M. Alexander Otto

SAN ANTONIO – Prehospital blood transfusions during air medical transport did not improve 24-hour or in-hospital mortality at Vanderbilt University Medical Center, Nashville.

Investigators there reviewed 5,581 patients transported by helicopter to Vanderbilt from the scene of injury from the period of 2007-2013; they excluded patients who died on the helipad or in the ED. Average flight time was 48 minutes; 231 patients (4%) received prehospital blood transfusions (PBT) of up to two units of O negative packed red blood cells, which is all that the helicopters carried. The decision to transfuse was up to helicopter personnel who were advised to transfuse hemodynamically unstable patients and those who had lost more than a half liter of blood.

©Keith Brofsky/Thinkstock

Vanderbilt reviewed its data because although PBT has become widespread in air medical transport, results from military and civilian studies are mixed. “A lot of evidence indicates that early, aggressive resuscitation with blood products improves survival once patients arrive at the hospital. It makes sense that starting the process early would improve outcomes, but relatively little is known about the prehospital environment,” said investigator and general surgery resident Dr. Benjamin Miller.

PBT didn’t seem to help at Vanderbilt. On multivariable regression, in-flight transfusion did not improve 24-hour mortality (OR 1.22; 95% CI 0.61-2.44) or overall in-hospital mortality (OR 1.20; 95% CI 0.55-1.79). It was the same story when 195 transfused patients were matched to 195 who were not transfused, based on mechanism of injury, scene vital signs, injury severity, travel duration, and other measures. Even with matching, PBT did not improve 24-hour mortality (OR 1.04; 95% CI 0.54-1.98) or overall mortality (OR 1.05; 95% CI 0.56-1.96).

There was a trend for improved 24-hour survival with transfusion when injury severity scores were below 20, but it wasn’t statistically significant, perhaps because few of the less injured patients died.

“Our results show no effect of PBT on 24-hour and overall in-hospital mortality. It’s puzzling to us because it’s counterintuitive to the damage control resuscitation strategy,” Dr. Miller said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.

The findings aren’t robust enough for Vanderbilt to cancel PBT, but they do suggest possible areas for improvement.

Maybe “one or two units of blood are not enough for patients who are severely injured and rapidly exsanguinating, or [maybe] fresh frozen plasma or platelets are needed. Maybe the trigger for transfusion is too low, or too high. It’s time from a prospective study,” Dr. Miller said.

Vanderbilt doesn’t use tranexamic acid to control trauma bleeding. The study didn’t capture volume of crystalloid infused, serum markers of shock, or coagulation study results.

Subjects were in their late 30s, on average, and 70% were men. Transfusions were more likely in younger patients and those with penetrating injuries, poorer at-scene vital signs and Glasgow coma scores, more severe injuries, and lower hematocrits. With the exception of younger age, those factors were also associated with death.

The investigators had no disclosures.

[email protected]

SAN ANTONIO – Prehospital blood transfusions during air medical transport did not improve 24-hour or in-hospital mortality at Vanderbilt University Medical Center, Nashville.

Investigators there reviewed 5,581 patients transported by helicopter to Vanderbilt from the scene of injury from the period of 2007-2013; they excluded patients who died on the helipad or in the ED. Average flight time was 48 minutes; 231 patients (4%) received prehospital blood transfusions (PBT) of up to two units of O negative packed red blood cells, which is all that the helicopters carried. The decision to transfuse was up to helicopter personnel who were advised to transfuse hemodynamically unstable patients and those who had lost more than a half liter of blood.

©Keith Brofsky/Thinkstock

Vanderbilt reviewed its data because although PBT has become widespread in air medical transport, results from military and civilian studies are mixed. “A lot of evidence indicates that early, aggressive resuscitation with blood products improves survival once patients arrive at the hospital. It makes sense that starting the process early would improve outcomes, but relatively little is known about the prehospital environment,” said investigator and general surgery resident Dr. Benjamin Miller.

PBT didn’t seem to help at Vanderbilt. On multivariable regression, in-flight transfusion did not improve 24-hour mortality (OR 1.22; 95% CI 0.61-2.44) or overall in-hospital mortality (OR 1.20; 95% CI 0.55-1.79). It was the same story when 195 transfused patients were matched to 195 who were not transfused, based on mechanism of injury, scene vital signs, injury severity, travel duration, and other measures. Even with matching, PBT did not improve 24-hour mortality (OR 1.04; 95% CI 0.54-1.98) or overall mortality (OR 1.05; 95% CI 0.56-1.96).

There was a trend for improved 24-hour survival with transfusion when injury severity scores were below 20, but it wasn’t statistically significant, perhaps because few of the less injured patients died.

“Our results show no effect of PBT on 24-hour and overall in-hospital mortality. It’s puzzling to us because it’s counterintuitive to the damage control resuscitation strategy,” Dr. Miller said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.

The findings aren’t robust enough for Vanderbilt to cancel PBT, but they do suggest possible areas for improvement.

Maybe “one or two units of blood are not enough for patients who are severely injured and rapidly exsanguinating, or [maybe] fresh frozen plasma or platelets are needed. Maybe the trigger for transfusion is too low, or too high. It’s time from a prospective study,” Dr. Miller said.

Vanderbilt doesn’t use tranexamic acid to control trauma bleeding. The study didn’t capture volume of crystalloid infused, serum markers of shock, or coagulation study results.

Subjects were in their late 30s, on average, and 70% were men. Transfusions were more likely in younger patients and those with penetrating injuries, poorer at-scene vital signs and Glasgow coma scores, more severe injuries, and lower hematocrits. With the exception of younger age, those factors were also associated with death.

The investigators had no disclosures.

[email protected]

SAN ANTONIO – Prehospital blood transfusions during air medical transport did not improve 24-hour or in-hospital mortality at Vanderbilt University Medical Center, Nashville.

Investigators there reviewed 5,581 patients transported by helicopter to Vanderbilt from the scene of injury from the period of 2007-2013; they excluded patients who died on the helipad or in the ED. Average flight time was 48 minutes; 231 patients (4%) received prehospital blood transfusions (PBT) of up to two units of O negative packed red blood cells, which is all that the helicopters carried. The decision to transfuse was up to helicopter personnel who were advised to transfuse hemodynamically unstable patients and those who had lost more than a half liter of blood.

©Keith Brofsky/Thinkstock

Vanderbilt reviewed its data because although PBT has become widespread in air medical transport, results from military and civilian studies are mixed. “A lot of evidence indicates that early, aggressive resuscitation with blood products improves survival once patients arrive at the hospital. It makes sense that starting the process early would improve outcomes, but relatively little is known about the prehospital environment,” said investigator and general surgery resident Dr. Benjamin Miller.

PBT didn’t seem to help at Vanderbilt. On multivariable regression, in-flight transfusion did not improve 24-hour mortality (OR 1.22; 95% CI 0.61-2.44) or overall in-hospital mortality (OR 1.20; 95% CI 0.55-1.79). It was the same story when 195 transfused patients were matched to 195 who were not transfused, based on mechanism of injury, scene vital signs, injury severity, travel duration, and other measures. Even with matching, PBT did not improve 24-hour mortality (OR 1.04; 95% CI 0.54-1.98) or overall mortality (OR 1.05; 95% CI 0.56-1.96).

There was a trend for improved 24-hour survival with transfusion when injury severity scores were below 20, but it wasn’t statistically significant, perhaps because few of the less injured patients died.

“Our results show no effect of PBT on 24-hour and overall in-hospital mortality. It’s puzzling to us because it’s counterintuitive to the damage control resuscitation strategy,” Dr. Miller said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.

The findings aren’t robust enough for Vanderbilt to cancel PBT, but they do suggest possible areas for improvement.

Maybe “one or two units of blood are not enough for patients who are severely injured and rapidly exsanguinating, or [maybe] fresh frozen plasma or platelets are needed. Maybe the trigger for transfusion is too low, or too high. It’s time from a prospective study,” Dr. Miller said.

Vanderbilt doesn’t use tranexamic acid to control trauma bleeding. The study didn’t capture volume of crystalloid infused, serum markers of shock, or coagulation study results.

Subjects were in their late 30s, on average, and 70% were men. Transfusions were more likely in younger patients and those with penetrating injuries, poorer at-scene vital signs and Glasgow coma scores, more severe injuries, and lower hematocrits. With the exception of younger age, those factors were also associated with death.

The investigators had no disclosures.

[email protected]

LOS ANGELES – In asymptomatic patients under 80 years old, carotid stenting and endarterectomy perform equally as well for severe carotid stenosis out to 5 years, according to a randomized trial published online in the New England Journal of Medicine.

Overall, 1,032 patients were stented, and 343 had endarterectomies in the trial, called Asymptomatic Carotid Trial I (ACT I). If stenting didn’t look safe on postrandomization angiography, patients were given the option of medical management or crossover into the surgical group. The subjects all had bifurcation carotid stenosis blocking at least 70% of the lumen. None were at high risk for surgical complications. “Asymptomatic” meant they hadn’t had a stroke, transient ischemic attack, or amaurosis fugax in the 6 months before enrollment. Stenting and endarterectomy were done by physicians and centers well experienced in the techniques (N Engl J Med. 2016 Feb 17. doi: 10.1056/NEJMoa1515706).

At 1 year, stenting was noninferior to endarterectomy for the primary composite endpoint of death, stroke, or myocardial infarction within 30 days after the procedure or ipsilateral stroke within 1 year; the event rate was 3.8% among stent patients and 3.4% among endarterectomy patients (P = .01 for noninferiority, with a noninferiority margin of 3 percentage points).

