American College Of Surgeons Research Articles

Modified Frailty Index as an Indicator for Outcomes After Lower Extremity Open Revascularization

The 5-factor frailty index (mFI-5) is a standardized score that has been used as a reliable tool in predicting outcomes after surgery. The purpose of this study was to evaluate the performance of the mFI-5 after lower extremity endovascular revascularization (LEOR). The American College of Surgeons' National Surgical Quality Improvement Program Database was retrospectively analyzed for patients undergoing LEOR between 2015 and 2019. Outcomes were assessed using univariate analysis (Mann-Whitney, univariate logistic regression, and Cochran-Armitage test) and multivariate logistic regression analysis. There were 13,210 LEOR performed between 2015 and 2019 that were identified from the National Surgical Quality Improvement Program database. Mean age was 68 ± 10.96 years and 4175 (31.6%) were female. Overall, 8177 procedures (61.9%) were elective and 9398 (71.1%) were performed for chronic limb-threatening ischemia (CLTI). The 30-day mortality was 1.7%. Univariate analysis demonstrated that a mFI-5 score greater than 0.6 was associated with higher rates of prolonged hospital stay more than 7 days (34.4% vs 17.7%; P < .001; reference mFI-5 = 0), readmission (23.4% vs 11.1%; P < .001), reoperation, (19.5% vs 15.1%; P < .001), myocardial infarction (5.0% vs 1.8%; P < .001), reintubation (2.5% vs 0.5%; P < .001), acute renal failure (91.1% vs 0.2%; P < .001), 30-day mortality (3.9 % vs 1.0%; P < .001), and wound infection (14.2% vs 9.7%; P < .001). Lack of beta blocker use, higher age, CLTI indication for surgery, nonelective surgeries, tibial target, and mFI-5 were all associated with increased 30-day mortality. Multivariate logistic regression (Table) showed that mFI-5 remained as a significant predictor with mFI-5 of greater than 0.6 predicting a more than twice higher odds for 30-day mortality (odds ratio [OR], 2.324; P = .006), with age (OR, 6.384; P < .001), CLTI Indication (OR, 2.617; P < .001) and nonelective procedures (OR, 1.865; P < .001) also showing increased risk for mortality. For patients undergoing LEOR, higher mFI-5 was associated with increased hospital use, 30-day mortality, and 30-day readmission. The mFI-5, an easily calculated tool, may assist to identify patients at high risk for inferior outcomes. The mFI-5 may be useful for preoperative risk stratification and predicting mortality, and 30-day readmission for patients undergoing LEOR.TableMultivariate analysis of factors affecting 30-day mortality after lower extremity endovascular revascularization (LEOR)ORP valueAge: 18-59 (ref) 60-691.951.022 70-793.423<.001 ≥806.384<.001mF5: 0 (ref) 0.21.221.482 0.41.133.666 0.6-1.02.324.006Sex: female (ref male)0.915.544Race: other/unknown (ref White)0.946.691Use of beta blocker0.764.076Anatomical high risk0.943.681Physiological high risk (excluded owing to collinearity)Indication: CLTI (ref asymptomatic/claudication)2.617<.001Nonelective1.865<.001Procedure: tibial (ref nontibial target)1.015.917Procedure: prosthetic (ref nonprosthetic)1.110.458C-statistic0.749CLTI, Chronic limb-threatening ischemia; mF5, 5-factor frailty index; OR, odds ratio. Open table in a new tab

Military-civilian partnerships and the clinical readiness mission: A preliminary study from the Military Health System and the American College of Surgeons.

