Paul M. Maggio, MD, MBA, FACS

All Publications

• A value-based approach to optimize red blood cell transfusion in patients receiving extracorporeal membrane oxygenation. Perfusion Shudo, Y., Cheng, N., He, H., Rosenberg, C., Hiesinger, W., Hadhazy, E., Shepard, J., Krishna, P., Resnik, J., Fong, R., Hill, C., Hsu, J. L., Maggio, P. M., Chang, S., Boyd, J. H., Woo, Y. J. 2022: 2676591221128138

  Abstract

  INTRODUCTION: The risk, cost, and adverse outcomes associated with packed red blood cell (RBC) transfusions in patients with cardiopulmonary failure requiring extracorporeal membrane oxygenation (ECMO) have raised concerns regarding the overutilization of RBC products. It is, therefore, necessary to establish optimal transfusion criteria and protocols for patients supported with ECMO. The goal of this study was to establish specific criteria for RBC transfusions in patients undergoing ECMO.METHODS: This was a retrospective cohort study conducted at Stanford University Hospital. Data on RBC utilization during the entire hospital stay were obtained, which included patients aged ≥18years who received ECMO support between 1 January 2017, and 30 June 2020 (n = 281). The primary outcome was in-hospital mortality.RESULTS: Hemoglobin (HGB) levels >10g/dL before transfusion did not improve in-hospital survival. Therefore, we revised the HGB threshold to ≤10g/dL to guide transfusion in patients undergoing ECMO. To validate this intervention, we prospectively compared the pre- and post-intervention cohorts for in-hospital mortality. Post-intervention analyses found 100% compliance for all eligible records and a decrease in the requirement for RBC transfusion by 1.2 units per patient without affecting the mortality.CONCLUSIONS: As an institution-driven value-based approach to guide transfusion in patients undergoing ECMO, we lowered the threshold HGB level. Validation of this revised intervention demonstrated excellent compliance and reduced the need for RBC transfusion while maintaining the clinical outcome. Our findings can help reform value-based healthcare in this cohort while maintaining the outcome.

  View details for DOI 10.1177/02676591221128138

  View details for PubMedID 36148806

• Improving tracheostomy delivery for trauma and surgical critical care patients: timely trach initiative. BMJ open quality McShane, E. K., Sun, B. J., Maggio, P. M., Spain, D. A., Forrester, J. D. 2022; 11 (2)

  Abstract

  BACKGROUND: Tracheostomy is recommended within 7days of intubation for patients with severe traumatic brain injury (TBI) or requiring prolonged mechanical ventilation. A quality improvement project aimed to decrease time to tracheostomy to ≤7days after intubation for eligible patients requiring tracheostomy in the surgical intensive care unit (SICU).LOCAL PROBLEM: From January 2017 to June 2018, approximately 85% of tracheostomies were performed >7days after intubation. The tracheostomy was placed a median of 10 days after intubation (range: 1-57).METHODS: Quality improvement principles were applied at an American College of Surgeons-verified level I trauma centre to introduce and analyse interventions to improve tracheostomy timing. Using the electronic health record, we analysed changes in tracheostomy timing, hospital length of stay (LOS), ventilator-associated pneumonia and peristomal bleeding rates for three subgroups: patients with TBI, trauma patients and all SICU patients.INTERVENTIONS: In July 2018, an educational roll-out for SICU residents and staff was launched to inform them of potential benefits of early tracheostomy and potential complications, which they should discuss when counselling patient decision-makers. In July 2019, an early tracheostomy workflow targeting patients with head injury was published in an institutional Trauma Guide app.RESULTS: Median time from intubation to tracheostomy decreased for all patients from 14 days (range: 4-57) to 8days (range: 1-32, p≤0.001), and median hospital LOS decreased from 38 days to 24 days (p<0.001, r=0.35). Median time to tracheostomy decreased significantly for trauma patients after publication of the algorithm (10 days (range: 3-21days) to 6days (range: 1-15days), p=0.03). Among patients with TBI, family meetings were held earlier for patients who underwent early versus late tracheostomy (p=0.008).CONCLUSIONS: We recommend regular educational meetings, enhanced by digitally published guidelines and strategic communication as effective ways to improve tracheostomy timing. These interventions standardised practice and may benefit other institutions.

