Academic Level-1 Trauma Center Research Articles

Ankle fracture surgery performed by orthopaedic residents without supervision has comparable outcomes to surgery performed by fellowship trained orthopaedic surgeons.

Unstable fractures often necessitate open reduction and internal fixation (ORIF), which generally yield favourable outcomes. However, the impact of surgical trainee autonomy on healthcare quality in these procedures remains uncertain. We hypothesized that surgery performed solely by residents, without supervision or participation of an attending surgeon, can provide similar outcomes to surgery performed by trauma or foot and ankle fellowship-trained orthopaedic surgeons. A single-center cohort of an academic level-1 trauma center was retrospectively reviewed for all ankle ORIF between 2015 and 2019. Data were compared between surgery performed solely by post-graduate-year 4 to 6 residents, and surgery performed by trauma or foot and ankle fellowship-trained surgeons. Demographics, surgical parameters, preoperative and postoperative radiographs, and primary (mortality, complications, and revision surgery) and secondary outcome variables were collected and analyzed. Univariate analysis was performed to evaluate outcomes. A total of 460 ankle fractures were included in the study. Nonoperative cases and cases operated by senior orthopaedic surgeons who are not trauma or foot and ankle fellowship-trained orthopaedic surgeons were excluded. The average follow-up time was 58.4 months (SD ± 12.5). Univariate analysis of outcomes demonstrated no significant difference between residents and attendings in complications and reoperations rate (p = 0.690, p = 0.388). Sub-analysis by fracture pattern (Lauge-Hansen classification) and the number of malleoli involved and fixated demonstrated similar outcomes. surgery time was significantly longer in the resident group (p < 0.001). The current study demonstrates that ankle fracture surgery can be performed by trained orthopaedic surgery residents, with similar results and complication rates as surgery performed by fellowship-trained attendings. These findings provide valuable insights into surgical autonomy in residency and its role in modern clinical training and surgical education. Level III - retrospective cohort study.

Distal femur nonunion: Risk factors and validation of RUST scores

Abstract Objectives: (1) The purpose of this study was to investigate immediate postoperative weight-bearing status and other potential risk factors for nonunion after locked plating of distal femur fractures and (2) to compare clinical and radiographic union using the previously validated Radiographic Union Scale for Tibia (RUST) and modified RUST scores. Design: This is a retrospective cohort analysis. Setting: Academic Level-1 trauma center. Patients/Participants: Ninety patients with distal femur fractures (OTA/AO 33-A, including periprosthetic) treated with lateral locked plating over a 10-year period. Intervention: Distal femur fracture fixation with lateral locked plating; surgical intervention to facilitate bone healing in cases of nonunion. Main Outcome Measurements: Nonunion rate, construct rigidity scores, RUST, and modified RUST scores. Results: Seventy-eight of 90 patients (87%) achieved clinical union (13% nonunion rate). Rigidity score was significantly associated with risk of nonunion (P = 0.003). No significant association was detected between nonunion and postoperative weight-bearing status (P = 0.77) or other previously identified risk factors. Patients who achieved fracture union had significantly higher mean (SD) RUST (10.67 [1.37] vs. 6.53 [1.48], P &lt; 0.001) and modified RUST (13.47 [2.20] vs. 6.94 [1.79], P &lt; 0.001) scores than patients who developed nonunion. Sensitivity (Sn) analyses identified a RUST score threshold of 9 for diagnosing clinical union (Sn 93.6% and specificity [Sp] 91.7%) and a modified RUST score threshold of 8 (Sn 93.6%, Sp 91.7%). Conclusions: Immediate postoperative weight-bearing status does not seem to affect nonunion rates. We observed a statistically significant association between rigidity score and nonunion. This study supports the utility of the RUST and modified RUST scores in distal femur metaphyseal fractures. Level of Evidence: Therapeutic Level IV.

Is the Presence of a Psychiatric Disorder Associated With More Aggressive Management of Compartment Syndrome?

