Management Of Solid Organ Injuries Research Articles

Impact of Trauma Verification Level on Management and Outcomes of Combined Traumatic Brain and Solid Organ Injuries: An NTDB Retrospective Review.

Level-I and level-II trauma centers are required to offer equivalent resources since "The Orange Book." This study evaluates differences between level-I and level-II management of solid organ injury (SOI) with traumatic brain injury (TBI). We conducted a retrospective review of the National Trauma Data Banks from 2013 to 2021 of adult (≥18years), blunt trauma patients with both TBI and SOI treated at level-I or level-II trauma centers. 48,479 TBI and SOI patients were identified, 32,611 (67.3%) at level-I centers. Unadjusted incidence of laparotomy was higher at level I (14.5% vs 11.7%, P < 0.001), and angiography rates were similar (3.3% vs 3.4%, P 0.717). Sub-group analysis of stable patients (SBP ≥100) showed an increase in nonoperative management at level II (87.3% vs 88.7%, P < 0.001) and decrease in laparotomy (9.9% vs 8.3%, P < 0.001). On logistic regression (LR), severe TBI, high-grade SOI, and level I trauma status were predictors of laparotomy. Logistic regression showed mild/moderate TBI with high-grade SOI and level II were associated with use of angiography. Unadjusted mortality rates were slightly different (14.8% vs 13.4%, P < 0.001), but there was no association with trauma level on LR. Nonoperative management was seen more at level-II centers with laparotomy at level I. Subgroup analysis showed no difference in mortality in trauma levels. Matched patients for level I and II showed no statistical difference in management. Patients were treated similarly at both levels with similar outcomes and mortality.

Low-Value Clinical Practices in Pediatric Trauma Care.

Reducing low-value care has the potential to improve patient experiences and outcomes and decrease the unnecessary use of health care resources. Research suggests that low-value practices (ie, the potential for harm exceeds the potential for benefit) in adult trauma care are frequent and subject to interhospital variation; evidence on low-value practices in pediatric trauma care is lacking. To estimate the incidence of low-value practices in pediatric trauma care and evaluate interhospital practice variation. A retrospective multicenter cohort study in a Canadian provincial trauma system was conducted. Children younger than 16 years admitted to any of the 59 provincial trauma centers from April 1, 2016, to March 31, 2022, were included. Low-value practices were identified from systematic reviews of clinical practice guidelines on pediatric trauma. The frequencies of low-value practices were evaluated by estimating incidence proportions and cases per 1000 admissions (low if ≤10% and ≤10 cases, moderate if >10% or >10 cases, and high if >10% and >10 cases) were identified. Interhospital variation with intraclass correlation coefficients (ICCs) were assessed (low if <5%, moderate if 5%-20%, and high if >20%). A total of 10 711 children were included (mean [SD] age, 7.4 [4.9] years; 6645 [62%] boys). Nineteen low-value practices on imaging, fluid resuscitation, hospital/intensive care unit admission, specialist consultation, deep vein thrombosis prophylaxis, and surgical management of solid organ injuries were identified. Of these, 14 (74%) could be evaluated using trauma registry data. Five practices had moderate to high frequencies and interhospital variation: head computed tomography in low-risk children (7.1%; 33 per 1000 admissions; ICC, 8.6%), pretransfer computed tomography in children with a clear indication for transfer (67.6%; 4 per 1000 admissions; ICC, 5.7%), neurosurgical consultation in children without clinically important intracranial lesions (11.6%; 13 per 1000 admissions; ICC, 15.8%), hospital admission in isolated mild traumatic brain injury (38.8%; 98 per 1000 admissions; ICC, 12.4%), and hospital admission in isolated minor blunt abdominal trauma (10%; 5 per 1000 admissions; ICC, 31%). In this cohort study, low-value practices appeared to be frequent and subject to interhospital variation. These practices may represent priority targets for deimplementation interventions, particularly as they can be measured using routinely collected data.

