American College Of Surgeons Level Research Articles

Comparative Analysis of META and SALT Disaster Triage in an Adult Trauma Population: A Retrospective Observational Study.

Medical professionals can use mass-casualty triage systems to assist them in prioritizing patients from mass-casualty incidents (MCIs). Correct triaging of victims will increase their chances of survival. Determining the triage system that has the best performance has proven to be a difficult question to answer. The Advanced Prehospital Triage Model (Modelo Extrahospitalario de Triaje Avanzado; META) and Sort, Assess, Lifesaving Interventions, Treatment/Transport (SALT) algorithms are the most recent triage techniques to be published. The present study aimed to evaluate the META and SALT algorithms' performance and statistical agreement with various standards. The secondary objective was to determine whether these two MCI triage systems predicted patient outcomes, such as mortality, length-of-stay, and intensive care unit (ICU) admission. This retrospective study used patient data from the trauma registry of an American College of Surgeons Level 1 trauma center, from January 1, 2018 through December 31, 2020. The sensitivity, specificity, and statistical agreement of the META and SALT triage systems to various standards (Revised Trauma Score [RTS]/Sort Triage, Injury Severity Score [ISS], and Lerner criteria) when applied using trauma patients. Statistical analysis was used to assess the relationship between each triage category and the secondary outcomes. A total of 3,097 cases were included in the study. Using Sort triage as the standard, SALT and META showed much higher sensitivity and specificity in the Immediate category than for Delayed (Immediate sensitivity META 91.5%, SALT 94.9%; specificity 60.8%, 72.7% versus Delayed sensitivity 28.9%, 1.3%; specificity 42.4%, 28.9%). With the Lerner criteria, in the Immediate category, META had higher sensitivity (77.1%, SALT 68.6%) but lower specificity (61.1%) than SALT (71.8%). For the Delayed category, SALT showed higher sensitivity (META 61.4%, SALT 72.2%), but lower specificity (META 75.1%, SALT 67.2%). Both systems showed a positive, though modest, correlation with ISS. For SALT and META, triaged Immediate patients tended to have higher mortality and longer ICU and hospital lengths-of-stay. Both META and SALT triage appear to be more accurate with Immediate category patients, as opposed to Delayed category patients. With both systems, patients triaged as Immediate have higher mortality and longer lengths-of-stay when compared to Delayed patients. Further research can help refine MCI triage systems and improve accuracy.

Strategies to Obtain and Deliver Blood Products Into Critically Injured Children: A Survey of Pediatric Trauma Society Members.

Timely transfusion is associated with improved survival and a reduction in in-hospital morbidity. The benefits of early hemorrhagic shock recognition may be limited by barriers to accessing blood products and their timely administration. We examined how pediatric trauma programs obtain blood products, the types of rapid infusion models used, and the metrics tracked to improve transfusion process efficiency in their emergency department (ED). We developed and distributed a self-report survey to members of the Pediatric Trauma Society. The survey consisted of 6 initial questions, including the respondent's role and institution, whether a blood storage refrigerator was present in their ED, the rapid infuser model used to transfuse critically injured children in their ED, if their program tracked 4 transfusion process metrics, and if a video recording system was present in the trauma bay. Based on these responses, additional questions were prompted with an option for a free-text response. We received 137 responses from 77 institutions. Most pediatric trauma programs have a blood storage refrigerator in the ED (n = 46, 59.7%) and use a Belmont rapid infuser to transfuse critically injured children (n = 45, 58.4%). The American College of Surgeons Level 1 designated trauma programs, or state-based equivalents, and "pediatric" trauma programs were more likely to have video recording systems for performance improvement review compared with lower designated trauma programs and "combined pediatric and adult" trauma programs, respectively. Strategies to improve the timely acquisition and infusion of blood products to critically injured children are underreported. This study examined the current practices that pediatric trauma programs use to transfuse critically injured children and may provide a resource for trauma programs to cite for transfusion-related quality improvement.

Addition of aspirin to venous thromboembolism chemoprophylaxis safely decreases venous thromboembolism rates in trauma patients

BackgroundTrauma patients exhibit a multifactorial hypercoagulable state and have increased risk of venous thromboembolism (VTE). Despite early and aggressive chemoprophylaxis (CP) with various heparin compounds (“standard” CP; sCP), VTE rates...

How do we PI? Results of an EAST quality, patient safety, and outcomes survey

BackgroundQuality improvement is a cornerstone for any verified trauma center. Conducting effective quality and performance improvement, however, remains a challenge. In this study, we sought to better explore the landscape...