To determine whether pre-existing psychiatric disorder is associated with potentially unnecessary fasciotomy. Retrospective cohort study. Academic Level-1 trauma center. All the patients with orthopaedic trauma undergoing leg fasciotomy at an academic Level I trauma center from 2006 to 2020. Pre-existing diagnosis of psychiatric disorder. Early primary wound closure and delayed primary wound closure. In total, 116 patients were included. Twenty-seven patients (23%) had a pre-existing diagnosis of psychiatric disorder with 13 having anxiety, 14 depression, 5 bipolar disorder, and 2 ADHD. Several patients had multiple diagnoses. Fifty-one patients (44%) had early primary closure (EPC), and 65 patients (56%) had delayed primary closure. Of patients with a psychiatric disorder, 52% received EPC compared with 42% of patients without a disorder, P = 0.38. This lack of a strong association did not seem to vary across specific psychiatric conditions. After adjusting for sex, age, injury type, and substance abuse, there was still no significant association between a psychiatric disorder and EPC with an odds ratio of 1.08 (95% CI, 0.43-2.75). Among patients with orthopaedic trauma undergoing emergent fasciotomy for acute compartment syndrome, a psychiatric disorder was not associated with a significantly increased rate of possibly unnecessary fasciotomy. Given the potential for a psychiatric condition to complicate the diagnosis of acute compartment syndrome, this data is somewhat reassuring; however, there remains a need for continued vigilance in treating patients with psychiatric conditions and research in this area. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

COVID-19 Vaccination Gap in Admitted Trauma Patients: A Critical Opportunity.

Coronavirus disease 2019 (COVID-19) vaccination is the core strategy for pandemic management. We hypothesized that a vaccination gap might exist between emergency department (ED) patients admitted for trauma and other ED patients. This was an observational quality improvement study using electronic health record data at an academic level-1 trauma center. Participants were all patients presenting to the adult ED with a Tennessee home address between January 1 and June 1, 2021. We measured the proportional difference in vaccination between admitted trauma patients and other ED patients over time (by week) and association via Spearman's rank correlation coefficient. Binary logistic regression facilitated covariate analysis to account for age, sex, race, home county, and ethnicity without and then with interaction between trauma admission and time. Geographic visual analysis compared county-level vaccination rates with odds of trauma admission by home county using a bivariate chloropleth map. The proportional difference in vaccination between trauma-admitted and other ED patients increased over time (Spearman's = 0.699). Adjusting for age, sex, race, home county, and ethnicity, there was a statistically significant vaccination difference between trauma-admitted and other ED patients (odds ratio = 0.53, 95% CI 0.43-0.65, p < 0.0001). Geographic analysis revealed increased trauma admission odds and lower vaccination rates in surrounding counties compared with Davidson County. We observed a widening COVID-19 vaccination gap between trauma-admitted and other ED patients. Vaccine outreach during trauma admission may provide a valuable point of contact for unvaccinated patients.

Analysis of Decreasing Adverse Events with Endoscopic Ultrasound in a New Advanced Endoscopy Program Over Time.

New innovations and increasing utility of endoscopic ultrasound (EUS) are associated with rare but serious risks. We investigate the rates and risk factors for post-procedural complications over a four-year period at a new advanced endoscopy program. We conducted a retrospective review of all adult patients who underwent upper EUS at an academic level-1 trauma center between April 2015 and November 2019. The primary outcome was the incidence of adverse events within 1 week of EUS. Secondary outcomes included emergency department visits and mortality within 30 days after EUS. Chi-square test, t test, and multivariable logistic regression were used to assess risk factors for post-procedural complications. A total of 968 EUS procedures were performed on 864 patients (54% female; 79% Caucasian; mean age 61 years). The overall incidence of post-procedural adverse event with EUS was 5.6%. The probability of an adverse event decreased by an average of 22% per year (p =0.01, OR 0.78). The risk for adverse events were 3.3% acute pancreatitis, 1.9% clinically significant bleeding, 0.3% bacteremia, 0.2% perforation, and 2.4% 30-day mortality. The adverse event rate was highest among low volume proceduralists (p =0.04). The 30-day mortality was more than threefolds among patients who had an adverse event within 7 days after EUS. The overall incidence of post-procedural adverse events at a new EUS program was 5.6%, with an average of 22% relative decrease in adverse events per year in the first 4 years.