The Blue Book , published in conjunction with the Military Health System Strategic Partnership with the American College of Surgeons, serves as a reference manual for institutions wishing to establish a military-civilian partnership (MCP). To evaluate the applicability of the criteria contained in the Blue Book , we created a survey to be distributed to MCP military surgeons and their civilian host champions. E-mail surveys were sent to MCP military surgeons and civilian host champions. Military surgeons were queried about basic demographic information and aspects of the MCP including type, duration of assignment, onboarding, malpractice coverage, and billing for services. We gathered information on the role of military surgeons at the MCP, workload information, and trauma cases. The civilian host champions survey focused on institutional activities including trauma surgical volume, clinical and educational opportunities for the military surgeons, and exposure to research. Military-civilian partnership military surgeons and civilian host champions were questioned on program attributes: administrative support, budget, and profile of the program within the institution. Ten MCP military surgeons and 7 host champions completed surveys. The majority of military surgeons were assigned to the MCP for a 3-year instructor role (90%), and most were trauma surgeons (80%). Clinical activities for the military surgeon were where 60% spent ≥13 weeks annually on trauma. Military surgeons identified host program support in academic growth, deployment preparation, and sense of value at the MCP as positive attributes. Civilian host champions unanimously reported that exposure to research, opportunities to lead trauma teams, dedicated intensive care unit time, and patient volume were positive program attributes. This preliminary survey demonstrates that the criteria put forth in the Blue Book align with experiences of MCP military surgeons and host champions. Continued development of this survey and others like it may be useful in the MCP program selection and evaluation process. Therapeutic/care management; Level V.

Impact of local treatment modality on overall- and disease-specific survival for nonmetastatic pelvic and sacral Ewing sarcoma.

The ideal local treatment modality for pelvic and sacral Ewing sarcoma (EWS) is controversial. We present the data from the American College of Surgeon's National Cancer Database (NCDB) and the National Cancer Institute'sSurveillance, Epidemiology and End Result (SEER) database to investigate the impact of local treatment modalities on survival for nonmetastatic pelvic and sacral Ewing sarcoma. Local treatment includes "surgery,""radiation,"and a combination of "surgery and radiation." A total of 235 cases from SEER and 285 cases from NCDB were analyzed. Patients with "localized"stage (intraosseous) in the SEER database did not show any statistically significant difference in the disease-specific survival (DSS)for any of the local treatment modalities. Similar findings were observed for overall survivalamong patients with American Joint Committee on Cancer (AJCC) stage II and III in the NCDB database. However, patients with nonmetastatic disease, particularly regional disease (extraosseous), showed improved DSS with surgery only, in the SEER. We found similar levels of efficacy for different treatment modalities for patients with intraosseous and AJCC II and III pelvic and sacral EWS. "Radiotherapy"is the most common local treatment modality employed in the United States. A prospective, randomized controlled trial with a direct head-to-head comparison is needed for a definitive conclusion.

Understanding the 30-day mortality burden after revision total hip arthroplasty.

Revision total hip arthroplasty (THA) is a challenging procedure that burdens the healthcare system. Despite being associated with worse outcomes relative to its primary counterpart, postoperative mortality after revision THA remains ill-defined. The present study aimed to (1) establish the overall 30-day mortality rate after revision THA and (2) explore the mortality rate stratified by age, comorbidity burden, and aseptic versus septic failure. The American College of Surgeons - National Surgical Quality Improvement Program (ACS-NSQIP) database was retrospectively reviewed for all patients who underwent revision THA from 2011 to 2019. A total of 23,501 patients were identified and grouped into mortality (n = 161) and mortality-free (n = 23,340) cohorts. Patient demographics, comorbidities, and aseptic/septic failure were evaluated. The overall 30-day mortality was 0.69%. The mortality rate by age group (normalised per 1000 patients) was 0 (18-39 years [Y]), 0.67 (40-49 Y), 1.10 (50-59 Y), 2.58 (60-69 Y), 6.15 (70-79 Y) 19.32 (80-89 Y), and 58.22 (90+Y) (p < 0.001). The mortality rate by ASA classification (normalised per 1000 patients) was 0 (ASA I), 1.47 (ASA II), 6.94 (ASA III), 45.42 (ASA IV), and 200 (ASA V) (p < 0.001). The 30-day mortality rate for the septic and aseptic cohorts was 1.03% and 0.65%, respectively (p = 0.038). CCI scores (p < 0.001), diabetes (p < 0.001), systematic sepsis (p < 0.001), poor functional status (p < 0.001), BMI < 24.9 kg/m2 (p < 0.001), and dirty/infected wounds (p < 0.001) were all associated with increased mortality risk. 1 in 145 patients will suffer mortality during the 30 days after revision THA. PJI-related revision THA was associated with 1.5-fold increase in 30-day mortality rate compared to its aseptic counterpart. Certain patient determinants and baseline comorbidities, as measured by ASA and CCI scores, were associated with higher 30-day mortality rates. Therefore, it is imperative to identify such risk factors and implement perioperative patient optimisation pathways to mitigate the risk among vulnerable patients.