Evaluation of therapy in traumatic elderly falls to return autonomy and functional status

BackgroundTraumatic falls among the elderly (≥65 years old) are the leading cause of injury, morbidity and mortality are increasing with rising medical costs. MethodsThis is a retrospective medical record review of elderly mechanical fall patients (288 patients) admitted to an American College of Surgeons level II trauma center from January 2016 to January 2021. Demographics and comorbidities were determined, and physical/occupational therapy used to predict subsequent fall readmissions. ResultsOut of 288 patients, 243 received therapy with 45 readmissions for subsequent falls. Age (P = .016), body mass index (P = .035), previous falls (P = .003), walker/cane use (P = .039), and dementia (P = .038) were predictive of readmission. Therapy was shown to benefit patients, but deferred therapy sessions were shown to be associated with prolonged hospitalization. ConclusionDirected therapy may improve functionality and return autonomy to elderly mechanical fall patients admitted to trauma services.

Night Radiology Coverage for Trauma: Residents, Teleradiology, or Both?

Overnight radiology coverage for trauma patients is often addressed with a combination of on-call radiology residents (RR) and a teleradiology service; however, the accuracy of these 2 readers has not been studied for trauma. We aimed to compare the accuracy of RR versus teleradiologist interpretations of CT scans for trauma patients. A retrospective analysis (March 2019 through May 2020) of trauma patients presenting to a single American College of Surgeons Level I trauma center was performed. Patients whose CT scans were performed between 10 pm to 8 am were included, because their scans were interpreted by both a RR and teleradiologist. Interpretations were compared with the final attending faculty radiologist's interpretation and graded for accuracy based on the RADPEER scoring system. Discrepancies were characterized as traumatic injury or incidental findings and missed findings or overcalls. Turnaround time was also compared. A total of 1,053 patients and 8,226 interpretations were included. Compared with teleradiologists, RR had a lower discrepancy (7.7% vs 9.0%, p = 0.026) and major discrepancy rate (3.8% vs 5.2%, p = 0.003). Among major discrepancies, RR had a lower rate of traumatic injury discrepancies (3.2% vs 4.4%, p = 0.004) and missed findings (3.4% vs 5.1%, p < 0.001), but a higher rate of overcalls (0.5% vs 0.1%, p < 0.001) compared with teleradiologists. The mean turnaround time was shorter for RR (51.3 vs 78.8 minutes, p < 0.001). The combination of both RR and teleradiologist interpretations had a lower overall discrepancy rate than RR (5.0% vs 7.7%, p < 0.001). This study identified lower discrepancy rates and a faster turnaround time by RR compared with teleradiologists for trauma CT studies. The combination of both interpreters had an even lower discrepancy rate, suggesting this combination is optimal when an in-house attending radiologist is not available.

Treatment Trends and Inpatient Mortality in Isolated Severe Traumatic Brain Injury Using the National Trauma Data Bank

Severe traumatic brain injury (TBI) remains a leading cause of morbidity and mortality. Despite recommendations from the Brain Trauma Foundation, there is wide variability in treatment paradigms for severe TBI. We aimed to elucidate the variability of treatment, particularly neurosurgical procedures and how it affects mortality. Adult patients (<65 years old) with a severe isolated TBI who were treated at an American College of Surgeons level I trauma center were identified in the National Trauma Data Bank for the years 2007-2016. International Classification of Diseases, Ninth Revision procedure codes were used to identify primary treatment approaches: intracranial pressure (ICP) monitoring and cranial surgery (craniotomy/craniectomy). Among 25,327 patients with severe isolated TBI, 14.0% underwent ICP and 18.0% underwent cranial surgery. ICP monitoring reduced the odds of mortality (odds ratio 0.89, 95% confidence interval [0.81, 0.98]), but not the extent of cranial surgery (odds ratio 0.71, 95% confidence interval [0.65, 0.77]). Brain Trauma Foundation guidelines recommend placement of an ICP monitor for severe TBI; however, only 14% of patients with isolated, severe TBI underwent ICP monitoring in 2007-2016. ICP monitoring and cranial surgery decrease the odds of inpatient mortality in patients with severe TBI.

Vascular Surgery Is the Most Commonly Consulted Specialty for Emergent Operative Trauma

Despite an increasing rate of intraoperative consultation of vascular surgery for trauma patients, vascular surgery is not one of the subspecialties required for American College of Surgeons level I trauma center verification. We sought to assess rates and patterns of emergent operative vascular surgery consultation compared with other surgical subspecialties in the trauma setting.