197 Evaluating Disparities in Management of Solid Organ Injury in Children Treated at Pediatric vs. Adult Trauma Centers

OBJECTIVES/GOALS: Non-operative management is preferred for pediatric solid organ injury (SOI). Despite this children treated at adult trauma centers (ATC) are more likely to be treated surgically and have worse outcomes than those treated at pediatric trauma centers (PTC). We hypothesize there are disparities by sex and race in management of pediatric SOI at ATC vs PTC. METHODS/STUDY POPULATION: Retrospective review of the National Trauma Data Bank (NTDB) from 2010-2018 was conducted. Inclusion criteria were age£18 and injury to spleen, liver or kidney. Outcomes at American College of Surgeons accredited ATC, PTC, and combined ATC/PTC trauma centers were evaluated. The primary outcome was operative management. Secondary outcomes include length of stay, and in-hospital complications. Multivariate logistical regression adjusting for race, sex, and insurance type will be performed. RESULTS/ANTICIPATED RESULTS: 40,111 children were treated for SOI from 2010-2018. 39.3% were treated at an ATC and 26.4% at a PTC. Of children treated at an ATC, 62% were White, 17% were Black, and 1% were Asian. Children treated at the PTC were 60% White, 20% Black, and 0.9% Asian. Primary insurance type was Medicaid for 33% of patients at an ATC and 39% at PTC. Median length of stay at ATC and PTC was 4 days (2-7) and 3 days (2-6) respectively. 3.85% of patients at ATC underwent splenectomy compared to 0.8% at PTC. It is anticipated that further analysis will demonstrate that ICU admission, transfusion, embolectomy, and other operative interventions will be more prevalent at ATC than MTC. Moreover, we anticipate that multivariate logistical regression will show the odds of receiving operative management at each center differ by race, sex and insurance type. DISCUSSION/SIGNIFICANCE: Initial analysis of the NTDB from 2010-2018 shows that children treated for SOI at ATC receive operative interventions more often than those treated at PTC. Elucidating disparities in SOI care is an important step towards minimizing the impact of these disparities and better allocating resources such that they may be eliminated.

Epidemiological profile of patients undergoing non-operative management of solid organ injury and associated factors with mortality.

Trauma primarily affects the economically active population, causing social and economic impact. The non-operative management of solid organ injuries aims to preserve organ function, reducing the morbidity and mortality associated with surgical interventions. The aim of study was to demonstrate the epidemiological profile of patients undergoing non-operative management in a trauma hospital and to evaluate factors associated with mortality in these patients. This is a historical cohort of patients undergoing non-operative management for solid organ injuries at a Brazilian trauma reference hospital between 2018 and 2022. Included were patients with blunt and penetrating trauma, analyzing epidemiological characteristics, blood transfusion, and association with the need for surgical intervention. A total of 365 patients were included in the study. Three hundred and forty-three patients were discharged (93.97%), and the success rate of non-operative treatment was 84.6%. There was an association between mortality and the following associated injuries: hemothorax, sternal fracture, aortic dissection, and traumatic brain injury. There was an association between the need for transfusion and surgical intervention. Thirty-eight patients required some form of surgical intervention. The profile of patients undergoing non-operative treatment consists of young men who are victims of blunt trauma. Non-operative treatment is safe and has a high success rate.

Analysis of Blunt Abdominal Solid Organ Injury in Children: A Single Centre Study

Aim: To determine the management of solid organ injuries in blunt trauma abdomen (BTA) in children whether to conserve or operate. Study design: Descriptive case series. Place and duration of study: Department of Paediatric Surgery Sahiwal Teaching Hospital and Sahiwal Medical College Sahiwal from 1st January 2020 to 31st March 2022. Methodology: Fifty eight patients with blunt abdominal trauma due to any cause, the medical records of all patients with trauma of any kind age upto 13 years were carefully reviewed. Initial resuscitation was done according to ATLS protocol. Ultimate management decision was based on stability of patients after resuscitation. Results: The mean age was 5.34 years. Most of the patients suffered from road traffic accident, 50(86.2%). Fifty two (89.65%) patients showed free fluid in the abdomen. Organ injury in 27(46.55%) patients. CT abdomen with intravenous contrast confirmed findings of ultra sonography. Despite resuscitation, 17(43.9%) patients remained unstable and were operated. Forty one patients were kept on conservative treatment. Hospital stay ranged from 1-19 days. Conclusion: Although non-operative management is the treatment of choice in blunt trauma abdomen with solid organ injury but stability of the injured child is the central pivot around which the whole management revolves. Delay in presentation and failure of timely resuscitation results into high operative intervention. Keywords: Blunt trauma, solid, Liver, Spleen, children

Non-operative management of solid organ injuries in a middle-income country, how does it stack up?