S3239 Evaluation of Sensitivity and Diagnostic Accuracy of Endoscopic Ultrasound for Diagnosis of Solid Pancreatic Lesions

INTRODUCTION: Endoscopic ultrasonography with fine needle aspiration/biopsy (EUS-FNA/FNB) facilitates a minimally invasive approach to obtaining pancreatic tissue for the workup of possible malignancies. The American Society of Gastrointestinal Endoscopy (ASGE) has set the benchmark for EUS-FNA/FNB to have a diagnostic rate of >75% and a sensitivity of >85% for solid pancreatic masses. The aim of this study is to assess the real-world rates of diagnostic accuracy, sensitivity and specificity of EUS-FNA for solid pancreatic masses, and factors associated with higher accuracy and sensitivity. METHODS: We conducted a retrospective chart review of all adult patients who underwent EUS-FNA/FNB at an academic level-1 trauma center in southeastern New England between April 2015 and March 2020. Patients were selected based on CPT billing codes for EUS with FNA/FNB. The primary outcomes were diagnostic accuracy and sensitivity, and these were stratified based on several intraprocedural factors including tumor size and number of passes. Samples with pathology reports of atypia without confirmed malignancy were considered non-malignant. RESULTS: Of 204 patients who underwent EUS with FNA/FNB, 38 were done for solid pancreatic masses. 166 patients were excluded due to cystic lesions (49) and 117 were done for intramural lesions or EUS-liver biopsy. For solid masses, the mean maximum tumor diameter was 26.9mm, with 46% occurring in the head or uncinate process (Table 2). The mean number of passes was 2.39 and 87% were done with a 22-gauge needle. On-site cytopathology was present for 37% of cases and 21% were done with general anesthesia. 53% had a duodenal approach. The overall diagnostic rate was 95%. Sensitivity for pancreatic malignancy was 85% and specificity was 100%. Sensitivity and diagnostic rates are higher with increasing tumor size, 2-4 needle passes vs 2-3 passes, and for masses in the pancreatic tail vs neck (Table 2). CONCLUSION: he diagnostic accuracy and sensitivity of EUS-FNA/FNB for solid pancreatic lesions were 95% and 85%, respectively, at our institution, thus meeting the ASGE grade 1C guidelines, despite fewer passes and less on-site cytopathology presence compared with larger studies[2].Table 1.: Demographics of patients with solid pancreatic tumorsTable 2.: Subgroup analysis by needle size, number of passes, tumor stage and approach (trans-gastric vs. trans-duodenum)

Complications of Methamphetamine Use in Orthopaedic Trauma.

To determine whether methamphetamine (MA) users are at an increased risk for complications compared to matched controls in the setting of orthopaedic trauma. Retrospective cohort study. Academic Level-1 Trauma Center. MA users and matched controls. MA use. Infection, Deep Vein Thrombosis (DVT), and nonunion. Five hundred sixty-seven patients were included in our study (189 MA users, 378 matched controls). On univariate analysis, MA users had a higher incidence of DVT (3.2% vs. 0.5%), but no statistically significant difference in infection or nonunion rates. MA users also had a higher incidence of intensive care unit admission (36.0% vs. 27.8%), leaving the hospital against medical advice (9.0% vs. 2.1%), nonadherence to weightbearing precautions (18.8% vs. 7.3%), and a higher incidence of loss of follow-up (47.1% vs. 30.4%). However, MA users had a lower incidence of surgical treatment for orthopaedic injuries (51.9% vs. 65.9%). When surgical treatment was pursued, more trips to the operating room were required for orthopaedic injuries in the MA group (2.6 vs. 1.5 trips). On multivariate analysis, MA users continued to demonstrate a higher incidence of DVT and a lower incidence of operative management, but more trips to the operating room when surgical management was pursued, a higher admission rate to the intensive care unit, and a greater incidence of loss of follow-up. MA use is associated with increased inpatient and outpatient complications. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Ballistic trauma patients have decreased early narcotic demand relative to blunt trauma patients: Blunt ballistic injury opioid use.