  View details for DOI 10.1136/bmjoq-2021-001589

  View details for PubMedID 35551095

• Engaging Frontline Physicians in Value Improvement: A Qualitative Evaluation of Physician-Directed Reinvestment. Journal of healthcare leadership Vilendrer, S., Amano, A., Asch, S. M., Brown-Johnson, C., Lu, A. C., Maggio, P. 2022; 14: 31-45

  Abstract

  Purpose: Physicians can limit upward trending healthcare costs, yet legal and ethical barriers prevent the use of direct financial incentives to engage physicians in cost-reduction initiatives. Physician-directed reinvestment is an alternative value-sharing arrangement in which a health system reinvests a portion of savings attributed to physician-led cost reduction initiatives back into professional areas of the physicians' choosing. Formal evaluations of such programs are lacking.Methods: To understand the impact of Stanford Health Care's physician-directed reinvestment in its first year (2017-2018) on physician engagement, adherence to program requirements around safety and fund use, and factors facilitating program dissemination, semi-structured qualitative interviews with physician participants, non-participants, and administrative stakeholders were conducted July-November 2019. Interview transcripts were qualitatively analyzed through an implementation science lens. To support contextual analysis of the qualitative data, a directional estimation of the program's impact on cost from the perspective of the health system was calculated by subtracting annual maintenance cost (derived from interview self-reported time estimates and public salary data) from internal cost accounting of the total savings from first year cohort to obtain annual net benefit, which was then divided by the annual maintenance cost.Results: Physician participation was low compared with the overall physician population (n=14 of approximately 2300 faculty physicians), though 32 qualitative interviews suggested deep engagement across physician participants and adherence to target program requirements. Reinvestment funds activated intrinsic motivators such as autonomy, purpose and inter-professional relations, and extrinsic motivators, such as the direction of resources and external recognition. Ongoing challenges included limited physician awareness of healthcare costs and the need for increased clarity around which projects rise above one's existing job responsibilities. Administrative data excluding physician time, which was not directly compensated, showed a direct cost savings of $8.9M. This implied an 11-fold return on investment excluding uncompensated physician time.Conclusion: A physician-directed reinvestment program appeared to facilitate latent frontline physician innovation towards value, though additional evaluation is needed to understand its long-term impact.

  View details for DOI 10.2147/JHL.S335763

  View details for PubMedID 35422669

• Patient and surgeon experiences with video visits in plastic surgery-toward a data-informed scheduling triage tool. Surgery Brown-Johnson, C. G., Spargo, T., Kling, S. M., Saliba-Gustafsson, E. A., Lestoquoy, A. S., Garvert, D. W., Vilendrer, S., Winget, M., Asch, S. M., Maggio, P., Nazerali, R. S. 2021

  Abstract

  BACKGROUND: Coronavirus disease 2019 provided the impetus for unprecedented adoption of telemedicine. This study aimed to understand video visit adoption by plastic surgery providers; and patient and surgeon perceptions about its efficacy, value, accessibility, and long-term viability. A secondary aim was to develop the proposed 'Triage Tool for Video Visits in Plastic Surgery' to help determine visit video eligibility.METHODS: This mixed-methods evaluation assessed provider-level scheduling data from the Division of Plastic and Reconstructive Surgery at Stanford Health Care to quantify telemedicine adoption and semi-structured phone interviews with patients (n= 20) and surgeons (n= 10) to explore stakeholder perspectives on video visits.RESULTS: During the 13-week period after the local stay-at-home orders due to coronavirus disease 2019, 21.4% of preoperative visits and 45.5% of postoperative visits were performed via video. Video visits were considered acceptable by patients and surgeons in plastic surgery in terms of quality of care but were limited by the inability to perform a physical examination. Interviewed clinicians reported that long-term viability needs to be centered around technology (eg, connection, video quality, etc) and physical examinations. Our findings informed a proposed triage tool to determine the appropriateness of video visits for individual patients that incorporates visit type, anesthesia, case, surgeon's role, and patient characteristics.CONCLUSION: Video technology has the potential to facilitate and improve preoperative and postoperative patient care in plastic surgery but the following components are needed: patient education on taking high-quality photos; standardized clinical guidelines for conducting video visits; and an algorithm-assisted triage tool to support scheduling.