IntroductionThe first trauma surgery unit in Malaysia was established in 2011. After 10 years, we examine our experience in the management, and outcomes of blunt liver, spleen, and kidney injuries. MethodsThis is a cross-sectional study of patients with blunt liver, spleen, and kidney injuries in a level 1 trauma centre in Malaysia between January 2018 to June 2021. Patients’ characteristics, new injury severity score, organ-specific AAST injury score, type of primary management (operative management [OM], non-operative management [NOM]), causes of failed NOM, management of failed NOM, and outcome of treatment were recorded and analysed. ResultsAmong 448 patients, 83.9% were male and in the working-age range of 15–64 years old (93.5%). Road traffic crashes made up 92.0% of blunt trauma resulting in 65.5% of isolated organ injuries and 34.5% combined injuries. An overwhelming 84.2% of the patients had major trauma (NISS>15). Three hundred and thirty-four patients (74.6%) underwent initial non-operative management. Patients in the OM group showed lower mean GCS scores (p = 0.022) and higher NISS scores (p < 0.001). High-grade liver and kidney injuries were mostly treated with NOM (p < 0.001). In contradistinction, patients with high-grade spleen injuries had more OM performed (p < 0.001). NOM had been successful in 325 patients (97.3%) with 9 failures. Underlying causes for NOM failure were hemodynamic instability due to secondary bleeding and infectious complications. Overall mortality was 11.2%, which was significantly higher in the OM group (23.7%) than in the NOM group (6.9%). ConclusionThis study represents one of the largest single centre experiences on the blunt liver, spleen, and kidney injuries in Malaysia and South-East Asia. With good selection and adequate resources, non-operative management of blunt liver, spleen, and kidney injuries is a safe and effective therapeutic approach with a high success rate of 97.3%, avoiding the morbidity of unnecessary laparotomies.

Management of solid organ injury in patient of blunt abdominal trauma

Background: In this ongoing era of 21st century, trauma is the leading cause of death in individuals between age 1 and 44. In trauma, also road traffic accidents (RTAs) are the major cause of death. Blunt abdominal trauma is a frequent emergency and is associated with significant morbidity and mortality.Methods: A prospective analysis of 50 patients of blunt abdominal trauma admitted in SMIMER hospital Surat within a span of 12 months was done. Unstable patients with initial resuscitation underwent focused assessment sonography for trauma (FAST). Failed resuscitation with free fluid in abdomen confirmed by FAST immediately shifted to operation theatre for laparotomy and proceed. Hemodynamically stable patients underwent computerized tomography of abdomen.Results: Most of the patients in our study were in the age group of 21-45 years with M:F ratio of 4:1. RTAs (62%) was the most common mechanism of injury. Spleen (38%) was the commonest organ injured and the most common surgery performed was splenectomy. In total non-operative management (NOM) was done in 58% of cases and surgical management was done in 42% of cases.Conclusions: Appropriate patient selection, early diagnosis and repeated clinical examination and use of appropriate investigations forms the key in management of blunt abdominal trauma. To conclude, initial resuscitation measures and correct diagnosis forms the most vital part of blunt abdominal trauma management.

Trauma patients in the pediatric ICU: rational use of a limited resource.

Traumatic injuries are a leading cause of pediatric mortality; pediatric ICUs (PICUs) are an important but potentially limited resource associated with high costs. In an era of rising healthcare costs, appropriate resource utilization is important. Here, we examine evidence-based guidelines supporting the management of pediatric traumatic injury outside of the PICU. Historical management of solid organ injury and traumatic brain injury was focused on operative management. However, over the past four decades, management of solid organ injury has shifted from invasive management to nonsurgical management with a growing body of evidence supporting the safety and efficacy of this trend. The management of traumatic brain injury (TBI) has had a similar evolution to that of solid organ injury with regard to nonoperative management and management outside the critical care setting. The use of evidence-based guidelines to support expectant management in the setting of pediatric trauma has the potential to reduce unnecessary resource utilization of the PICU. In this review, we present findings that support nonoperative management and management of pediatric trauma outside of the PICU setting. In resource-poor areas, this approach may facilitate care for pediatric trauma patients. The implications are also important in resource-rich settings because of the unintended risks associated with PICU.