The cumulative 5-year stroke-free survival rate was 93.1% in the stenting group and 94.7% in the endarterectomy group (P = .44).

For now, the results mean that sometimes choosing between carotid endarterectomy or stenting (or medical management) has as much to do with patient and physician preference as medical science, raising the difficult question of how to choose. In a video interview at the International Stroke Conference, investigator Dr. Lawrence Wechsler, professor of neurology/neurosurgery and chair of the department of neurology at the University of Pittsburgh, shared his thoughts on that and the other implications of the study. The work was funded by Abbott Vascular.

[email protected]

LOS ANGELES – In asymptomatic patients under 80 years old, carotid stenting and endarterectomy perform equally as well for severe carotid stenosis out to 5 years, according to a randomized trial published online in the New England Journal of Medicine.

Overall, 1,032 patients were stented, and 343 had endarterectomies in the trial, called Asymptomatic Carotid Trial I (ACT I). If stenting didn’t look safe on postrandomization angiography, patients were given the option of medical management or crossover into the surgical group. The subjects all had bifurcation carotid stenosis blocking at least 70% of the lumen. None were at high risk for surgical complications. “Asymptomatic” meant they hadn’t had a stroke, transient ischemic attack, or amaurosis fugax in the 6 months before enrollment. Stenting and endarterectomy were done by physicians and centers well experienced in the techniques (N Engl J Med. 2016 Feb 17. doi: 10.1056/NEJMoa1515706).

At 1 year, stenting was noninferior to endarterectomy for the primary composite endpoint of death, stroke, or myocardial infarction within 30 days after the procedure or ipsilateral stroke within 1 year; the event rate was 3.8% among stent patients and 3.4% among endarterectomy patients (P = .01 for noninferiority, with a noninferiority margin of 3 percentage points).

The cumulative 5-year stroke-free survival rate was 93.1% in the stenting group and 94.7% in the endarterectomy group (P = .44).

For now, the results mean that sometimes choosing between carotid endarterectomy or stenting (or medical management) has as much to do with patient and physician preference as medical science, raising the difficult question of how to choose. In a video interview at the International Stroke Conference, investigator Dr. Lawrence Wechsler, professor of neurology/neurosurgery and chair of the department of neurology at the University of Pittsburgh, shared his thoughts on that and the other implications of the study. The work was funded by Abbott Vascular.

[email protected]

LOS ANGELES – In asymptomatic patients under 80 years old, carotid stenting and endarterectomy perform equally as well for severe carotid stenosis out to 5 years, according to a randomized trial published online in the New England Journal of Medicine.

Overall, 1,032 patients were stented, and 343 had endarterectomies in the trial, called Asymptomatic Carotid Trial I (ACT I). If stenting didn’t look safe on postrandomization angiography, patients were given the option of medical management or crossover into the surgical group. The subjects all had bifurcation carotid stenosis blocking at least 70% of the lumen. None were at high risk for surgical complications. “Asymptomatic” meant they hadn’t had a stroke, transient ischemic attack, or amaurosis fugax in the 6 months before enrollment. Stenting and endarterectomy were done by physicians and centers well experienced in the techniques (N Engl J Med. 2016 Feb 17. doi: 10.1056/NEJMoa1515706).

At 1 year, stenting was noninferior to endarterectomy for the primary composite endpoint of death, stroke, or myocardial infarction within 30 days after the procedure or ipsilateral stroke within 1 year; the event rate was 3.8% among stent patients and 3.4% among endarterectomy patients (P = .01 for noninferiority, with a noninferiority margin of 3 percentage points).

The cumulative 5-year stroke-free survival rate was 93.1% in the stenting group and 94.7% in the endarterectomy group (P = .44).

For now, the results mean that sometimes choosing between carotid endarterectomy or stenting (or medical management) has as much to do with patient and physician preference as medical science, raising the difficult question of how to choose. In a video interview at the International Stroke Conference, investigator Dr. Lawrence Wechsler, professor of neurology/neurosurgery and chair of the department of neurology at the University of Pittsburgh, shared his thoughts on that and the other implications of the study. The work was funded by Abbott Vascular.

[email protected]

LOS ANGELES – Nondiabetic, insulin-resistant patients who started pioglitazone within 6 months of an ischemic stroke or transient ischemic attack had almost a 3% absolute risk reduction in secondary strokes and myocardial infarctions after 5 years, in a randomized, clinical trial published online Feb. 17 in the New England Journal of Medicine.

Stroke or MI – the study’s primary combined outcome – occurred in 175 of 1,939 (9.0%) pioglitazone (Actos) patients, but 228 of 1,937 (11.8%) placebo patients (hazard ratio, 0.76; P = 0.007). There was no significant difference in all-cause mortality (HR, 0.93; P = 0.52).

Seventy-three pioglitazone patients (3.8%) developed diabetes, compared with 149 (7.7%) in the placebo group (HR, 0.48; P less than 0.001). That wasn’t a surprise; pioglitazone has been shown to protect insulin resistant patients against diabetes, the study investigators noted (N Engl J Med. 2016 Feb 17; doi: 10.1056/NEJMoa1506930).

Known side effects showed up as well. Pioglitazone was associated with a greater frequency of weight gain exceeding 4.5 kg (52.2% versus 33.7%, P less than 0.001), edema (35.6% versus 24.9%, P less than 0.001), and bone fracture requiring surgery or hospitalization (5.1% versus 3.2%, P = 0.003).

Heart failure – another known risk with the drug – did not show up in the trial; people with heart failure histories or other risk factors were excluded.

The median baseline modified Rankin Scale in both groups was 1, and the median NIH Stroke Scale score was 0. The pioglitazone target dose was 45 mg daily.

Insulin resistance is a risk factor for heart attack and stroke, which may help explain the thiazolidinedione’s apparent protective effects. It was defined in the trial as a score greater than 3.0 on the homeostasis model assessment of insulin resistance (HOMA-IR) index.

So, should pioglitazone be a part of routine post-stroke care?

In a video interview at the International Stroke Conference, lead investigator Dr. Walter N. Kernan, a professor of general medicine at Yale University, New Haven, Conn., shared his thoughts.

[email protected]

LOS ANGELES – Nondiabetic, insulin-resistant patients who started pioglitazone within 6 months of an ischemic stroke or transient ischemic attack had almost a 3% absolute risk reduction in secondary strokes and myocardial infarctions after 5 years, in a randomized, clinical trial published online Feb. 17 in the New England Journal of Medicine.

Stroke or MI – the study’s primary combined outcome – occurred in 175 of 1,939 (9.0%) pioglitazone (Actos) patients, but 228 of 1,937 (11.8%) placebo patients (hazard ratio, 0.76; P = 0.007). There was no significant difference in all-cause mortality (HR, 0.93; P = 0.52).

Seventy-three pioglitazone patients (3.8%) developed diabetes, compared with 149 (7.7%) in the placebo group (HR, 0.48; P less than 0.001). That wasn’t a surprise; pioglitazone has been shown to protect insulin resistant patients against diabetes, the study investigators noted (N Engl J Med. 2016 Feb 17; doi: 10.1056/NEJMoa1506930).

Known side effects showed up as well. Pioglitazone was associated with a greater frequency of weight gain exceeding 4.5 kg (52.2% versus 33.7%, P less than 0.001), edema (35.6% versus 24.9%, P less than 0.001), and bone fracture requiring surgery or hospitalization (5.1% versus 3.2%, P = 0.003).

Heart failure – another known risk with the drug – did not show up in the trial; people with heart failure histories or other risk factors were excluded.

The median baseline modified Rankin Scale in both groups was 1, and the median NIH Stroke Scale score was 0. The pioglitazone target dose was 45 mg daily.

Insulin resistance is a risk factor for heart attack and stroke, which may help explain the thiazolidinedione’s apparent protective effects. It was defined in the trial as a score greater than 3.0 on the homeostasis model assessment of insulin resistance (HOMA-IR) index.

So, should pioglitazone be a part of routine post-stroke care?

In a video interview at the International Stroke Conference, lead investigator Dr. Walter N. Kernan, a professor of general medicine at Yale University, New Haven, Conn., shared his thoughts.

[email protected]

LOS ANGELES – Nondiabetic, insulin-resistant patients who started pioglitazone within 6 months of an ischemic stroke or transient ischemic attack had almost a 3% absolute risk reduction in secondary strokes and myocardial infarctions after 5 years, in a randomized, clinical trial published online Feb. 17 in the New England Journal of Medicine.

Stroke or MI – the study’s primary combined outcome – occurred in 175 of 1,939 (9.0%) pioglitazone (Actos) patients, but 228 of 1,937 (11.8%) placebo patients (hazard ratio, 0.76; P = 0.007). There was no significant difference in all-cause mortality (HR, 0.93; P = 0.52).

Seventy-three pioglitazone patients (3.8%) developed diabetes, compared with 149 (7.7%) in the placebo group (HR, 0.48; P less than 0.001). That wasn’t a surprise; pioglitazone has been shown to protect insulin resistant patients against diabetes, the study investigators noted (N Engl J Med. 2016 Feb 17; doi: 10.1056/NEJMoa1506930).

Known side effects showed up as well. Pioglitazone was associated with a greater frequency of weight gain exceeding 4.5 kg (52.2% versus 33.7%, P less than 0.001), edema (35.6% versus 24.9%, P less than 0.001), and bone fracture requiring surgery or hospitalization (5.1% versus 3.2%, P = 0.003).

Heart failure – another known risk with the drug – did not show up in the trial; people with heart failure histories or other risk factors were excluded.