Does Adding a Measure of Social Vulnerability to a Surgical Risk Calculator Improve Its Performance?

Emerging literature suggests that measures of social vulnerability should be incorporated into surgical risk calculators. The Social Vulnerability Index (SVI) is a measure designed by the CDC that encompasses 15 socioeconomic and demographic variables at the census tract level. We examined whether adding the SVI into a parsimonious surgical risk calculator would improve model performance. The eight-variable Surgical Risk Preoperative Assessment System (SURPAS), developed using the entire American College of Surgeons (ACS) NSQIP database, was applied to local ACS-NSQIP data from 2012 to 2018 to predict 12 postoperative outcomes. Patient addresses were geocoded and used to estimate the SVI, which was then added to the model as a ninth predictor variable. Brier scores and c-indices were compared for the models with and without the SVI. The analysis included 31,222 patients from five hospitals. Brier scores were identical for eight outcomes and improved by only one to two points in the fourth decimal place for four outcomes with addition of the SVI. Similarly, c-indices were not significantly different (p values ranged from 0.15 to 0.96). Of note, the SVI was associated with most of the eight SURPAS predictor variables, suggesting that SURPAS may already indirectly capture this important risk factor. The eight-variable SURPAS prediction model was not significantly improved by adding the SVI, showing that this parsimonious tool functions well without including a measure of social vulnerability.

Preoperative hypoalbuminemia and dialysis increase morbidity/mortality after spine surgery for primary pyogenic spinal infections (ACS-NSQIP Study).

Background: We analyzed the role of hypoalbuminemia, dialysis, and other risk factors that increase morbidity/ mortality following surgery for primary pyogenic spinal infections (PSIs). The American College of Surgeons’ National Surgical Quality Improvement Program (ACS-NSQIP) that included 627 patients was utilized as our database.Methods: Primary spinal surgery for spondylodiscitis was evaluated in a ACS-NSQIP database involving 627 patients between 2010 and 2019. Outcome assessment included evaluation of 30-day postoperative morbidity, and mortality rates.Results: Within 30 postoperative days, complications occurred in 14.6% (92/627) of patients; 59 (9.4%) required readmission, and 39 (6.2%) required additional surgery. The most common complications were: wound infections, pneumonia, septic shock, and death (1.8%). Hypoalbuminemia (i.e., significantly associated with unplanned readmission and reoperation), and dialysis were the two major risk factors contributing to increased perioperative morbidity and mortality.Conclusion: Among 627 ACS-NSQIP patients undergoing primary surgery for PSIs, hypoalbuminemia and dialysis were associated with higher risks of major perioperative morbidity (i.e., within 30 postoperative days – mostly readmissions and reoperations) and mortality.

Trends in Surgeon Subspecialty and Surgical Indications for Vaginal Hysterectomy [A75

INTRODUCTION: Although the American College of Obstetricians and Gynecologists recommends vaginal hysterectomy (VH) as the preferred approach for benign hysterectomy whenever feasible, the number of VH performed is declining in the US. Our objective was to describe trends in gynecologic surgeon subspecialty and surgical indications for patients who underwent vaginal hysterectomy between 2015-2019. METHODS: Institutional review board approval was waived for this study of patients who underwent VH for benign indications between 2015-2019 in the American College of Surgeons’ National Surgical Quality Improvement Program database. Patients were identified using current procedural terminology (CPT) codes. To analyze trends over time, two cohorts were compared: VH surgeries between 2015-2017 versus 2018-2019. RESULTS: Of 122,457 benign hysterectomies captured, 18,262 (14.9%) were VH. The proportion of VH decreased from 15.8% during 2015-2017 to 14.0% during 2018-2019 (P 05 for all). CONCLUSION: Trends in surgeon subspecialty and surgical indications for vaginal hysterectomy are important to consider in addressing the shift away from VH, as they may have implications for patient outcomes and surgical education.