  View details for DOI 10.1016/j.surg.2021.03.029

  View details for PubMedID 33941389

• Cost of Health Care-Associated Infections in the United States. Journal of patient safety Forrester, J. D., Maggio, P. M., Tennakoon, L. n. 2021

  Abstract

  Health care-associated infections (HAIs) are costly, and existing national cost estimates are out-of-date.We retrospectively analyzed the Agency for Healthcare Cost and Utilization Project's 2016 National Inpatient Sample, the largest all-payer U.S. inpatient database. We included all inpatient encounters with primary or secondary International Classification of Disease, 10th Revision Clinical Modification diagnosis codes corresponding to infection with catheter-associated urinary tract infections (T85.511), catheter- and line-associated blood stream infections (T80.211), surgical site infections (SSIs; T81.49), ventilator-associated pneumonias (J95.851), and Infection with Clostridioides difficile (CDI; A04.7). We combined HAI incidence data from the National Inpatient Sample with additional hospital inpatient HAI cost estimates to create national cost estimates for HAI individually and collectively.In 2016, 7.2 to 14.9 billion U.S. dollars were spent on HAIs in the United States. For admissions with any diagnosis of HAI, the frequencies of HAI in descending order were as follows: CDI (n = 356,754 [56%]), SSI (n = 196,215 [31%]), catheter- and line-associated blood stream infection (n = 42,811 [7%]), catheter-associated urinary tract infection (n = 23,546 [4%]), and ventilator-associated pneumonia (n = 16,767 [3%]). Collectively, CDI and SSI accounted for 79% of the cost of HAI in the United States.Health care-associated infections remain a significant economic burden for health care systems in the United States.

  View details for DOI 10.1097/PTS.0000000000000845

  View details for PubMedID 33881808

• Modified percutaneous tracheostomy in patients with COVID-19. Trauma surgery & acute care open Sun, B. J., Wolff, C. J., Bechtold, H. M., Free, D., Lorenzo, J., Minot, P. R., Maggio, P. G., Spain, D. A., Weiser, T. G., Forrester, J. D. 2020; 5 (1): e000625

  Abstract

  Patients hospitalized with COVID-19 are at risk of developing hypoxic respiratory failure and often require prolonged mechanical ventilation. Indication and timing to perform tracheostomy is controversial in patients with COVID-19.This was a single-institution retrospective review of tracheostomies performed on patients admitted for COVID-19 between April 8, 2020 and August 1, 2020 using a modified percutaneous tracheostomy technique to minimize hypoxia and aerosolization.Twelve tracheostomies were performed for COVID-related respiratory failure. Median patient age was 54 years (range: 36-76) and 9 (75%) were male. Median time to tracheostomy was 17 days (range: 10-27), and 5 (42%) patients had failed attempts at extubation prior to tracheostomy. There were no intraprocedural complications, including hypoxia. Post-tracheostomy bleeding was noted in two patients. Eight (67%) patients have been discharged at the time of this study, and there were four patient deaths unrelated to tracheostomy placement. No healthcare worker transmissions resulted from participating in the tracheostomy procedure.A modified percutaneous tracheostomy is feasible and can be safely performed in patients infected with COVID-19.Level V, case series.

  View details for DOI 10.1136/tsaco-2020-000625

  View details for PubMedID 34192161

  View details for PubMedCentralID PMC7736959

• The Consequences of Delaying Elective Surgery: Surgical Perspective. Annals of surgery Fu, S. J., George, E. L., Maggio, P. M., Hawn, M., Nazerali, R. 2020; 272 (2): e79-e80

  View details for DOI 10.1097/SLA.0000000000003998

  View details for PubMedID 32675504

• An Incentive to Innovate: Improving Health Care Value and Restoring Physician Autonomy Through Physician-Directed Reinvestment. Academic medicine : journal of the Association of American Medical Colleges Vilendrer, S. M., Asch, S. M., Anzai, Y., Maggio, P. 2020

  Abstract

  PROBLEM: Many health care systems in the United States are shifting from a fee-for-service reimbursement model to a value-based payment model. To remain competitive, health care administrators must engage frontline clinicians in their efforts to reduce costs and improve patient outcomes. Engaging physicians and other clinicians is challenging, however, as many feel overwhelmed with clinical responsibilities and do not view cost reduction as in their purview. Even if they are willing, providing a direct financial incentive to clinicians to control costs poses ethical and legal challenges. An effective incentive in the current system must motivate clinicians to engage in creative problem solving and mitigate ethical and legal risk.APPROACH: Evidence suggests the most successful behavior change interventions in physicians are multi-faceted and combine intrinsic motivators, such as increased autonomy, with extrinsic motivators, such as access to funding or social recognition. Two academic health centers-the University of Utah Health and Stanford Health Care-have begun experimenting with an alternative value-sharing arrangement. Physician-directed reinvestment is an explicit agreement in which a health care system reinvests a portion of savings attributed to physician-led cost reduction initiatives back into areas of the physician's choosing, such as capital investment, research, or education.OUTCOMES: Both organizations reported similar positive outcomes, including increased engagement from clinicians and administrators, sustained or improved quality of care, reduced costs of care, and benefits from reinvested funds. Many savings opportunities were previously unknown to administrators.NEXT STEPS: Physician-directed reinvestment appears to effectively engage physicians in ongoing efforts to improve value in health care, although formal evaluation is still needed. This incentive structure may hold promise in other configurations, such as inviting non-physicians to apply as project leaders (clinician-directed reinvestment) and expanding the program to non-academic and ambulatory settings.