The median baseline modified Rankin Scale in both groups was 1, and the median NIH Stroke Scale score was 0. The pioglitazone target dose was 45 mg daily.

Insulin resistance is a risk factor for heart attack and stroke, which may help explain the thiazolidinedione’s apparent protective effects. It was defined in the trial as a score greater than 3.0 on the homeostasis model assessment of insulin resistance (HOMA-IR) index.

So, should pioglitazone be a part of routine post-stroke care?

In a video interview at the International Stroke Conference, lead investigator Dr. Walter N. Kernan, a professor of general medicine at Yale University, New Haven, Conn., shared his thoughts.

[email protected]

SAN ANTONIO – Tourniquets are being overemphasized in preparations for mass shootings in the United States, according to a review by the Committee for Tactical Emergency Casualty Care of wounding patterns in 12 mass shootings.

Since the 2012 shootings in Newtown, Conn., efforts to improve survival have tended to emphasize tourniquets to stop bleeding from wounded limbs. The recently-launched federal “Stop the Bleed” campaign promotes public awareness of compression and tourniquets, and the American College of Surgeons and other groups recently called for public education and use of tourniquets as one of many responses to mass-casualty and active-shooter events, stating that “the most significant preventable cause of death in the prehospital environment is external hemorrhage.” There are thoughts of making tourniquets at least as common as automated external defibrillators in public settings.

The efforts are driven by combat experience in Afghanistan and Iraq, where about half of wounds were to arms and legs, and tourniquets saved many lives.

Wikimedia Creative Commons License/INDNAM

Tourniquets are important especially for civilian bombings, but fatalities in civilian mass shootings – shootings with at least four deaths in which killing is the primary aim – are from head and chest wounds, not extremity wounds. The emphasis on bleeding control overshadows public education about other simple interventions that could be more useful in shootings, according to emergency physician Dr. Reed Smith, medical director of the Arlington County (Va.) Fire Department and cofounder and cochairman of the Committee for Tactical Emergency Casualty Care (C-TECC).

“We need a civilian perspective on civilian incidents, not a military perspective,” he said at the Eastern Association for the Surgery of Trauma scientific assembly.

Dr. Smith and other C-TECC investigators reviewed autopsy reports from 12 U.S. civilian mass shootings from the period of 1996-2012. They tried to get data for more, but ran into significant resistance from authorities.

There were 371 bullet wounds and 139 deaths, an average of 2.7 wounds per victim but a range of 1-10. About 40% of deaths were from shots to the head; another 40% from shots to the chest or upper back; and the rest from shots to the face/neck, abdomen/lower back, or multiple regions.

“We looked at every one of these events, and with the exception of the Gabby Giffords Tucson shooting, no tourniquets were used. There were no cases of major peripheral vascular injury, and no fatalities from extremity exsanguination,” Dr. Smith said.

The investigators estimated that nine fatalities were potentially survivable, without injuries to the heart, brain, or major blood vessels, and definitive care available within 60 minutes. The victims died from face and torso wounds, not wounds to the limbs.

“Wounding in active-shooter events differs from combat and may require different therapeutic emphasis. Although tourniquets and external hemorrhage control techniques hold value, their role in active-shooter events may be overemphasized as a means to decrease fatality. The focus on external hemorrhage is important, but it’s not enough,” Dr. Smith said.

Additional interventions could be taught for every step in the chain of contact, from citizen to trauma surgeon, that could have greater benefit. Teachers, for instance, could be taught to roll victims on their sides and clear out their mouths to keep airways open, and to keep them warm to prevent hypothermia until help arrives. Police could learn to insert nasal airways, and occlude sucking chest wounds. Fire/EMS could start initial damage control. “Everything builds,” Dr. Smith said.

C-TECC made many recommendations for enhanced mass-causality response its 2015 Tactical Emergency Casualty Care Guidelines.

Dr. Smith had no disclosures.

[email protected]

SAN ANTONIO – Tourniquets are being overemphasized in preparations for mass shootings in the United States, according to a review by the Committee for Tactical Emergency Casualty Care of wounding patterns in 12 mass shootings.

Since the 2012 shootings in Newtown, Conn., efforts to improve survival have tended to emphasize tourniquets to stop bleeding from wounded limbs. The recently-launched federal “Stop the Bleed” campaign promotes public awareness of compression and tourniquets, and the American College of Surgeons and other groups recently called for public education and use of tourniquets as one of many responses to mass-casualty and active-shooter events, stating that “the most significant preventable cause of death in the prehospital environment is external hemorrhage.” There are thoughts of making tourniquets at least as common as automated external defibrillators in public settings.

The efforts are driven by combat experience in Afghanistan and Iraq, where about half of wounds were to arms and legs, and tourniquets saved many lives.

Wikimedia Creative Commons License/INDNAM

Tourniquets are important especially for civilian bombings, but fatalities in civilian mass shootings – shootings with at least four deaths in which killing is the primary aim – are from head and chest wounds, not extremity wounds. The emphasis on bleeding control overshadows public education about other simple interventions that could be more useful in shootings, according to emergency physician Dr. Reed Smith, medical director of the Arlington County (Va.) Fire Department and cofounder and cochairman of the Committee for Tactical Emergency Casualty Care (C-TECC).

“We need a civilian perspective on civilian incidents, not a military perspective,” he said at the Eastern Association for the Surgery of Trauma scientific assembly.

Dr. Smith and other C-TECC investigators reviewed autopsy reports from 12 U.S. civilian mass shootings from the period of 1996-2012. They tried to get data for more, but ran into significant resistance from authorities.

There were 371 bullet wounds and 139 deaths, an average of 2.7 wounds per victim but a range of 1-10. About 40% of deaths were from shots to the head; another 40% from shots to the chest or upper back; and the rest from shots to the face/neck, abdomen/lower back, or multiple regions.

“We looked at every one of these events, and with the exception of the Gabby Giffords Tucson shooting, no tourniquets were used. There were no cases of major peripheral vascular injury, and no fatalities from extremity exsanguination,” Dr. Smith said.

The investigators estimated that nine fatalities were potentially survivable, without injuries to the heart, brain, or major blood vessels, and definitive care available within 60 minutes. The victims died from face and torso wounds, not wounds to the limbs.

“Wounding in active-shooter events differs from combat and may require different therapeutic emphasis. Although tourniquets and external hemorrhage control techniques hold value, their role in active-shooter events may be overemphasized as a means to decrease fatality. The focus on external hemorrhage is important, but it’s not enough,” Dr. Smith said.

Additional interventions could be taught for every step in the chain of contact, from citizen to trauma surgeon, that could have greater benefit. Teachers, for instance, could be taught to roll victims on their sides and clear out their mouths to keep airways open, and to keep them warm to prevent hypothermia until help arrives. Police could learn to insert nasal airways, and occlude sucking chest wounds. Fire/EMS could start initial damage control. “Everything builds,” Dr. Smith said.

C-TECC made many recommendations for enhanced mass-causality response its 2015 Tactical Emergency Casualty Care Guidelines.

Dr. Smith had no disclosures.

[email protected]

SAN ANTONIO – Tourniquets are being overemphasized in preparations for mass shootings in the United States, according to a review by the Committee for Tactical Emergency Casualty Care of wounding patterns in 12 mass shootings.

Since the 2012 shootings in Newtown, Conn., efforts to improve survival have tended to emphasize tourniquets to stop bleeding from wounded limbs. The recently-launched federal “Stop the Bleed” campaign promotes public awareness of compression and tourniquets, and the American College of Surgeons and other groups recently called for public education and use of tourniquets as one of many responses to mass-casualty and active-shooter events, stating that “the most significant preventable cause of death in the prehospital environment is external hemorrhage.” There are thoughts of making tourniquets at least as common as automated external defibrillators in public settings.

The efforts are driven by combat experience in Afghanistan and Iraq, where about half of wounds were to arms and legs, and tourniquets saved many lives.

Wikimedia Creative Commons License/INDNAM

Tourniquets are important especially for civilian bombings, but fatalities in civilian mass shootings – shootings with at least four deaths in which killing is the primary aim – are from head and chest wounds, not extremity wounds. The emphasis on bleeding control overshadows public education about other simple interventions that could be more useful in shootings, according to emergency physician Dr. Reed Smith, medical director of the Arlington County (Va.) Fire Department and cofounder and cochairman of the Committee for Tactical Emergency Casualty Care (C-TECC).

“We need a civilian perspective on civilian incidents, not a military perspective,” he said at the Eastern Association for the Surgery of Trauma scientific assembly.

Dr. Smith and other C-TECC investigators reviewed autopsy reports from 12 U.S. civilian mass shootings from the period of 1996-2012. They tried to get data for more, but ran into significant resistance from authorities.

There were 371 bullet wounds and 139 deaths, an average of 2.7 wounds per victim but a range of 1-10. About 40% of deaths were from shots to the head; another 40% from shots to the chest or upper back; and the rest from shots to the face/neck, abdomen/lower back, or multiple regions.

“We looked at every one of these events, and with the exception of the Gabby Giffords Tucson shooting, no tourniquets were used. There were no cases of major peripheral vascular injury, and no fatalities from extremity exsanguination,” Dr. Smith said.

The investigators estimated that nine fatalities were potentially survivable, without injuries to the heart, brain, or major blood vessels, and definitive care available within 60 minutes. The victims died from face and torso wounds, not wounds to the limbs.

“Wounding in active-shooter events differs from combat and may require different therapeutic emphasis. Although tourniquets and external hemorrhage control techniques hold value, their role in active-shooter events may be overemphasized as a means to decrease fatality. The focus on external hemorrhage is important, but it’s not enough,” Dr. Smith said.