Mapping of Vertical Femoral Neck Fractures in Young Patients Using Advanced 2 and 3-Dimensional Computed Tomography.

To better describe the pathoanatomy of young patients' femoral neck fractures with the goal of improving surgeons' decisions for treatment including reduction and fixation. This is a retrospective study of patient records, plain radiographs, and the modern computed tomography scans to study the pathoanatomy of Pauwels II and III femoral neck fractures (coronal angle >30 degrees) in young adults. One American College of Surgeons Level 1 trauma center. All patients 18-49 years of age with a surgically repaired Pauwels' II and III (>30 degrees) femoral neck fracture between 2013 and 2017. Fifty-six adult patients younger than 50 years were identified with a femoral neck fracture in the study period, of whom 30 met study criteria. We evaluated plain radiography and computed tomography data including fracture orientation, characteristics of fracture morphology including size, shape, and dimensions, comminution, displacement, and deformity. Fracture morphology typically included a wide-based caudal head-neck segment (80%) that ends at a variable location along the medial calcar, sometimes as caudal as the lesser trochanter. Comminution was present in 90% of cases mostly located in the inferior quadrant, but anterior or posterior to the void left by the head-neck's caudal segment. The fractures orientations and deformities were reported by means and ranges. We investigated and reported on the pathoanatomy of high-energy femoral neck fractures in young adults with the goal of increasing understanding of the injury and improving surgeons' ability to provide for improved treatment decisions and quality fracture repair. Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Unseen Burden of Injury: Post-Hospitalization Mortality in Geriatric Trauma Patients.

Older adults are at risk for adverse outcomes after trauma, but little is known about post-acute survival as state and national trauma registries collect only inpatient or 30-day outcomes. This study investigates long-term, out-of-hospital mortality in geriatric trauma patients. Level I Trauma Center registry data were matched to the US Social Security Death Index (SSDI) to determine long-term and out-of-hospital outcomes of older patients. Blunt trauma patients aged ≥65 were identified from 2009 to 2015 in an American College of Surgeons Level 1 Trauma Center registry, n = 6289 patients with an age range 65-105years, mean age 78.5 ± 8.4years. Dates of death were queried using social security numbers and unique patient identifiers. Demographics, injury, treatments, and outcomes were compared using descriptive and univariate statistics. Of 6289 geriatric trauma patients, 505 (8.0%) died as an inpatient following trauma. Fall was the most common mechanism of injury (n = 4757, 76%) with mortality rate of 46.5% at long-term follow-up; motor vehicle crash (MVC) (n = 1212, 19%) had long-term mortality of 27.6%. Overall, 24.1% of patients died within 1year of trauma. Only 8 of 488 patients who died between 1 and 6months post-trauma were inpatient. Mortality rate varied by discharge location: 25.1% home, 36.4% acute rehabilitation, and 51.5% skilled nursing facility, P < .0001. Inpatient and 30-day mortality rates in national outcome registries fail to fully capture the burden of trauma on older patients. Though 92% of geriatric trauma patients survived to discharge, almost one-quarter had died by 1year following their injuries.

Futile trauma transfers: An infrequent but costly component of regionalized trauma care.

Appropriate interfacility transfers are a key component of highly functioning trauma systems but transfer of unsalvageable patients can overburden the resources of higher-level centers. We sought to identify the occurrence and associated reasons for futile transfers within our trauma system. Using prospectively collected data from our system database, a retrospective cohort study was conducted to identify patients who underwent interfacility transfer to our American College of Surgeons level I center. Adult patients from June 2017 to June 2019 who died, had comfort measures implemented, were discharged, or went to hospice care within 48 hours of admission without significant operation, procedure, or radiologic intervention were examined. Futility was defined as resulting in death or hospice discharge within 48 hours of transfer without major operative, endoscopic, or radiologic intervention. A total of 1,241 patients transferred to our facility during the study period. Four hundred seven patients had a length of stay less than or equal to 48 hours. Eighteen (1.5%) met the criteria for futility. The most common reason for transfer in the futile population was traumatic brain injury (56%) and need for neurosurgical capabilities (62%). Futile patients had a median age and Injury Severity Score of 75 and 21. The main transportation method was ground 9 (50%) with 8 (44.4%) being transported by helicopter and 1 (5.6%) being transported by both. Combining transport costs with hospital charges, each futile transfer was estimated to cost US $56,396 (interquartile range, 41,889-106,393) with a total cost exceeding US $1.7 million. With an estimated 33,000 interfacility transfers annually for trauma in the United States, the cost of futile transfers to the American trauma system would exceed 27 million dollars each year. Futile transfers represent a small but costly portion transfer volume. Identification of patients whose conditions preclude the benefit of transfer due to futility and development of appropriate support for referral will significantly improve appropriate allocation of health care resources. Economic; Care management, level IV.

