EAST 2012

LAKE BUENA VISTA, FLA.  – An emergency surgical service rotation delivers more than half of ACGME requirements for laparoscopic surgery in just 2 months of training, a retrospective analysis shows.

"Emergency surgery has the potential to reduce the need for hospital hopping and will increase the time residents spend under their program director," Dr. Hesham Ahmed said at the annual meeting of the Eastern Association for the Surgery of Trauma.

His analysis compared ACGME (Accreditation Council for Graduate Medical Education) requirements before and after the creation of an ESS (emergency surgical service) at Robert Wood Johnson University Hospital in New Brunswick, N.J. Case loads were tabulated for the last four graduating classes (two pre-ESS and two post-ESS) using the hospital’s prospectively accrued ESS database.

More than 70 different types of procedures were recorded in the ESS registry, including multispecialty approaches, reoperations, delayed abdominal closures, urgent surgical airway management, and seldom performed operations such as vagotomy and repair of perforated peptic ulcers.

Residents rotating on the ESS completed 816 cases between 2010 and 2011, 39% of which were laparoscopic, said Dr. Ahmed, a trauma and critical care surgeon at the hospital. This included 109 laparoscopic appendectomies, 99 laparoscopic cholecystectomies, and 14 advanced laparoscopic cases.

ESS significantly increased the total number of laparoscopic appendectomy cases performed by residents compared with the pre-ESS classes of 2008 and 2009 (P value less than .001).

Similar results were found for laparoscopic cholecystectomy cases (P less than .003), notably without a significant increase in conversion to open cholecystectomy (P less than .09), he said.

Within a 2-month period, residents that rotated on the ESS achieved on average 61% of the 60 ACGME required cases for laparoscopy.

ESS faculty supervised 24% of all chief resident major operative and endoscopy cases performed at the academic hospital for the class of 2011.

ESS also increased the total surgical volume at the institution from an almost even split with its participating sites during the two pre-ESS graduating classes of 48% and 50% to 63% and 68% during the two post-ESS graduating classes, Dr. Ahmed said. The increase in volume was statistically significant (P less than .001).

Invited discussant Dr. Jeannette Capella, a surgeon with the department of emergency medicine and trauma service at Altoona (Pa.) Regional Medical Center, said there are numerous financial and practical advantages to including emergency general surgery under the acute care surgery umbrella.

"However, in the struggle to make our specialty financially secure and professionally appealing, we need to make sure that the education of our general surgery residents does not suffer," she said. "To my knowledge, this is the first study to look at how our new practice model is affecting our residents."

Dr. Capella agreed with Dr. Ahmed that shifting residents from affiliated hospital rotations to the ESS at the primary institution would improve residents’ education, but said specific measures such as improved board scores or patient outcomes are needed to demonstrate the quality of education during such a shift.

Anecdotally, Dr. Ahmed said that in the last 2 years, three students went on to critical care or acute care fellowships and that previously "everyone wanted to go to plastic surgery. So there is a big change in the residents."

Dr. Capella then asked how residents’ exposure to other areas of general surgery had been affected and whether the increased workload posed any problems for the hospital in complying with resident work-hour rules. Dr. Ahmed said that no deficiencies arose in the residents’ exposure to other surgical areas, nor were problems encountered with work hours.

Finally, audience members questioned where the cases came from that were filtered to the new ESS. Dr. Ahmed said that they did not do outreach and that prior to the development of the ESS, trauma surgeons would perform the acute care procedures now handled by the ESS.

Dr. Ahmed and his coauthors reported no conflicts of interest.

LAKE BUENA VISTA, FLA.  – An emergency surgical service rotation delivers more than half of ACGME requirements for laparoscopic surgery in just 2 months of training, a retrospective analysis shows.

"Emergency surgery has the potential to reduce the need for hospital hopping and will increase the time residents spend under their program director," Dr. Hesham Ahmed said at the annual meeting of the Eastern Association for the Surgery of Trauma.

His analysis compared ACGME (Accreditation Council for Graduate Medical Education) requirements before and after the creation of an ESS (emergency surgical service) at Robert Wood Johnson University Hospital in New Brunswick, N.J. Case loads were tabulated for the last four graduating classes (two pre-ESS and two post-ESS) using the hospital’s prospectively accrued ESS database.

More than 70 different types of procedures were recorded in the ESS registry, including multispecialty approaches, reoperations, delayed abdominal closures, urgent surgical airway management, and seldom performed operations such as vagotomy and repair of perforated peptic ulcers.

Residents rotating on the ESS completed 816 cases between 2010 and 2011, 39% of which were laparoscopic, said Dr. Ahmed, a trauma and critical care surgeon at the hospital. This included 109 laparoscopic appendectomies, 99 laparoscopic cholecystectomies, and 14 advanced laparoscopic cases.

ESS significantly increased the total number of laparoscopic appendectomy cases performed by residents compared with the pre-ESS classes of 2008 and 2009 (P value less than .001).

Similar results were found for laparoscopic cholecystectomy cases (P less than .003), notably without a significant increase in conversion to open cholecystectomy (P less than .09), he said.

Within a 2-month period, residents that rotated on the ESS achieved on average 61% of the 60 ACGME required cases for laparoscopy.

ESS faculty supervised 24% of all chief resident major operative and endoscopy cases performed at the academic hospital for the class of 2011.

ESS also increased the total surgical volume at the institution from an almost even split with its participating sites during the two pre-ESS graduating classes of 48% and 50% to 63% and 68% during the two post-ESS graduating classes, Dr. Ahmed said. The increase in volume was statistically significant (P less than .001).

Invited discussant Dr. Jeannette Capella, a surgeon with the department of emergency medicine and trauma service at Altoona (Pa.) Regional Medical Center, said there are numerous financial and practical advantages to including emergency general surgery under the acute care surgery umbrella.

"However, in the struggle to make our specialty financially secure and professionally appealing, we need to make sure that the education of our general surgery residents does not suffer," she said. "To my knowledge, this is the first study to look at how our new practice model is affecting our residents."

Dr. Capella agreed with Dr. Ahmed that shifting residents from affiliated hospital rotations to the ESS at the primary institution would improve residents’ education, but said specific measures such as improved board scores or patient outcomes are needed to demonstrate the quality of education during such a shift.

Anecdotally, Dr. Ahmed said that in the last 2 years, three students went on to critical care or acute care fellowships and that previously "everyone wanted to go to plastic surgery. So there is a big change in the residents."

Dr. Capella then asked how residents’ exposure to other areas of general surgery had been affected and whether the increased workload posed any problems for the hospital in complying with resident work-hour rules. Dr. Ahmed said that no deficiencies arose in the residents’ exposure to other surgical areas, nor were problems encountered with work hours.

Finally, audience members questioned where the cases came from that were filtered to the new ESS. Dr. Ahmed said that they did not do outreach and that prior to the development of the ESS, trauma surgeons would perform the acute care procedures now handled by the ESS.

Dr. Ahmed and his coauthors reported no conflicts of interest.

LAKE BUENA VISTA, FLA.  – An emergency surgical service rotation delivers more than half of ACGME requirements for laparoscopic surgery in just 2 months of training, a retrospective analysis shows.

"Emergency surgery has the potential to reduce the need for hospital hopping and will increase the time residents spend under their program director," Dr. Hesham Ahmed said at the annual meeting of the Eastern Association for the Surgery of Trauma.

His analysis compared ACGME (Accreditation Council for Graduate Medical Education) requirements before and after the creation of an ESS (emergency surgical service) at Robert Wood Johnson University Hospital in New Brunswick, N.J. Case loads were tabulated for the last four graduating classes (two pre-ESS and two post-ESS) using the hospital’s prospectively accrued ESS database.

More than 70 different types of procedures were recorded in the ESS registry, including multispecialty approaches, reoperations, delayed abdominal closures, urgent surgical airway management, and seldom performed operations such as vagotomy and repair of perforated peptic ulcers.

Residents rotating on the ESS completed 816 cases between 2010 and 2011, 39% of which were laparoscopic, said Dr. Ahmed, a trauma and critical care surgeon at the hospital. This included 109 laparoscopic appendectomies, 99 laparoscopic cholecystectomies, and 14 advanced laparoscopic cases.

ESS significantly increased the total number of laparoscopic appendectomy cases performed by residents compared with the pre-ESS classes of 2008 and 2009 (P value less than .001).

Similar results were found for laparoscopic cholecystectomy cases (P less than .003), notably without a significant increase in conversion to open cholecystectomy (P less than .09), he said.

Within a 2-month period, residents that rotated on the ESS achieved on average 61% of the 60 ACGME required cases for laparoscopy.

ESS faculty supervised 24% of all chief resident major operative and endoscopy cases performed at the academic hospital for the class of 2011.

ESS also increased the total surgical volume at the institution from an almost even split with its participating sites during the two pre-ESS graduating classes of 48% and 50% to 63% and 68% during the two post-ESS graduating classes, Dr. Ahmed said. The increase in volume was statistically significant (P less than .001).

Invited discussant Dr. Jeannette Capella, a surgeon with the department of emergency medicine and trauma service at Altoona (Pa.) Regional Medical Center, said there are numerous financial and practical advantages to including emergency general surgery under the acute care surgery umbrella.

"However, in the struggle to make our specialty financially secure and professionally appealing, we need to make sure that the education of our general surgery residents does not suffer," she said. "To my knowledge, this is the first study to look at how our new practice model is affecting our residents."

Dr. Capella agreed with Dr. Ahmed that shifting residents from affiliated hospital rotations to the ESS at the primary institution would improve residents’ education, but said specific measures such as improved board scores or patient outcomes are needed to demonstrate the quality of education during such a shift.

Anecdotally, Dr. Ahmed said that in the last 2 years, three students went on to critical care or acute care fellowships and that previously "everyone wanted to go to plastic surgery. So there is a big change in the residents."

Dr. Capella then asked how residents’ exposure to other areas of general surgery had been affected and whether the increased workload posed any problems for the hospital in complying with resident work-hour rules. Dr. Ahmed said that no deficiencies arose in the residents’ exposure to other surgical areas, nor were problems encountered with work hours.

Finally, audience members questioned where the cases came from that were filtered to the new ESS. Dr. Ahmed said that they did not do outreach and that prior to the development of the ESS, trauma surgeons would perform the acute care procedures now handled by the ESS.

Dr. Ahmed and his coauthors reported no conflicts of interest.

LAKE BUENA VISTA, FLA. – Just 49.3% of patients undergoing emergency trauma laparotomy received antibiotics in accordance with the Surgical Care Improvement Project guidelines in a multicenter, retrospective analysis of 306 patients.

