Inpatient Mortalities Research Articles

The Role of Structured Goals of Care Discussions in Critically Ill Thoracic Surgery Patients.

Objective: The American College of Surgeons recommends structured family meetings (FM) for high-risk surgical patients. We hypothesized that goals of care discussions (GOCD) in the form of an FM, multidisciplinary family meeting (MDFM), or palliative care consult (PCC) would be underutilized in imminently dying thoracic surgery patients. Methods: A retrospective chart review at a tertiary academic medical center was performed on all inpatient mortalities and discharges to hospice after any thoracic surgery operation. The utilization of GOCDs was compared between the 2 groups. Secondary outcomes were length-of-stay, comatose status and ventilator dependence during initial GOCD, and timing of code status change. Results: In total, 56 patients met inclusion criteria: 44 of 56 (78.6%) died and 12 of 56 (21.4%) were discharged to hospice. Most patients had a FM (79.5% mortality vs 100% hospice, P = .29) and few had an MDFM (25.0% mortality vs 25.0% hospice, P = 1.00). Patients discharged to hospice were more likely to have a PCC (66.7% vs 31.2%, P = .03) and less likely to be comatose (16.7% vs 59.1%, P = .009) or ventilator dependent during initial GOCD (16.7% vs 70.5%, P = .001). Among patients who died and were DNR-CC (do not resuscitate-comfort care; 37 of 44), 75.7% died the same day of code status change and 67.6% died within 48 h of initial GOCD. Discussion: Although FMs were common, MDFMs were infrequent. Patients discharged to hospice were more likely to have a PCC. Most deaths occurred shortly after initial GOCD and most code status changes occurred on day-of-death. This data suggest an opportunity to improve GOCDs in critically ill thoracic surgery patients.

Super-elderly, spinal surgery, evaluating the risks and benefits: a retrospective single-centre cohort study.

An increasingly ageing population presents emerging healthcare challenges. Adequate clinical evaluation and understanding of outcome-predicting factors are integral to delivering safe spinal surgery to super-elderly patients. To evaluate spine surgery outcomes in patients aged 80 or above. We retrospectively evaluated patients 80 years and above who underwent elective or emergency spinal surgery between 2017 and 2022. The Eurospine Surgery Classification (ESC) was used to classify operations into Large, Medium, and Small. We calculated and compared Clinical Frailty Scores (CFS) pre- and post-operatively. Two hundred forty-five patients met the inclusion criteria. Most were male (n = 145). The age range was 80 to 99 (mean 83.3). Most operations were elective (n = 151, 62%). In our cohort, 211, 22, 10,2 and 1patients had degenerative, trauma, tumour, infective and vascular pathologies, respectively. According to the Eurospine classification, 201 (82.0%) had Minor spine surgery (63 emergently and 138 electively), 38 had Medium surgery (15.5% - 30 emergently and 8 electively), and 6 had Large surgery (2.4% - 1 emergently and 5 electively). 163 (66.5%) were discharged or under follow-up. There were 11 in-patient mortalities (4.5%). Outpatient mortality was 51 (20.8%), with the median time from surgery to death being 504.5 days, all the outpatient mortalities were neither non-spinal pathology nor spinal surgical related. CFS improved across the cohort, from 5 pre-operatively to 4 post-operatively (p < 0.001). Spine surgery in those over the 80s can be performed safely and improve their quality of life, as demonstrated by improvements in the CFS. Good patient selection and adequate pre-operative workup is essential, although it may not be possible in emergencies.

Cholecystectomy in the red centre: a review of the surgical outcomes in Central Australia in a five-year period.

Despite the high rates of cholecystectomy in Australia, there is minimal literature regarding the outcomes of cholecystectomy in rural Central Australia within the Northern Territory. This study aims to better characterize the outcomes for patients undergoing cholecystectomy in Central Australia and review clinical and patient characteristics, which may affect outcomes. A retrospective case-control study was performed using data obtained from medical records for all patients undergoing cholecystectomy at Alice Springs Hospital in the Northern Territory from January 2018 until December 2022. Patient characteristics were gathered, and key outcomes examined included: inpatient mortality and 30-day mortality, bile duct injury, bile leak, return to theatre, conversion to open, duration of procedure, length of stay, and up-transfer to a tertiary referral centre. A total of 466 patients were included in this study. Majority of the patients were female and there was a large portion of Indigenous Australians (56%). There were no inpatient mortalities, or 30-day mortalities recorded. There were two bile leaks and/or bile duct injuries (0.4%) and two unplanned returned to theatres (0.4%). Indigenous Australians were more likely to require an emergency operation and had a longer median length of stay (P < 0.001). Cholecystectomy can be performed safely and to a high standard in Central Australia. Surgeons in Central Australia must appreciate the nuances in the management of patients who come from a significantly different socioeconomic background, with complex medical conditions when compared to metropolitan centres.