Quality Indicators for Children With Traumatic Brain Injury After Transition to an American College of Surgeons Level I Pediatric Trauma Center.

The aim of the study was to compare quality indicators, including frequency of acute surgical and emergent interventions, and resource utilization before and after American College of Surgeons (ACS) level I trauma verification among children with moderate or severe traumatic brain injury (TBI). This is a retrospective review of patients younger than 18 years treated for moderate or severe TBI, as determined by International Classification of Disease codes. Our institution obtained ACS level I trauma verification in 2013. Outcomes during the pre-ACS (June 2003-May 2008), interim (June 2008-May 2013), and post-ACS (June 2013-May 2018) periods were compared via nonparametric tests. Tests for linear trend were conducted using Cochran-Armitage tests for categorical data and by linear regression for continuous variables. There were 677 children with moderate or severe TBIs (pre-ACS, 125; interim, 198; post-ACS, 354). Frequency of any surgical intervention increased significantly in the post-ACS period (12.2%) compared with interim (5.1%) and pre-ACS periods (5.6%, P = 0.007). More children in the post-ACS period required intracranial pressure monitoring (P = 0.017), external ventricular drain placement (P = 0.003), or endotracheal intubation (P = 0.001) compared with interim and pre-ACS periods. There was no significant change in time to operating room (P = 0.514), frequency of decompression (P = 0.096), or time to decompression (P = 0.788) between study periods. The median time to head CT decreased significantly in the post-ACS period (26 minutes; interquartile range [IQR], 9-60) compared with interim (36 minutes; IQR, 21-69) and pre-ACS periods (53 minutes; IQR, 36-89; P < 0.001). Frequency of repeat head computed tomography decreased significantly in the post-ACS period (30.2%) compared with interim (56.1%) and pre-ACS periods (64.0%, Ptrend = 0.044). Transition to an ACS level I trauma verification was associated with improvements in quality indicators for children with moderate or severe TBI.

Which Surgical Specialties Provide Craniomaxillofacial Trauma Services at American College of Surgeons Level I Trauma Centers

Which Surgical Specialties Provide Craniomaxillofacial Trauma Services at American College of Surgeons Level I Trauma Centers

The Impact of an Emergency Department Upgrade to Level I Trauma Status on the Timeliness of Nontrauma Computed Tomography Scans.

Resources such as computed tomography (CT) scanners are sometimes shared when separate adult and pediatric emergency departments (EDs) exist in proximity. To assess the impact of American College of Surgeons Level I trauma verification of an adult ED on the timeliness of nontrauma CT scans in a pediatric and adult ED that share a CT scanner. ED patient records were retrospectively reviewed to determine the time from order to completion of nontrauma CT scans. We compared the timeliness of CT scan completion between the year leading up to the adult ED being verified as a Level I Trauma Center (2015), and the 2 subsequent years (2016-2017). The median time for nontrauma CT completion in the adult ED prior to Level I verification was 39min, compared with 50min and 49min for the subsequent 2years (p<0.001). Similarly, the median time for completion of nontrauma CT scans in the pediatric ED increased from 33min to 41min and 39min (p<0.001). The proportion of patients who received CT scans within 30min from order decreased after adult ED trauma upgrade, from 40% in 2015 to 30% and 32% (p<0.001) in the 2 subsequent years. The pediatric ED showed similar results, with 48% of patients receiving CT scans within 30min in 2015, compared with 34% in 2016 and 35% in 2017 (p<0.001). Level I trauma verification of the adult ED adversely affected the timeliness of nontrauma CT scans in the EDs.

Impact of shelter-in-place order for COVID-19 on trauma activations: Santa Clara County, California, March 2020.

