The Affordable Care Act currently requires hospitals to report 30-day readmission rates for certain medical conditions. It has been suggested that surveillance will expand to include hip and knee surgery-related readmissions in the future. To ensure quality of care and avoid penalties, readmissions related to hip fractures require further investigation. The goal of this study was to evaluate factors associated with 30-day hospital readmission after hip fracture at a level I trauma center. This retrospective cohort study included 1486 patients who were 65 years or older and had a surgical procedure performed to treat a femoral neck, intertrochanteric, and/or subtrochanteric hip fracture during an 8-year period. Analysis of these patients showed a 30-day readmission rate of 9.35% (n=139). Patients in the readmission group had a significantly higher rate of pre-existing diabetes and pulmonary disease and a longer initial hospital length of stay. Readmissions were primarily the result of medical complications, with only one-fourth occurring secondary to orthopedic surgical failure. Pre-existing pulmonary disease (odds ratio [OR], 1.885; 95% confidence interval [CI], 1.305–2.724), initial hospitalization of 8 days or longer (OR, 1.853; 95% CI, 1.223–2.807), and discharge to a skilled nursing facility (OR, 1.586; 95% CI, 1.043–2.413) were determined to be predictors of readmission. Accordingly, patient management should be consistently geared toward optimizing chronic disease states while concomitantly working to minimize the duration of initial hospitalization and decrease readmission rates.

Enoxaparin regimens commonly used for prophylaxis fail to achieve optimal anti-factor Xa levels in up to 70 per cent of trauma patients. Accordingly, trauma services at the study institution endeavored to develop a standardized approach to optimize pharmacologic prevention with enoxaparin. An enoxaparin venous thromboembolism (VTE) prophylaxis protocol implemented in October 2015 provided weight-adjusted initial dosing parameters with subsequent dose titration to achieve targeted anti-factor Xa levels. Symptomatic VTE rate was evaluated 12 months pre- and post-implementation. Data were obtained from the trauma registry and charts were reviewed from electronic medical records. The rate of symptomatic VTE significantly declined post-implementation (2.0% vs 0.9%, P = 0.009). Enoxaparin use was comparable in these two phases validating that the decline in symptomatic VTEs was not due to an increase in enoxaparin use. Symptomatic VTE rate for patients who received enoxaparin in the post-implementation cohort decreased from 3.2 to 1.0 per cent (P = 0.023, 95% confidence interval = 0.124–0.856). There was also a significant decrease in the rate of symptomatic deep vein thrombosis (2.8% vs 0.9%, P = 0.040, 95% confidence interval = 0.117–0.950). This approach to VTE prophylaxis with enoxaparin resulted in a significant reduction in symptomatic VTE rates. Implementation of similar practices may be equally impactful in other institutions that use enoxaparin.

Objective The objective of this study was to assess the predictive value of lactate and base deficit in determining outcomes in trauma patients who are positive for ethanol. Methods Retrospective cohort study of patients admitted to a level 1 trauma center between 2005 and 2014. Adult patients who had a serum ethanol, lactate, base deficit, and negative urine drug screen obtained upon presentation were included. Results Data for 2482 patients were analyzed with 1127 having an elevated lactate and 1092 an elevated base deficit. In these subgroups, patients with a positive serum ethanol had significantly lower 72-hour mortality, overall mortality, and hospital length of stay compared with the negative ethanol group. Abnormal lactate (odds ratio [OR], 2.607; 95% confidence interval [CI], 1.629–4.173; P = .000) and base deficit (OR, 1.917; 95% CI, 1.183–3.105; P = .008) were determined to be the strongest predictors of mortality in the ethanol-negative patients. Injury Severity Score was found to be the lone predictor of mortality in patients positive for ethanol (OR, 1.104; 95% CI, 1.070–1.138; P=.000). Area under the curve and Youden index analyses supported a relationship between abnormal lactate, base deficit, and mortality in ethanol-positive patients when the serum lactate was greater than 4.45 mmol/L and base deficit was greater than −6.95 mmol/L. Conclusions Previously established relationships between elevated lactate, base deficit, and outcome do not remain consistent in patients presenting with positive serum ethanol concentrations. Ethanol skews the relationship between lactate, base deficit, and mortality thus resetting the threshold in which lactate and base deficit are associated with increased mortality.