Radiological Parameters for Conservative Management of Solid Organ Injuries in a Tertiary Care Hospital

The management of solid organ injuries has changed drastically over the past couple of decades, with there being a shift from operative to conservative mode of management. The main purpose of this study is to establish radiological parameters for conservative management in order to make conservative mode of management more efficient. Retrospective analysis of solid organ injuries was done for 50 patients between January 2020 and March 2020 in a tertiary care hospital. It is found that conservative mode of management can be considered for patients belonging to grade I, II and III according to AAST classification of Splenic and Hepatic injuries whereas in Renal injuries it is considered for patients belonging to grade I and II

Pediatric solid organ injury management: the role of initial hematocrit in lean times

Injury is the leading cause of death and disability in children and young adults from ages 1–24 (1). Blunt trauma accounts for over 90% of traumatic mechanisms of injury in children. with blunt abdominal trauma accounting for approximately 10–15% of all blunt mechanisms (2-4).

Intra-Abdominal Solid Organ Injury Management in Pediatrics

Abdominal trauma is relatively uncommon in children but can leads to a significant morbidity and mortality in the pediatric population. The abdomen is the third most commonly injured anatomic region in children, after the head and the extremities. The abdomen is the most common site of initially unrecognized fatal injury in traumatized children. We are reporting a case of a child with multiple solid organ injury that was successfully treated non-operatively at our center. We presented a previously healthy 9-month-old girl, presented with fluctuating GCS secondary to motor vehicle accident with borderline hemodynamic stability. She was intubated, blood transfusion commenced and a single inotrope support started. She subsequently diagnosed with grade III liver injury, grade II splenic injury, right grade IV renal injury with large perinephric and retroperitoneal hematoma and moderate hemoperitoneum, a non-displaced left superior pubic rami fracture and cerebral edema on computed tomography (CT). She was admitted to pediatric intensive care unit (PICU). Her intra-abdominal injury injuries were successfully treated conservatively. She required a right chest tube on post trauma day 2, for right hemothorax. The chest tube was removed 3 days later following adequate drainage. She eventually was weaned off from ventilator on post trauma day 11. Feeding was commenced on day 7 of post trauma. She was discharge home well after 3 weeks post trauma with periodical follow up. Conclusion: Pediatric intra-abdominal solid organ injury is relatively uncommon, but a potential source of significant morbidity. Non-operative management is the standard of care for the majority of these injuries, which have shown successful rate more than 95%, although continued hemodynamic instability mandates operative intervention.

Safe phlebotomy reduction in stable pediatric liver and spleen injuries

PurposePediatric blunt solid organ injury management based on hemodynamic monitoring rather than grade may safely reduce resource expenditure and improve outcomes. Previously we have reported a retrospectively validated management algorithm for pediatric liver and spleen injuries which monitors hemodynamics without use of routine phlebotomy. We hypothesize that stable blunt pediatric isolated splenic/liver injuries can be managed safely using a protocol reliant on vital signs and not repeat hemoglobin levels. MethodsA prospective multi-institutional study was performed at three pediatric trauma centers. All pediatric patients from 07/2016–12/2017 diagnosed with liver or splenic injuries were identified. If appropriate for the protocol, only a baseline hemoglobin was obtained unless hemodynamic instability as defined in an age-appropriate fashion was determined by treating physician discretion. Descriptive statistics were conducted. ResultsOne hundred four patients were identified of which 38 were excluded from the protocol. There was a significant difference in abnormal shock index, pediatric age-adjusted (SIPA) values, hematocrit, and percentage of patients with hemoglobin less than 10 between the excluded and included patients. Of the 66 patients managed on the protocol, four patients had to be removed, two each on day one and day two. Of those four patients, only one required intervention. There were no mortalities. ConclusionA phlebotomy limiting protocol may be a safe option for stable pediatric splenic and liver injuries cared for in a pediatric trauma center with the resources for rapid intervention should the need arise. The differences in groups highlight the importance of utilizing this protocol in the correct patient population. Reduced phlebotomy offers the potential for reduced resource expenditure without any evidence of increased morbidity or mortality. Level of EvidenceLevel IV.