"Many of the non-SCIP patients received the wrong antibiotic or antibiotics for too long after their index operation," lead author Brian P. Smith said at the annual meeting of the Eastern Association for the Surgery of Trauma.

Moreover, compliance with the guidelines slashed surgical site infection rates from 32.9% among patients with noncompliant antibiotic management to 16.6% (P less than .001).

The Surgical Care Improvement Project (SCIP) established surgical antibiotic prophylaxis guidelines as part of a collaborative effort by the Centers for Medicare and Medicaid Services and the Centers for Disease Control and Prevention to reduce surgical complications. While these antibiotic prophylaxis guidelines have become well established in patients undergoing elective operative procedures, they have never been studied in trauma patients undergoing emergency surgery, said Dr. Smith, a surgical resident at Temple University Hospital in Philadelphia.*

He reported on an analysis involving 306 trauma patients who survived for more than 4 days after undergoing emergency laparotomy within 2 hours of admission at two level 1 trauma centers during 2007 and 2008. Patients were compared on the basis of adherence to the following SCIP guidelines: prophylactic antibiotic given, antibiotic received within 1 hour prior to incision, correct antibiotic selection, and discontinuation of antibiotic within 24 hours after surgery.

Their mean age was 32 years, 70% had penetrating wounds, 44% had enteric injuries, and 20% had preoperative hypotension.

In all, 155 patients received noncompliant perioperative antibiotic management. Of these, 55% received no prophylaxis or incorrect antibiotics, 46% received antibiotics outside of the recommended 60-minute window, and 54% received them beyond the 24-hour limit, Dr. Smith said.

"It’s important to note these because they represent simple practice maneuvers that can be changed to help improve antibiotic stewardship in our trauma patients," he said.

The SCIP group spent significantly fewer days than the non-SCIP group in the ICU (mean 4 days vs. 7 days; P = .02) and in the hospital (mean 14 days vs. 19 days; P = .01), although no significant difference in mortality was detected (3% vs. 6%; P = .41).

Notably, Injury Severity Score was higher at admission in the non-SCIP group at 16 vs. 13 in the SCIP group (P = .03). Prehospital transfer time, which could influence the prolongation of antibiotics before surgery, was not available.

In a multivariate regression analysis that adjusted for such confounding factors as age, Injury Severity Score, shock, presence of enteric injury, transfusion requirements, damage control surgery, surgery duration, and hospital, complete adherence to the four SCIP guidelines independently decreased the risk of a surgical site infection (odds ratio, 0.448).

The non-SCIP group had significantly more enteric injuries than the SCIP group (52% vs. 35%; P = .027), and the rate of prolonged antibiotics was higher in patients with enteric injuries, compared with those without enteric injuries (38.6% vs. 19.4%; P = .001), Dr. Smith pointed out.

"This suggests the possibility that the extent of antibiotics rather than the enteric injuries themselves explained the wound infection rates in these two groups," he said.

Discussant Dr. John Santaniello, a critical care surgeon from Loyola University Chicago, Maywood, Ill., said the authors need to further elucidate antibiotic usage in patients with enteric injuries to distinguish true SCIP prophylaxis violations from empiric treatment for contamination.

He also questioned why the authors included only four of the six SCIP measures, omitting preoperative skin preparation and intraoperative normothermia maintenance, which have been shown to reduce surgical wound infections.

Dr. Smith said missing data and difficulty in abstracting data from handwritten records kept them from analyzing these two measures.

Attendee Dr. Patrick Reilly, chief of traumatology, surgical critical care, and emergency surgery at the University of Pennsylvania in Philadelphia, questioned how SCIP compliance was defined in a damage-control patient, and asked whether the investigators have a routine way of closing the skin when the fascia can be closed in these patients.

"For a number of years, we have had a practice – we don’t really call it a practice management guideline because we don’t really have any evidence for it – where we leave the skin open if we close the fascia, at least initially, because we’ve realized a high incidence of wound infections regardless of what antibiotic regimen we use," Dr. Reilly said.

Dr. Smith responded that they used the time from the index operation as the cut-point for SCIP compliance in the damage-control setting, but acknowledged that in many practices, patients receive another dose of antibiotics when they return to the operating room for a second look or washout.

Preliminary data on skin management in damage-control patients is being analyzed, but "we suspect, as you do at your institution, that it is probably the management of the skin in the setting of the fascial closure that may contribute to surgical site infections and are looking at a future study," he said.

Finally, when asked how the results have changed practice at Temple University, Dr. Smith said they’d like to believe they are using only 24 hours’ worth of antibiotics in the setting of prophylaxis but lack the evidence to confirm this. He pointed out that although more than a decade has passed since the Eastern Association for the Surgery of Trauma published its own antibiotic guidelines, more than 50% of surgeons in the study were not in compliance.

"Certainly, there is always room for improvement in how we treat our patients," he added.

Dr. Smith and Dr. Santaniello reported no conflicts of interest. Conflict of interest information for Dr. Reilly was not available.

*Correction, 2/22/2012: An earlier version of this article misidentified the lead author of the study.

LAKE BUENA VISTA, FLA. – Just 49.3% of patients undergoing emergency trauma laparotomy received antibiotics in accordance with the Surgical Care Improvement Project guidelines in a multicenter, retrospective analysis of 306 patients.

"Many of the non-SCIP patients received the wrong antibiotic or antibiotics for too long after their index operation," lead author Brian P. Smith said at the annual meeting of the Eastern Association for the Surgery of Trauma.

Moreover, compliance with the guidelines slashed surgical site infection rates from 32.9% among patients with noncompliant antibiotic management to 16.6% (P less than .001).

The Surgical Care Improvement Project (SCIP) established surgical antibiotic prophylaxis guidelines as part of a collaborative effort by the Centers for Medicare and Medicaid Services and the Centers for Disease Control and Prevention to reduce surgical complications. While these antibiotic prophylaxis guidelines have become well established in patients undergoing elective operative procedures, they have never been studied in trauma patients undergoing emergency surgery, said Dr. Smith, a surgical resident at Temple University Hospital in Philadelphia.*

He reported on an analysis involving 306 trauma patients who survived for more than 4 days after undergoing emergency laparotomy within 2 hours of admission at two level 1 trauma centers during 2007 and 2008. Patients were compared on the basis of adherence to the following SCIP guidelines: prophylactic antibiotic given, antibiotic received within 1 hour prior to incision, correct antibiotic selection, and discontinuation of antibiotic within 24 hours after surgery.

Their mean age was 32 years, 70% had penetrating wounds, 44% had enteric injuries, and 20% had preoperative hypotension.

In all, 155 patients received noncompliant perioperative antibiotic management. Of these, 55% received no prophylaxis or incorrect antibiotics, 46% received antibiotics outside of the recommended 60-minute window, and 54% received them beyond the 24-hour limit, Dr. Smith said.

"It’s important to note these because they represent simple practice maneuvers that can be changed to help improve antibiotic stewardship in our trauma patients," he said.

The SCIP group spent significantly fewer days than the non-SCIP group in the ICU (mean 4 days vs. 7 days; P = .02) and in the hospital (mean 14 days vs. 19 days; P = .01), although no significant difference in mortality was detected (3% vs. 6%; P = .41).

Notably, Injury Severity Score was higher at admission in the non-SCIP group at 16 vs. 13 in the SCIP group (P = .03). Prehospital transfer time, which could influence the prolongation of antibiotics before surgery, was not available.

In a multivariate regression analysis that adjusted for such confounding factors as age, Injury Severity Score, shock, presence of enteric injury, transfusion requirements, damage control surgery, surgery duration, and hospital, complete adherence to the four SCIP guidelines independently decreased the risk of a surgical site infection (odds ratio, 0.448).

The non-SCIP group had significantly more enteric injuries than the SCIP group (52% vs. 35%; P = .027), and the rate of prolonged antibiotics was higher in patients with enteric injuries, compared with those without enteric injuries (38.6% vs. 19.4%; P = .001), Dr. Smith pointed out.

"This suggests the possibility that the extent of antibiotics rather than the enteric injuries themselves explained the wound infection rates in these two groups," he said.

Discussant Dr. John Santaniello, a critical care surgeon from Loyola University Chicago, Maywood, Ill., said the authors need to further elucidate antibiotic usage in patients with enteric injuries to distinguish true SCIP prophylaxis violations from empiric treatment for contamination.

He also questioned why the authors included only four of the six SCIP measures, omitting preoperative skin preparation and intraoperative normothermia maintenance, which have been shown to reduce surgical wound infections.

Dr. Smith said missing data and difficulty in abstracting data from handwritten records kept them from analyzing these two measures.

Attendee Dr. Patrick Reilly, chief of traumatology, surgical critical care, and emergency surgery at the University of Pennsylvania in Philadelphia, questioned how SCIP compliance was defined in a damage-control patient, and asked whether the investigators have a routine way of closing the skin when the fascia can be closed in these patients.

"For a number of years, we have had a practice – we don’t really call it a practice management guideline because we don’t really have any evidence for it – where we leave the skin open if we close the fascia, at least initially, because we’ve realized a high incidence of wound infections regardless of what antibiotic regimen we use," Dr. Reilly said.

Dr. Smith responded that they used the time from the index operation as the cut-point for SCIP compliance in the damage-control setting, but acknowledged that in many practices, patients receive another dose of antibiotics when they return to the operating room for a second look or washout.

Preliminary data on skin management in damage-control patients is being analyzed, but "we suspect, as you do at your institution, that it is probably the management of the skin in the setting of the fascial closure that may contribute to surgical site infections and are looking at a future study," he said.

Finally, when asked how the results have changed practice at Temple University, Dr. Smith said they’d like to believe they are using only 24 hours’ worth of antibiotics in the setting of prophylaxis but lack the evidence to confirm this. He pointed out that although more than a decade has passed since the Eastern Association for the Surgery of Trauma published its own antibiotic guidelines, more than 50% of surgeons in the study were not in compliance.

"Certainly, there is always room for improvement in how we treat our patients," he added.

Dr. Smith and Dr. Santaniello reported no conflicts of interest. Conflict of interest information for Dr. Reilly was not available.

*Correction, 2/22/2012: An earlier version of this article misidentified the lead author of the study.

LAKE BUENA VISTA, FLA. – Just 49.3% of patients undergoing emergency trauma laparotomy received antibiotics in accordance with the Surgical Care Improvement Project guidelines in a multicenter, retrospective analysis of 306 patients.

"Many of the non-SCIP patients received the wrong antibiotic or antibiotics for too long after their index operation," lead author Brian P. Smith said at the annual meeting of the Eastern Association for the Surgery of Trauma.

Moreover, compliance with the guidelines slashed surgical site infection rates from 32.9% among patients with noncompliant antibiotic management to 16.6% (P less than .001).