Tuberculosis Mortalities Among In-patients at a Tertiary Hospital in Zambia Between 2018 and 2019 - The Spectrum of Clinical Presentations

Background: Tuberculosis (TB) has remained one of the most important public health diseases and a leading cause of mortality from a single infectious agent in the world. In-patient mortalities have remained relatively high despite massive investment towards TB elimination. This prompted us to undertake a TB mortality review aimed at understanding the spectrum of clinical presentations in TB mortalities among in-patients in a local hospital set up in Zambia.&#x0D; Methods: Files of 74 in-patient TB related mortalities that had occurred at Kitwe Teaching Hospital over a 12-month period between June 2018 and June 2019 were audited using a structured questionnaire. The data was analyzed using SPSS v 16.0 statistical software while descriptive statistics and cross tabulation was used to determine the frequencies and cross relationships among the variables followed by univariate logistic regression whose significance was set at a p-value of 0.05 and a 95 percent confidence interval. Variables that were found to be significant at univariate logistic regression were fitted into the multivariable logistic regression.&#x0D; Results: The audit revealed that 50 (67.6%) of the files were for male patients with a mean age of 39.2 ± 11.6 years. 60(80%) were HIV positive, 60(80%) resided in high-density residential areas. On presentation to hospital, the commonest symptoms included productive cough and fever [31(41.9%) and 30(40.5%) respectively]. HIV positive male patients were presenting in hyperdynamic state (mean pulse rate of 117.2 ± 32.4 per minute, p = .001) and HIV positive females presented with mean arterial pressure (72.3 ± 19.5 mmHg, p = .002). Other findings included signs of multi-organ involvement [hypoalbuminemia 9(12.2%), deranged renal function 8(10.8%) and deranged liver enzymes 9(12.2%)] before mortality occurred.&#x0D; Conclusion: The spectrum of clinical presentations among in-patients with TB in a tertiary hospital include the following; male gender, age younger than 50 years, being HIV positive, residing in a high-density residential area and presenting with unstable hemodynamics. There is a need to focus strategies targeted at strengthening early recognition of clinical instability among admitted TB patients for at-risk populations, including young to middle aged males who are HIV positive.

Ensuring No Death Is Ignored: Development of a Hospital Mortality Review and Notification System.

Standardized review of mortalities may identify potential system improvements. We designed a hospitalwide identification, review, and notification system for inpatient pediatric mortalities. Key stakeholders constructed a future state process map for identification and review of deaths. An online mortality review form was modified through a series of Plan-Do-Study-Act cycles and spread to all pediatric services in January 2019. Mortalities occurring within 30 days of discharge were added in December 2019. Our primary outcome was percentage of mortalities reviewed, and the process measure was time to review completion. Additional Plan-Do-Study-Act cycles were used to refine 2 mechanisms for monthly notification of deaths. We surveyed monthly mortality notification e-mail recipients to elicit feedback to further improve notifications. After the pilot, 284 of 328 (86.6%) of mortalities were reviewed. Average time to review completion decreased by 49% compared with baseline after an increase during the first year of the pandemic. Qualitative analysis of a subset of these mortalities showed that 154 of 229 (67.2%) underwent further review. We added a summary of mortalities by unit to a monthly hospitalwide safety report and developed monthly mortality notification e-mails. The survey showed that 89% of respondents (70 of 79) learned about a death they did not know about, 58% (46 of 79) sought additional information through discussion with a colleague, and 76% (65 of 86) agreed that the notifications helped process grief. We describe an effective and well-received approach to the identification, review, and notification of mortalities at an academic pediatric hospital, which may be useful at other institutions.