Validation of a risk prediction calculator in Australian patients undergoing head and neck microsurgery reconstruction

The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) surgical risk calculator (SRC) is an open access calculator predicting patients' risk of postoperative complications. This study aims to assess the validity of the SRC in patients undergoing microsurgical free flap reconstruction at an Australian tertiary referral centre. This is a retrospective cohort study of 200 consecutive patients treated up to November 2020. SRC-predicted rates of postoperative complications and hospital length of stay (LOS) were compared to those observed for the ablative and reconstructive components of the procedure. The performance of the SRC was assessed using Brier scores, area under the receiver operating characteristic (ROC) curve (AUC), and the Hosmer-Lemeshow test. For both ablative and reconstructive components, the SRC discriminates well for pneumonia and urinary tract infection, and it is calibrated well for readmission and sepsis, but it does not discriminate and calibrate well for any single outcome. SRC-predicted hospital LOS and actual LOS did not correlate well for the reconstructive component, but they correlated strongly for the ablative component. The SRC is a poor predictor of postoperative complication rates and hospital LOS in patients undergoing head and neck microsurgical reconstruction.

Trauma Registry Data Collection Practices and the Impact of Hospital Data Dictionaries: A National Survey.

Trauma programs are required to collect a uniform set of trauma variables and submit data to regional, state, and or national registries. Programs may also collect unique data elements to support hospital-specific initiatives. This study explored what additional data elements are being collected by U.S. trauma programs and the impact of having a hospital-specific data dictionary. An anonymous, cross-sectional survey exploring what additional data are being collected, and the impact of having a hospital-specific data dictionary, was distributed by the Society of Trauma Nurses, Trauma System News, and the American College of Surgeons. The survey was open from July 2020 to September, 2020. There were 693 respondents from approximately 368 Level I/II trauma programs. The estimated trauma center response rate was 59.4% (n = 368/620). Level I programs had a higher response rate than Level II programs (66.9% and 53.4%, respectively).In our sample, 85.5% of responding centers collect additional data. The most common additional data collected at Level I/II programs concerned quality improvement initiatives (70.3% and 66.1%, respectively). Other commonly collected data pertained to deaths (60.6%) and complications (50.3%).Only 43% of responding centers (n = 161/368) have a hospital-specific data dictionary. Hospitals that collect additional data were more likely to have such a resource compared with those that do not (n = 147/315, 46.7% vs. n = 14/53, 26.4%, p = .01). Most trauma programs collect data outside required fields. Fewer than half define these data in a data dictionary. Centers should consider establishing a data dictionary to define data collected.

Functional panniculectomy vs cosmetic abdominoplasty: Multicenter analysis of risk factors and complications

Amidst the rising trend of bariatric surgical procedures being performed across the country and around the world, patients seeking functional panniculectomy after massive weight loss represent a different population than those seeking cosmetic abdominoplasty. The purpose of this study was to determine whether certain complications are more likely to occur in patients undergoing functional panniculectomy, as well as identify risk factors that are implicated in the occurrence of adverse events. Retrospective cohort study was conducted of patients undergoing cosmetic abdominoplasty and functional panniculectomy in North America between 2015 and 2019 using the National Surgical Quality Improvement Program database sponsored by the American College of Surgeons. Comorbidities and postoperative complications between these two cohorts were analyzed with appropriate statistics. During the study interval, 11,137 patients underwent excision of excessive infraumbilical abdominal skin, including 57.4% (n=6397) patients undergoing functional panniculectomy and 42.6% (n=4740) patients undergoing cosmetic abdominoplasty. Patients undergoing functional panniculectomy were significantly more likely to have comorbidities than those undergoing cosmetic abdominoplasty (p<.001). Overall adverse events (p<.001), medical complications (p=.047), surgical complications (p<.001), related readmission (p<.001), and related reoperation (p<.001) were significantly higher in patients undergoing functional panniculectomy. Surgical complications significantly higher in functional panniculectomy included superficial incisional infection (p<.001), deep incisional infection (p<.001), organ/space infection (p<.001), dehiscence (p=.003), and bleeding requiring transfusion (p=.003). Patients undergoing functional panniculectomy are significantly more likely to have comorbidities and experience postoperative wound infection, dehiscence, sepsis, bleeding, related readmission, and related reoperation.