The Surgical Care Improvement Project (SCIP) established surgical antibiotic prophylaxis guidelines as part of a collaborative effort by the Centers for Medicare and Medicaid Services and the Centers for Disease Control and Prevention to reduce surgical complications. While these antibiotic prophylaxis guidelines have become well established in patients undergoing elective operative procedures, they have never been studied in trauma patients undergoing emergency surgery, said Dr. Smith, a surgical resident at Temple University Hospital in Philadelphia.*

He reported on an analysis involving 306 trauma patients who survived for more than 4 days after undergoing emergency laparotomy within 2 hours of admission at two level 1 trauma centers during 2007 and 2008. Patients were compared on the basis of adherence to the following SCIP guidelines: prophylactic antibiotic given, antibiotic received within 1 hour prior to incision, correct antibiotic selection, and discontinuation of antibiotic within 24 hours after surgery.

Their mean age was 32 years, 70% had penetrating wounds, 44% had enteric injuries, and 20% had preoperative hypotension.

In all, 155 patients received noncompliant perioperative antibiotic management. Of these, 55% received no prophylaxis or incorrect antibiotics, 46% received antibiotics outside of the recommended 60-minute window, and 54% received them beyond the 24-hour limit, Dr. Smith said.

"It’s important to note these because they represent simple practice maneuvers that can be changed to help improve antibiotic stewardship in our trauma patients," he said.

The SCIP group spent significantly fewer days than the non-SCIP group in the ICU (mean 4 days vs. 7 days; P = .02) and in the hospital (mean 14 days vs. 19 days; P = .01), although no significant difference in mortality was detected (3% vs. 6%; P = .41).

Notably, Injury Severity Score was higher at admission in the non-SCIP group at 16 vs. 13 in the SCIP group (P = .03). Prehospital transfer time, which could influence the prolongation of antibiotics before surgery, was not available.

In a multivariate regression analysis that adjusted for such confounding factors as age, Injury Severity Score, shock, presence of enteric injury, transfusion requirements, damage control surgery, surgery duration, and hospital, complete adherence to the four SCIP guidelines independently decreased the risk of a surgical site infection (odds ratio, 0.448).

The non-SCIP group had significantly more enteric injuries than the SCIP group (52% vs. 35%; P = .027), and the rate of prolonged antibiotics was higher in patients with enteric injuries, compared with those without enteric injuries (38.6% vs. 19.4%; P = .001), Dr. Smith pointed out.

"This suggests the possibility that the extent of antibiotics rather than the enteric injuries themselves explained the wound infection rates in these two groups," he said.

Discussant Dr. John Santaniello, a critical care surgeon from Loyola University Chicago, Maywood, Ill., said the authors need to further elucidate antibiotic usage in patients with enteric injuries to distinguish true SCIP prophylaxis violations from empiric treatment for contamination.

He also questioned why the authors included only four of the six SCIP measures, omitting preoperative skin preparation and intraoperative normothermia maintenance, which have been shown to reduce surgical wound infections.

Dr. Smith said missing data and difficulty in abstracting data from handwritten records kept them from analyzing these two measures.

Attendee Dr. Patrick Reilly, chief of traumatology, surgical critical care, and emergency surgery at the University of Pennsylvania in Philadelphia, questioned how SCIP compliance was defined in a damage-control patient, and asked whether the investigators have a routine way of closing the skin when the fascia can be closed in these patients.

"For a number of years, we have had a practice – we don’t really call it a practice management guideline because we don’t really have any evidence for it – where we leave the skin open if we close the fascia, at least initially, because we’ve realized a high incidence of wound infections regardless of what antibiotic regimen we use," Dr. Reilly said.

Dr. Smith responded that they used the time from the index operation as the cut-point for SCIP compliance in the damage-control setting, but acknowledged that in many practices, patients receive another dose of antibiotics when they return to the operating room for a second look or washout.

Preliminary data on skin management in damage-control patients is being analyzed, but "we suspect, as you do at your institution, that it is probably the management of the skin in the setting of the fascial closure that may contribute to surgical site infections and are looking at a future study," he said.

Finally, when asked how the results have changed practice at Temple University, Dr. Smith said they’d like to believe they are using only 24 hours’ worth of antibiotics in the setting of prophylaxis but lack the evidence to confirm this. He pointed out that although more than a decade has passed since the Eastern Association for the Surgery of Trauma published its own antibiotic guidelines, more than 50% of surgeons in the study were not in compliance.

"Certainly, there is always room for improvement in how we treat our patients," he added.

Dr. Smith and Dr. Santaniello reported no conflicts of interest. Conflict of interest information for Dr. Reilly was not available.

*Correction, 2/22/2012: An earlier version of this article misidentified the lead author of the study.

LAKE BUENA VISTA, FLA. – Mortality was sharply reduced in elderly patients undergoing trauma care with an aggressive protocol marked by multidisciplinary teamwork and prompt identification of occult shock.

The survival benefit was significant even among patients older than 75 years, a group with notoriously high mortality rates, Dr. Eric Bradburn said at the annual meeting of the Eastern Association for the Surgery of Trauma.

Injured geriatric patients pose unique challenges to the trauma team because of their abnormal responses to shock and injury and frequent polypharmacy. They are also increasing in numbers with today’s active geriatric population, comprising 36% of all admissions at his own level II trauma center, said Dr. Bradburn, an acute care surgeon at Lancaster General Hospital in Hershey, Pa.

With the protocol, patients older than 65 years were screened on admission for high-risk injuries, comorbidities, and/or physiologic parameters associated with increased geriatric mortality in the literature. If one or more high-risk indicator was present, a high-risk protocol was initiated that included:

• ICU admission.

• STAT arterial blood gas (ABG).

• An ABG every 4 hours, if base deficit is –6 mmol/L or more, until base deficit is –2 mmol/L.

• STAT echocardiogram (EKG).

• Basic metabolic profile; magnesium and phosphorus tests in morning.

• Prothrombin time, partial thromboplastin time, and international normalized ratio in morning.

• Neurologic checks every hour for 24 hours.

• For unexplained hemodynamic instability, obtain a STAT EKG.

• Geriatric medicine consult.

The protocol was initiated in January 2006, with all 4,534 geriatric trauma patients admitted from 2000 to 2010 included in the analysis. Of these, 309 patients died for an overall mortality rate of 6.8%, Dr. Bradburn said.

Mortality rates increased sharply at age 75 years – consistent with the literature – from less than 4% to more than 6% and rose steadily to more than 11% by age 95 years.

In multivariate adjusted analysis of 3,902 patients with full data available, mortality significantly improved for geriatric patients on the protocol (odds ratio, 0.63), he said. The receiver operating curve was 0.86. Variables includes in the analysis were Injury Severity Score (ISS), trauma level, Revised Trauma Score (RTS), and age.

Patients on the protocol had significantly lower mortality rates regardless of whether they were 75-84 years (OR, 2.72), older than 85 years (OR, 4.62), had an Injury Severity Score of 17-25 (OR, 6.45) or ISS greater than 25 (OR, 15.93).

Furthermore, mortality was significantly lower among patients who received the full protocol even at the highest ISS categories, compared with those who did not receive the protocol or received either the protocol or the geriatric consult, "demonstrating the synergy and impact our full protocol has on this population," Dr. Bradburn said.

"We believe the implications of this study demonstrate that an aggressive approach to the geriatric trauma patient can result in a positive outcome in this population," he concluded.

Invited discussant Dr. Carl Schulman, a trauma and burn surgeon at the University of Miami’s Ryder Trauma Center, pointed out that geriatric consultations alone have been shown to improve mortality.

"Can you really show that your protocol added anything to this?" he asked. "Maybe all the results you have shown are from the geriatric consult alone, and this geriatric protocol is unnecessary. This would save a lot of unnecessary testing and improve the cost/benefit ratio, by simply having the geriatric consult."

The audience also questioned what services the geriatricians provided.

Dr. Bradburn said the geriatricians assisted most with social, rehabilitative, and end-of-life issues and medication issues, but also managed some comorbidities. He said the combined approach goes beyond these issues by alerting the trauma team early on to abnormal values "rather than waiting until the reserves are tapped." He noted that elderly trauma patients often present with occult hypotension leading to bias and that the literature is replete with data showing that not enough attention is paid to this population until it is too late.

Later, in a interview following the meeting, Dr. Bradburn explained that his trauma team managed the patients "from the bay to discharge."

Additional input from the geriatric team included recommendations continuing/discontinuing certain medications; assisting with management of delirium; and addressing DNR status, preinjury functional assessments, as well as social and rehab needs, he said.

"They were key in addressing the polypharmacy issue removing many of those medications that might lead to falls or increased risk for delirium."

Geriatricians’ direction on appropriate rehabilitation can boost measures such as 30-day mortality or 6-month mortality, he said. For example, in the case of an elderly fall resulting in a traumatic brain injury and extremity fractures, aggressive focused rehab to address the preexisting physical deficits that led to the fall, as well as the deficits acquired by the fall, would certainly improve the quality of life for that individual and potentially prevent additional falls.

At the meeting, Dr. Schulman also asked whether the high DNR rate of 20% could have contributed to the results. Dr. Bradburn responded that if a DNR is put into the regression model, it actually makes the results better, changing the odds ratio from 0.63 to 0.36.

Dr. Bradburn said his team had hoped to investigate functional outcomes, but that these data were not complete.

He noted that the current study is limited by its retrospective design and acknowledged that "from our data you cannot fully attribute its success solely to one part of our protocol." Still, he said, the benefits are "clear."

"This study lays the groundwork for a prospective multi-institutional study – in which we can potentially tease if one part of our protocol is more effective than any other."

The protocol should be replicable beyond Lancaster General Hospital, he said. "We think the approach is unique, but believe with further study we can show this can be applied at other institutions with equivalent successes."

Dr. Bradburn and Dr. Schulman reported no relevant conflicts of interest.

LAKE BUENA VISTA, FLA. – Mortality was sharply reduced in elderly patients undergoing trauma care with an aggressive protocol marked by multidisciplinary teamwork and prompt identification of occult shock.

The survival benefit was significant even among patients older than 75 years, a group with notoriously high mortality rates, Dr. Eric Bradburn said at the annual meeting of the Eastern Association for the Surgery of Trauma.

Injured geriatric patients pose unique challenges to the trauma team because of their abnormal responses to shock and injury and frequent polypharmacy. They are also increasing in numbers with today’s active geriatric population, comprising 36% of all admissions at his own level II trauma center, said Dr. Bradburn, an acute care surgeon at Lancaster General Hospital in Hershey, Pa.