Additional interventions could be taught for every step in the chain of contact, from citizen to trauma surgeon, that could have greater benefit. Teachers, for instance, could be taught to roll victims on their sides and clear out their mouths to keep airways open, and to keep them warm to prevent hypothermia until help arrives. Police could learn to insert nasal airways, and occlude sucking chest wounds. Fire/EMS could start initial damage control. “Everything builds,” Dr. Smith said.

C-TECC made many recommendations for enhanced mass-causality response its 2015 Tactical Emergency Casualty Care Guidelines.

Dr. Smith had no disclosures.

[email protected]

SAN ANTONIO – Initiation of venous thromboembolism prophylaxis within 72 hours of severe traumatic brain injury (TBI) reduced the odds of venous thromboembolism by 50% without increasing subsequent intracranial complications or death in a large, propensity-matched cohort study from the University of Toronto.

The investigators matched 1,234 adult patients given prophylaxis before 72 hours – the early-prophylaxis (EP) group – to 1,234 given prophylaxis at 72 hours or later – the late-prophylaxis (LP) group – based on demographics, injury characteristics, intracranial lesions, early neurosurgical procedures, and prophylaxis type.

EP patients had a significantly lower rate of pulmonary embolism (1.1% vs. 2.4%; odds ratio, 0.48; 95% confidence interval, 0.25-0.91) and deep vein thrombosis (4.2% vs. 7.9%; OR, 0.51; 95% CI, 0.36-0.72), with no significant increase in the risk of death (9.8% EP vs. 9% LP; OR, 1.1; 95% CI 0.84-1.4) or late secondary craniotomy/-ectomy (EP 2.5% vs. LP 2.9%; OR, 0.86; 95% CI 0.53-1.4) or intracranial monitoring/drainage (EP 1.1% vs. LP 1.4%; OR, 0.76; 95% CI 0.37-1.6) from VTE complications or other reasons.

“Practice guidelines say we should initiate VTE [venous thromboembolism] prophylaxis” in severe TBI “as early as possible. It’s a very loose recommendation,” so some centers wait 72 hours or longer for fear of extending intracranial hemorrhages. Pending results from prospective trials, “our study lends evidence that early prophylaxis in this population may be safe,” said investigator and University of Toronto general surgery resident, Dr. James Byrne.

The study included 3,634 severe, adult TBI patients in the American College of Surgeons Trauma Quality Improvement Program database from 2012-2014. The subjects had head Abbreviated Injury Scale (AIS) scores of at least 3, Glasgow Coma Scale scores of no more than 8, and, in almost all cases, initial surgeries within 48 hours. Injury was due to blunt trauma. Patients who died or were discharged within 5 days of their injury and those with severe injuries to other body areas were excluded from the analysis.

The median time to starting VTE prophylaxis was 84 hours across the 186 trauma centers in the study, but ranged from 48-150 hours. Centers started prophylaxis within 72 hours in 18%-54% of patients. Fifty-five percent of patients had prophylaxis with low-molecular-weight heparin, and the rest with unfractionated heparin. Overall, 1.7% of patients developed pulmonary emboli, and 6.5% deep vein thromboses. Less than 3% had secondary neurosurgical interventions.

Prophylaxis was more likely to be delayed past 72 hours in patients with higher head AIS scores; subdural hematomas; subarachnoid hemorrhages; blood transfusions within 12 hours of admission; and early neurosurgery. Low-molecular-weight heparin was the more likely option past 72 hours.

Among the 114 centers who treated 10 or more patients, there was a continuous trend toward lower VTE rates with higher EP use, a rate of 9.1% in centers using EP in 18% of patients, but 6.1% in centers using it in 54% (P = .126).

The decision of when to start prophylaxis in severe TBI “still needs to be made at the patient level, but it may be safe to start earlier than 72 hours,” Dr. Byrne said.

The median age in the study was about 43 years, and three-quarters of the subjects were men. Most of the injuries were due to falls or motor vehicle crashes.

Dr. Byrne had no disclosures.

[email protected]

SAN ANTONIO – Initiation of venous thromboembolism prophylaxis within 72 hours of severe traumatic brain injury (TBI) reduced the odds of venous thromboembolism by 50% without increasing subsequent intracranial complications or death in a large, propensity-matched cohort study from the University of Toronto.

The investigators matched 1,234 adult patients given prophylaxis before 72 hours – the early-prophylaxis (EP) group – to 1,234 given prophylaxis at 72 hours or later – the late-prophylaxis (LP) group – based on demographics, injury characteristics, intracranial lesions, early neurosurgical procedures, and prophylaxis type.

EP patients had a significantly lower rate of pulmonary embolism (1.1% vs. 2.4%; odds ratio, 0.48; 95% confidence interval, 0.25-0.91) and deep vein thrombosis (4.2% vs. 7.9%; OR, 0.51; 95% CI, 0.36-0.72), with no significant increase in the risk of death (9.8% EP vs. 9% LP; OR, 1.1; 95% CI 0.84-1.4) or late secondary craniotomy/-ectomy (EP 2.5% vs. LP 2.9%; OR, 0.86; 95% CI 0.53-1.4) or intracranial monitoring/drainage (EP 1.1% vs. LP 1.4%; OR, 0.76; 95% CI 0.37-1.6) from VTE complications or other reasons.

“Practice guidelines say we should initiate VTE [venous thromboembolism] prophylaxis” in severe TBI “as early as possible. It’s a very loose recommendation,” so some centers wait 72 hours or longer for fear of extending intracranial hemorrhages. Pending results from prospective trials, “our study lends evidence that early prophylaxis in this population may be safe,” said investigator and University of Toronto general surgery resident, Dr. James Byrne.

The study included 3,634 severe, adult TBI patients in the American College of Surgeons Trauma Quality Improvement Program database from 2012-2014. The subjects had head Abbreviated Injury Scale (AIS) scores of at least 3, Glasgow Coma Scale scores of no more than 8, and, in almost all cases, initial surgeries within 48 hours. Injury was due to blunt trauma. Patients who died or were discharged within 5 days of their injury and those with severe injuries to other body areas were excluded from the analysis.

The median time to starting VTE prophylaxis was 84 hours across the 186 trauma centers in the study, but ranged from 48-150 hours. Centers started prophylaxis within 72 hours in 18%-54% of patients. Fifty-five percent of patients had prophylaxis with low-molecular-weight heparin, and the rest with unfractionated heparin. Overall, 1.7% of patients developed pulmonary emboli, and 6.5% deep vein thromboses. Less than 3% had secondary neurosurgical interventions.

Prophylaxis was more likely to be delayed past 72 hours in patients with higher head AIS scores; subdural hematomas; subarachnoid hemorrhages; blood transfusions within 12 hours of admission; and early neurosurgery. Low-molecular-weight heparin was the more likely option past 72 hours.

Among the 114 centers who treated 10 or more patients, there was a continuous trend toward lower VTE rates with higher EP use, a rate of 9.1% in centers using EP in 18% of patients, but 6.1% in centers using it in 54% (P = .126).

The decision of when to start prophylaxis in severe TBI “still needs to be made at the patient level, but it may be safe to start earlier than 72 hours,” Dr. Byrne said.

The median age in the study was about 43 years, and three-quarters of the subjects were men. Most of the injuries were due to falls or motor vehicle crashes.

Dr. Byrne had no disclosures.

[email protected]

SAN ANTONIO – Initiation of venous thromboembolism prophylaxis within 72 hours of severe traumatic brain injury (TBI) reduced the odds of venous thromboembolism by 50% without increasing subsequent intracranial complications or death in a large, propensity-matched cohort study from the University of Toronto.

The investigators matched 1,234 adult patients given prophylaxis before 72 hours – the early-prophylaxis (EP) group – to 1,234 given prophylaxis at 72 hours or later – the late-prophylaxis (LP) group – based on demographics, injury characteristics, intracranial lesions, early neurosurgical procedures, and prophylaxis type.

EP patients had a significantly lower rate of pulmonary embolism (1.1% vs. 2.4%; odds ratio, 0.48; 95% confidence interval, 0.25-0.91) and deep vein thrombosis (4.2% vs. 7.9%; OR, 0.51; 95% CI, 0.36-0.72), with no significant increase in the risk of death (9.8% EP vs. 9% LP; OR, 1.1; 95% CI 0.84-1.4) or late secondary craniotomy/-ectomy (EP 2.5% vs. LP 2.9%; OR, 0.86; 95% CI 0.53-1.4) or intracranial monitoring/drainage (EP 1.1% vs. LP 1.4%; OR, 0.76; 95% CI 0.37-1.6) from VTE complications or other reasons.

“Practice guidelines say we should initiate VTE [venous thromboembolism] prophylaxis” in severe TBI “as early as possible. It’s a very loose recommendation,” so some centers wait 72 hours or longer for fear of extending intracranial hemorrhages. Pending results from prospective trials, “our study lends evidence that early prophylaxis in this population may be safe,” said investigator and University of Toronto general surgery resident, Dr. James Byrne.

The study included 3,634 severe, adult TBI patients in the American College of Surgeons Trauma Quality Improvement Program database from 2012-2014. The subjects had head Abbreviated Injury Scale (AIS) scores of at least 3, Glasgow Coma Scale scores of no more than 8, and, in almost all cases, initial surgeries within 48 hours. Injury was due to blunt trauma. Patients who died or were discharged within 5 days of their injury and those with severe injuries to other body areas were excluded from the analysis.