719 Decreased Morbidity in Patients with Hidradenitis Suppurativa Insured by Medicaid or Medicare

Abstract Introduction Hidradenitis suppurativa (HS) is a chronic condition that is defined by recurring inflammation and fibrosis of intertriginous areas. Patients with HS have had increasing inpatient hospitalization rates over the years. Our study investigates inpatient mortality and morbidity factors in patients with HS by primary payer status. We hypothesized that patients who are uninsured or insured by Medicaid or Medicare will have worse in-hospital mortality rates when compared to those insured by private insurance. Methods Using a national database, we performed a cross-sectional study of patients hospitalized from 2017-2019 with a primary diagnosis of HS. The sample size included 12,365 patients with HS. The independent variable was primary payer status, and the dependent variables were age, gender, race, and zip code income quartiles. The primary outcome was in-hospital mortality. The secondary outcomes were morbidity factors (infection and wound dehiscence rates, postoperative complications), time from admission to first procedure, and resource utilization (total hospitalization charges and costs, and length of hospitalization). Statistical analyses were performed to determine frequencies, odds ratios, and significance. Statistical significance was set at p&amp;lt; 0.05. We controlled for the above-defined dependent variables in the logistic regression analysis. Results Primary payer status was not associated with inpatient mortality in patients with HS (p=0.092). From 2017-2019, there were a total of five (0.04%) of in-patient mortalities in patients with HS, with all five being insured by Medicaid and occurring in 2017. Compared with private insurance, Medicare was associated with significantly lower incidences of wound dehiscence (aOR=0.21 (0.06-0.70); p=0.011) and longer time from admission to first procedure (mean days=1.85 vs 1.23; p=0.01). Medicaid was associated with significantly lower incidences of infection (aOR=0.21 (0.08-0.58); p=0.002) and longer time from admission to first procedure (mean days=1.73 vs 1.23; p=0.024). The only difference observed in the uninsured, when compared to privately insured, was significantly lower total costs ($10601.78 vs $13658.37; p=0.030). Conclusions Our study demonstrates that in patients with HS, inpatient morbidity factors are overall better in those who are publicly insured over those privately insured. However, publicly insured patients face a longer wait to first procedure from admission over those privately insured. Applicability of Research to Practice By raising awareness in treatment outcomes and resource utilization for patients with HS in inpatient settings, the medical team caring for these patients can begin to identify reasons for the disparities shown by insurance status.

Outcomes and Prognostic Factors of Pulmonary Hypertension Patients Undergoing Emergent Endotracheal Intubation.

Background: Emergent endotracheal intubations (ETI) in pulmonary hypertension (PH) patients are associated with increased mortality. Post-intubation interventions that could increase survivability in this population have not been explored. We evaluate early clinical characteristics and complications following emergent endotracheal intubation and seek predictors of adverse outcomes during this post-intubation period. Methods: Retrospective cohort analysis of adult patients with groups 1 and 3 PH who underwent emergent intubation between 2005-2021 in medical and liver transplant ICUs at a tertiary medical center. PH patients were compared to non-PH patients, matched by Charlson Comorbidity Index. Primary outcomes were 24-h post-intubation and inpatient mortalities. Various 24-h post-intubation secondary outcomes were compared between PH and control cohorts. Results: We identified 48 PH and 110 non-PH patients. Pulmonary hypertension was not associated with increased 24-h mortality (OR 1.32, 95%CI 0.35-4.94, P = .18), but was associated with inpatient mortality (OR 4.03, 95%CI 1.29-12.5, P = .016) after intubation. Within 24 h post-intubation, PH patients experienced more frequent acute kidney injury (43.5% vs. 19.8%, P = .006) and required higher norepinephrine dosing equivalents (6.90 [0.13-10.6] mcg/kg/min, vs. 0.20 [0.10-2.03] mcg/kg/min, P = .037). Additionally, the median P/F ratio (PaO2/FiO2) was lower in PH patients (96.3 [58.9-201] vs. 233 [146-346] in non-PH, P = .001). Finally, a post-intubation increase in PaCO2 was associated with mortality in the PH cohort (post-intubation change in PaCO2 +5.14 ± 16.1 in non-survivors vs. -18.7 ± 28.0 in survivors, P = .007). Conclusions: Pulmonary hypertension was associated with worse outcomes after emergent endotracheal intubation than similar patients without PH. More importantly, our data suggest that the first 24 hours following intubation in the PH group represent a particularly vulnerable period that may determine long-term outcomes. Early post-intubation interventions may be key to improving survival in this population.