With the protocol, patients older than 65 years were screened on admission for high-risk injuries, comorbidities, and/or physiologic parameters associated with increased geriatric mortality in the literature. If one or more high-risk indicator was present, a high-risk protocol was initiated that included:

• ICU admission.

• STAT arterial blood gas (ABG).

• An ABG every 4 hours, if base deficit is –6 mmol/L or more, until base deficit is –2 mmol/L.

• STAT echocardiogram (EKG).

• Basic metabolic profile; magnesium and phosphorus tests in morning.

• Prothrombin time, partial thromboplastin time, and international normalized ratio in morning.

• Neurologic checks every hour for 24 hours.

• For unexplained hemodynamic instability, obtain a STAT EKG.

• Geriatric medicine consult.

The protocol was initiated in January 2006, with all 4,534 geriatric trauma patients admitted from 2000 to 2010 included in the analysis. Of these, 309 patients died for an overall mortality rate of 6.8%, Dr. Bradburn said.

Mortality rates increased sharply at age 75 years – consistent with the literature – from less than 4% to more than 6% and rose steadily to more than 11% by age 95 years.

In multivariate adjusted analysis of 3,902 patients with full data available, mortality significantly improved for geriatric patients on the protocol (odds ratio, 0.63), he said. The receiver operating curve was 0.86. Variables includes in the analysis were Injury Severity Score (ISS), trauma level, Revised Trauma Score (RTS), and age.

Patients on the protocol had significantly lower mortality rates regardless of whether they were 75-84 years (OR, 2.72), older than 85 years (OR, 4.62), had an Injury Severity Score of 17-25 (OR, 6.45) or ISS greater than 25 (OR, 15.93).

Furthermore, mortality was significantly lower among patients who received the full protocol even at the highest ISS categories, compared with those who did not receive the protocol or received either the protocol or the geriatric consult, "demonstrating the synergy and impact our full protocol has on this population," Dr. Bradburn said.

"We believe the implications of this study demonstrate that an aggressive approach to the geriatric trauma patient can result in a positive outcome in this population," he concluded.

Invited discussant Dr. Carl Schulman, a trauma and burn surgeon at the University of Miami’s Ryder Trauma Center, pointed out that geriatric consultations alone have been shown to improve mortality.

"Can you really show that your protocol added anything to this?" he asked. "Maybe all the results you have shown are from the geriatric consult alone, and this geriatric protocol is unnecessary. This would save a lot of unnecessary testing and improve the cost/benefit ratio, by simply having the geriatric consult."

The audience also questioned what services the geriatricians provided.

Dr. Bradburn said the geriatricians assisted most with social, rehabilitative, and end-of-life issues and medication issues, but also managed some comorbidities. He said the combined approach goes beyond these issues by alerting the trauma team early on to abnormal values "rather than waiting until the reserves are tapped." He noted that elderly trauma patients often present with occult hypotension leading to bias and that the literature is replete with data showing that not enough attention is paid to this population until it is too late.

Later, in a interview following the meeting, Dr. Bradburn explained that his trauma team managed the patients "from the bay to discharge."

Additional input from the geriatric team included recommendations continuing/discontinuing certain medications; assisting with management of delirium; and addressing DNR status, preinjury functional assessments, as well as social and rehab needs, he said.

"They were key in addressing the polypharmacy issue removing many of those medications that might lead to falls or increased risk for delirium."

Geriatricians’ direction on appropriate rehabilitation can boost measures such as 30-day mortality or 6-month mortality, he said. For example, in the case of an elderly fall resulting in a traumatic brain injury and extremity fractures, aggressive focused rehab to address the preexisting physical deficits that led to the fall, as well as the deficits acquired by the fall, would certainly improve the quality of life for that individual and potentially prevent additional falls.

At the meeting, Dr. Schulman also asked whether the high DNR rate of 20% could have contributed to the results. Dr. Bradburn responded that if a DNR is put into the regression model, it actually makes the results better, changing the odds ratio from 0.63 to 0.36.

Dr. Bradburn said his team had hoped to investigate functional outcomes, but that these data were not complete.

He noted that the current study is limited by its retrospective design and acknowledged that "from our data you cannot fully attribute its success solely to one part of our protocol." Still, he said, the benefits are "clear."

"This study lays the groundwork for a prospective multi-institutional study – in which we can potentially tease if one part of our protocol is more effective than any other."

The protocol should be replicable beyond Lancaster General Hospital, he said. "We think the approach is unique, but believe with further study we can show this can be applied at other institutions with equivalent successes."

Dr. Bradburn and Dr. Schulman reported no relevant conflicts of interest.

LAKE BUENA VISTA, FLA. – Mortality was sharply reduced in elderly patients undergoing trauma care with an aggressive protocol marked by multidisciplinary teamwork and prompt identification of occult shock.

The survival benefit was significant even among patients older than 75 years, a group with notoriously high mortality rates, Dr. Eric Bradburn said at the annual meeting of the Eastern Association for the Surgery of Trauma.

Injured geriatric patients pose unique challenges to the trauma team because of their abnormal responses to shock and injury and frequent polypharmacy. They are also increasing in numbers with today’s active geriatric population, comprising 36% of all admissions at his own level II trauma center, said Dr. Bradburn, an acute care surgeon at Lancaster General Hospital in Hershey, Pa.

With the protocol, patients older than 65 years were screened on admission for high-risk injuries, comorbidities, and/or physiologic parameters associated with increased geriatric mortality in the literature. If one or more high-risk indicator was present, a high-risk protocol was initiated that included:

• ICU admission.

• STAT arterial blood gas (ABG).

• An ABG every 4 hours, if base deficit is –6 mmol/L or more, until base deficit is –2 mmol/L.

• STAT echocardiogram (EKG).

• Basic metabolic profile; magnesium and phosphorus tests in morning.

• Prothrombin time, partial thromboplastin time, and international normalized ratio in morning.

• Neurologic checks every hour for 24 hours.

• For unexplained hemodynamic instability, obtain a STAT EKG.

• Geriatric medicine consult.

The protocol was initiated in January 2006, with all 4,534 geriatric trauma patients admitted from 2000 to 2010 included in the analysis. Of these, 309 patients died for an overall mortality rate of 6.8%, Dr. Bradburn said.

Mortality rates increased sharply at age 75 years – consistent with the literature – from less than 4% to more than 6% and rose steadily to more than 11% by age 95 years.

In multivariate adjusted analysis of 3,902 patients with full data available, mortality significantly improved for geriatric patients on the protocol (odds ratio, 0.63), he said. The receiver operating curve was 0.86. Variables includes in the analysis were Injury Severity Score (ISS), trauma level, Revised Trauma Score (RTS), and age.

Patients on the protocol had significantly lower mortality rates regardless of whether they were 75-84 years (OR, 2.72), older than 85 years (OR, 4.62), had an Injury Severity Score of 17-25 (OR, 6.45) or ISS greater than 25 (OR, 15.93).

Furthermore, mortality was significantly lower among patients who received the full protocol even at the highest ISS categories, compared with those who did not receive the protocol or received either the protocol or the geriatric consult, "demonstrating the synergy and impact our full protocol has on this population," Dr. Bradburn said.

"We believe the implications of this study demonstrate that an aggressive approach to the geriatric trauma patient can result in a positive outcome in this population," he concluded.

Invited discussant Dr. Carl Schulman, a trauma and burn surgeon at the University of Miami’s Ryder Trauma Center, pointed out that geriatric consultations alone have been shown to improve mortality.

"Can you really show that your protocol added anything to this?" he asked. "Maybe all the results you have shown are from the geriatric consult alone, and this geriatric protocol is unnecessary. This would save a lot of unnecessary testing and improve the cost/benefit ratio, by simply having the geriatric consult."

The audience also questioned what services the geriatricians provided.

Dr. Bradburn said the geriatricians assisted most with social, rehabilitative, and end-of-life issues and medication issues, but also managed some comorbidities. He said the combined approach goes beyond these issues by alerting the trauma team early on to abnormal values "rather than waiting until the reserves are tapped." He noted that elderly trauma patients often present with occult hypotension leading to bias and that the literature is replete with data showing that not enough attention is paid to this population until it is too late.

Later, in a interview following the meeting, Dr. Bradburn explained that his trauma team managed the patients "from the bay to discharge."

Additional input from the geriatric team included recommendations continuing/discontinuing certain medications; assisting with management of delirium; and addressing DNR status, preinjury functional assessments, as well as social and rehab needs, he said.

"They were key in addressing the polypharmacy issue removing many of those medications that might lead to falls or increased risk for delirium."

Geriatricians’ direction on appropriate rehabilitation can boost measures such as 30-day mortality or 6-month mortality, he said. For example, in the case of an elderly fall resulting in a traumatic brain injury and extremity fractures, aggressive focused rehab to address the preexisting physical deficits that led to the fall, as well as the deficits acquired by the fall, would certainly improve the quality of life for that individual and potentially prevent additional falls.

At the meeting, Dr. Schulman also asked whether the high DNR rate of 20% could have contributed to the results. Dr. Bradburn responded that if a DNR is put into the regression model, it actually makes the results better, changing the odds ratio from 0.63 to 0.36.

Dr. Bradburn said his team had hoped to investigate functional outcomes, but that these data were not complete.

He noted that the current study is limited by its retrospective design and acknowledged that "from our data you cannot fully attribute its success solely to one part of our protocol." Still, he said, the benefits are "clear."

"This study lays the groundwork for a prospective multi-institutional study – in which we can potentially tease if one part of our protocol is more effective than any other."

The protocol should be replicable beyond Lancaster General Hospital, he said. "We think the approach is unique, but believe with further study we can show this can be applied at other institutions with equivalent successes."

Dr. Bradburn and Dr. Schulman reported no relevant conflicts of interest.

LAKE BUENA VISTA, Fla.– Score one for the trauma surgeons. Outcomes are no different for patients with small intracranial hemorrhages managed by a trauma surgeon rather than a neurosurgeon, a new study shows.

Investigators at the JPS Health Network in Fort Worth, Tex., compared trauma activations for 124 patients before and 199 patients after a protocol was instituted at the level 1 trauma center allowing trauma surgeons to manage patients with a traumatic brain injury due to a fall resulting in a 1-cm or less intracranial hemorrhage (ICH). Patients with penetrating wounds or who were transferred to other acute care facilities were excluded from the analysis.

After the protocol was initiated, neurosurgery consults significantly decreased from 93.5% to 83.4% (P less than .01), Ms. Tiffany Littleton, trauma services research associate, and her colleagues reported at the annual meeting of the Eastern Association for the Surgery of Trauma.

No significant differences at discharge were observed pre- and postprotocol for patient age (61.5 years vs. 58 years), sex (71% male vs. 65%), race (69.4% white vs. 70.4%), Glasgow Coma Scale scores (median 14.5 vs. 15), or Injury Severity Score (both median 20).