Blunt and ballistic injuries are two common injury mechanisms encountered by orthopaedic traumatologists. However the intrinsic nature of these injures may necessitate differences in operative and post-operative care. Given the evolving opioid crisis in the medical community, considerable attention has been given to appropriate management of pain; particularly in orthopaedic patients. We sought to evaluate relative postoperative narcotic use in blunt injuries and ballistic injuries. Retrospective Cohort Study. Academic Level-1 Trauma Center. 96 Patients with blunt or ballistic fractures. Inpatient narcotic pain management after orthopaedic fracture management. Morphine equivalent units (MEU). Patients with blunt injuries had a higher MEU compared to ballistic injuries in the first 24 hours postoperatively (35.0 vs 29.5 MEU, p=0.02). There were no differences in opiate consumption 24-48 hours (34.8 vs 28.0 MEU),48 hours - 7 days post op (28.4 vs 30.4 MEU) or the 24 hours before discharge (30.0 vs 28.6 MEU). On multivariate analysis, during the 24-48 hours and 24 hours before discharge timepoints total EBL was associated with increased opioid usage. During days 3-7 (p<0.001) and in the final 24 hours prior to discharge (p=0.012), the number of orthopaedic procedures was a predictor of opioid consumption. Blunt injuries required an increased postoperative narcotic consumption during the first 24 hours of inpatient stay following orthopedic fracture fixation. However, there was no difference at other time points. Immediate post-operative pain regimens may be decreased for patients with ballistic injuries. III.

Common peroneal nerve injury in the setting of multi-ligament knee injury: incidence and recovery in a prospective cohort

Objectives:Multiligament knee injuries (MLKI’s) are rare, but life-altering injuries which can be made worse with the presence of a concomitant nerve palsy or drop foot. Common peroneal nerve (CPN) palsy has previously been reported to be present in 5-40% of MLKI patients. The purpose of this study was to identify factors that predict CPN palsy at the time of MLKI presentation as well as determine variables that impact likelihood of neurologic recovery.Methods:Between 2006-2017, adults with MLKIs were identified at an academic level 1-trauma center and those with CPN palsy symptoms at presentation were identified. Patients were enrolled in prospective data collection and followed routinely after surgery. The primary outcome was MRC score to analyze associations between age, gender, BMI, injury severity (Schenck classification), surgical timing and presence of fibular head fracture. Secondarily, those with CPN palsy were also compared to a matched cohort of MLKI patients without CPN palsy for demographic as well as functional outcome differences using multiligament quality of life scores (MLQoL).Results:152 patients were identified with MLKIs, of which 57 presented with a CPN palsy (38%). When comparing those with CPN palsy to those without, there were significantly more males in the CPN palsy cohort (p=0.001), significantly more lateral sided injuries – 84% versus 36% (p<0.001), and significantly more fibular head fractures – 35% versus 12% (p=0.001). There was no difference in age, BMI or injury severity or sidedness. Percentage of full or near full recovery for patients with CPN palsy at presentation was 58% (MRC>/=4). In comparing those with permanent CPN palsies to those who recovered, there was a trend towards significance for those with fibula head fractures being more likely to recover (Chi-squared 3.21, p=0.07). There was no significant difference in age, sex, BMI, sidedness, laterality, or time from presentation to surgery in terms of nerve recovery. There was no significant difference in MLQoL scores between those without CPN palsy, those with CPN palsy which recovered (MRC>/=4) and those with permanent CPN palsy (MRC<4). Analysis of MRC grading and sensory grading at presentation and factors influencing the likelihood of recovery is pending.Conclusions:The rate of CPN palsy within MLKI identified in our study matches previously reported literature. Male gender, lateral sided injury and presence of a fibular head fracture were found to be risk factors for CPN palsy at the time of injury. We found no significant difference between demographic or injury mechanism between patients who developed permanent CPN palsy and those who recovered, though there was a trend towards better recovery in those with fibular head fracture. Additionally, we found no difference between patients with CPN palsy compared to those without with respect to MLQoL scores in any domain, which calls into question whether a MLKI patient report outcome measure should incorporate nerve specific questions given the high rate of nerve injuries. The authors intend to analyze the likelihood of recovery in partial versus complete CPN palsy at the time of presentation. To our knowledge this is the largest prospectively collected dataset on CPN palsies after MLKIs, and will provide important insight into neurologic prognostication, especially when combined with previously reported data elsewhere in the literature.