Increased risk of hip fracture mortality associated with intraoperative hypotension in elderly hip fracture patients is related to under resuscitation

BackgroundAs the US and world population ages, hip fractures are increasingly more common. The mortality associated with these fractures remains high both in the immediate postoperative period and at one year. Perioperative resuscitation in this population is of key interest to prevent organ injury and mortality. Our objectives were to evaluate the effect of fluid resuscitation and hemodynamic status in the form of mean arterial pressure (MAP) on inpatient mortality of hip fracture patients. MethodsAn institutional database was queried to compare elderly hip fracture patients that sustained in-hospital mortality to a matched control cohort. Pre-, intra-, and post-operative intravenous fluid (IVF) administration and MAP were extracted from the electronic medical record. Time from hospital presentation to the OR was also recorded. Results1,114 total hip fractures were identified during the two-year study period, 16 of which suffered inpatient mortalities. The mortality cohort was then matched with a control of 394 hip fracture patients for the same period based on age, sex, and Charlson Comorbidity Index (CCI). Conditional logistical regression analysis found odds ratios (OR) indicating that longer time between presentation and surgery (OR per additional hour: 1.05; 95% CI: 1.01–1.08) and lower intraoperative minimum MAP (OR per 5 mmHg decrease: 0.77; 95% CI: 0.61–0.97) were associated with significantly increased odds of mortality. There was also a marginal relationship between greater intraoperative IVF administration and reduced odds of mortality (OR per 500 cc additional fluid: 0.61; 95% CI: 0.37–1.00). ConclusionExtended time from presentation to surgery and intraoperative hypotension were associated with increased likelihood of inpatient mortality in an elderly hip fracture cohort, with a possible additional effect of under-resuscitation. Further investigation into a safe intraoperative minimum MAP should be pursued. Level of evidenceLevel III.

The U-shape relationship between pulse pressure level on inpatient admission and long-term mortality in acute coronary syndrome patients undergoing percutaneous coronary intervention.

The association between pulse pressure and long‐term mortality was investigated among acute coronary syndrome (ACS) patients who received percutaneous coronary intervention (PCI). The study population included 5055 ACS patients in the Department of Cardiology of Beijing Friendship Hospital who were enrolled from January 2013 to July 2019. The median duration of follow‐up was 24 months. Multivariate Cox regression was used to analyze the relationships between PP on inpatient admission and mortalities. Non‐linear associations were studied by restricted cubic splines. Considering the heart function, the analyses were performed in the whole cohort and the LVEF > = 0.5 cohort separately. Subgroup analyses were performed according to the different diagnosis (the myocardial infarction subgroup and the unstable angina pectoris subgroup). When PP was used as categorical variable, the high PP group (≥61 mm Hg) significantly increased the risk of death compared with the intermediate PP group (50–60 mm Hg) in the both cohorts. When PP was used as continuous variable, a U‐shape relationship were found between PP and mortalities in the whole cohort (p (for nonlinearity) = .005 and .003, respectively), with reference PP level of 55 mm Hg. However, this U‐shape relationship disappeared in the LVEF > 0.5 cohort (p (for nonlinearity) = .111 and .117, respectively). The similar results were obtained in MI subgroup. From this study, the U‐shape relationships between PP level and all‐cause and cardiac mortalities were found in ACS patients who underwent PCI. The U‐shape relationships disappeared in the LVEF > 0.5 cohort. The reference PP level was 55 mm Hg.

Treatment of acute respiratory distress syndrome from COVID-19 with extracorporeal membrane oxygenation in obstetrical patients