  View details for DOI 10.1097/ACM.0000000000003650

  View details for PubMedID 32739931

• The Consequences of Delaying Elective Surgery: Surgical Perspective. Annals of surgery Fu, S. J., George, E. L., Maggio, P. M., Hawn, M., Nazerali, R. 2020

  View details for DOI 10.1097/SLA.0000000000003998

  View details for PubMedID 32355120

• A minimalist electronic health record-based intervention to reduce standing lab utilisation. Postgraduate medical journal Chin, K., Krishnamurthy, A., Zubair, T., Ramaswamy, T., Hom, J., Maggio, P., Shieh, L. 2020

  Abstract

  BACKGROUND: Repetitive laboratory testing in stable patients is low-value care. Electronic health record (EHR)-based interventions are easy to disseminate but can be restrictive.OBJECTIVE: To evaluate the effect of a minimally restrictive EHR-based intervention on utilisation.SETTING: One year before and after intervention at a 600-bed tertiary care hospital. 18000 patients admitted to General Medicine, General Surgery and the Intensive Care Unit (ICU).INTERVENTION: Providers were required to specify the number of times each test should occur instead of being able to order them indefinitely.MEASUREMENTS: For eight tests, utilisation (number of labs performed per patient day) and number of associated orders were measured.RESULTS: Utilisation decreased for some tests on all services. Notably, complete blood count with differential decreased 9% (p<0.001) on General Medicine and 21% (p<0.001) in the ICU.CONCLUSIONS: Requiring providers to specify the number of occurrences of labs changes significantly reduces utilisation in some cases.

  View details for DOI 10.1136/postgradmedj-2019-136992

  View details for PubMedID 32051280

• Precautions for Operating Room Team Members during the COVID-19 Pandemic. Journal of the American College of Surgeons Forrester, J. D., Nassar, A. K., Maggio, P. M., Hawn, M. T. 2020

  Abstract

  The novel corona virus SARS-CoV-2 (COVID-19) can infect healthcare workers. We developed an institutional algorithm to protect operating room team members during the COVID-19 pandemic and rationally conserve personal protective equipment (PPE).An interventional platform (operating room, interventional suites, and endoscopy) PPE taskforce was convened by the hospital and medical school leadership and tasked with developing a common algorithm for PPE use, to be used throughout the interventional platform. In conjunction with our infection disease experts, we developed our guidelines based upon potential patterns of spread, risk of exposure and conservation of PPE.A decision tree algorithm describing our institutional guidelines for precautions for operating room team members was created. This algorithm is based on urgency of operation, anticipated viral burden at the surgical site, opportunity for a procedure to aerosolize virus, and likelihood a patient could be infected based on symptoms and testing.Despite COVID-19 being a new threat, we have shown that by developing an easy-to-follow decision tree algorithm for the interventional platform teams, we can ensure optimal healthcare worker safety.

  View details for DOI 10.1016/j.jamcollsurg.2020.03.030

  View details for PubMedID 32247836

• Modified percutaneous tracheostomy in patients with COVID-19 Trauma Surg Acute Care Open Sun, B. J., Wolff, C. J., Bechtold, H. M., Free, D., Lorenzo, J., Minot, P. R., Maggio, P. G., Spain, D. A., Weiser, T. G., Forrester, J. D. 2020; 5 (1)

  View details for DOI 10.1136/tsaco-2020-000625

• Mandatory Use of Perioperative Disposable Jackets-Things We Do for No Good Reason. JAMA surgery Maggio, P. M., Hawn, M. T. 2019

  View details for DOI 10.1001/jamasurg.2019.4086

  View details for PubMedID 31642892

• Developing an Inpatient Relationship-Centered Communication Curriculum for Surgical Teams: Pilot Study Nassar, A., Weimer-Elder, B., Kline, M., Minthorn, C., Staudenmayer, K. L., Yang, R., Spain, D. A., Maggio, P., Korndorffer, J. R., Johnson, T. ELSEVIER SCIENCE INC. 2019: E48

