-up, indicating successful implementation of our trauma screening program. Routine screening of trauma patients should be considered to increase diagnosis rate, increase linkage-to-care rates, and decrease disease transmission. These screening efforts would help bridge the health care gap that exists in the trauma population due to lower insurance rates and limited access to primary care. LEVEL OF EVIDENCE: Therapeutic/Care management, level III.

Proportional costs in trauma and acute care surgery patients: dominant role of intensive care unit costs.

BACKGROUND: Controlling inpatient costs is increasingly important. Identifying proportionately larger cost categories may help focus cost control efforts. The purpose of this study was to identify proportionate patient cost categories in trauma and acute care surgery (TACS) patients and determine subgroups in which the largest opportunities for cost savings might exist. STUDY DESIGN: Administrative data from our academic, urban, level I trauma center were used to identify all adult TACS patients from FY07 through FY11. We determined, on average, what proportion of the whole each cost category contributed to patients' total costs and examined the same proportions for subgroups of patients. RESULTS: We identified 6,008 TACS patients. Trauma patients (n = 3,904) made up 65% of the cohort (mean Injury Severity Score 13.2). Payers were: 22% government (Medicare, Medicaid, Champus), 27% private, 43% self-pay/indigent, 3% other, and 5% workers compensation. Nontrauma (general surgery) patients (n = 2,104) made up 35% of the cohort. Payers were: 44% government, 24% private, 29% self-pay/indigent, 2% other, and 1% workers compensation. Total inpatient costs were $141,304,993. Per patient costs rose from $17,245 in FY07 to $26,468 in FY11. In the aggregate, supplies, ICU stays, and ward stays represented the largest proportionate cost categories. On a per patient basis, however, ICU stays were by far the largest cost. Patients with ICU stay greater than 10 days were only 7% of all patients but accounted for 41% of total costs. CONCLUSIONS: Trauma and acute care surgery patients represent a significant and increasing institutional cost. Per patient ICU costs were the largest single category, suggesting that cost control efforts should focus heavily on critically ill patients. Nontrauma patients who require critical care have the highest per patient ICU costs and may represent a previously underappreciated opportunity for cost control.

Incidental pulmonary embolism identified on chest CT during initial trauma evaluation.

Deep venous thrombosis and pulmonary embolism frequently occur after trauma and continue to account for significant morbidity and mortality in this population. Asymptomatic pulmonary emboli are also believed to be quite common, but the incidence as well as the implications of these events is unknown. This case report describes two patients whose pulmonary emboli were found incidentally on the initial trauma workup. Very little has been written concerning this issue and in this case report we review the risk factors and clinical significance of these "incidentally discovered" pulmonary emboli.

Impact of an alcohol withdrawal syndrome practice guideline on surgical patient outcomes.

STUDY OBJECTIVE: To standardize treatment of alcohol withdrawal syndrome (AWS) in surgical patients using an AWS practice guideline with a symptom-triggered approach. DESIGN: Prospective interventional (pilot group) and retrospective (comparison group). SETTING: University teaching hospital. PATIENTS: Thirty-eight trauma, orthopedic, and general surgery patients identified at risk for AWS in the pilot group, and 34 patients who were managed using nonstandardized approaches. INTERVENTIONS: At-risk patients in the pilot group were assessed using the AWS Type Indicator. They received lorazepam, clonidine, or haloperidol, based on AWS Type Indicator assessment and AWS practice guideline criteria. MEASUREMENTS AND MAIN RESULTS: A standardized symptom-triggered approach to managing AWS was expected to decrease the use of benzodiazepines, avoid undertreatment of adrenergic hyperactivity and delirium, decrease the need for sitters and physical restraints, and reduce hospital length of stay. Pilot patients received a mean of 23 mg less benzodiazepine (p=0.01), 0.1 mg more clonidine (p=0.01), and 20 mg less haloperidol (p=0.06) than comparison patients. Pilot patients also required significantly fewer sitter hours (p=0.04) and hours of restraint use (p=0.09) than comparison patients. No significant differences were found between groups for length of stay (p=0.77). CONCLUSIONS: This pilot project suggests that trauma, orthopedic, and general surgery patients at risk for AWS can be safely and effectively managed with a standardized, symptom-triggered approach. Moreover, this approach decreased the amounts of benzodiazepines and haloperidol administered to patients at risk for AWS.

DeTMan: a decision tree management tool for the Web and PDA environments.

Illness management protocols, often represented as decision trees, are used in many areas of medicine. Some clinical departments maintain numerous, often quite complex protocols. Protocol access in acute care situations can be challenging, especially when available only in hardcopy format. Access via the web and especially via personal digital assistants would be more helpful. In the absence of the prior availability of a general purpose web/PDA decision tree editor/navigator, we are developing such a tool.

Percutaneous endoscopic gastrostomy complications in a tertiary-care center.

Since its introduction in 1980 the percutaneous endoscopic gastrostomy (PEG) has become the procedure of choice for establishing enteral access. However, there is still a relatively high complication rate associated with PEG placement. We reviewed the complications associated with PEG placement at our tertiary-care referral center. A retrospective chart review was conducted on patients over 17 years of age undergoing PEG placement between January 1, 1994 and March 1, 1996. Indications for surgery, antibiotic use, and postoperative complications were determined. There were 166 PEGs placed during this time and 27 (16.3%) complications. There was one death (0.6%) directly related to PEG placement. Thirteen patients (7.8%) died within 30 days of PEG placement and an additional 12 patients (7.2%) died before leaving the hospital. Wound infections occurred in nine (5.4%) patients including one case of necrotizing fasciitis. Only four of 153 (2.6%) patients who received preoperative antibiotics developed wound infections, whereas five of 13 (38.5%) patients without antibiotic prophylaxis developed infections. We conclude that percutaneous endoscopic gastrostomy is a safe and effective way of establishing enteral access in most patients. A relatively high mortality rate can be expected as a result of underlying medical problems. Antibiotics should be given to help prevent local wound infections.

Impact of a major hurricane on surgical services in a University Hospital

Hurricane Hugo struck Charleston, South Carolina, on September 21, 1989. This report analyzes the impact this storm had upon surgical care at university medical center. Although disaster planning began on September 17, hurricane damage by high winds and 8.7 foot tidal surge led to loss of emergency power and water. Consequently, system failures occurred in air consitionaing, vacuum suction, steam and ethylene oxide sterilization, plumbing, central paging, lighting, and refrigiration. The following surgical support services were affected. In the blood bank, lack of refrigeration meant no platelet packs for 2 days. In radilogy, loss of electrical power damaged CT/MRI scanners and flooding ruined patient files, resulting in lost information. In the intensive care unit, loss of electricity meant no monitors and hand ventilation was used for 4 hours. In the operating room, lack of tenperature and humidity control (steam, water, and suction supply) halted elective surgery until October 2. Ground and air transportation were limited by unsafe landing sites, impassable roads, and personnel exhaustion. Surgical planning for a major hurricane should include 1) a fail-safe source of electrical power, 2) evacuation of as many critically ill patients as possible before the storm, 3) cancellation of all elective surgery, and 4) augmented ancillary service staffing with some, although limited, physician support (AU)