Additionally, there were no differences in outcomes such as length of stay (median 4 days for both; P = .86), condition on discharge (P = .57), where patients were discharged to (P = .14), or Glasgow Outcome Scale (GOS) scores (P = .18), she reported.

At discharge, most patients pre- and postprotocol had moderate disability (70.2% vs. 50.3%), went home without the need for professional assistance (59.7% vs. 49.2%), and were GOS classified as "good recovery" (50% vs. 60%).

"Due to the demand placed on neurosurgeons for more severe brain injuries, these data suggest patients managed by trauma surgeons could have comparable outcomes to those managed by neurosurgeons," the authors concluded.

The results are particularly relevant, as the literature is scant regarding the management of ICHs of 1 cm or less. Moreover, the number of trauma activations resulting from falls is expected to increase with the aging American population, the investigators noted.

Falls are the second leading cause of trauma activations, and half of fall fatalities and associated costs are related to traumatic brain injury. Falls also constitute 52% of emergency department visits for adults aged 75 years or older.

Despite the potential for turf wars when departmental duties are shifted, "neurosurgeons were delighted" with the new protocol, senior author and JPS medical director of trauma services Dr. Rajesh Gandhi said in an interview. In fact, it was two neurosurgeons who developed and initiated the protocol change.

The researchers are currently acquiring data from the National Trauma Bank to examine differences in ICH outcomes in a larger sample.

"Additionally, we want to look at the range in which trauma surgeons can effectively manage ICH, and determine the point at which neurosurgeon management results in significant differences in outcome," said Ms. Littleton. "This can also translate to rural health care in terms of transferring these types of patients to trauma centers."

Ms. Littleton and her coauthors reported no financial conflicts of interest. Dr. Gandhi serves as a speaker for LifeCell and KCI.

LAKE BUENA VISTA, Fla.– Score one for the trauma surgeons. Outcomes are no different for patients with small intracranial hemorrhages managed by a trauma surgeon rather than a neurosurgeon, a new study shows.

Investigators at the JPS Health Network in Fort Worth, Tex., compared trauma activations for 124 patients before and 199 patients after a protocol was instituted at the level 1 trauma center allowing trauma surgeons to manage patients with a traumatic brain injury due to a fall resulting in a 1-cm or less intracranial hemorrhage (ICH). Patients with penetrating wounds or who were transferred to other acute care facilities were excluded from the analysis.

After the protocol was initiated, neurosurgery consults significantly decreased from 93.5% to 83.4% (P less than .01), Ms. Tiffany Littleton, trauma services research associate, and her colleagues reported at the annual meeting of the Eastern Association for the Surgery of Trauma.

No significant differences at discharge were observed pre- and postprotocol for patient age (61.5 years vs. 58 years), sex (71% male vs. 65%), race (69.4% white vs. 70.4%), Glasgow Coma Scale scores (median 14.5 vs. 15), or Injury Severity Score (both median 20).

Additionally, there were no differences in outcomes such as length of stay (median 4 days for both; P = .86), condition on discharge (P = .57), where patients were discharged to (P = .14), or Glasgow Outcome Scale (GOS) scores (P = .18), she reported.

At discharge, most patients pre- and postprotocol had moderate disability (70.2% vs. 50.3%), went home without the need for professional assistance (59.7% vs. 49.2%), and were GOS classified as "good recovery" (50% vs. 60%).

"Due to the demand placed on neurosurgeons for more severe brain injuries, these data suggest patients managed by trauma surgeons could have comparable outcomes to those managed by neurosurgeons," the authors concluded.

The results are particularly relevant, as the literature is scant regarding the management of ICHs of 1 cm or less. Moreover, the number of trauma activations resulting from falls is expected to increase with the aging American population, the investigators noted.

Falls are the second leading cause of trauma activations, and half of fall fatalities and associated costs are related to traumatic brain injury. Falls also constitute 52% of emergency department visits for adults aged 75 years or older.

Despite the potential for turf wars when departmental duties are shifted, "neurosurgeons were delighted" with the new protocol, senior author and JPS medical director of trauma services Dr. Rajesh Gandhi said in an interview. In fact, it was two neurosurgeons who developed and initiated the protocol change.

The researchers are currently acquiring data from the National Trauma Bank to examine differences in ICH outcomes in a larger sample.

"Additionally, we want to look at the range in which trauma surgeons can effectively manage ICH, and determine the point at which neurosurgeon management results in significant differences in outcome," said Ms. Littleton. "This can also translate to rural health care in terms of transferring these types of patients to trauma centers."

Ms. Littleton and her coauthors reported no financial conflicts of interest. Dr. Gandhi serves as a speaker for LifeCell and KCI.

LAKE BUENA VISTA, Fla.– Score one for the trauma surgeons. Outcomes are no different for patients with small intracranial hemorrhages managed by a trauma surgeon rather than a neurosurgeon, a new study shows.

Investigators at the JPS Health Network in Fort Worth, Tex., compared trauma activations for 124 patients before and 199 patients after a protocol was instituted at the level 1 trauma center allowing trauma surgeons to manage patients with a traumatic brain injury due to a fall resulting in a 1-cm or less intracranial hemorrhage (ICH). Patients with penetrating wounds or who were transferred to other acute care facilities were excluded from the analysis.

After the protocol was initiated, neurosurgery consults significantly decreased from 93.5% to 83.4% (P less than .01), Ms. Tiffany Littleton, trauma services research associate, and her colleagues reported at the annual meeting of the Eastern Association for the Surgery of Trauma.

No significant differences at discharge were observed pre- and postprotocol for patient age (61.5 years vs. 58 years), sex (71% male vs. 65%), race (69.4% white vs. 70.4%), Glasgow Coma Scale scores (median 14.5 vs. 15), or Injury Severity Score (both median 20).

Additionally, there were no differences in outcomes such as length of stay (median 4 days for both; P = .86), condition on discharge (P = .57), where patients were discharged to (P = .14), or Glasgow Outcome Scale (GOS) scores (P = .18), she reported.

At discharge, most patients pre- and postprotocol had moderate disability (70.2% vs. 50.3%), went home without the need for professional assistance (59.7% vs. 49.2%), and were GOS classified as "good recovery" (50% vs. 60%).

"Due to the demand placed on neurosurgeons for more severe brain injuries, these data suggest patients managed by trauma surgeons could have comparable outcomes to those managed by neurosurgeons," the authors concluded.

The results are particularly relevant, as the literature is scant regarding the management of ICHs of 1 cm or less. Moreover, the number of trauma activations resulting from falls is expected to increase with the aging American population, the investigators noted.

Falls are the second leading cause of trauma activations, and half of fall fatalities and associated costs are related to traumatic brain injury. Falls also constitute 52% of emergency department visits for adults aged 75 years or older.

Despite the potential for turf wars when departmental duties are shifted, "neurosurgeons were delighted" with the new protocol, senior author and JPS medical director of trauma services Dr. Rajesh Gandhi said in an interview. In fact, it was two neurosurgeons who developed and initiated the protocol change.

The researchers are currently acquiring data from the National Trauma Bank to examine differences in ICH outcomes in a larger sample.

"Additionally, we want to look at the range in which trauma surgeons can effectively manage ICH, and determine the point at which neurosurgeon management results in significant differences in outcome," said Ms. Littleton. "This can also translate to rural health care in terms of transferring these types of patients to trauma centers."

Ms. Littleton and her coauthors reported no financial conflicts of interest. Dr. Gandhi serves as a speaker for LifeCell and KCI.

LAKE BUENA VISTA, FLA. – Patients on one of the powerful new oral anticoagulants are left without a good antidote for bleeding if they experience a traumatic injury.

The use of these agents is climbing as baby boomers age and the number of patients with atrial fibrillation continues its steady rise from 2.0 million in 1995 to a projected 4.34 million by 2030.

"If you think it’s an epidemic now, it will become even more so in the coming years," Dr. Mark Cipolle, medical director of trauma and neurocritical care at Christiana Care Health System in Wilmington, Del., said at the annual meeting of the Eastern Association for the Surgery of Trauma.

Currently, no specific antidote is available for dabigatran (Pradaxa) or the factor Xa inhibitor rivaroxaban (Xarelto), both of which are approved for stroke prevention in nonvalvular atrial fibrillation and for deep vein thrombosis following hip or knee replacement surgery.

The oral Xa inhibitor apixaban (Eliquis) is under priority review for stroke and DVT prevention in atrial fibrillation and will likely move, sans antidote, into the marketplace later this year based on robust results from the recent ARISTOTLE trial.

Vitamin K and protamine sulfate are not expected to affect the anticoagulant activity of the new oral anticoagulants. Some centers have had anectodal success in reversing dabigatran with activated prothrombin complex concentrates (aPCCs), but this has not been widely adopted, according to Dr. Cipolle.

"Some of my colleagues in pharmacy think this may be the drug to help us reverse dabigatran ... but our blood bank hematologists aren’t thrilled about going to this because of the development of antibodies for the new agents," he said.

The two aPCCs available in the United States are factor eight inhibitor binding activity (FEIBA) and anti-inhibitor coagulant complex, heat treated (Autoplex T); both are indicated for bypass therapy in patients with acquired inhibitors and contain the coagulation factors II, VII, IX, and X.

One of the first randomized trials to look at a specific PCC (Cofact) showed that a single bolus immediately and completely reversed the anticoagulation effect of rivaroxaban in 12 healthy volunteers who were taking 20 mg twice daily, but the PCC had no influence on the effect of dabigatran 150 mg twice daily (Circulation 2011;124:1573-9), said copanelist John Gallagher, clinical nurse specialist for the surgical/trauma ICU at the Hospital of the University of Pennsylvania in Philadelphia.

Recombinant activated factor VIIa has been widely studied in trauma, but not for this specific indication. Early research on antibody monoclonal development is showing promise, Dr. Cipolle said. A recent study described a monoclonal mouse antibody with a high and specific affinity to inhibit dabigatran in both human plasma and whole blood and in a rat in vivo model (J. Am. Coll. Cardiol. 2011;57:E1130).

The package insert for dabigatran recommends emergency dialysis as a reversal strategy, stating that about 60% of dabigatran is removed over 2-3 hours. "This [strategy] may work," said Dr. Cipolle, observing that about 80% of dabigatran is renally excreted, compared with 66% of rivaroxaban and only 25% of apixaban.

Although not trivial, the half-lives of dabigatran (14-17 hours), rivaroxaban (9 hours), and apixaban (9-14 hours) are shorter than that of warfarin (40 hours), which means that "if you can wait and just not give them the drug, you are probably going to be okay," he said.