Strategies to Improve the Rural Surgical Workforce.

The rural surgical workforce is in crisis, resulting in significant health care access issues for the 60 million rural Americans. Rural surgeons encounter unique barriers to providing care for patients that are different than their urban counterparts. Rural hospitals are failing at an alarming rate. The American College of Surgeons (ACS) and the ACS Advisory Council for Rural Surgery have worked to improve communication among isolated rural surgeons and to bring recognition to rural surgeons as a distinct group. The rural workforce is aging at a rapid rate and multiple factors prevent newly trained surgeons from replacing those that retire. Loss of a surgeon in a small community leads to significant economic losses and possibly even closure of the local hospital. Changes in surgical training, subspecialization, demographic trends, and economic issues all lead to less numbers of young surgeons choosing to practice in small communities. Increasing the numbers of trainees will not reverse the trend unless it is combined with a change in the training paradigm for surgeons with a rural interest, additional funding for more rural training programs and financial support for surgeons to work in rural areas, and collaboration with urban and academic health care systems and their surgeons.

Kidney Disease: Improving Global Outcomes Classification of Chronic Kidney Disease and Short-Term Outcomes of Patients Undergoing Liver Resection.

The impact of chronic kidney disease (CKD) on surgery is still not well defined. We sought to characterize the association of preoperative CKD with 30-day mortality after hepatic resection. Patients included in the American College of Surgeons (ACS) NSQIP who underwent hepatectomy between 2014 and 2018 were identified. Kidney function was stratified according to the "Kidney Disease: Improving Global Outcomes" (KDIGO) Classification: G1, normal/high function (estimated glomerular-filtration-rate ≥ 90 ml/min/1.73m2); G2-3, mild/moderate CKD (89-30 ml/min/1.73m2); G4-5, severe CKD (≤ 29 ml/min/1.73m2). Overall, 18,321 patients were included. Older patients (ie more than 70 years old) and those with serious medical comorbidities (ie American Society of Anesthesiologists [ASA] class 3) had an increased incidence of severe CKD (both p < 0.001). Patients with G2-3 and G4-5 CKD were more likely to have a prolonged length of stay and to experience postoperative complications (both p < 0.001). Adjusted odds of 30-day mortality increased with the worsening CKD (p = 0.03). The degree of CKD was able to stratify patients within the NSQIP risk calculator. Among patients who underwent major hepatectomy for primary cancer, the rate of 30-day mortality was 2-fold higher with G2-3 and G4-5 CKD vs normal kidney function (p = 0.03). The degree of CKD was related to the risk of complications and 30-day mortality after hepatectomy. CKD classification should be strongly considered in the preoperative risk estimation of these patients.

Development and Validation of a Decision Analytical Model for Posttreatment Surveillance for Patients With Oropharyngeal Carcinoma

Clinical practice regarding posttreatment radiologic surveillance for patients with oropharyngeal carcinoma (OPC) is neither adapted to individual patient risk nor fully evidence based. To construct a microsimulation model for posttreatment OPC progression and use it to optimize surveillance strategies while accounting for both tumor stage and human papillomavirus (HPV) status. In this decision analytical modeling study, a Markov model of 3-year posttreatment patient trajectories was created. The training data source was the American College of Surgeon's National Cancer Database from 2010 to 2015. The external validation data set was the 2016 International Collaboration on Oropharyngeal Cancer Network for Staging (ICON-S) study. Training data comprised 2159 patients with OPC treated with primary radiotherapy who had known HPV status and disease staging information. Patients with American Joint Committee on Cancer, 7th edition stage III to IVB disease and those with clinical metastases during the time of primary treatment were included. Data were analyzed from August 1 to October 31, 2020. Main outcomes included disease stage and HPV status, specific disease transition probabilities, and latency of surveillance regimens, defined as time between recurrence incidence and disease discovery. Training data consisted of 2159 total patients (1708 men [79.1%]; median age, 59.6 years [range, 40-90 years]; 401 with stage III disease, 1415 with stage IVA disease, and 343 with stage IVB disease). Cohorts predominantly had HPV-negative disease (1606 [74.4%]). With model-optimized regimens, recurrent disease was discovered a mean of 0.6 months (95% CI, 0.5-0.8 months) earlier than with a standard surveillance regimen based on current clinical guidelines. Recurrent disease was discovered using the optimized regimens without significant reduction in sensitivity. Compared with strategies based on reimbursement guidelines, the model-optimized regimens found disease a mean of 1.8 months (95% CI, 1.3-2.3 months) earlier. Optimized, risk-stratified surveillance regimens consistently outperformed nonoptimized strategies. These gains were obtained without requiring any additional imaging studies. This approach to risk-stratified surveillance optimization is generalizable to a broad range of tumor types and risk factors.