The median time to starting VTE prophylaxis was 84 hours across the 186 trauma centers in the study, but ranged from 48-150 hours. Centers started prophylaxis within 72 hours in 18%-54% of patients. Fifty-five percent of patients had prophylaxis with low-molecular-weight heparin, and the rest with unfractionated heparin. Overall, 1.7% of patients developed pulmonary emboli, and 6.5% deep vein thromboses. Less than 3% had secondary neurosurgical interventions.

Prophylaxis was more likely to be delayed past 72 hours in patients with higher head AIS scores; subdural hematomas; subarachnoid hemorrhages; blood transfusions within 12 hours of admission; and early neurosurgery. Low-molecular-weight heparin was the more likely option past 72 hours.

Among the 114 centers who treated 10 or more patients, there was a continuous trend toward lower VTE rates with higher EP use, a rate of 9.1% in centers using EP in 18% of patients, but 6.1% in centers using it in 54% (P = .126).

The decision of when to start prophylaxis in severe TBI “still needs to be made at the patient level, but it may be safe to start earlier than 72 hours,” Dr. Byrne said.

The median age in the study was about 43 years, and three-quarters of the subjects were men. Most of the injuries were due to falls or motor vehicle crashes.

Dr. Byrne had no disclosures.

[email protected]

SAN ANTONIO – Perioperative risk factors affect postoperative morbidity and mortality differently in emergency and nonemergency surgery, according to an analysis of the ACS National Surgical Quality Improvement Program (ACS NSQIP) database by investigators from Massachusetts General Hospital, Boston.

“Instead of using the same risk-adjustment model for both ... as is currently being done, our findings strongly suggest the need to benchmark emergent and elective surgeries separately,” they concluded.

“Most risk-adjustment models simply have an on/off switch for whether or not the patient underwent emergency surgery and treat comorbidities and other perioperative variables the same.” Those variables, however, “don’t behave the same way in emergency surgery,” said investigator Dr. Jordan Bohnen, a surgical research resident at Mass General.

Because risk adjustment doesn’t take into account variables that have a particularly strong negative impact in emergency settings, acute care surgeons are getting “unnecessarily dinged for having higher complication rates,” he said at the Eastern Association for the Surgery of Trauma scientific assembly.

For example, the team found that preop transfusions and white blood counts (WBC) at or below 4.5 carry a significantly higher risk of 30-day major morbidity or mortality (MMM) in emergency versus nonemergency surgery. Conversely, ascites, preop anemia, and leukocytosis carry a greater MMM risk in nonemergent cases.

The findings come from a comparison of 110,182 nonemergent surgeries to 59,949 emergency cases – generally meaning surgery within 12 hours of emergency department (ED) admission – from the NSQIP database for 2011-2012.

As expected, the overall risk of MMM was significantly higher for emergency cases (16.75% vs. 9.73%; P less than .001), and four procedures – laparoscopic cholecystectomy, exploratory laparotomy, and umbilical and incisional hernia repairs – were relatively riskier when done emergently.

“As surgical quality improvement efforts mature, it’s increasingly important to apply accurate risk-adjustment models to benchmark quality improvement for surgeons, hospitals, and health care systems.” The current “assumption that perioperative variables have an equal impact on outcomes in emergent and nonemergent settings” is incorrect. “Risk factors for bad outcomes change depending on the setting,” Dr. Bohnen said.

Dr. Bohnen has no disclosures.

[email protected]

SAN ANTONIO – Perioperative risk factors affect postoperative morbidity and mortality differently in emergency and nonemergency surgery, according to an analysis of the ACS National Surgical Quality Improvement Program (ACS NSQIP) database by investigators from Massachusetts General Hospital, Boston.

“Instead of using the same risk-adjustment model for both ... as is currently being done, our findings strongly suggest the need to benchmark emergent and elective surgeries separately,” they concluded.

“Most risk-adjustment models simply have an on/off switch for whether or not the patient underwent emergency surgery and treat comorbidities and other perioperative variables the same.” Those variables, however, “don’t behave the same way in emergency surgery,” said investigator Dr. Jordan Bohnen, a surgical research resident at Mass General.

Because risk adjustment doesn’t take into account variables that have a particularly strong negative impact in emergency settings, acute care surgeons are getting “unnecessarily dinged for having higher complication rates,” he said at the Eastern Association for the Surgery of Trauma scientific assembly.

For example, the team found that preop transfusions and white blood counts (WBC) at or below 4.5 carry a significantly higher risk of 30-day major morbidity or mortality (MMM) in emergency versus nonemergency surgery. Conversely, ascites, preop anemia, and leukocytosis carry a greater MMM risk in nonemergent cases.

The findings come from a comparison of 110,182 nonemergent surgeries to 59,949 emergency cases – generally meaning surgery within 12 hours of emergency department (ED) admission – from the NSQIP database for 2011-2012.

As expected, the overall risk of MMM was significantly higher for emergency cases (16.75% vs. 9.73%; P less than .001), and four procedures – laparoscopic cholecystectomy, exploratory laparotomy, and umbilical and incisional hernia repairs – were relatively riskier when done emergently.

“As surgical quality improvement efforts mature, it’s increasingly important to apply accurate risk-adjustment models to benchmark quality improvement for surgeons, hospitals, and health care systems.” The current “assumption that perioperative variables have an equal impact on outcomes in emergent and nonemergent settings” is incorrect. “Risk factors for bad outcomes change depending on the setting,” Dr. Bohnen said.

Dr. Bohnen has no disclosures.

[email protected]

SAN ANTONIO – Perioperative risk factors affect postoperative morbidity and mortality differently in emergency and nonemergency surgery, according to an analysis of the ACS National Surgical Quality Improvement Program (ACS NSQIP) database by investigators from Massachusetts General Hospital, Boston.

“Instead of using the same risk-adjustment model for both ... as is currently being done, our findings strongly suggest the need to benchmark emergent and elective surgeries separately,” they concluded.

“Most risk-adjustment models simply have an on/off switch for whether or not the patient underwent emergency surgery and treat comorbidities and other perioperative variables the same.” Those variables, however, “don’t behave the same way in emergency surgery,” said investigator Dr. Jordan Bohnen, a surgical research resident at Mass General.

Because risk adjustment doesn’t take into account variables that have a particularly strong negative impact in emergency settings, acute care surgeons are getting “unnecessarily dinged for having higher complication rates,” he said at the Eastern Association for the Surgery of Trauma scientific assembly.

For example, the team found that preop transfusions and white blood counts (WBC) at or below 4.5 carry a significantly higher risk of 30-day major morbidity or mortality (MMM) in emergency versus nonemergency surgery. Conversely, ascites, preop anemia, and leukocytosis carry a greater MMM risk in nonemergent cases.

The findings come from a comparison of 110,182 nonemergent surgeries to 59,949 emergency cases – generally meaning surgery within 12 hours of emergency department (ED) admission – from the NSQIP database for 2011-2012.

As expected, the overall risk of MMM was significantly higher for emergency cases (16.75% vs. 9.73%; P less than .001), and four procedures – laparoscopic cholecystectomy, exploratory laparotomy, and umbilical and incisional hernia repairs – were relatively riskier when done emergently.

“As surgical quality improvement efforts mature, it’s increasingly important to apply accurate risk-adjustment models to benchmark quality improvement for surgeons, hospitals, and health care systems.” The current “assumption that perioperative variables have an equal impact on outcomes in emergent and nonemergent settings” is incorrect. “Risk factors for bad outcomes change depending on the setting,” Dr. Bohnen said.

Dr. Bohnen has no disclosures.

[email protected]

JACKSONVILLE, FLA. – Accreditation Council for Graduate Medical Education (ACGME) rules that shortened surgery resident shifts and expanded breaks didn’t improve patient safety or surgery resident well-being in a trial presented at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.

“This national, prospective, randomized trial showed that flexible, less-restrictive duty-hour policies for surgical residents were noninferior to standard ACGME duty-hour policies,” wrote Dr. Karl Bilimoria, associate surgery professor at Northwestern University, Chicago, and associates. The work was published simultaneously Feb. 2 in the New England Journal of Medicine (doi: 10.1056/NEJMoa1515724).

©Hemera Technologies/Thinkstock

Recent ACGME residency reforms were meant to reduce fatigue-related errors, but there have been concerns that they have come at the cost of increased handoffs and reduced education.

To get a handle on the situation, the investigators randomized 59 teaching-hospital surgery programs to standard ACGME duty hours and 58 others to a freer approach in the 2014-2015 academic year. Residents weren’t allowed to work more than 80 hours per week in either group, but hospitals in the flexible-hour arm were allowed to push residents past ACGME policy, working first-year residents longer than 16 hours per shift and others more than 28 hours, with breaks of less than 14 hours after 24-hour shifts and less than 8-10 hours after shorter ones.

Among the 138,691 adult general surgery cases during the academic year, there was no increase in 30-day rates of postoperative deaths or serious complications in the flexible group (9.1% vs. 9.0% with standard policy, P = .92) or secondary postoperative outcomes, based on risk-adjusted data from the American College of Surgeons’ National Surgical Quality Improvement Program (ACS NSQIP).

The 4,330 residents in the study filled out a multiple-choice questionnaire midway through the project in January 2015. Those in the flexible group said they weren’t significantly unhappier with the quality of their education (11.0% vs. 10.7% in the standard group, P = .86) or well-being (14.9% and 12.0%, P = .10). The investigators didn’t report the lengths of shifts or breaks.

There were no significant differences in resident-reported perceptions of fatigue on personal or patient safety. Residents in the flexible group were less likely to report leaving an operation (7.0% vs. 13.2%, P less than .001) or handing off patients with active issues (32% vs. 46.3%, P less than .001).