Patient-Reported Outcomes of Femoral Head Fractures with a Minimum 10-Year Follow-Up.

To evaluate the clinical-reported and patient-reported outcomes of patients with femoral head fractures treated at a single level I trauma center with a minimum 10-year follow-up. Retrospective review. Academic Level-1 Trauma Center. One hundred one consecutive femoral head fractures were identified for this study. The final study group consisted of 28 patients with a minimum of 10 years of clinical follow-up. All patients were treated with one or in combination with the following treatments: nonoperative management, open reduction and internal fixation, fragment excision, or total hip arthroplasty (THA). The Oxford Hip Score (OHS) at final follow-up along with clinical and radiological complications: infection, avascular necrosis, post-traumatic osteoarthritis, heterotopic ossification, and conversion to THA. Twenty-eight patients with greater than 10 years of follow-up were included in this evaluation. The average follow-up was 14 years, and the average age was 39.2 years. Surgical management occurred in 86% of patients, and the mean time to definitive treatment was 3.7 days. Overall, 21 patients (75%) experienced a complication. Seven patients (30%) were later converted to a THA at an average of 6.4 years from initial injury. Three of the 7 late THA conversions (43%) required later revision. OHSs were obtained in all 28 patients at the final follow-up. The average OHS was 36.6. The mean OHS of the native hips was 37 at an average follow-up of 13.6 years. The mean OHS of primary THA was 41, and the mean OHS of secondary THA at final follow-up was 31.4, but this was not statistically significant (P = 0.134). Patients should be counseled that the long-term results of open reduction and internal fixation may be satisfactory but unfortunately are not predictable. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Retrospective analysis of eFAST ultrasounds performed on trauma activations at an academic level-1 trauma center.

Point-of-care ultrasound (POCUS) has become increasingly integrated into the practice of emergency medicine. A common application is the extended focused assessment with sonography in trauma (eFAST) exam. The American College of Emergency Physicians has guidelines regarding the scope of ultrasound in the emergency department and the appropriate documentation. The objective of this study was to conduct a review of performed, documented and billed eFAST ultrasounds on trauma activation patients. This was a retrospective review of all trauma activation patients during a 10-month period at an academic level-one trauma center. A list comparing all trauma activations was cross-referenced with a list of all billed eFAST scans. Medical records were reviewed to determine whether an eFAST was indicated, performed, and appropriately documented. We found that 1,507 of 1,597 trauma patients had indications for eFAST, but 396 (27%) of these patients did not have a billed eFAST. Of these 396 patients, 87 (22%) had documentation in the provider note that an eFAST was performed but there was no separate procedure note. The remaining 309 (78%) did not have any documentation of the eFAST in the patient's chart although an eFAST was recorded and reviewed during ultrasound quality assurance. A significant proportion of trauma patients had eFAST exams performed but were not documented or billed. Lack of documentation was multifactorial. Emergency ultrasound programs require appropriate reimbursement to support training, credentialing, equipment, quality assurance, and device maintenance. Our study demonstrates a significant absence of adequate documentation leading to potential revenue loss for an emergency ultrasound program.