Dr. Cipolle cautioned, however, that reversal of labs may not indicate loss of anticoagulant effects. Also, clotting factors and continued prolongation of anticoagulation assays do not indicate lack of effect.

"The drug industry has spent years developing a drug that we could take orally that you don’t have to measure, and all we want to do is measure it," he said. "We would like to know just how much anticoagulant effect is present, and if our reversal strategies are working.

"A normal PTT [partial thromboplastin time] is very helpful, but other than that, the classic anticoagulation studies aren’t terribly helpful."

This point was also referenced in a recent letter to the New England Journal of Medicine penned by two trauma surgeons and an emergency physician who treated several injured patients on dabigatran, all of whom had poor outcomes (N. Engl. J. Med. 2011;365:2039-40). Although their values for activated clotting time on rapid thromboelastography (rTEG) were grossly abnormal at the time of admission, all of the patients had normal results on conventional anticoagulation studies.

"Unfortunately, even with the aid of rTEG, supportive care is all that is available in the emergency setting," wrote the authors, who strongly urged that hemorrhagic complications and death resulting from trauma be included as part of routine surveillance of all newly approved oral anticoagulants. The authors also argued that "the ability to perform rapid dialysis in patients with bleeding whose condition is unstable or in those with large intracranial hemorrhages will present an incredible challenge, even at level 1 trauma centers."

Both Dr. Cipolle and Mr. Gallagher emphasized that institutions should have a protocol in place for anticoagulant reversal. The protocol should be based on evidence and practice guidelines, be transparent and modifiable, and identify specific anticoagulant agents, triggers for reversal such as intracranial hemorrhage or solid organ injury, and reversal strategies and methods for monitoring both the use of anticoagulants and reversal strategies, Mr. Gallagher said.

During a discussion of the study, attendees asked how to address anticoagulation at discharge in, for example, a 72-year-old man with early Alzheimer’s disease and a fourth admission for a fall. Dr. Cipolle replied that a recommendation would be placed in his chart based on his initial risk and that a hospitalist or cardiologist would also be called in. He observed that trauma surgeons typically overestimate the fall risk, compared with the stroke risk, and often feel that making such a recommendation may be out of their purview.

Audience member Dr. Ronald Gross, chief of trauma and emergency surgery at Baystate Medical Center in Springfield, Mass., said trauma surgeons need to play a more active role in anticoagulation. He added that physicians at his center have a conversation prior to discharge with every single fall patient about the risks and benefits of anticoagulation, and also contact their prescribing physicians.

Session moderator Dr. Lewis Kaplan, a trauma and critical care surgeon at Yale University, New Haven, Conn., said the nurse practitioners at his center call primary care physicians when trauma patients are admitted and make a follow-up call upon discharge. The trauma surgeon makes an anticoagulation recommendation at discharge, although half the time, despite the conversation, patients are back on their anticoagulants in a matter of weeks, Dr. Kaplan said.

Dr. Cipolle and Mr. Gallagher reported no conflicts of interest. Dr. Lewis serves as a consultant to Pfizer.

LAKE BUENA VISTA, FLA. – Patients on one of the powerful new oral anticoagulants are left without a good antidote for bleeding if they experience a traumatic injury.

The use of these agents is climbing as baby boomers age and the number of patients with atrial fibrillation continues its steady rise from 2.0 million in 1995 to a projected 4.34 million by 2030.

"If you think it’s an epidemic now, it will become even more so in the coming years," Dr. Mark Cipolle, medical director of trauma and neurocritical care at Christiana Care Health System in Wilmington, Del., said at the annual meeting of the Eastern Association for the Surgery of Trauma.

Currently, no specific antidote is available for dabigatran (Pradaxa) or the factor Xa inhibitor rivaroxaban (Xarelto), both of which are approved for stroke prevention in nonvalvular atrial fibrillation and for deep vein thrombosis following hip or knee replacement surgery.

The oral Xa inhibitor apixaban (Eliquis) is under priority review for stroke and DVT prevention in atrial fibrillation and will likely move, sans antidote, into the marketplace later this year based on robust results from the recent ARISTOTLE trial.

Vitamin K and protamine sulfate are not expected to affect the anticoagulant activity of the new oral anticoagulants. Some centers have had anectodal success in reversing dabigatran with activated prothrombin complex concentrates (aPCCs), but this has not been widely adopted, according to Dr. Cipolle.

"Some of my colleagues in pharmacy think this may be the drug to help us reverse dabigatran ... but our blood bank hematologists aren’t thrilled about going to this because of the development of antibodies for the new agents," he said.

The two aPCCs available in the United States are factor eight inhibitor binding activity (FEIBA) and anti-inhibitor coagulant complex, heat treated (Autoplex T); both are indicated for bypass therapy in patients with acquired inhibitors and contain the coagulation factors II, VII, IX, and X.

One of the first randomized trials to look at a specific PCC (Cofact) showed that a single bolus immediately and completely reversed the anticoagulation effect of rivaroxaban in 12 healthy volunteers who were taking 20 mg twice daily, but the PCC had no influence on the effect of dabigatran 150 mg twice daily (Circulation 2011;124:1573-9), said copanelist John Gallagher, clinical nurse specialist for the surgical/trauma ICU at the Hospital of the University of Pennsylvania in Philadelphia.

Recombinant activated factor VIIa has been widely studied in trauma, but not for this specific indication. Early research on antibody monoclonal development is showing promise, Dr. Cipolle said. A recent study described a monoclonal mouse antibody with a high and specific affinity to inhibit dabigatran in both human plasma and whole blood and in a rat in vivo model (J. Am. Coll. Cardiol. 2011;57:E1130).

The package insert for dabigatran recommends emergency dialysis as a reversal strategy, stating that about 60% of dabigatran is removed over 2-3 hours. "This [strategy] may work," said Dr. Cipolle, observing that about 80% of dabigatran is renally excreted, compared with 66% of rivaroxaban and only 25% of apixaban.

Although not trivial, the half-lives of dabigatran (14-17 hours), rivaroxaban (9 hours), and apixaban (9-14 hours) are shorter than that of warfarin (40 hours), which means that "if you can wait and just not give them the drug, you are probably going to be okay," he said.

Dr. Cipolle cautioned, however, that reversal of labs may not indicate loss of anticoagulant effects. Also, clotting factors and continued prolongation of anticoagulation assays do not indicate lack of effect.

"The drug industry has spent years developing a drug that we could take orally that you don’t have to measure, and all we want to do is measure it," he said. "We would like to know just how much anticoagulant effect is present, and if our reversal strategies are working.

"A normal PTT [partial thromboplastin time] is very helpful, but other than that, the classic anticoagulation studies aren’t terribly helpful."

This point was also referenced in a recent letter to the New England Journal of Medicine penned by two trauma surgeons and an emergency physician who treated several injured patients on dabigatran, all of whom had poor outcomes (N. Engl. J. Med. 2011;365:2039-40). Although their values for activated clotting time on rapid thromboelastography (rTEG) were grossly abnormal at the time of admission, all of the patients had normal results on conventional anticoagulation studies.

"Unfortunately, even with the aid of rTEG, supportive care is all that is available in the emergency setting," wrote the authors, who strongly urged that hemorrhagic complications and death resulting from trauma be included as part of routine surveillance of all newly approved oral anticoagulants. The authors also argued that "the ability to perform rapid dialysis in patients with bleeding whose condition is unstable or in those with large intracranial hemorrhages will present an incredible challenge, even at level 1 trauma centers."

Both Dr. Cipolle and Mr. Gallagher emphasized that institutions should have a protocol in place for anticoagulant reversal. The protocol should be based on evidence and practice guidelines, be transparent and modifiable, and identify specific anticoagulant agents, triggers for reversal such as intracranial hemorrhage or solid organ injury, and reversal strategies and methods for monitoring both the use of anticoagulants and reversal strategies, Mr. Gallagher said.

During a discussion of the study, attendees asked how to address anticoagulation at discharge in, for example, a 72-year-old man with early Alzheimer’s disease and a fourth admission for a fall. Dr. Cipolle replied that a recommendation would be placed in his chart based on his initial risk and that a hospitalist or cardiologist would also be called in. He observed that trauma surgeons typically overestimate the fall risk, compared with the stroke risk, and often feel that making such a recommendation may be out of their purview.

Audience member Dr. Ronald Gross, chief of trauma and emergency surgery at Baystate Medical Center in Springfield, Mass., said trauma surgeons need to play a more active role in anticoagulation. He added that physicians at his center have a conversation prior to discharge with every single fall patient about the risks and benefits of anticoagulation, and also contact their prescribing physicians.

Session moderator Dr. Lewis Kaplan, a trauma and critical care surgeon at Yale University, New Haven, Conn., said the nurse practitioners at his center call primary care physicians when trauma patients are admitted and make a follow-up call upon discharge. The trauma surgeon makes an anticoagulation recommendation at discharge, although half the time, despite the conversation, patients are back on their anticoagulants in a matter of weeks, Dr. Kaplan said.

Dr. Cipolle and Mr. Gallagher reported no conflicts of interest. Dr. Lewis serves as a consultant to Pfizer.

LAKE BUENA VISTA, FLA. – Patients on one of the powerful new oral anticoagulants are left without a good antidote for bleeding if they experience a traumatic injury.

The use of these agents is climbing as baby boomers age and the number of patients with atrial fibrillation continues its steady rise from 2.0 million in 1995 to a projected 4.34 million by 2030.

"If you think it’s an epidemic now, it will become even more so in the coming years," Dr. Mark Cipolle, medical director of trauma and neurocritical care at Christiana Care Health System in Wilmington, Del., said at the annual meeting of the Eastern Association for the Surgery of Trauma.

Currently, no specific antidote is available for dabigatran (Pradaxa) or the factor Xa inhibitor rivaroxaban (Xarelto), both of which are approved for stroke prevention in nonvalvular atrial fibrillation and for deep vein thrombosis following hip or knee replacement surgery.

The oral Xa inhibitor apixaban (Eliquis) is under priority review for stroke and DVT prevention in atrial fibrillation and will likely move, sans antidote, into the marketplace later this year based on robust results from the recent ARISTOTLE trial.

Vitamin K and protamine sulfate are not expected to affect the anticoagulant activity of the new oral anticoagulants. Some centers have had anectodal success in reversing dabigatran with activated prothrombin complex concentrates (aPCCs), but this has not been widely adopted, according to Dr. Cipolle.

"Some of my colleagues in pharmacy think this may be the drug to help us reverse dabigatran ... but our blood bank hematologists aren’t thrilled about going to this because of the development of antibodies for the new agents," he said.

The two aPCCs available in the United States are factor eight inhibitor binding activity (FEIBA) and anti-inhibitor coagulant complex, heat treated (Autoplex T); both are indicated for bypass therapy in patients with acquired inhibitors and contain the coagulation factors II, VII, IX, and X.