Characteristics of Adult Patients for Violence-Related Injuries Presenting to a Level 1 Trauma Center in Midwest United States

Background Hospital violence intervention programs (HVIPs) have recently been initiated in trauma centers across the United States. However, violence-related injuries have unique factors and issues that should be addressed in the health care provided in emergency departments. Purpose This study aimed to characterize the patient population presenting at a level 1 ACS verified trauma center, with a chief complaint of violent trauma, and identify characteristics of patients most at risk for violence-related trauma. Methods The cross-sectional retrospective study examined patients’ electronic health records, at least 18 years, with a diagnosis of blunt or penetrating injury treated by the emergency and trauma team at level 1 ACS verified trauma center in the Midwest. Results Assault injuries accounted for most of the mechanisms that required treatment at the hospital and disposed to home. Nearly 80% of the population had no documentation of the relationship of the assailant. The average age of the patients was 33 years and black males. Eleven patients were treated in the emergency department twice for a trauma-related injury during the six-month data collection. Conclusion Injuries from violence require comprehensive care from various healthcare disciplines, similar to managing acute and chronic illnesses. The American College of Surgeons (ACS) guidelines support the development of an HVIP to identify risk factors and treatment plans for any patient exposed to violence. This research demonstrates that HVIPs should provide standardized screening and follow-up care while in the emergency department or immediately following the hospital to reduce the cyclical events.

Multidisciplinary Project to Prevent Postoperative Urinary Tract Infection.

Postoperative urinary tract infections (UTIs) are associated with increased lengths of stay, inpatient costs, and mortality. Review of institutional data from the American College of Surgeons (ACS) NSQIP revealed opportunities to improve practices with respect to urinary catheter (Foley) insertion, catheter care, adherence to diagnosis and prevention protocols, and ACS NSQIP reporting. A multidisciplinary quality improvement team convened and implemented interventions based on a literature review and analysis of institutional drivers of postoperative UTI. The team educated the ACS NSQIP surgical clinical reviewers and clinical teams about UTI diagnostic criteria and prevention, trained staff in proper catheterization technique, and provided performance feedback. The team also developed kits with supplies and instructions for patients who were discharged home with catheters, along with an instructional video. The investigators evaluated project effectiveness by comparing pre- and postintervention process measures and rates of postoperative UTI. After interventions, compliance rates improved for hand hygiene (62% to 83%, p = 0.04), precleansing of the periurethral area (66% to 97%, p = 0.001), and catheter positioning (41% to 93%, p < 0.001), and the composite performance (10% to 73%, p < 0.001). Surgery residents' scores on a UTI knowledge assessment improved from 71% to 81% (p = 0.005). The majority of residents and staff strongly agreed that the training sessions would change their practice (57% and 69%, respectively). The unadjusted rate of postoperative UTIs at our institution decreased from 1.55% to 0.69% (p = 0.016), corresponding to an improvement in the ACS NSQIP odds ratio from 1.51 to 0.86. A series of interventions, including provider training, patient education, and audits of practice with performance feedback, are associated with improvements in both practice and the incidence of postoperative UTI.

Hospital-Acquired Condition Rate of Admitting Facility Does Not Predict Mortality in Traumatically Injured Patients.