Background: Intravenous contrast media-enhanced computed tomography is vitally important in the early identification of traumatic injuries. Contrast media, however, has the propensity to promote nephrotoxicity. Age, injury severity score, renal dysfunction, and hypotension upon presentation are factors associated with contrast-associated acute kidney injury in current trauma literature. This study endeavors to expand upon these findings and evaluate the relationship between traumatic injuries and contrast-associated acute kidney injury. Methods: This is a retrospective cohort study conducted at a Level 1 Trauma Center between January 2005 and August 2013. Patients identified by the institution's Trauma Registry were divided into two groups: contrast-associated acute kidney injury-positive and negative based on previously published definitions. Results: The analysis consisted of 831 intensive care patients; 161 contrast-associated acute kidney injury-positive and 670 contrast-associated acute kidney injury-negative. Logistic regression using significant findings from univariate comparisons between the study groups indicated that genitourinary (OR ¼ 2.859, 95% CI 1.587-5.152, p ¼ 0.000), arterial injuries (OR ¼ 2.464, 95% CI 1.294-4.690, p ¼ 0.006), and concomitant exposure to medications that are potentially nephrotoxic or alter renal hemodynamics (OR ¼ 1.483, 95% CI 1.018-2.158, p ¼ 0.040) were independent risk factors for contrast-associated acute kidney injury. Increasing revised trauma score (OR ¼ 0.874, 95% CI 0.790-0.966, p ¼ 0.009) and fluid administration prior to contrast (OR ¼ 0.445, 95% CI 0.301-0.656, p ¼ 0.000) were independently associated with decreased risk of contrast-associated acute kidney injury. Conclusion: The risk of contrast-associated acute kidney injury increases with escalating injury severity. Unless contraindicated, fluids should be administered prior to contrast, and concomitant exposure to agents that may increase the potential for contrast-associated acute kidney injury should be limited. These practices are increasingly important in patients presenting with arterial or genitourinary trauma.

Introduction The surging popularity of all-terrain vehicles (ATV) in the United States has caused an “epidemic of injuries and mortality.” The U.S. Consumer Product Safety Commission reported 99,600 injuries and 426 fatalities from ATV accidents in 2013. The aim of this study was to examine the relationship between helmet use and positive toxicology screenings on outcomes in ATV accident victims. Methods This is a retrospective study of patients admitted to a Level 1 Trauma Center in southwestern West Virginia following an ATV accident between 2005 and 2013. Data were obtained from the institution’s Trauma Registry. Results A total of 1,857 patients were admitted during the study period with 39 (1.9%) reported deaths. Positive serum alcohol and/or urine drug screens were obtained in 66.4% of the patients tested (n = 1,293). Those with positive screenings were 9.5% less likely to utilize a helmet (13.2% vs. 22.7%, p < 0.001); and the lack of helmet use was associated with an increase in traumatic brain injury (57.1% vs. 41.7%, p < 0.001). Positivity for substances or the lack of helmet use was significantly associated with higher morbidity. Lack of helmet use resulted in a 3.94-fold increase in the risk of discharge in a vegetative state or death. Conclusions Drugs and alcohol use may predispose riders to be less likely to wear helmets and significantly increase the risk of a poor clinical outcome following an ATV accident. Rigorous efforts should be made to enhance safety measures through educational endeavors and amendment of current regulations to promote safe and responsible use of ATVs. Practical applications Modification of regulatory requirements should be considered in order to mandate the wearing of helmets during ATV operation. In addition, expansion of safety programs should be considered in an effort to improve availability, affordability and awareness of safe ATV practices.