Flexible duty-hour residents “noted numerous benefits with respect to nearly all aspects of patient safety, continuity of care, surgical training, and professionalism. However, residents reported that less-restrictive duty-hour policies had a negative effect on [their] time with family and friends, time for extracurricular activities, rest, and health. Importantly … residents’ satisfaction with overall well-being did not differ significantly between study groups,” Dr. Karl Bilimoria and associates concluded.

The investigators “did not specifically collect data on needle sticks and car accidents, because these are notoriously challenging outcomes to capture in surveys,” they noted.

In an interview, Dr. Bilimoria commented, “Increasingly over time we’ve had more regulations of duty hours, and with each set of regulations the surgical community became increasingly concerned about patient handoffs and continuity of care, so our focus was to identify those policies that we thought affected continuity of care and work with the ACGME to waive those for the centers that were in the flexible arm of the study.”

His comments on the impact on residents:  “The residents very clearly noted that the flexible policy arm provided better continuity of care, allowed them to take care of their patients in a way that they wanted to and stay with their patients in the operating room and at times when their patients were unstable.”

When asked if the findings could be extrapolated to these smaller nonparticipating centers, Dr. Bilimoria responded, “We captured the majority of residents, and we’re working on an analysis now that seeks to understand what the generalizability would be to those nonparticipating programs. That will be fairly enlightening as well.”

“95% of eligible programs participated in the trial, showing overwhelming support from the community for bringing high level data to this question. There had never before been a randomized trial nationally on this topic and for understanding and testing the notion of flexibility. They saw a need for both of those things.”

ACGME paid for the work, along with the American Board of Surgery and the American College of Surgeons. Dr. Bilimoria and five other authors reported payments from ACGME and the other entities.

[email protected]

UPDATE: This story was updated 2/2/16

JACKSONVILLE, FLA. – Accreditation Council for Graduate Medical Education (ACGME) rules that shortened surgery resident shifts and expanded breaks didn’t improve patient safety or surgery resident well-being in a trial presented at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.

“This national, prospective, randomized trial showed that flexible, less-restrictive duty-hour policies for surgical residents were noninferior to standard ACGME duty-hour policies,” wrote Dr. Karl Bilimoria, associate surgery professor at Northwestern University, Chicago, and associates. The work was published simultaneously Feb. 2 in the New England Journal of Medicine (doi: 10.1056/NEJMoa1515724).

©Hemera Technologies/Thinkstock

Recent ACGME residency reforms were meant to reduce fatigue-related errors, but there have been concerns that they have come at the cost of increased handoffs and reduced education.

To get a handle on the situation, the investigators randomized 59 teaching-hospital surgery programs to standard ACGME duty hours and 58 others to a freer approach in the 2014-2015 academic year. Residents weren’t allowed to work more than 80 hours per week in either group, but hospitals in the flexible-hour arm were allowed to push residents past ACGME policy, working first-year residents longer than 16 hours per shift and others more than 28 hours, with breaks of less than 14 hours after 24-hour shifts and less than 8-10 hours after shorter ones.

Among the 138,691 adult general surgery cases during the academic year, there was no increase in 30-day rates of postoperative deaths or serious complications in the flexible group (9.1% vs. 9.0% with standard policy, P = .92) or secondary postoperative outcomes, based on risk-adjusted data from the American College of Surgeons’ National Surgical Quality Improvement Program (ACS NSQIP).

The 4,330 residents in the study filled out a multiple-choice questionnaire midway through the project in January 2015. Those in the flexible group said they weren’t significantly unhappier with the quality of their education (11.0% vs. 10.7% in the standard group, P = .86) or well-being (14.9% and 12.0%, P = .10). The investigators didn’t report the lengths of shifts or breaks.

There were no significant differences in resident-reported perceptions of fatigue on personal or patient safety. Residents in the flexible group were less likely to report leaving an operation (7.0% vs. 13.2%, P less than .001) or handing off patients with active issues (32% vs. 46.3%, P less than .001).

Flexible duty-hour residents “noted numerous benefits with respect to nearly all aspects of patient safety, continuity of care, surgical training, and professionalism. However, residents reported that less-restrictive duty-hour policies had a negative effect on [their] time with family and friends, time for extracurricular activities, rest, and health. Importantly … residents’ satisfaction with overall well-being did not differ significantly between study groups,” Dr. Karl Bilimoria and associates concluded.

The investigators “did not specifically collect data on needle sticks and car accidents, because these are notoriously challenging outcomes to capture in surveys,” they noted.

In an interview, Dr. Bilimoria commented, “Increasingly over time we’ve had more regulations of duty hours, and with each set of regulations the surgical community became increasingly concerned about patient handoffs and continuity of care, so our focus was to identify those policies that we thought affected continuity of care and work with the ACGME to waive those for the centers that were in the flexible arm of the study.”

His comments on the impact on residents:  “The residents very clearly noted that the flexible policy arm provided better continuity of care, allowed them to take care of their patients in a way that they wanted to and stay with their patients in the operating room and at times when their patients were unstable.”

When asked if the findings could be extrapolated to these smaller nonparticipating centers, Dr. Bilimoria responded, “We captured the majority of residents, and we’re working on an analysis now that seeks to understand what the generalizability would be to those nonparticipating programs. That will be fairly enlightening as well.”

“95% of eligible programs participated in the trial, showing overwhelming support from the community for bringing high level data to this question. There had never before been a randomized trial nationally on this topic and for understanding and testing the notion of flexibility. They saw a need for both of those things.”

ACGME paid for the work, along with the American Board of Surgery and the American College of Surgeons. Dr. Bilimoria and five other authors reported payments from ACGME and the other entities.

[email protected]

UPDATE: This story was updated 2/2/16

JACKSONVILLE, FLA. – Accreditation Council for Graduate Medical Education (ACGME) rules that shortened surgery resident shifts and expanded breaks didn’t improve patient safety or surgery resident well-being in a trial presented at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.

“This national, prospective, randomized trial showed that flexible, less-restrictive duty-hour policies for surgical residents were noninferior to standard ACGME duty-hour policies,” wrote Dr. Karl Bilimoria, associate surgery professor at Northwestern University, Chicago, and associates. The work was published simultaneously Feb. 2 in the New England Journal of Medicine (doi: 10.1056/NEJMoa1515724).

©Hemera Technologies/Thinkstock

Recent ACGME residency reforms were meant to reduce fatigue-related errors, but there have been concerns that they have come at the cost of increased handoffs and reduced education.

To get a handle on the situation, the investigators randomized 59 teaching-hospital surgery programs to standard ACGME duty hours and 58 others to a freer approach in the 2014-2015 academic year. Residents weren’t allowed to work more than 80 hours per week in either group, but hospitals in the flexible-hour arm were allowed to push residents past ACGME policy, working first-year residents longer than 16 hours per shift and others more than 28 hours, with breaks of less than 14 hours after 24-hour shifts and less than 8-10 hours after shorter ones.

Among the 138,691 adult general surgery cases during the academic year, there was no increase in 30-day rates of postoperative deaths or serious complications in the flexible group (9.1% vs. 9.0% with standard policy, P = .92) or secondary postoperative outcomes, based on risk-adjusted data from the American College of Surgeons’ National Surgical Quality Improvement Program (ACS NSQIP).

The 4,330 residents in the study filled out a multiple-choice questionnaire midway through the project in January 2015. Those in the flexible group said they weren’t significantly unhappier with the quality of their education (11.0% vs. 10.7% in the standard group, P = .86) or well-being (14.9% and 12.0%, P = .10). The investigators didn’t report the lengths of shifts or breaks.

There were no significant differences in resident-reported perceptions of fatigue on personal or patient safety. Residents in the flexible group were less likely to report leaving an operation (7.0% vs. 13.2%, P less than .001) or handing off patients with active issues (32% vs. 46.3%, P less than .001).

Flexible duty-hour residents “noted numerous benefits with respect to nearly all aspects of patient safety, continuity of care, surgical training, and professionalism. However, residents reported that less-restrictive duty-hour policies had a negative effect on [their] time with family and friends, time for extracurricular activities, rest, and health. Importantly … residents’ satisfaction with overall well-being did not differ significantly between study groups,” Dr. Karl Bilimoria and associates concluded.

The investigators “did not specifically collect data on needle sticks and car accidents, because these are notoriously challenging outcomes to capture in surveys,” they noted.

In an interview, Dr. Bilimoria commented, “Increasingly over time we’ve had more regulations of duty hours, and with each set of regulations the surgical community became increasingly concerned about patient handoffs and continuity of care, so our focus was to identify those policies that we thought affected continuity of care and work with the ACGME to waive those for the centers that were in the flexible arm of the study.”

His comments on the impact on residents:  “The residents very clearly noted that the flexible policy arm provided better continuity of care, allowed them to take care of their patients in a way that they wanted to and stay with their patients in the operating room and at times when their patients were unstable.”

When asked if the findings could be extrapolated to these smaller nonparticipating centers, Dr. Bilimoria responded, “We captured the majority of residents, and we’re working on an analysis now that seeks to understand what the generalizability would be to those nonparticipating programs. That will be fairly enlightening as well.”

“95% of eligible programs participated in the trial, showing overwhelming support from the community for bringing high level data to this question. There had never before been a randomized trial nationally on this topic and for understanding and testing the notion of flexibility. They saw a need for both of those things.”

ACGME paid for the work, along with the American Board of Surgery and the American College of Surgeons. Dr. Bilimoria and five other authors reported payments from ACGME and the other entities.