  View details for Web of Science ID 000492749600102

• Performance improvement in surgery. Current problems in surgery Alban, R. F., Anania, E. C., Cohen, T. N., Fabri, P. J., Gewertz, B. L., Jain, M. n., Jopling, J. K., Maggio, P. M., Sanchez, J. A., Sax, H. C. 2019; 56 (6): 211–46

  View details for DOI 10.1067/j.cpsurg.2019.02.002

  View details for PubMedID 31155033

• Performance improvement in surgery. Current problems in surgery Alban, R. F., Anania, E. C., Cohen, T. N., Fabri, P. J., Gewertz, B. L., Jain, M. n., Jopling, J. K., Maggio, P. M., Sanchez, J. A., Sax, H. C. 2019; 56 (6): 204–8

  View details for DOI 10.1067/j.cpsurg.2019.02.003

  View details for PubMedID 31155032

• The association between angioembolization and splenic salvage for isolated splenic injuries. The Journal of surgical research Rosenberg, G. M., Weiser, T. G., Maggio, P. M., Browder, T. D., Tennakoon, L., Spain, D. A., Staudenmayer, K. L. 2018; 229: 150–55

  Abstract

  BACKGROUND: Recent data suggest improved splenic salvage rates when angioembolization (AE) is routinely employed for high-grade splenic injuries; however, protocols and salvage rates vary among centers.MATERIALS/METHODS: Adult patients with isolated splenic injuries were identified using the National Trauma Data Bank, 2013-2014. Patients were excluded if they underwent immediate splenectomy or died in the emergency department. To characterize patterns of AE, trauma centers were grouped into quartiles based on frequency of AE use. Unadjusted analyses and mixed-effects logistical regression controlling for center effects were performed.RESULTS: Five thousand and ninety three adult patients were identified. Overall, 705 (13.8%) underwent AE and 290 (5.7%) required a splenectomy. In unadjusted comparisons, splenectomy rates were lower for patients with severe spleen injuries who underwent AE (7% versus 11%, P=0.02). In mixed-effect logistical regression patients with severe splenic injuries undergoing AE had a lower odds ratio (OR) for splenectomy (OR = 0.67, P=0.04). Patients treated at centers in the highest quartile of AE use had a lower OR for splenectomy (OR = 0.58, P=0.02).CONCLUSIONS: The use of AE in patients with isolated severe splenic injuries is associated with decreased splenectomy rates. There is an association between centers that perform AE frequently and reduced splenectomy rates.

  View details for PubMedID 29936983

• The association between angioembolization and splenic salvage for isolated splenic injuries Rosenberg, G. M., Weiser, T. G., Maggio, P. M., Browder, T. D., Tennakoon, L., Spain, D. A., Staudenmayer, K. L. ACADEMIC PRESS INC ELSEVIER SCIENCE. 2018: 150–55

  View details for DOI 10.1016/j.jss.2018.03.013

  View details for Web of Science ID 000436501300021

• Night-time communication at Stanford University Hospital: perceptions, reality and solutions BMJ QUALITY & SAFETY Sun, A., Wang, L., Go, M., Eggers, Z., Deng, R., Maggio, P., Shieh, L. 2018; 27 (2): 156–62

  Abstract

  Resident work hour restrictions have led to the creation of the 'night float' to care for the patients of multiple primary teams after hours. These residents are often inundated with acute issues in the numerous patients they cover and are less able to address non-urgent issues that arise at night. Further, non-urgent pages may contribute to physician alarm fatigue and negatively impact patient outcomes.To delineate the burden of non-urgent paging at night and propose solutions.We performed a resident review and categorisation of 1820 pages to night floats between September 2014 and December 2014. Both attending and nursing review of 10% of pages was done and compared.Of reviewed pages, 62.1% were urgent and 27.7% were non-urgent. Attending review of random page samples correlated well with resident review. Common reasons for non-urgent pages were non-urgent patient status updates, low-priority order requests and non-critical lab values.A significant number of non-urgent pages are sent at night. These pages likely distract from acute issues that arise at night and place an unnecessary burden on night floats. Both behavioural and systemic adjustments are needed to address this issue. Possible interventions include integrating low-priority messaging into the electronic health record system and use of charge nurses to help determine urgency of issues and batch non-urgent pages.