BACKGROUNDExtracorporeal membrane oxygenation therapy has been used as a rescue therapy for patients with severe acute respiratory distress syndrome from COVID-19 who have failed conventional ventilatory strategies. Little is known about the outcome of pregnant and postpartum patients on extracorporeal membrane oxygenation therapy.OBJECTIVETo describe the medical and surgical outcomes of pregnant and postpartum patients who were placed on extracorporeal membrane oxygenation therapy for severe acute respiratory distress syndrome from COVID-19.STUDY DESIGNA case series reviewing pregnant or postpartum patients with laboratory-confirmed COVID-19 who were placed on extracorporeal membrane oxygenation therapy was conducted within the Baylor Scott & White Healthcare system. The demographics and the medical and surgical outcomes were collected and reviewed.RESULTSBetween March 2020 and October 2021, 5 pregnant and 5 postpartum women were supported with venovenous extracorporeal membrane oxygenation therapy. The median age was 30 years (interquartile range, 26–33.5) and the median body mass index was 36.6 kg/m2 (interquartile range, 29.5–42.0). There was a median of 4.5 days (interquartile range, 1.5–6.8) from admission to any hospital to intubation and 9 days (interquartile range, 7–13) to extracorporeal membrane oxygenation therapy cannulation. One patient had an ischemic stroke, 1 patient had a presumed hemorrhagic stroke, and 9 patients developed bleeding while on extracorporeal membrane oxygenation therapy. Of the 5 pregnant women, 2 patients had intrauterine fetal demise and 3 underwent delivery for maternal hemodynamic instability. The 5 postpartum women were initiated on extracorporeal membrane oxygenation therapy a median of 10 days (interquartile range, 3–11) after delivery. The median length of time on extracorporeal membrane oxygenation therapy was 22 days (interquartile range, 11–31). At the time of the study, there were 2 inpatient mortalities, 6 patients survived to discharge from the extracorporeal membrane oxygenation therapy hospital, and 2 patients were still admitted.CONCLUSIONThere is limited information regarding the use of extracorporeal membrane oxygenation therapy for COVID-19 acute respiratory distress syndrome in obstetrical patients. This case series describes the use of extracorporeal membrane oxygenation therapy and survival in pregnant and postpartum patients with COVID-19.

Improving Unadjusted and Adjusted Mortality With an Early Warning Sepsis System in the Emergency Department and Inpatient Wards

Mortality reduction has been a major focus of improvement for health care systems. Although several studies have noted improved sepsis-related mortality with the use of electronic health record (EHR) systems, there are no known published early warning sepsis systems using the Veterans Health Administration (VHA) EHR system. The Malcom Randall Veterans Affairs Medical Center (MRVAMC), a large academic 1a VHA facility within the North Florida/South Georgia Veterans Health System (NF/SGVHS), was identified as having opportunities for improvement related to inpatient mortality outcomes. Sepsis was discovered as the primary contributor to inpatient mortality for MRVAMC's acute level of care (LOC). Education along with implementation of an early warning sepsis system (EWSS) was subsequently integrated in the VHA EHR known as the Veterans Information Systems and Technology Architecture/ Computerized Patient Record System (VistA/CPRS) at NF/SGVHS, which applied a combination of informatics solutions within a Lean Six Sigma quality improvement framework. At MRVAMC, there was an observed decrease in the number of inpatient deaths for the acute LOC from a high of 48 in fiscal year (FY) 2017, quarter 3 to a low of 27 in FY 2019, quarter 4. This resulted in as large of an improvement as a 44% reduction in unadjusted mortality with education and implementation of an EWSS from FYs 2017 to 2019. Additionally, the MRVAMC acute LOC risk-adjusted mortality (standardized mortality ratio) improved from > 1.0 to < 1.0, demonstrating fewer inpatient mortalities than predicted from FYs 2017 to 2019. Education along with the possible implementation of an EWSS within the VHA EHR was associated with improvement in unadjusted and adjusted inpatient mortality at MRVAMC. This may be an effective approach for patients with sepsis.

1039 Maternal transfer of care and mortality risk in obstetric patients with sepsis

Maternal sepsis is a leading cause of maternal mortality in the United States. Management typically involves prompt treatment and possible transfer to centers with higher levels of care. There is little data on obstetric transfers with sepsis. The objective of this study was to assess sepsis transfers and associated maternal mortality. A cross sectional analysis of obstetric hospitalizations with a diagnosis of shock/sepsis was conducted using the 2008-2015 National Inpatient Sample. Patients were stratified based on whether they were directly admitted or transferred in from another acute care facility. The primary outcome was inpatient mortality. Hospitals were analyzed by location and teaching status. Log linear models were fit to determine associations between transfer status and hospital factors and inpatient mortality, adjusting for patient, clinical, year, and whether patients were hospitalized antepartum, for delivery, or postpartum. Of the 58,554 cases of maternal sepsis, there were 1,806 (3.1%) inpatient mortalities and 4,942 (8.5%) maternal transfers. Most patients were admitted during an antepartum hospitalization (49.7%) followed by during a delivery (32.9%) and postpartum (17.4%) hospitalizations. Mortality rates were higher among transfer patients (9.0% vs. 2.5%), and overall higher when stratified by hospital bed size and teaching status (Figure). Adjusted analysis noted that maternal transfers were at nearly three times higher risk of mortality (aRR 2.70, 95% CI: 2.40, 3.04) compared to non-transfers. Urban teaching, urban non-teaching, and larger sized facilities were associated with significantly higher risks of maternal mortality (Table). Maternal transfers are associated with a disproportionately higher risk of inpatient mortality in the context of other hospital factors. Earlier identification of patients with sepsis and appropriate transfers to referral centers may be important in reducing maternal death from this cause.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Pregnancy in Liver Transplantation Recipients Is Associated With Increased Complications and Healthcare Utilization.