[email protected]

UPDATE: This story was updated 2/2/16

SAN ANTONIO – A new pain relief option for multiple rib fractures means that you might not have to wait around anymore for anesthesiology to place thoracic epidurals.

It’s called posterior paramedian subrhomboidal (PoPS) analgesia. A skin incision is made below the lowest fractured rib just paramedian to the spinus processes; a tunneling device is then used to work a catheter upwards under the rhomboids just past the highest fractured rib. The catheter has multiple openings along its length – like a sprinkler hose – so analgesic bathes the intercostal nerves as it runs down from a reservoir into the patient. The reservoir can be set to a desired flow rate or for on-demand use (ON-Q Pain Relief System – Halyard).

A pilot study at the University of Kansas, Kansas City, found that pain control from PoPS was at least equivalent to standard thoracic epidural analgesia (TEA), and that the system can be placed by a variety of hospital staff, not just anesthesiologists.

The 11 PoPS patients also used fewer rescue narcotics than the 19 TEA patients and had less hypotension. Because they weren’t at risk for epidural hematomas, they started venous thromboembolism prophylaxis without delay and at full dose.

“Our results are very promising. PoPS provides pain control similar to that of TEA,” with several “other benefits. You are not relying on one specialty for pain control,” so patients probably get faster relief. “PoPS can also be placed in patients whose injuries prohibit TEA, such as those with spinal cord injuries or increased intracranial pressure,” said investigator Dr. Casey Shelley, a University of Kansas general surgery resident.

PoPS was placed in the study either by anesthesiologists or by a trauma surgeon who practiced placement beforehand in the cadaver lab. The do-it-yourself potential for surgeons “is key. Most of us trauma surgeons are sick of begging anesthesiologists to come place thoracic epidurals,” said an audience member after Dr. Shelley’s presentation at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.

Courtesy of Dr. Michael Truitt, Methodist Dallas Medical Center

Ropivacaine 0.2% was used in both PoPS and TEA patients, all of whom had at least three broken ribs.

Median pain scores dropped from 8.5 to 2.5 on a 10-point scale an hour after PoPS placement, versus a median drop from 8 to 5 points an hour after TEA (P = .03). Although not statistically significant, median pain scores were about 1.5 points better with PoPS over the next several days, hovering around 3.5 versus around 5 points with TEA. Anesthesiology “usually won’t place high thoracic epidurals. With PoPS, you can tunnel up as far as you need to go to get to higher ribs,” which might explain the better pain control, Dr. Shelley said.

PoPS patients used about 70 mg/day oral morphine equivalents versus about 90 mg/day with TEA through day 6, but again the difference was not statistically significant. Even so, it might explain why six TEA patients (32%) were hypotensive over that time, compared with two PoPS patients (18%).

PoPS patients were a little older on average (mean 63 versus 55 years), with more fractured ribs (mean eight versus seven), and higher Injury Severity Scale scores (mean 20 versus 16). They were also more likely to have bilateral fractures, longer ICU stays (mean 4.9 versus 3.1 days), and longer overall lengths of stay (mean 14.8 versus 9.8 days), but none of those trends were statistically significant.

Both groups had mean chest Abbreviated Injury Scale scores of 3, and there were no statistical differences in daily spirometry readings. The majority of patients in both groups were men.

Favorable results were also reported in 2010 for ON-Q rib pain control, but the investigators did not compare the system to TEA (World J Surg. 2010 Oct;34:2359-62).

Dr. Shelley said Halyard was not involved in the study, and that she has no disclosures.

[email protected]

SAN ANTONIO – A new pain relief option for multiple rib fractures means that you might not have to wait around anymore for anesthesiology to place thoracic epidurals.

It’s called posterior paramedian subrhomboidal (PoPS) analgesia. A skin incision is made below the lowest fractured rib just paramedian to the spinus processes; a tunneling device is then used to work a catheter upwards under the rhomboids just past the highest fractured rib. The catheter has multiple openings along its length – like a sprinkler hose – so analgesic bathes the intercostal nerves as it runs down from a reservoir into the patient. The reservoir can be set to a desired flow rate or for on-demand use (ON-Q Pain Relief System – Halyard).

A pilot study at the University of Kansas, Kansas City, found that pain control from PoPS was at least equivalent to standard thoracic epidural analgesia (TEA), and that the system can be placed by a variety of hospital staff, not just anesthesiologists.

The 11 PoPS patients also used fewer rescue narcotics than the 19 TEA patients and had less hypotension. Because they weren’t at risk for epidural hematomas, they started venous thromboembolism prophylaxis without delay and at full dose.

“Our results are very promising. PoPS provides pain control similar to that of TEA,” with several “other benefits. You are not relying on one specialty for pain control,” so patients probably get faster relief. “PoPS can also be placed in patients whose injuries prohibit TEA, such as those with spinal cord injuries or increased intracranial pressure,” said investigator Dr. Casey Shelley, a University of Kansas general surgery resident.

PoPS was placed in the study either by anesthesiologists or by a trauma surgeon who practiced placement beforehand in the cadaver lab. The do-it-yourself potential for surgeons “is key. Most of us trauma surgeons are sick of begging anesthesiologists to come place thoracic epidurals,” said an audience member after Dr. Shelley’s presentation at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.

Courtesy of Dr. Michael Truitt, Methodist Dallas Medical Center

Ropivacaine 0.2% was used in both PoPS and TEA patients, all of whom had at least three broken ribs.

Median pain scores dropped from 8.5 to 2.5 on a 10-point scale an hour after PoPS placement, versus a median drop from 8 to 5 points an hour after TEA (P = .03). Although not statistically significant, median pain scores were about 1.5 points better with PoPS over the next several days, hovering around 3.5 versus around 5 points with TEA. Anesthesiology “usually won’t place high thoracic epidurals. With PoPS, you can tunnel up as far as you need to go to get to higher ribs,” which might explain the better pain control, Dr. Shelley said.

PoPS patients used about 70 mg/day oral morphine equivalents versus about 90 mg/day with TEA through day 6, but again the difference was not statistically significant. Even so, it might explain why six TEA patients (32%) were hypotensive over that time, compared with two PoPS patients (18%).

PoPS patients were a little older on average (mean 63 versus 55 years), with more fractured ribs (mean eight versus seven), and higher Injury Severity Scale scores (mean 20 versus 16). They were also more likely to have bilateral fractures, longer ICU stays (mean 4.9 versus 3.1 days), and longer overall lengths of stay (mean 14.8 versus 9.8 days), but none of those trends were statistically significant.

Both groups had mean chest Abbreviated Injury Scale scores of 3, and there were no statistical differences in daily spirometry readings. The majority of patients in both groups were men.

Favorable results were also reported in 2010 for ON-Q rib pain control, but the investigators did not compare the system to TEA (World J Surg. 2010 Oct;34:2359-62).

Dr. Shelley said Halyard was not involved in the study, and that she has no disclosures.

[email protected]

SAN ANTONIO – A new pain relief option for multiple rib fractures means that you might not have to wait around anymore for anesthesiology to place thoracic epidurals.

It’s called posterior paramedian subrhomboidal (PoPS) analgesia. A skin incision is made below the lowest fractured rib just paramedian to the spinus processes; a tunneling device is then used to work a catheter upwards under the rhomboids just past the highest fractured rib. The catheter has multiple openings along its length – like a sprinkler hose – so analgesic bathes the intercostal nerves as it runs down from a reservoir into the patient. The reservoir can be set to a desired flow rate or for on-demand use (ON-Q Pain Relief System – Halyard).

A pilot study at the University of Kansas, Kansas City, found that pain control from PoPS was at least equivalent to standard thoracic epidural analgesia (TEA), and that the system can be placed by a variety of hospital staff, not just anesthesiologists.

The 11 PoPS patients also used fewer rescue narcotics than the 19 TEA patients and had less hypotension. Because they weren’t at risk for epidural hematomas, they started venous thromboembolism prophylaxis without delay and at full dose.

“Our results are very promising. PoPS provides pain control similar to that of TEA,” with several “other benefits. You are not relying on one specialty for pain control,” so patients probably get faster relief. “PoPS can also be placed in patients whose injuries prohibit TEA, such as those with spinal cord injuries or increased intracranial pressure,” said investigator Dr. Casey Shelley, a University of Kansas general surgery resident.

PoPS was placed in the study either by anesthesiologists or by a trauma surgeon who practiced placement beforehand in the cadaver lab. The do-it-yourself potential for surgeons “is key. Most of us trauma surgeons are sick of begging anesthesiologists to come place thoracic epidurals,” said an audience member after Dr. Shelley’s presentation at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.

Courtesy of Dr. Michael Truitt, Methodist Dallas Medical Center

Ropivacaine 0.2% was used in both PoPS and TEA patients, all of whom had at least three broken ribs.

Median pain scores dropped from 8.5 to 2.5 on a 10-point scale an hour after PoPS placement, versus a median drop from 8 to 5 points an hour after TEA (P = .03). Although not statistically significant, median pain scores were about 1.5 points better with PoPS over the next several days, hovering around 3.5 versus around 5 points with TEA. Anesthesiology “usually won’t place high thoracic epidurals. With PoPS, you can tunnel up as far as you need to go to get to higher ribs,” which might explain the better pain control, Dr. Shelley said.

PoPS patients used about 70 mg/day oral morphine equivalents versus about 90 mg/day with TEA through day 6, but again the difference was not statistically significant. Even so, it might explain why six TEA patients (32%) were hypotensive over that time, compared with two PoPS patients (18%).