Background: Hospital-acquired conditions (HACs) are increasingly scrutinized as markers of hospital quality and are subject to increasing regulatory and financial pressure. Despite this, there is little evidence that HACs are associated with poor outcomes in traumatically injured patients, or that lower HAC rates are a marker of a better quality of care. Our study compares mortality rates in hospitals with high versus low rates of HAC. Our hypothesis is that high HAC trauma centers have higher mortality.Methods: The latest editions of the National Trauma Data Bank (NTDB) containing facility identification keys (2011 to 2015) were combined. The HACs targeted by the Centers for Medicare and Medicaid Services (CMS) Hospital-Acquired Condition Reduction Program (HACRP) were identified. Hospital-acquired conditions per 1000 patient-days were calculated for individual trauma centers, and these facilities were stratified into quartiles by HAC rate. Propensity score matching was used to match patients admitted to hospitals in the highest versus the lowest quartiles.Results: Complete data was available for 3,510,818 patients; 58,296 (1.67%) developed HACs recorded in the NTDB. Good performing centers had a mean of 0.84 HACs per 1000 patient-days compared to 7.82 at poor-performing centers. After propensity matching, patients treated at good performing centers had higher mortality of 1.22% versus 1.02% at poor-performing centers (p<0.001). The facility characteristics most over-represented in the poor performing quartile were: University (45.19% vs 10.59%, p<0.001), American College of Surgeons (ACS) Level I Status (31.85% vs 2.24%, p<0.001), and bed size > 600 (28.15% vs 5.5%, p<0.001).Conclusion: Injured patients treated at poor-performing centers (high HAC) have reduced mortality relative to good performing centers (low HAC). Large academic centers were overwhelmingly represented in the poor-performing quartile. Hospital-acquired conditions may be markers of a non-modifiable underlying patient and facility characteristics rather than markers of poor hospital quality.

Mortality of adolescents with isolated traumatic brain injury does not vary with type of level I trauma center.

Pediatric patients with isolated severe traumatic brain injury (TBI) treated at pediatric trauma centers (PTCs) have lower mortality than those treated at adult trauma centers (ATCs) or mixed trauma centers (MTCs). The primary objective of this study was to determine if adolescent patients (15-17 years) with isolated severe TBI also benefited from treatment at PTCs. This was a cross-sectional analysis using a national sample of adolescent trauma patients obtained from the American College of Surgeons' Trauma Quality Program Participant Use Files for 2013 to 2017 (n = 3,524). Mortality, the primary outcome variable, was compared between Level I PTCs, ATCs, and MTCs using multiple logistic regression controlling for patient characteristics and injury severity. Secondary outcomes included discharge disposition, utilization of craniotomy, intensive care unit (ICU) utilization, ICU length of stay (LOS), and hospital LOS. Prior to adjustment, patients treated at ATCs (odds ratio [OR], 2.76; p = 0.032) and MTCs (OR, 2.36; p = 0.070) appeared to be at greater risk of mortality than those treated at PTCs. However, after adjustment, this difference disappeared (ATC OR, 1.21; p = 0.733; MTC OR, 0.95; p = 0.919). Patients treated at ATCs and MTCs were more severely injured than those treated at PTCs and more likely to be admitted to an ICU (ATC OR, 2.12; p < 0.001; MTC OR, 1.91; p < 0.001). No other secondary outcome differed between center types. Adolescent patients with isolated severe TBI treated at ATCs and MTCs had similar mortality risk as those treated at PTCs. The difference in injury severity across center types warrants additional research. Prognostic/Epidemiological; Level III.

Care of the older trauma patient following low-energy transfer trauma-highlighting a research void.