One of the first randomized trials to look at a specific PCC (Cofact) showed that a single bolus immediately and completely reversed the anticoagulation effect of rivaroxaban in 12 healthy volunteers who were taking 20 mg twice daily, but the PCC had no influence on the effect of dabigatran 150 mg twice daily (Circulation 2011;124:1573-9), said copanelist John Gallagher, clinical nurse specialist for the surgical/trauma ICU at the Hospital of the University of Pennsylvania in Philadelphia.

Recombinant activated factor VIIa has been widely studied in trauma, but not for this specific indication. Early research on antibody monoclonal development is showing promise, Dr. Cipolle said. A recent study described a monoclonal mouse antibody with a high and specific affinity to inhibit dabigatran in both human plasma and whole blood and in a rat in vivo model (J. Am. Coll. Cardiol. 2011;57:E1130).

The package insert for dabigatran recommends emergency dialysis as a reversal strategy, stating that about 60% of dabigatran is removed over 2-3 hours. "This [strategy] may work," said Dr. Cipolle, observing that about 80% of dabigatran is renally excreted, compared with 66% of rivaroxaban and only 25% of apixaban.

Although not trivial, the half-lives of dabigatran (14-17 hours), rivaroxaban (9 hours), and apixaban (9-14 hours) are shorter than that of warfarin (40 hours), which means that "if you can wait and just not give them the drug, you are probably going to be okay," he said.

Dr. Cipolle cautioned, however, that reversal of labs may not indicate loss of anticoagulant effects. Also, clotting factors and continued prolongation of anticoagulation assays do not indicate lack of effect.

"The drug industry has spent years developing a drug that we could take orally that you don’t have to measure, and all we want to do is measure it," he said. "We would like to know just how much anticoagulant effect is present, and if our reversal strategies are working.

"A normal PTT [partial thromboplastin time] is very helpful, but other than that, the classic anticoagulation studies aren’t terribly helpful."

This point was also referenced in a recent letter to the New England Journal of Medicine penned by two trauma surgeons and an emergency physician who treated several injured patients on dabigatran, all of whom had poor outcomes (N. Engl. J. Med. 2011;365:2039-40). Although their values for activated clotting time on rapid thromboelastography (rTEG) were grossly abnormal at the time of admission, all of the patients had normal results on conventional anticoagulation studies.

"Unfortunately, even with the aid of rTEG, supportive care is all that is available in the emergency setting," wrote the authors, who strongly urged that hemorrhagic complications and death resulting from trauma be included as part of routine surveillance of all newly approved oral anticoagulants. The authors also argued that "the ability to perform rapid dialysis in patients with bleeding whose condition is unstable or in those with large intracranial hemorrhages will present an incredible challenge, even at level 1 trauma centers."

Both Dr. Cipolle and Mr. Gallagher emphasized that institutions should have a protocol in place for anticoagulant reversal. The protocol should be based on evidence and practice guidelines, be transparent and modifiable, and identify specific anticoagulant agents, triggers for reversal such as intracranial hemorrhage or solid organ injury, and reversal strategies and methods for monitoring both the use of anticoagulants and reversal strategies, Mr. Gallagher said.

During a discussion of the study, attendees asked how to address anticoagulation at discharge in, for example, a 72-year-old man with early Alzheimer’s disease and a fourth admission for a fall. Dr. Cipolle replied that a recommendation would be placed in his chart based on his initial risk and that a hospitalist or cardiologist would also be called in. He observed that trauma surgeons typically overestimate the fall risk, compared with the stroke risk, and often feel that making such a recommendation may be out of their purview.

Audience member Dr. Ronald Gross, chief of trauma and emergency surgery at Baystate Medical Center in Springfield, Mass., said trauma surgeons need to play a more active role in anticoagulation. He added that physicians at his center have a conversation prior to discharge with every single fall patient about the risks and benefits of anticoagulation, and also contact their prescribing physicians.

Session moderator Dr. Lewis Kaplan, a trauma and critical care surgeon at Yale University, New Haven, Conn., said the nurse practitioners at his center call primary care physicians when trauma patients are admitted and make a follow-up call upon discharge. The trauma surgeon makes an anticoagulation recommendation at discharge, although half the time, despite the conversation, patients are back on their anticoagulants in a matter of weeks, Dr. Kaplan said.

Dr. Cipolle and Mr. Gallagher reported no conflicts of interest. Dr. Lewis serves as a consultant to Pfizer.

LAKE BUENA VISTA, FLA. – The Trauma-Related Injury Severity Score is outdated and should be replaced by a survival prediction model derived from more contemporary mortality rates, a study showed.

The score, known as TRISS, is the workhorse of outcome prediction in trauma. It is integral to the federal Performance Improvement and Patient Safety plan for trauma, is used for benchmarking hospital performance and comparing interhospital performance, and has been incorporated into most commercial trauma registries, including the National Trauma Registry System and the National Trauma Data Bank (NTDB).

Unfortunately, it is based on data collected in the Major Trauma Outcome Study (MTOS) during the 1980s, and its coefficients of survival prediction were last updated in 1995, said lead author Dr. Frederick Rogers, medical director of the Lancaster (Pa.) General Health Trauma Center.

"Few of us have really complained about TRISS up until this point because TRISS is what we consider an easy grader, making our results much better than they really are by comparing ourselves to trauma care in the last century," he said at the annual meeting of the Eastern Association for the Surgery of Trauma (EAST). "We really must be honest with ourselves.

"We must retire TRISS and create a mortality prediction model for the next century that reflects contemporary results."

Invited discussant Dr. Avery Nathens, director of the American College of Surgeons’ Trauma Quality Improvement Program and trauma director at St. Michael’s Hospital in Toronto, said, "I feel like we just heard the obituary for TRISS."

He said the study confirms many of the concerns regarding TRISS and pointed out that no fewer than 93 publications over the last 5 years have used TRISS to compare their outcomes.

"Dr. Rogers’ work could not have come too soon," he remarked.

To get an overall snapshot of mortality, the first part of the study compared outcomes from the 1982-1987 MTOS database for 80,544 patients from 139 U.S. and Canadian hospitals with those from 1.9 million patients from 900 U.S. trauma centers in the 2002-2006 NTDB. Patients were then stratified by mortality and age into 5-year age groups, up to 85-89 years.

In all age groups examined, there was a significant decrease in mortality in the NTDB data set, compared with the MTOS data set (P less than .001), he said. Overall mortality was more than double in the MTOS at 9.0% vs. just 4.4% in the NTDB.

To determine how well TRISS predicts survival over time, the researchers then compared observed to expected (O/E) mortality ratios using TRISS longitudinally and data on 451,868 patients in the Pennsylvania Trauma Outcome Study (PTOS) from 1990 to 2010.

PTOS entry criteria are ICU admission, a hospital length of stay greater than 48 hours, transfers in, and transfers out. The data are drawn from 31 accredited trauma centers and are maintained with strict internal and external auditing, Dr. Rogers said.

The O/E mortality ratios declined significantly over time for all patients in the PTOS database compared with TRISS. This was also true for the 403,935 patients with blunt trauma injuries (P less than .001 for both), indicative of improved outcomes over what would be predicted.

There was a more gradual decline in the O/E mortality ratio among the 47,933 patients with penetrating trauma injuries (P = .73), suggesting that mortality has not improved as much in this population, he said.

If TRISS were accurate, it would have an O/E ratio equal to 1, but the scoring system fell short of this in the PTOS analysis by about 20%, Dr. Rogers said.

"TRISS is drifting out of calibration," he said.

The obvious reason is that trauma care has significantly improved over the last 30 years, particularly in blunt trauma management, and, as expected, O/E mortality ratios have dropped.

In addition, TRISS is based in part on the Injury Severity Score (ISS) and Revised Trauma Score, and as such inherits their limitations. Dr. Rogers pointed out that the ISS isn’t monotonic with respect to death and isn’t linear in the logit of death. Also, the Glasgow Coma Scale can’t be computed for many patients at the highest risk of dying because of endotracheal tubes and chemical paralytic agents. Attempts to fill this gap have been made by data imputation, which he described as a form of mathematical trickery.

"In short, we believe continued attempts to resuscitate TRISS as an outcome predictor are untenable," he said. "With the incredible talent in EAST and other trauma organizations, we believe we can do better."

Dr. Rogers called for a prediction model with a fundamentally sound statistical underpinning that would minimize missing variables such as Glasgow Coma Scale scores, maintain accuracy over time, and contain a clear mechanism for periodic updating.

During the discussion of the study, Dr. Rogers said they compared mortality across ISS categories in the NTDB and PCOS databases and that their comparison confirmed the PTOS finding that mortality has declined over time, after controlling for both ISS and age, in blunt trauma and less convincingly for penetrating trauma.

He suggested that outcomes may have improved in blunt trauma patients because CT scanning has allowed more accurate probing of injuries and that improved field care may be allowing more penetrating trauma patients to survive long enough to get into the data set, but not necessarily out of the hospital.

Finally, TRISS founder and former EAST president Dr. Howard Champion rose from the audience to congratulate the authors on the study and for pointing out the "obvious frailties of TRISS." He suggested the issue revolves around three problematic elements: taxonomy coding, the model, and the coefficients attached to the model.

He pointed out that the United States uses the ICD-9 code, while the rest of the world uses the ICD-10 code and the ICD-11 code is on the horizon. "In other words, we are about two generations behind."

He went on to say that the Abbreviated Injury Score, which is integral to the ISS, was developed in the 1960s and 1970s for engineers and had 78 codes. That number has mushroomed to more than 2,000, and up to 80% of those codes are not used. "There are huge inter-reliability problems with it, suggesting that the Abbreviated Injury Score needs another careful look, as well as the models and the coefficients."

He closed by saying, "There’s a lot to be done. It is not a simple problem; it’s a very challenging problem."

Dr. Rogers said progress will be made by identifying better, more robust predictors for use in trauma outcome models.

Dr. Rogers, his coauthors, and Dr. Nathens reported no conflicts of interest.

LAKE BUENA VISTA, FLA. – The Trauma-Related Injury Severity Score is outdated and should be replaced by a survival prediction model derived from more contemporary mortality rates, a study showed.

The score, known as TRISS, is the workhorse of outcome prediction in trauma. It is integral to the federal Performance Improvement and Patient Safety plan for trauma, is used for benchmarking hospital performance and comparing interhospital performance, and has been incorporated into most commercial trauma registries, including the National Trauma Registry System and the National Trauma Data Bank (NTDB).