Given the increased rates of pregnancy in liver transplant recipients, evaluating the safety of pregnancy is crucial. We aim to evaluate pregnancy-related complications and outcomes in liver transplant recipients. A retrospective nationwide review comparing pregnancy outcomes in liver transplant recipients vs the general population was performed between 2005 and 2013. Propensity-matched and multivariable regression analyses were performed to study pregnancy- and delivery-related complications in addition to patient and hospital outcomes. A total of 38,449,030 pregnancy-related admissions were evaluated in this study including 1,469 (0.004%) admissions in liver transplant recipients. Liver transplant recipients were more likely to undergo a caesarean delivery (60% vs 36%) and have a pregnancy-related complication (56% vs 27%) including miscarriage, intrauterine growth restriction, portpartum hemorrhage, hypertension, preeclampsia, and thromboembolism (P < 0.001) compared with the general population. Propensity-weighted analysis revealed higher rates of pregnancy complications (odds ratio 2.11, 95% confidence interval [CI] 1.63-2.73), cost ($3,023, 95% CI $850-$5,197), and longer length of stay (1.52 days, 95% CI 0.62-2.41) in transplant recipients. Liver transplant recipients experienced zero inpatient mortalities compared with 0.01% of the general population. Transplant recipients with at least 1 complication had a longer length of stay (2.45 days, 95% CI 1.44-3.45) and higher cost of admission ($5,205, 95% CI $2,848-$7,561) compared with transplant recipients without a complication. Pregnancy after liver transplant is associated with higher rates of complications and worse outcomes without an increased risk of mortality.

ASA Physical Status Classification Improves Predictive Ability of a Validated Trauma Risk Score.

Introduction:The Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) is a validated mortality risk score that evaluates 4 major physiologic criteria: age, comorbidities, vital signs, and anatomic injuries. The aim of this study was to investigate whether the addition of ASA physical status classification system to the STTGMA tool would improve risk stratification of a middle-aged and elderly trauma population.Methods:A total of 1332 patients aged 55 years and older who sustained a hip fracture through a low-energy mechanism between October 2014 and February 2020 were included. The STTGMA and STTGMAASA mortality risk scores were calculated. The ability of the models to predict inpatient mortality was compared using area under the receiver operating characteristic curves (AUROCs) by DeLong’s test. Patients were stratified into minimal, low, moderate, and high risk cohorts based on their risk scores. Comparative analyses between risk score stratification distribution of mortality, complications, length of stay, ICU admission, and readmission were performed using Fisher’s exact test. Total cost of admission was fitted by univariate linear regression with STTGMA and STTGMAASA.Results:There were 27 inpatient mortalities (2.0%). When STTGMA was used, the AUROC was 0.742. When STTGMAASA was used, the AUROC was 0.823. DeLong’s test resulted in significant difference in predictive capacity for inpatient mortality between STTGMA and STTGMAASA (p = 0.04). Risk score stratification yielded significantly different distribution of all outcomes between risk cohorts (p < 0.01). STTGMAASA stratification produced a larger percentage of all negative outcomes with increasing risk cohort. Total hospital cost was statistically correlated with both STTGMAASA (p < 0.01) and STTGMA (p = 0.02).Conclusion:Including ASA physical status as a variable in STTGMA improves the model’s ability to predict inpatient mortality and risk stratify middle-aged and geriatric hip fracture patients.

Pediatric Intensive Care Unit Admissions for COVID-19: Insights Using State-Level Data.