in high-income countries trauma patients are becoming older, more likely to have comorbidities, and are being injured by low-energy mechanisms. This systematic review investigates the association between higher-level trauma centre care and outcomes of adult patients who were admitted to hospital due to injuries sustained following low-energy trauma. a systematic review was conducted in January 2021. Studies were eligible if they reported outcomes in adults admitted to hospital due to low-energy trauma. In the presence of study heterogeneity, a narrative synthesis was pre-specified. three studies were included from 2,898 unique records. The studies' risk of bias was moderate-to-serious. All studies compared outcomes in trauma centres verified by the American College of Surgeons in the USA. The mean/median ages of patients in the studies were 73.4, 74.5 and 80years. The studies reported divergent results. One demonstrated improved outcomes in level 3 or 4 trauma centres (Observed: Expected Mortality 0.973, 95% CI: 0.971-0.975), one demonstrated improved outcomes in level 1 trauma centres (Adjusted Odds Ratio 0.71, 95% CI: 0.56-0.91), and one demonstrated no difference between level 1 or 2 and level 3 or 4 trauma centre care (adjusted odds ratio 0.91, 95% CI: 0.80-1.04). the few relevant studies identified provided discordant evidence for the value of major trauma centre care following low-energy trauma. The main implication of this review is the paucity of high-quality research into the optimum care of patients injured in low-energy trauma. Further studies into triage, interventions and research methodology are required.

597 Reconstruction of Lop Ear Deformities After Severe Burn Injury in Pediatric Patients: An 11-year Experience

IntroductionThe ear is one of the most highly visible structures on the face. One or both ears are frequently involved in panfacial burns. Because they are bilateral structures, asymmetries are clearly visible. Reconstruction of burned ear deformity often requires replacement or modification of skin and/or cartilage. Even these are successfully replaced, scar contractile forces can cause deformation of the ear. One of these deformities is lop or cup ear, in which the helical rim is either folded over, wrinkled or tight. We describe the necessity of applying otoplasty techniques to address this problem.MethodsA retrospective chart review analysis was performed to assess demographic variables, procedural indications and procedural outcomes in pediatric patients treated at our hospital for complex ear reconstruction for ear deformities after her surgery. Inclusion criteria were pediatric patients aged 0 to 21 years admitted to Shriners Hospital for Children-Boston from January 1, 2010 to January 1, 2021 for burn injury, who subsequently required follow-up complex ear reconstruction for ear deformities after burn injury. Of these patients, those with lop ear deformities who required construction were examined. Using the Trauma Registry of the American College of Surgeons (TRACS) and Shriners Hospital for Children Information Source (SHCIS) databases, we identified 12 eligible patients. Surgical procedure data was obtained from the SHCIS electronic medical records. Surgical photographs were obtained with patient informed consent. Those patients who required Medpor or cartilage frame reconstructions were excluded.Results12 patients required an otoplasty-type procedure to obtain desired results or symmetry with the contralateral ear. This technique involved a posterior incision in the auriculomastoidmastoid sulcus, are you a year and cartilage modification with sutures to to re-create the antihelical fold an superior crus as well as conchal setback sutures.ConclusionsBecause ears are bilateral structures, symmetry is extremely poor. Because of multiple contractile forces on the external ear from secondary healing or contraction of skin grafts, the ear is often displaced anteriorly and the upper portions become folded. Treatment requires reconstruction of the natural folds of the ear and shortening of the helical rim to mastoid distance. this requires an otoplasty approach with a posterior incision,, exposure of the cartilaginous framework and modification of the cartilage with incisions and sutures. This technique however requires adequate soft tissue coverage of the ear.

Applying Lessons from COVID-19 to Cost Centers across the Phases of Surgical Care.

SummaryThe financial impact of the COVID-19 pandemic has been particularly significant in surgical specialties, with an estimated loss of $22 billion due to deferrals and cancelations of procedures. Evidence suggests that alternative payment models may have reduced the financial impact of COVID-19 for some providers; however, representation of plastic surgery in these models has historically been limited. It is critical for plastic surgeons to understand cost drivers throughout the surgical care episode to design strategies to reduce costs in the wake of the COVID-19 pandemic. In this perspective, we use the American College of Surgeons Five Phases of Surgical Care framework to examine inflationary spending pressures at each stage of the surgical continuum of care. We then highlight cost-containment strategies relevant to plastic and reconstructive surgery within these stages, including those developed before the COVID-19 pandemic, such as bundled payment models and utilization of ambulatory surgery centers, and others expanded during the pandemic, including further use of telemedicine for pre and postoperative visits and expansion of enhanced recovery after surgery pathways and home-based rehabilitation for breast reconstruction. Using innovations from the COVID-19 pandemic can help plastic surgeons further innovate to decrease costs and improve outcomes for patients.