IntroductionThe shelter-in-place order for Santa Clara County, California on 16 March was the first of its kind in the USA. It was unknown what impact this order would have on trauma activations.MethodsWe performed a retrospective analysis of institutional trauma registries among the two American College of Surgeons Level 1 trauma centers serving Santa Clara County, California. Trauma activation volumes at the trauma centers from January to March 2020 were compared with month-matched historical cohorts from 2018 to 2019.ResultsOnly 81 (3%) patients were trauma activations at the trauma centers in the 15 days after the shelter-in-place order went into effect on 16 March 2020, compared with 389 activations during the same time period in 2018 and 2019 (p<0.0001). There were no other statistically significant changes to the epidemiology of trauma activations. Only one trauma activation had a positive COVID-19 test.DiscussionOverall trauma activations decreased 4.8-fold after the shelter-in-place order went into effect in Santa Clara County on 16 March 2020, with no other effect on the epidemiology of persons presenting after traumatic injury.ConclusionShelter-in-place orders may reduce strain on healthcare systems by diminishing hospital admissions from trauma, in addition to reducing virus transmission.

Are all trauma centers created equal? Level 1 to level 1 trauma center patient transfers in the setting of rapid trauma center proliferation.

Level 1 trauma centers should provide definitive care for every aspect of injury. However, in environments that have experienced trauma center proliferation, not all level 1 centers may have the resources or expertise needed for every patient, necessitating transfer to another trauma center. The purpose of this study was to assess the incidence of such transfers and associated impact on patient outcome and burden on the receiving level 1 center. In a metropolitan area experiencing trauma center proliferation, we performed a 5.5-year review of patient transfers to an established level 1 (index center) from other state designated level 1 centers. American College of Surgeons verification level was identified for each facility. Comparisons were performed between the cohort of transferred patients and patients with similar demographics, injury patterns, and severity managed at the index center using propensity score matching. A total of 104 patients were received from other state level 1 centers (39% American College of Surgeons level 2, 61% American College of Surgeons level 1). Nearly 70% of patients were transferred for definitive evaluation and/or management of brain, spine, or cerebrovascular injury. For 76% of this subgroup, specialty consultation was available, but the injury was deemed beyond their capability. Comparison of the transfer cohort propensity score matched to the control cohort (93 vs. 558 patients) demonstrated increased length of stay (6.5 days vs. 4.6 days, p = 0.001) and cost (US $36,027 vs. US $30,654, p = 0.033) associated with the transfer cohort, with similar mortality (12.1% vs. 9.7%, p = 0.492). The number of level 1 to level 1 transfers observed imply a disparity in resources and capability among level 1 trauma centers in the region. The majority of transfers were for neurosurgical care, suggestive of a deficit of adequate neurosurgical coverage in the setting of trauma center proliferation. Both patients and established trauma centers bear the burden for these transfers with respect to increased cost and length of stay. Care management, level IV.

A Volume-Based Feeding Protocol Improves Nutrient Delivery and Glycemic Control in a Surgical Trauma Intensive Care Unit.

Inadequate delivery of nutrition in critically ill patients has been shown to have adverse outcomes. A surgical trauma intensive care unit provides unique challenges to enteral feeds. Although volume-based feeding protocols, like Enhanced Protein-Energy Provision via the Enteral Route Feeding Protocol (PEP uP), have been successfully used in medical intensive care patients, data are sparse on its safety and efficacy in a surgical intensive care unit population. A PEP uP protocol was recently initiated at our American College of Surgeons Level 1 verified trauma center. Medical records of 197 patients before this change (pre-PEP uP) were compared with 295 patients after this change (post-PEP uP). The post-PEP uP group met/exceeded energy goals (defined as 80% of target) more often (57.0% compared with 26.9%, P-value < .001), with an adjusted odds ratio (OR) of 4.98 (95% CI 3.49-7.10), and more often met/exceeded protein goals (57.4% compared with 18.6%, P-value < .001), with an adjusted OR of 11.84 (95% CI 7.94-17.64). There was no significant difference in emesis during this time. Additionally, patients in the post-PEP uP arm had less episodes of hyperglycemia (9% compared with 14.4%, P-value < .001). Volume-based feeding protocols like PEP uP are safe in critically ill trauma patients and are more effective at delivering energy and protein while limiting hyperglycemic episodes when compared with a traditional delivery method.