Introduction Intensive care has played a pivotal role during the COVID-19 pandemic as many patients developed severe pulmonary complications. The availability of information in pediatric intensive care units (PICUs) remains limited. The purpose of this study is to characterize COVID-19 positive admissions (CPAs) in the United States and to determine factors that may impact those admissions. Materials and Methods This is a retrospective cohort study using data from the COVID-19 Virtual Pediatric System (VPS) dashboard containing information regarding respiratory support and comorbidities for all CPAs between March and April 2020. The state-level data contained 13 different factors from population density, comorbid conditions, and social distancing score. The absolute CPA count was converted to frequency using the state's population. Univariate and multivariate regression analyses were performed to assess the association between CPA frequency and admission endpoints. Results A total of 205 CPAs were reported by 167 PICUs across 48 states. The estimated CPA frequency was 2.8 per million children in a one-month period. A total of 3,235 tests were conducted of which 6.3% were positive. Children above 11 years of age comprised 69.7% of the total cohort and 35.1% had moderated or severe comorbidities. The median duration of a CPA was 4.9 days (1.25–12.00 days). Out of the 1,132 total CPA days, 592 (52.2%) involved mechanical ventilation. The inpatient mortalities were 3 (1.4%). Multivariate analyses demonstrated an association between CPAs with greater population density (beta coefficient 0.01, p < 0.01). Multivariate analyses also demonstrated an association between pediatric type 1 diabetes mellitus with increased CPA duration requiring advanced respiratory support (beta coefficient 5.1, p < 0.01) and intubation (beta coefficient 4.6, p < 0.01). Conclusions Inpatient mortality during PICU CPAs is relatively low at 1.4%. CPA frequency seems to be impacted by population density. Type 1 DM appears to be associated with increased duration of HFNC and intubation. These factors should be included in future studies using patient-level data.

Adult Cranioplasty and Perioperative Patient Safety: Does Plastic Surgery Facility Volume Matter?

Cranioplasty lies at the intersection of neurosurgery and plastic surgery, though little is known about the impact of plastic surgery involvement. The authors hypothesized that adult cranioplasty patients at higher volume plastic surgery facilities would have improved inpatient outcomes. Adult cranioplasty encounters were extracted from the National Inpatient Sample from 2012 to 2014 based on International Classification of Diseases, Ninth Revision (ICD-9) codes. Regression models included the following variables: age, gender, race/ethnicity, Elixhauser Comorbidity Index, payer, hospital size, region, and urban/teaching status. Outcomes included odds of receiving a flap, perioperative patient safety indicators, and mortality. The weighted sample included 49,305 encounters with diagnoses of neoplasm (31.2%), trauma (56.4%), infection (5.2%), a combination of these diagnoses (3.9%), or other diagnoses (3.2%). There were 1375 inpatient mortalities, of which 10 (0.7%) underwent a flap procedure. On multivariable regression, higher volume plastic surgery facilities and all diagnoses except uncertain neoplasm were associated with an increased likelihood of a flap procedure during the admission for cranioplasty, using benign neoplasm as a reference (P < 0.001). Plastic surgery facility volume was not significantly associated with likelihood of a patient safety indicator event. The highest volume plastic surgery quartile was associated with lower likelihood of inpatient mortality (P = 0.008). These findings support plastic surgery involvement in adult cranioplasty and suggest that these patients are best served at high volume plastic surgery facilities.

Related Factors Associated With Earthquake Inpatient Mortality.

To date, we have only limited evidence of the determinants of earthquake inpatient mortality-related factors. This study is among the first to explore related factors of inpatient deaths using data from multiple hospitals and multiple earthquakes. We included and retrospectively analyzed data on 32,976 earthquake inpatients in the West China Earthquake Patients Database. Of these, we analyzed the records of 284 patients who died during hospitalization. We collected 12 dichotomous variables with reference to previous reports: patients' age (both ≤ 15 years and ≥ 65 years), gender, prehospital treatment, intensive care unit (ICU) admission, the presence of severe traumatic brain injury (TBI), trunk injury, severe poly-trauma, crush syndrome, multiple-system organ failure (MSOF), infection, and cardiac/respiratory disease. We performed multivariate logistic regression analysis to explore independent related factors of mortality. Ultimately, we identified severe TBI, MSOF, old age (≥ 65 years), ICU admission, crush syndrome, and cardiac/respiratory disease as independent mortality-related factors. Severe TBI was the greatest risk factor of inpatient death (ods ratio [OR], 31.913, 95% confidence interval [CI], 20.484-49.720), followed by MSOF (OR 30.905, 95% CI, 21.733-43.947). To reduce earthquake inpatient mortalities, the related factors analyzed in this study should be prioritized in future inpatient earthquake response strategies.