The Challenge of Blunt Abdominal Trauma in Children: Report of a Case and Review of Management

Blunt abdominal trauma is the most frequent cause of abdominal injuries in children. The term solid organ injury (SOI) is referred to liver, spleen and kidney. Splenic injuries are the most common. The management of SOI has been motive of discussion for years and has undergone a radical shift in the last decades. Currently, non-operative management is the gold standard of care when circumstances are favorable. In 1977, non-operative management was supported by surgeons in Toronto. Later, the American Pediatric Surgical Association (APSA) pointed that management should be based on imaging findings and CT grading of the American Association for the Surgery of Trauma. However, this caused long stays and unnecessary follow-up imaging. Soon, APSA guidelines were questioned and raised controversy. Finally, hemodynamic status was defined as the main key for taking decisions and ATOMAC guidelines gained support. However, facing a blunt trauma in children is always a challenge. Hemodynamic stability is not easy to define and heart rate and blood pulse are poor markers for stability. This complicates the management of blunt trauma in children. As consequence, it is important that these children are treated in pediatric centers. We report a case of a 15-year-old male who suffered from a blunt abdominal trauma with splenic and renal injuries treated by adult surgeons when playing football. We review the current recommendations for blunt abdominal trauma in children and the differences with adult management. J Med Cases. 2017;8(11):340-346 doi: https://doi.org/10.14740/jmc2901w

Surgical Management of Solid Organ Injuries.

Surgery used to be the treatment of choice in patients with solid organ injuries. This has changed over the past 2 decades secondary to advances in noninvasive diagnostic techniques, increased availability of less invasive procedures, and a better understanding of the natural history of solid organ injuries. Now, nonoperative management (NOM) has become the initial management strategy used for most solid organ injuries. Even though NOM has become the standard of care in patients with solid organ injuries in most trauma centers, surgeons should not hesitate to operate on a patient to control life-threatening hemorrhage.

Safety of early ambulation following blunt abdominal solid organ injury: A prospective observational study

BackgroundThere is continued debate regarding the optimal period of bed-rest and in-hospital monitoring for non-operative management of solid organ injury following blunt trauma. MethodsSingle center, prospective, observational study of blunt solid organ injuries from 07/2014–02/2016, managed initially without surgical or angiographic intervention. Early ambulation was defined as ≤24 h. Results79 patients met inclusion criteria, with 36 (45.6%) in the early ambulation group and 43 (54.4%) in the late ambulation group. There were zero complications in the early ambulation group, and three complications in the late ambulation group (complications, p = 0.246; further interventions, p = 0.498). Median ICU LOS was zero days and three days for early vs. late ambulation, p = 0.001. Median total LOS was two days and five days for early vs. late ambulation, p < 0.001. ConclusionEarly ambulation is safe in patients undergoing non-operative management of their solid organ injury, and may result in a reduced length of stay.

Role of Interventional Radiology in Solid Organ Trauma

This review describes the current role of diagnostic and interventional radiology in the management of solid organ trauma, particularly the role of non-operative endovascular interventions such as angioembolization (AE). We will also provide a brief highlight of interventions available for thoracic trauma. There has been a paradigm shift over the past 2 decades in the management of solid organ injuries from surgical management to non-operative management, especially in cases of minor injuries. Many factors, including the advances in multidetector contrast enhanced CT (MD-CECT) imaging, demands of cost-effective healthcare, and innovation of minimally invasive interventions with lower complication rates than surgical laparotomy have all contributed to this shift. Interventional radiology now plays a crucial role in the management of solid organ trauma, focusing on less invasive endovascular therapies. In addition, the grading and triaging of patients with stable solid organ traumatic injuries has become more reliant on MD-CECT findings. This review article highlights the common imaging findings, grading systems, and most current management guidelines for solid organ trauma with a brief highlight of thoracic trauma.

Should grade of solid organ injury determine need for hospitalization in children?