Effect of American College of Surgeons Level 1 Trauma Center Designation on Management of Adult Severe TBI Patients

Abstract INTRODUCTION Severe traumatic brain injury (TBI) remains a leading cause of morbidity and mortality. There is a wide variability in treatment paradigm for patients with severe TBI. American College of Surgeons (ACS) level 1 trauma centers have access to 24 h neurosurgical coverage. In this study, we use the National Trauma Database (NTDB) to evaluate if ACS trauma center designation correlates with the management and outcomes of severe TBI in adults. METHODS Adult patients (&lt;65 yr) with a severe isolated nonpenetrating TBI were identified in the NTDB from years 2007 to 2014. ICD-9 procedure codes were used to identify primary treatment approaches: intracranial pressure monitoring and cranial surgery. Multivariate logistic regression was used to determine the impact of ACS designation on procedures and patient outcomes. Patient and injury characteristics were included in the analysis. RESULTS A total of 54 769 TBI patients were identified. Among those, 22 316 (42%) were treated at an ACS level 1 trauma center and 31 835 (58%) were treated elsewhere. Level 1 designated patients had significantly more intracranial pressure (ICP) monitors placed (12.3% vs10.8%; P &lt; .0001) and more cranial surgeries performed (17.7% vs 15.7%; P &lt; .0001). A greater percentage of patients were admitted to the intensive care unit (ICU; 89.9% vs 83.9%; P &lt; .0001) and had a longer hospital stay (16.1 vs 15.2; P &lt; .0001) at ACS level 1 trauma centers. In a regression analysis, patients at level 1 centers were associated with a 14% and 17% increased odds of obtaining a cranial surgery or ICP monitor, respectively. Patients treated at a level 1 center were associated with a 6% decrease in odds of mortality (P = .01). CONCLUSION ACS level 1 designation did correlate with increased rates of neurosurgical intervention and ICU admissions. This translated into patient outcomes as those treated at level 1 facilities were associated with lower rates of mortality.

The Affordable Care Act: Long-Term Financial Impact on a Level I Trauma Center

BackgroundPrior studies of the impact of the Affordable Care Act on reimbursement for inpatient trauma care do not include disproportionate share hospital (DSH) funding. Because trauma centers and other safety-net hospitals are sensitive to any changes in financial support, it is essential to include DSH funding in evaluating overall reimbursement. This study analyzes the long-term financial trends, including DSH, of a level I trauma center in Ohio, a state that expanded Medicaid. MethodsCharges, reimbursement, sources of insurance coverage, Injury Severity Scores, and DSH funding for the trauma patient population of an Ohio American College of Surgeons level 1 trauma center were studied from 2012 to 2017. Data were collected from Transition Systems, Inc. ResultsDuring 2012-2017, self-pay patient cases decreased from 15.0% to 4.1% and commercial insurance patients decreased from 34.2% to 27.6%. The percentage of Medicaid patients increased from 15.5% to 27.1%; however, Medicaid reimbursement average per case declined from $17,779 in 2012 to $10,115 in 2017 (a decline of 43.1%). Self-pay charges decreased from $22.0 million to $6.7 million. Total DSH funding, compensation given to hospitals that disproportionately treat underserved populations, decreased 17.4%. ConclusionsSelf-pay charges and self-pay patients decreased dramatically; Medicaid patients and charges increased substantially in the years after the implementation of the Affordable Care Act at our trauma center. However, there was a decrease in commercial insurance, which had the highest reimbursement for our hospital, and a significant decline in DSH, a critical supplemental source of funding for safety-net hospitals.

Using Historical Variation in Opioid Prescribing Immediately After Fracture Surgery to Guide Maximum Initial Prescriptions.

Recent studies have advocated for prescription opioid maximums (based on percentage reductions from historical amounts) to reduce excess prescribing. Implementing this in orthopaedic trauma has been difficult, given the injury variety and limited historical data on postoperative prescribing. We report on the initial opioid prescriptions for a large cohort of postoperative, opiate-naive fracture patients and hypothesize that prescribing was associated with fracture location and morphology. Retrospective cohort analysis. Two American College of Surgeons Level I trauma centers. Six thousand eight hundred seventy-nine orthopaedic trauma patients treated between 2002 and 2015. Only patients who had a single operatively treated injury and were opiate naive (had not received an opioid prescription in the 6 months before presentation) were included. Postoperative opioid discharge prescription. We analyzed the quantity of initial opioids prescribed in morphine milligram equivalents (MMEs, a standardized unit of opioid dosage used for comparison across opioid types). Fracture location and morphology were classified using the OTA/AO classification. Fracture location was an independent predictor of the MME prescribed (P < 0.001). All other fracture locations were prescribed significantly higher MME than distal radius fractures (control group, 150 MME, P < 0.01). There was no difference in MMEs prescribed by articular involvement or degree of comminution. We demonstrate significant variation in initial postoperative opioid prescribing to opiate-naive orthopaedic trauma patients by fracture location, but not by fracture morphology. We use these data to propose a guideline based on the OTA/AO fracture classification for the maximum initial prescription of opioids. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.