Early Versus Delayed Surgery Results In Similar Outcomes Following Multiligament Knee Injury; A Prospective Cohort

Objectives: Multiligament knee injuries (MLKI’s) are rare, but life-altering injuries that have significant implications on patients’ functional status, quality of life and return to work and sport. While the treatment of these injuries is far from standardized, there exists good evidence to support operative intervention. Unfortunately there are no guidelines to indicate the ideal timing of surgery after injury to optimize clinical outcomes and patient satisfaction. With that in mind, the aim of this study was to assess injury specific functional outcomes following surgery for MKLIs and identify advantages to early versus delayed surgery. Methods: Between 2006-2017, adults with MLKIs were identified at an academic level 1-trauma center. Patients were enrolled in prospective data collection and followed routinely after surgery. Study participants were stratified into early (&lt;45 days from injury) and delayed surgical intervention (&gt;45 days from injury). The primary analysis was patient reported outcomes in the form of a specific and validated score (MLQOL) to compare early vs delayed surgical intervention. We secondarily analyzed associations between age, gender, BMI, injury severity (Schenck classification), associated nerve injuries, and reoperation rates to our primary outcome measure. Results: A total of 152 patients were identified, with 85 patients in the early group and 67 in the delayed. The mean time to surgery was 16.7 ± 7.9 days in the early group versus 253 ± 132.6 days in the delayed. Average follow-up was 46.7 months. There was no significant difference between groups with respect to age, gender distribution, BMI, injury mechanism, nor severity. The early surgery group was found to include more patients with lateral sided injuries (p=0.010) as well as nerve injuries at initial presentation (p=0.002). The delayed group was found to have more patients with PCL involvement compared to early surgery (P=0.003). We did not identify a significant difference in pain, stiffness, or instability patient reported outcome scores between the early and delayed surgical groups. 49 of the 152 patients underwent a repeat operation (32%) including manipulation under anesthesia, arthroscopic debridement, removal of hardware, revision and/or conversion to total knee arthroplasty. No significant difference was found in reoperation rates between the two groups. In our primary outcome, we did not identify any relationship between early or late surgery and MLQOL scores. In our secondary analysis, using a linear regression model, we determined older age to be independently predictive of poor outcomes with respect to pain (p=0.018), stiffness (p=0.048) and instability (p=0.004) as assessed through MLQOL questionnaire. Conclusion: In our analysis, stratifying patients to early vs delayed surgery had no effect patient reported outcomes following MLKI reconstruction. In the secondary outcome measures, we identified that regardless of time from injury to surgical intervention, older age was independently predictive of poor pain, stiffness, and instability scores in the MLQOL questionnaire. To our knowledge this is the largest prospectively collected dataset of injury specific outcomes in MLKIs. This analysis will allow for an evidence based approach to guide discussion, manage expectations, and predict outcomes of MLKI patients as well as provide the framework for how surgeons manage these significant injuries.