Management of solid organ injuries (SOI) in children is often predicated on radiologic grade of injury. Hypothesizing that grade may not necessarily determine hospitalization need, we investigated factors associated with hospitalization in cases of isolated SOI in children. Retrospective review of all cases admitted to one pediatric trauma centre over 10 yrs revealed 86 cases with SOI established by computed tomography (CT) scan upon admission. Review of all scans by one pediatric radiologist was performed to determine SOI grade. χ and Fisher's tests were used to determine associations with presenting clinical features and SOI grade with early outcomes. Ninety-one cases of SOI were identified. Of these, 56 were isolated to solid organs, whereas the others were multisystem; 12 were grades I and II and 44 grades III to V. Variables associated with length of stay longer than 2 days were admission hematocrit (Hct) less than 33% (p = 0.006) and need for narcotics or anti-emetics upon admission (p = 0.002; p < 0.0001). Significant associations between these features and need for narcotics or anti-emetics the following day were also observed. No features predicted a significant drop in Hct over the first 24 hours or need for transfusion. Nineteen patients did not require narcotics, anti-emetics, or transfusions; 11 of these stayed in hospital for 2 days or shorter. The CT grade was not predictive of any short term outcomes. Clinical status, low admission Hct, and need for medications may be better predictors of admission requirements of patients with isolated SOI than CT grade. Brief emergency department observation and discharge home may be appropriate for stable patients with isolated BAT without concerning clinical features, despite findings of SOI on imaging. Therapeutic study, level V.

The Challenge of Blunt Abdominal Trauma in Children: Report of a Case and Review of Management

Blunt abdominal trauma is the most frequent cause of abdominal injuries in children. The term solid organ injury (SOI) is referred to liver, spleen and kidney. Splenic injuries are the most common. The management of SOI has been motive of discussion for years and has undergone a radical shift in the last decades. Currently, non-operative management is the gold standard of care when circumstances are favorable. In 1977, non-operative management was supported by surgeons in Toronto. Later, the American Pediatric Surgical Association (APSA) pointed that management should be based on imaging findings and CT grading of the American Association for the Surgery of Trauma. However, this caused long stays and unnecessary follow-up imaging. Soon, APSA guidelines were questioned and raised controversy. Finally, hemodynamic status was defined as the main key for taking decisions and ATOMAC guidelines gained support. However, facing a blunt trauma in children is always a challenge. Hemodynamic stability is not easy to define and heart rate and blood pulse are poor markers for stability. This complicates the management of blunt trauma in children. As consequence, it is important that these children are treated in pediatric centers. We report a case of a 15-year-old male who suffered from a blunt abdominal trauma with splenic and renal injuries treated by adult surgeons when playing football. We review the current recommendations for blunt abdominal trauma in children and the differences with adult management. J Med Cases. 2017;8(11):340-346 doi: https://doi.org/10.14740/jmc2901w

Renal Trauma: When to Embolize?

Purpose of Review The management of solid organ injury continues to evolve from operative therapy to non-operative therapy with the highest success rates seen in the management of blunt renal trauma. Angio-embolization has emerged as an important modality to increase the success rate of non-operative management of kidney injuries.

A paradigm for achieving successful pediatric trauma verification in the absence of pediatric surgical specialists while ensuring quality of care

Pediatric trauma centers (PTCs) are concentrated in urban areas, leaving large areas where children do not have access. Although adult trauma centers (ATCs) often serve to fill the gap, disparities exist. Given the limited workforce in pediatric subspecialties, many adult centers that are called upon to care for children cannot sufficiently staff their program to meet the requirements of verification as a PTC. We hypothesized that ATCs in collaboration with a PTC could achieve successful American College of Surgeons (ACS) verification as a PTC with measurable improvements in care. This article serves to provide an initial description of this collaborative approach. Beginning in 2008, a Level I PTC partnered with three ATC seeking ACS-PTC verification. The centers adopted a plan for education, simulation training, guidelines, and performance improvement support. Results of ACS verification, patient volumes, need to transfer patients, and impact on solid organ injury management were evaluated. Following partnership, each of the ATCs has achieved Level II PTC verification. As part of each review, the collaborative was noted to be a significant strength. Total pediatric patient volume increased from 128.1 to 162.1 a year (p = 0.031), and transfers out decreased from 3.8% to 2.4% (p = 0.032) from prepartnership to postpartnership periods. At the initial ATC partner site, 10.7 children per year with solid organ injury were treated before the partnership and 11.8 children per year after the partnership. Following partnership, we found significant reductions in length of stay, number of images, and laboratory draws among this limited population. The collaborative has resulted in ACS Level II PTC verification in the absence of on-site pediatric surgical specialists. In addition, more patients were safely cared for in their community without the need for transfer with improved quality of care. This paradigm may serve to advance the care of injured children at sites without access to pediatric surgical specialists through a collaborative partnership with an experienced Level I PTC. Further risk-adjusted analysis of outcomes will need to be performed in the future. Therapeutic/care management, level IV.