Unfortunately, it is based on data collected in the Major Trauma Outcome Study (MTOS) during the 1980s, and its coefficients of survival prediction were last updated in 1995, said lead author Dr. Frederick Rogers, medical director of the Lancaster (Pa.) General Health Trauma Center.

"Few of us have really complained about TRISS up until this point because TRISS is what we consider an easy grader, making our results much better than they really are by comparing ourselves to trauma care in the last century," he said at the annual meeting of the Eastern Association for the Surgery of Trauma (EAST). "We really must be honest with ourselves.

"We must retire TRISS and create a mortality prediction model for the next century that reflects contemporary results."

Invited discussant Dr. Avery Nathens, director of the American College of Surgeons’ Trauma Quality Improvement Program and trauma director at St. Michael’s Hospital in Toronto, said, "I feel like we just heard the obituary for TRISS."

He said the study confirms many of the concerns regarding TRISS and pointed out that no fewer than 93 publications over the last 5 years have used TRISS to compare their outcomes.

"Dr. Rogers’ work could not have come too soon," he remarked.

To get an overall snapshot of mortality, the first part of the study compared outcomes from the 1982-1987 MTOS database for 80,544 patients from 139 U.S. and Canadian hospitals with those from 1.9 million patients from 900 U.S. trauma centers in the 2002-2006 NTDB. Patients were then stratified by mortality and age into 5-year age groups, up to 85-89 years.

In all age groups examined, there was a significant decrease in mortality in the NTDB data set, compared with the MTOS data set (P less than .001), he said. Overall mortality was more than double in the MTOS at 9.0% vs. just 4.4% in the NTDB.

To determine how well TRISS predicts survival over time, the researchers then compared observed to expected (O/E) mortality ratios using TRISS longitudinally and data on 451,868 patients in the Pennsylvania Trauma Outcome Study (PTOS) from 1990 to 2010.

PTOS entry criteria are ICU admission, a hospital length of stay greater than 48 hours, transfers in, and transfers out. The data are drawn from 31 accredited trauma centers and are maintained with strict internal and external auditing, Dr. Rogers said.

The O/E mortality ratios declined significantly over time for all patients in the PTOS database compared with TRISS. This was also true for the 403,935 patients with blunt trauma injuries (P less than .001 for both), indicative of improved outcomes over what would be predicted.

There was a more gradual decline in the O/E mortality ratio among the 47,933 patients with penetrating trauma injuries (P = .73), suggesting that mortality has not improved as much in this population, he said.

If TRISS were accurate, it would have an O/E ratio equal to 1, but the scoring system fell short of this in the PTOS analysis by about 20%, Dr. Rogers said.

"TRISS is drifting out of calibration," he said.

The obvious reason is that trauma care has significantly improved over the last 30 years, particularly in blunt trauma management, and, as expected, O/E mortality ratios have dropped.

In addition, TRISS is based in part on the Injury Severity Score (ISS) and Revised Trauma Score, and as such inherits their limitations. Dr. Rogers pointed out that the ISS isn’t monotonic with respect to death and isn’t linear in the logit of death. Also, the Glasgow Coma Scale can’t be computed for many patients at the highest risk of dying because of endotracheal tubes and chemical paralytic agents. Attempts to fill this gap have been made by data imputation, which he described as a form of mathematical trickery.

"In short, we believe continued attempts to resuscitate TRISS as an outcome predictor are untenable," he said. "With the incredible talent in EAST and other trauma organizations, we believe we can do better."

Dr. Rogers called for a prediction model with a fundamentally sound statistical underpinning that would minimize missing variables such as Glasgow Coma Scale scores, maintain accuracy over time, and contain a clear mechanism for periodic updating.

During the discussion of the study, Dr. Rogers said they compared mortality across ISS categories in the NTDB and PCOS databases and that their comparison confirmed the PTOS finding that mortality has declined over time, after controlling for both ISS and age, in blunt trauma and less convincingly for penetrating trauma.

He suggested that outcomes may have improved in blunt trauma patients because CT scanning has allowed more accurate probing of injuries and that improved field care may be allowing more penetrating trauma patients to survive long enough to get into the data set, but not necessarily out of the hospital.

Finally, TRISS founder and former EAST president Dr. Howard Champion rose from the audience to congratulate the authors on the study and for pointing out the "obvious frailties of TRISS." He suggested the issue revolves around three problematic elements: taxonomy coding, the model, and the coefficients attached to the model.

He pointed out that the United States uses the ICD-9 code, while the rest of the world uses the ICD-10 code and the ICD-11 code is on the horizon. "In other words, we are about two generations behind."

He went on to say that the Abbreviated Injury Score, which is integral to the ISS, was developed in the 1960s and 1970s for engineers and had 78 codes. That number has mushroomed to more than 2,000, and up to 80% of those codes are not used. "There are huge inter-reliability problems with it, suggesting that the Abbreviated Injury Score needs another careful look, as well as the models and the coefficients."

He closed by saying, "There’s a lot to be done. It is not a simple problem; it’s a very challenging problem."

Dr. Rogers said progress will be made by identifying better, more robust predictors for use in trauma outcome models.

Dr. Rogers, his coauthors, and Dr. Nathens reported no conflicts of interest.

LAKE BUENA VISTA, FLA. – The Trauma-Related Injury Severity Score is outdated and should be replaced by a survival prediction model derived from more contemporary mortality rates, a study showed.

The score, known as TRISS, is the workhorse of outcome prediction in trauma. It is integral to the federal Performance Improvement and Patient Safety plan for trauma, is used for benchmarking hospital performance and comparing interhospital performance, and has been incorporated into most commercial trauma registries, including the National Trauma Registry System and the National Trauma Data Bank (NTDB).

Unfortunately, it is based on data collected in the Major Trauma Outcome Study (MTOS) during the 1980s, and its coefficients of survival prediction were last updated in 1995, said lead author Dr. Frederick Rogers, medical director of the Lancaster (Pa.) General Health Trauma Center.

"Few of us have really complained about TRISS up until this point because TRISS is what we consider an easy grader, making our results much better than they really are by comparing ourselves to trauma care in the last century," he said at the annual meeting of the Eastern Association for the Surgery of Trauma (EAST). "We really must be honest with ourselves.

"We must retire TRISS and create a mortality prediction model for the next century that reflects contemporary results."

Invited discussant Dr. Avery Nathens, director of the American College of Surgeons’ Trauma Quality Improvement Program and trauma director at St. Michael’s Hospital in Toronto, said, "I feel like we just heard the obituary for TRISS."

He said the study confirms many of the concerns regarding TRISS and pointed out that no fewer than 93 publications over the last 5 years have used TRISS to compare their outcomes.

"Dr. Rogers’ work could not have come too soon," he remarked.

To get an overall snapshot of mortality, the first part of the study compared outcomes from the 1982-1987 MTOS database for 80,544 patients from 139 U.S. and Canadian hospitals with those from 1.9 million patients from 900 U.S. trauma centers in the 2002-2006 NTDB. Patients were then stratified by mortality and age into 5-year age groups, up to 85-89 years.

In all age groups examined, there was a significant decrease in mortality in the NTDB data set, compared with the MTOS data set (P less than .001), he said. Overall mortality was more than double in the MTOS at 9.0% vs. just 4.4% in the NTDB.

To determine how well TRISS predicts survival over time, the researchers then compared observed to expected (O/E) mortality ratios using TRISS longitudinally and data on 451,868 patients in the Pennsylvania Trauma Outcome Study (PTOS) from 1990 to 2010.

PTOS entry criteria are ICU admission, a hospital length of stay greater than 48 hours, transfers in, and transfers out. The data are drawn from 31 accredited trauma centers and are maintained with strict internal and external auditing, Dr. Rogers said.

The O/E mortality ratios declined significantly over time for all patients in the PTOS database compared with TRISS. This was also true for the 403,935 patients with blunt trauma injuries (P less than .001 for both), indicative of improved outcomes over what would be predicted.

There was a more gradual decline in the O/E mortality ratio among the 47,933 patients with penetrating trauma injuries (P = .73), suggesting that mortality has not improved as much in this population, he said.

If TRISS were accurate, it would have an O/E ratio equal to 1, but the scoring system fell short of this in the PTOS analysis by about 20%, Dr. Rogers said.

"TRISS is drifting out of calibration," he said.

The obvious reason is that trauma care has significantly improved over the last 30 years, particularly in blunt trauma management, and, as expected, O/E mortality ratios have dropped.

In addition, TRISS is based in part on the Injury Severity Score (ISS) and Revised Trauma Score, and as such inherits their limitations. Dr. Rogers pointed out that the ISS isn’t monotonic with respect to death and isn’t linear in the logit of death. Also, the Glasgow Coma Scale can’t be computed for many patients at the highest risk of dying because of endotracheal tubes and chemical paralytic agents. Attempts to fill this gap have been made by data imputation, which he described as a form of mathematical trickery.

"In short, we believe continued attempts to resuscitate TRISS as an outcome predictor are untenable," he said. "With the incredible talent in EAST and other trauma organizations, we believe we can do better."

Dr. Rogers called for a prediction model with a fundamentally sound statistical underpinning that would minimize missing variables such as Glasgow Coma Scale scores, maintain accuracy over time, and contain a clear mechanism for periodic updating.

During the discussion of the study, Dr. Rogers said they compared mortality across ISS categories in the NTDB and PCOS databases and that their comparison confirmed the PTOS finding that mortality has declined over time, after controlling for both ISS and age, in blunt trauma and less convincingly for penetrating trauma.

He suggested that outcomes may have improved in blunt trauma patients because CT scanning has allowed more accurate probing of injuries and that improved field care may be allowing more penetrating trauma patients to survive long enough to get into the data set, but not necessarily out of the hospital.

Finally, TRISS founder and former EAST president Dr. Howard Champion rose from the audience to congratulate the authors on the study and for pointing out the "obvious frailties of TRISS." He suggested the issue revolves around three problematic elements: taxonomy coding, the model, and the coefficients attached to the model.

He pointed out that the United States uses the ICD-9 code, while the rest of the world uses the ICD-10 code and the ICD-11 code is on the horizon. "In other words, we are about two generations behind."

He went on to say that the Abbreviated Injury Score, which is integral to the ISS, was developed in the 1960s and 1970s for engineers and had 78 codes. That number has mushroomed to more than 2,000, and up to 80% of those codes are not used. "There are huge inter-reliability problems with it, suggesting that the Abbreviated Injury Score needs another careful look, as well as the models and the coefficients."

He closed by saying, "There’s a lot to be done. It is not a simple problem; it’s a very challenging problem."

Dr. Rogers said progress will be made by identifying better, more robust predictors for use in trauma outcome models.

Dr. Rogers, his coauthors, and Dr. Nathens reported no conflicts of interest.