PoPS patients were a little older on average (mean 63 versus 55 years), with more fractured ribs (mean eight versus seven), and higher Injury Severity Scale scores (mean 20 versus 16). They were also more likely to have bilateral fractures, longer ICU stays (mean 4.9 versus 3.1 days), and longer overall lengths of stay (mean 14.8 versus 9.8 days), but none of those trends were statistically significant.

Both groups had mean chest Abbreviated Injury Scale scores of 3, and there were no statistical differences in daily spirometry readings. The majority of patients in both groups were men.

Favorable results were also reported in 2010 for ON-Q rib pain control, but the investigators did not compare the system to TEA (World J Surg. 2010 Oct;34:2359-62).

Dr. Shelley said Halyard was not involved in the study, and that she has no disclosures.

[email protected]

SAN ANTONIO – Automatically bumping elderly Level 2 trauma patients to Level 1 status reduced mortality and emergency department lengths of stay at Indiana University Health Methodist Hospital, Indianapolis.

Like trauma services elsewhere, the Methodist team is trying to figure out how best to handle the coming increase in elderly patients as the Baby Boom generation ages. It’s known that older trauma patients tend to be undertriaged. To improve the situation, “we need to respond quickly with a lot of resources up front so we don’t delay diagnosis” and treatment, said investigator Dr. Peter Hammer, assistant professor of surgery at Indiana University, Indianapolis.

The solution Methodist has tried since October 2013 is a Level 1 response to any patient aged 70 years or older who meets Level 2 criteria, regardless of vital sign stability or injury mechanism. With Level 1, trauma attendings, residents, respiratory therapists, clinical pharmacists, and others are at the bedside within 15 minutes and CT services and operating rooms are on standby, among other measures. Compared with the 1,271 patients aged 70 years or older treated in the almost 2 years before the change, the 998 treated in the year and a half afterwards were, after controlling for age, comorbidities, and injury severity scores (ISS), more likely to leave the ED in less than 2 hours (odds ratio, 1.614; 95% confidence interval, 1.088-2.394) and less likely to die (OR, 0.689, 95% CI, 0.484-0.979).

The before and after groups were similar, with a mean age of 81 years, a mean ISS of 12.2, a high comorbidity burden, and, for most, a blunt injury: 8.3% died in the before group, versus 7.6% in the after group. The shorter ED stays occurred despite a nursing staff reduction in 2014. Patients who went into cardiac arrest before arrival or died in the ED were excluded from the analysis.

“A simple, focused intervention of a higher level of trauma activation can decrease ED length of stay and in-hospital mortality in elderly trauma patients,” Dr. Hammer said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.

Among many initiatives as many trauma centers gear up for aging baby boomers, others are trying age as a criteria for higher activation, too, and recent guidelines from EAST recommend a lower threshold for trauma activation for patients 65 years or older, among other steps.

With more expertise and resources to brought to bear, it’s not surprising that Level 1 patients left the ED sooner, but it’s unclear what role that played in reducing mortality. “I wouldn’t hazard [to say] that shorter lengths of stay necessarily” saved lives, Dr. Hammer said.

Before the intervention, just 4.8% of geriatric patients left the ED within 2 hours, versus 6.5% afterwards. The numbers are low because, “as in most hospitals, there are more trauma patients than beds. [Reducing ED] length or stay [remains] an ongoing project” at Methodist, and not just for the elderly. “The ED is always overcrowded come afternoon and into the evening,” Dr. Hammer said.

That’s one of the reasons management supported the project. “They like the concept of getting patients moved through quickly. We have a lot of resources in the ED, so there doesn’t seem to be much of a slowdown” with increased Level 1 activation. It probably costs more up front, “but the hope is we’ll save money on the back end with lower mortality and shorter ED stays,” he said.

The investigators had no disclosures.

[email protected]

SAN ANTONIO – Automatically bumping elderly Level 2 trauma patients to Level 1 status reduced mortality and emergency department lengths of stay at Indiana University Health Methodist Hospital, Indianapolis.

Like trauma services elsewhere, the Methodist team is trying to figure out how best to handle the coming increase in elderly patients as the Baby Boom generation ages. It’s known that older trauma patients tend to be undertriaged. To improve the situation, “we need to respond quickly with a lot of resources up front so we don’t delay diagnosis” and treatment, said investigator Dr. Peter Hammer, assistant professor of surgery at Indiana University, Indianapolis.

The solution Methodist has tried since October 2013 is a Level 1 response to any patient aged 70 years or older who meets Level 2 criteria, regardless of vital sign stability or injury mechanism. With Level 1, trauma attendings, residents, respiratory therapists, clinical pharmacists, and others are at the bedside within 15 minutes and CT services and operating rooms are on standby, among other measures. Compared with the 1,271 patients aged 70 years or older treated in the almost 2 years before the change, the 998 treated in the year and a half afterwards were, after controlling for age, comorbidities, and injury severity scores (ISS), more likely to leave the ED in less than 2 hours (odds ratio, 1.614; 95% confidence interval, 1.088-2.394) and less likely to die (OR, 0.689, 95% CI, 0.484-0.979).

The before and after groups were similar, with a mean age of 81 years, a mean ISS of 12.2, a high comorbidity burden, and, for most, a blunt injury: 8.3% died in the before group, versus 7.6% in the after group. The shorter ED stays occurred despite a nursing staff reduction in 2014. Patients who went into cardiac arrest before arrival or died in the ED were excluded from the analysis.

“A simple, focused intervention of a higher level of trauma activation can decrease ED length of stay and in-hospital mortality in elderly trauma patients,” Dr. Hammer said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.

Among many initiatives as many trauma centers gear up for aging baby boomers, others are trying age as a criteria for higher activation, too, and recent guidelines from EAST recommend a lower threshold for trauma activation for patients 65 years or older, among other steps.

With more expertise and resources to brought to bear, it’s not surprising that Level 1 patients left the ED sooner, but it’s unclear what role that played in reducing mortality. “I wouldn’t hazard [to say] that shorter lengths of stay necessarily” saved lives, Dr. Hammer said.

Before the intervention, just 4.8% of geriatric patients left the ED within 2 hours, versus 6.5% afterwards. The numbers are low because, “as in most hospitals, there are more trauma patients than beds. [Reducing ED] length or stay [remains] an ongoing project” at Methodist, and not just for the elderly. “The ED is always overcrowded come afternoon and into the evening,” Dr. Hammer said.

That’s one of the reasons management supported the project. “They like the concept of getting patients moved through quickly. We have a lot of resources in the ED, so there doesn’t seem to be much of a slowdown” with increased Level 1 activation. It probably costs more up front, “but the hope is we’ll save money on the back end with lower mortality and shorter ED stays,” he said.

The investigators had no disclosures.

[email protected]

SAN ANTONIO – Automatically bumping elderly Level 2 trauma patients to Level 1 status reduced mortality and emergency department lengths of stay at Indiana University Health Methodist Hospital, Indianapolis.

Like trauma services elsewhere, the Methodist team is trying to figure out how best to handle the coming increase in elderly patients as the Baby Boom generation ages. It’s known that older trauma patients tend to be undertriaged. To improve the situation, “we need to respond quickly with a lot of resources up front so we don’t delay diagnosis” and treatment, said investigator Dr. Peter Hammer, assistant professor of surgery at Indiana University, Indianapolis.

The solution Methodist has tried since October 2013 is a Level 1 response to any patient aged 70 years or older who meets Level 2 criteria, regardless of vital sign stability or injury mechanism. With Level 1, trauma attendings, residents, respiratory therapists, clinical pharmacists, and others are at the bedside within 15 minutes and CT services and operating rooms are on standby, among other measures. Compared with the 1,271 patients aged 70 years or older treated in the almost 2 years before the change, the 998 treated in the year and a half afterwards were, after controlling for age, comorbidities, and injury severity scores (ISS), more likely to leave the ED in less than 2 hours (odds ratio, 1.614; 95% confidence interval, 1.088-2.394) and less likely to die (OR, 0.689, 95% CI, 0.484-0.979).

The before and after groups were similar, with a mean age of 81 years, a mean ISS of 12.2, a high comorbidity burden, and, for most, a blunt injury: 8.3% died in the before group, versus 7.6% in the after group. The shorter ED stays occurred despite a nursing staff reduction in 2014. Patients who went into cardiac arrest before arrival or died in the ED were excluded from the analysis.

“A simple, focused intervention of a higher level of trauma activation can decrease ED length of stay and in-hospital mortality in elderly trauma patients,” Dr. Hammer said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.

Among many initiatives as many trauma centers gear up for aging baby boomers, others are trying age as a criteria for higher activation, too, and recent guidelines from EAST recommend a lower threshold for trauma activation for patients 65 years or older, among other steps.

With more expertise and resources to brought to bear, it’s not surprising that Level 1 patients left the ED sooner, but it’s unclear what role that played in reducing mortality. “I wouldn’t hazard [to say] that shorter lengths of stay necessarily” saved lives, Dr. Hammer said.

Before the intervention, just 4.8% of geriatric patients left the ED within 2 hours, versus 6.5% afterwards. The numbers are low because, “as in most hospitals, there are more trauma patients than beds. [Reducing ED] length or stay [remains] an ongoing project” at Methodist, and not just for the elderly. “The ED is always overcrowded come afternoon and into the evening,” Dr. Hammer said.

That’s one of the reasons management supported the project. “They like the concept of getting patients moved through quickly. We have a lot of resources in the ED, so there doesn’t seem to be much of a slowdown” with increased Level 1 activation. It probably costs more up front, “but the hope is we’ll save money on the back end with lower mortality and shorter ED stays,” he said.

The investigators had no disclosures.

[email protected]