Early Surgical Treatment of High-grade Multiligamentous Knee Injuries

Objectives: The aim of this study was to describe the clinical outcomes of patients with high-grade multiligamentous knee injuries treated with early surgery and range of motion. Design: This study was a case series. Setting: This study was conducted in the setting of an academic level-1 trauma center. Patients: Forty-seven patients (83% male individuals; average age 35 y; range, 18 to 70) with high-grade multiligamentous knee injuries were included in this study. Patients who had suffered knee dislocations III to V (KD III-KD V) (28 KD III, 16 KD IV, and 3 KD V injuries) between July 2006 and May 2014 were treated using a standard protocol of surgical treatment within 3 weeks of injury followed by early postoperative range of motion. Treatment: The treatment consisted of open primary repair [21/42 (50%), anterior cruciate ligament; 36/43 (83%), posterior cruciate ligament; 26/27 (92%), lateral cruciate ligament; 17/18 (96%), posterolateral corner] or allograft reconstruction with early range of motion. Main Outcome Measurements: The main outcome measurements were infection, range of motion, International Knee Documentation Committee, and Tegner and Lysholm scores at 12 months after surgery. Results: No patient had a postoperative deep wound infection requiring surgery. Two patients had a superficial infection that required oral antibiotics only. The average extension was 0 degrees. All but 1 patient achieved full extension; the patient developed a 5-degree flexion contracture. Mean active range of motion at 6 and 12 months was a mean arc of 119 and 123 degrees, respectively. Anterior tibiofemoral translation of &gt;5 mm measured with KT-1000 was present in 6 (13%) patients. Six of the 47 patients (13%) had circumferential avulsions, and 1 patient with a poor subjective outcome had a concomitant complete patellar tendon avulsion in the setting of an open dislocation. One patient (2%) had laxity and instability requiring revision arthroscopic reconstruction of the posterior cruciate ligament and manipulation under anesthesia, and 3 patients required manipulation under anesthesia or open lysis because of stiffness. Fifteen (32%) patients reported knee function between 7 and 10 (competitive or higher) on the Tegner activity level scale. The mean International Knee Documentation Committee ±SD scores were 53.3±26.7 (range, 8 to 97.7) with 16/47 (34%) knees found to be normal, 13/47 (27.6%) near normal, 13 (27.6%) abnormal, and 5 (10.6%) severely abnormal. The mean Lysholm knee score was 75.4±22.1 (range, 25 to 98). No patient in the study had rotational instability at final follow-up with clinical assessment of posteromedial or posterolateral rotation (Dial test). Conclusions: Open operative treatment within the first 3 weeks of injury with primary repair or reconstruction of all injured structures can yield outcomes similar to those reported in patients treated with delayed or staged reconstruction of ligaments. Early treatment allows definitive management of injuries that are difficult to address on a delayed basis. Complications of infection, revision because of laxity, and stiffness are uncommon with this approach.

Normal saline versus Normosol™-R in sepsis resuscitation: A retrospective cohort study.

To determine the effect of Normosol™-R as compared to normal saline on the outcomes of acute kidney injury and the need for renal replacement therapy in the resuscitation phase of sepsis. Our study is a retrospective before-and-after cohort study. The study occurred at a 700-bed tertiary academic level 1-trauma center. A total of 1218 patients were enrolled through emergency department admissions. The normal saline (before) cohort was defined as the dates between 1 March and 30 September 2014 and the Normosol™-R (after) cohort was assessed from 1 March to 30 September 2015. None. Intravenous fluid volumes received during the first 24 h, 72 h, and total hospital stays were compared. Sodium, chloride, potassium, and bicarbonate levels at 72 h were also compared. The medical coded diagnosis of acute kidney failure, need for renal replacement therapy, hospital LOS, ICU admission, ICU LOS, in-hospital mortality, and need for mechanical ventilation were all compared. There was no significant difference in intravenous fluid volumes between groups. Regression modelling controlling for baseline characteristics and 24-h fluid intake volume found no differences between groups for the primary outcomes of acute kidney injury (P = 0.99) and renal replacement therapy (P = 0.88). Patients in the Normosol™-R cohort were found to have a lower rate of hyperchloremia at 72 h post-admission (28% vs. 13%, P < 0.0001). There was a trend toward a decrease in the hospital and ICU LOS in the Normosol™-R cohort; however, the data were not statistically significant. This study was unable to detect any difference in outcomes between sepsis patients who received intravenous fluid resuscitation with either a balanced crystalloid (Normosol™-R) or normal saline, except for a decreased rate of hyperchloremia.

Opening a New Level II Trauma Center Near an Established Level I Trauma Center: Is This Good for Trauma Care?

To describe how the initiation and later removal of a provisional level II trauma center (PL2TC) status at a community hospital affected the volume and severity of injured patients seen at an established academic level 1 trauma center (AL1TC). Census data including counts of injury ICD-9 codes and patients seen in the emergency department (ED) and trauma center at an AL1TC were collected monthly from January 2010 to October 2014. An interrupted time series analysis was used to model the monthly census data with 2 time interruptions to describe the change in patient volume at the interruptions. The interruptions were (1) the initiation of the PL2TC status at a nearby community hospital and (2) the subsequent removal of the PL2TC status. The number of diagnoses, encounters, and patients seen at the AL1TC ED decreased while the PL2TC was operating. After the removal of the PL2TC status, there was a 19.4% increase in the ED patient volume per month at the AL1TC. The number of orthopaedic trauma patients seen through the ED at the AL1TC dropped 11.1% per month when the PL2TC began functioning as a trauma center. However, the volume of orthopaedic patients at the AL1TC did not recuperate after the PL2TC lost level 2 status. A significant decrease in patient volume was seen at the AL1TC with the initiation of the PL2TC in close proximity. Orthopaedic patient volume did not recuperate after the removal of the PL2TC status.