Development of a Value-based Algorithm for Inpatient Triage of Elderly Hip Fracture Patients.

The purpose of this study was to combine a validated middle-age and geriatric trauma risk assessment tool (STTGMA) with a novel cost-prediction tool to create an objective triage tool for elderly hip fractures that would guide value-based care initiatives. From October 2014 to January 2018, all patients aged ≥55 years who were admitted with a primary diagnosis of hip fracture to a single level 1 trauma center were enrolled. Upon evaluation in the emergency department, demographics, injury severity, and functional status were recorded to calculate the trauma triage score (STTGMARisk). A model to predict high-cost hip fracture patients was created using similar variables (STTGMACost). Three hundred sixty-one consecutive operative hip fracture patients were enrolled. Inpatient mortalities were skewed toward STTGMARisk3 with 21.4% of patients in this high-risk group ultimately expiring during their hospitalization. High-cost patients were correctly skewed to the STTGMACost2 and STTGMACost3 groups with 88.9% of all high-cost operatively treated hip fracture correctly triaged to these cohorts. Statistically significant variations were found in cost within each STTGMARisk group. A simple risk score calculated upon admission (STTGMARisk and STTGMACost) was able to be used as a triage tool not only to differentiate increased mortality risk but also to predict high-cost patients based on resource utilization in hip fracture patients. Prognostic, level II.

Endovascular management of mycotic aortic aneurysms- A 20-year experience from a single UK centre

To present the authors' experience of endovascular treatment of confirmed and presumed (microbiology negative) mycotic aortic aneurysms (MAA). Patients undergoing endovascular aortic repair were identified retrospectively from 1998 using the radiology information system and an internally kept database until 2018. The primary aim was to assess the technical success and peri-operative morbidity and mortality. The secondary aim was to assess progression of infection, re-interventions, late mortality, and correlation to antibiotic duration pre- and post-procedure. Thirty-four endovascular aortic procedures were performed for MAA, excluding aorto-enteric fistulas, inflammatory aneurysms, and infected grafts without a new aneurysm. Seventy-six percent of these were thoracic and 24% abdominal. The technical success was 100%. Additional procedures were undertaken in four patients with two requiring a further endovascular procedure. There were two inpatient aneurysm-related mortalities and no inpatient conversions to open repair. The 30-day re-admission and re-intervention rate was 0%. Blood cultures were positive in 45%. There were no secondary graft infections. This is the largest European single-centre study. It supports endovascular management of MAA as a lower-risk alternative to open surgery with the majority of patients presenting acutely, later in life and requiring emergency management.

Penetrating Spinal Column Injuries (pSI): An Institutional Experience with 100 Consecutive Cases in an Urban Trauma Center

Gunshot wound (GSW) injuries are among the leading causes of penetrating spinal column injury (pSI). pSI patients often have concurrent polytrauma that complicate management. We retrospectively reviewed charts between January 2012 to June 2018 at an urban Level 1 Trauma Center and analyzed bracing and surgical indications, antibiotic and MRI use, and patient outcomes. We identified 100 pSI patients with an average age of 27.2 years (range 15-58). Five patients had knife injuries and 95 suffered GSW. Polytrauma occurred in 90% of patients with an average of 3.39 bullets per patient (range 1-23). Fourteen patients underwent either decompressive surgery (n=8) or decompression and fusion (n=6). Thirty-five patients were externally braced. 43% of patients presented as ASIA-A compared to 26% who were intact. While 14 patients received prophylactic antibiotics for retained bullets or durotomies, only two patients had postoperative wound infections and four had extraspinal infections from retained bullets. All inpatient mortalities (n=5) were patients with cervical pSI. Thirteen GSW patients obtained MRI scans without complications. Among our cohort, only 65 patients had followup with a median followup period of 1.25 (range 1-60) months. Management of pSI in urban trauma centers is complex, as these victims routinely have polytrauma that take precedence. Indications for surgical intervention are narrow and secondary to surgery for polytrauma. External bracing may be overutilized. The efficacy of prophylactic antibiotics remains unclear. MRI can contribute valuable information but is limited by uncertainty regarding bullet compatibility. Lack of follow-up limits study of this population.