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Introduction: To evaluate the implementation of a stress ulcer prophylaxis guideline (SUPG) in a Nueroscience ICU (NSICU). Hypothesis: SUPG will increase appropriate use of SUP pharmacotherapy, decrease adverse effects (GI Bleeding, pneumonia, Clostridium Difficile (C. Diff)) and decrease pharmacy costs. Methods: Single center, retrospective, cohort study conducted at an academic level-1 trauma center. Patients admitted to the NSICU in 2009 and 2010 with a duration of stay greater than 72 hours were included. Patients were identified through use of NSICU admission records and the pharmacy billing database. Additionally, demographic information was captured through use of the University Health system Consortium database. Patients were divided into two groups pre-SUPG (PRE) implementation and post SUGP (POST) Results: 300 patients (PRE 150, POST 150) were included. SUP use/100 NSICU days differed between PRE and POST (96 vs. 89 days; p=0.010).There was no difference in the total number of patients who received SUP between PRE and POST (141(93%) vs. 143(95%); p=0.667). No difference was observed in overall proton pump inhibitor (PPI) use between PRE and POST groups (45(32%) vs. 57(40%); p=0.203) or in the number of PPI use/100 NSICU days (69 vs. 77 days; p=0.784). There was no difference between PRE and POST incidence of GI bleed (1(0.7%) vs. 2(1.4%); p=0.981), pneumonia (29(19.6%) vs. 19 (13.2%); p=0.188) or in C. diff occurrence (8(5.4%) vs. 2(1.4%); p=0.113). There was no difference between PRE and POST in overall cost of SUP ($1,400 vs. $1,075; p=1.00), PPI use ($995 vs. $800; p=1.00) or histamine receptor antagonist use ($405 vs. $265; p=1.00). Conclusions: The implementation of this stress ulcer prophylaxis guideline reduced the total use of stress ulcer prophylaxis/100 days with no change in the rate of GI bleed. Therefore, a stress ulcer prophylaxis guideline is useful to reduce potentially unnecessary medication use. Additionally, the results showed a trend toward reductions in pneumonia and C. diff infection. While there was no significant reduction in cost, cost savings were evident.

High-Energy Proximal Femur Fractures in Geriatric Patients

There is limited information in the literature on the outcomes and complications in elderly patients who sustain high-energy hip fractures. As the population ages, the incidence of high-energy geriatric hip fractures is expected to increase. The purpose of this study was to analyze the outcomes and complications in patients aged 65 years or older, who sustained a high-energy proximal femur fracture. Retrospective review of a prospective trauma database from January 2000 to April 2011 at a single US academic level-1 trauma center. Inclusion criteria consisted of all patients of age 65 years or older, who sustained a proximal femur fracture related to a high-energy trauma mechanism. Details concerning injury, acute treatment, and clinical course and outcome were obtained from medical records and radiographs. We identified 509 proximal femur fractures in patients older than 65 years of age, of which 32 (6.3%) were related to a high-energy trauma mechanism. The mean age in the study group was 72.2 years (range 65-87), with a mean injury severity score of 20 points (range 9-57). Three patients died before discharge (9.4%), and 22 of 32 patients sustained at least one complication (68.8%). Blunt chest trauma represented the most frequently associated injury, and the main root cause of pulmonary complications. The patients' age and comorbidities did not significantly correlate with the rate of complications and the 1-year mortality. High-energy proximal femur fractures in elderly patients are not very common and are associated with a low in-hospital mortality rate of less than 10%, despite high rate of complications of nearly 70%. This selective cohort of patients requires a particular attention to respiratory management due to the high incidence of associated chest trauma.