  View details for PubMedID 29055898

• Real-Time Clinical Decision Support Decreases Inappropriate Plasma Transfusion AMERICAN JOURNAL OF CLINICAL PATHOLOGY Shah, N., Baker, S. A., Spain, D., Shieh, L., Shepard, J., Hadhazy, E., Maggio, P., Goodnough, L. T. 2017; 148 (2): 154–60

  Abstract

  To curtail inappropriate plasma transfusions, we instituted clinical decision support as an alert upon order entry if the patient's recent international normalized ratio (INR) was 1.7 or less.The alert was suppressed for massive transfusion and within operative or apheresis settings. The plasma order was automatically removed upon alert acceptance while clinical exception reasons allowed for continued transfusion. Alert impact was studied comparing a 7-month control period with a 4-month intervention period.Monthly plasma utilization decreased 17.4%, from a mean ± SD of 3.40 ± 0.48 to 2.82 ± 0.6 plasma units per hundred patient days (95% confidence interval [CI] of difference, -0.1 to 1.3). Plasma transfused below an INR of 1.7 or less decreased from 47.6% to 41.6% (P = .0002; odds ratio, 0.78; 95% CI, 0.69-0.89). The alert recommendation was accepted 33% of the time while clinical exceptions were chosen in the remaining cases (active bleeding, 31%; other clinical indication, 33%; and apheresis, 2%). Alert acceptance rate varied significantly among different provider specialties.Clinical decision support can help curtail inappropriate plasma use but needs to be part of a comprehensive strategy including audit and feedback for comprehensive, long-term changes.

  View details for PubMedID 28898990

• Clinical phenotypes of US level I trauma centers: use of clustering methodology Forrester, J. D., Weiser, T. G., Maggio, P., Browder, T., Tennakoon, L., Spain, D. A., Staudenmayer, K. ACADEMIC PRESS INC ELSEVIER SCIENCE. 2017: 146–52

  Abstract

  American College of Surgeons Level I Trauma Centers (ACSL1TCs) meet the same personnel and structural requirements but serve different populations. We hypothesized that these nuanced differences may amenable to description through mathematical clustering methodology.The National Trauma Data Bank 2014 was used to derive information on ACSL1TCs. Explorative cluster hypothesis generation was performed using Ward's linkage to determine expected number of clusters based on patient and injury characteristics. Subsequent k-means clustering was applied for analysis. Comparison between clusters was performed using the Kruskal-Wallis or chi-square test.In 2014, 113 ACSL1TCs admitted 267,808 patients (median = 2220 patients, range: 928-6643 patients). Three clusters emerged. Cluster I centers (n = 53, 47%) were more likely to admit older, Caucasian patients who suffered from falls (P < 0.05) and had higher proportions of private (31%) and Medicare payers (29%) (P = 0.001). Cluster II centers (n = 18, 16%) were more likely to admit younger, minority males who suffered from penetrating trauma (P < 0.05) and had higher proportions of Medicaid (24%) or self-pay patients (19%) (P = 0.001). Cluster III centers (n = 42, 37%) were similar to cluster I with respect to racial demographic and payer status but resembled cluster II centers with respect to injury patterns (P < 0.05).Our analysis identified three unique, mathematically definable clusters of ACSL1TCs serving three broadly different patient populations. Understanding these mathematically definable clusters should have utility when assessing an institution's financial risk profile, directing prevention and outreach programs, and performing needs and resource assessments. Ultimately, clustering allows for more meaningful direct comparisons between phenotypically similar trauma centers.

  View details for PubMedID 28688640

• The prevalence of psychiatric diagnoses and associated mortality in hospitalized US trauma patients JOURNAL OF SURGICAL RESEARCH Townsend, L. L., Esquivel, M. M., Uribe-Leitz, T., Weiser, T. G., Maggio, P. M., Spain, D. A., Tennakoon, L., Staudenmayer, K. 2017; 213: 171–76

  Abstract

  We hypothesized that psychiatric diagnoses would be common in hospitalized trauma patients in the United States and when present, would be associated with worse outcomes.The Nationwide Inpatient Sample (NIS, 2012) was used to determine national estimates for the number of patients admitted with an injury. Psychiatric diagnoses were identified using diagnosis codes according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.A total of 36.5 million patients were admitted to hospitals in the United States in 2012. Of these, 1.3 million (4%) were due to trauma. Psychiatric conditions were more common in patients admitted for trauma versus those admitted for other reasons (44% versus 34%, P < 0.001). Trauma patients who had a psychiatric diagnosis compared to trauma patients without a psychiatric diagnosis were older (mean age: 61 versus 56 y, P < 0.001), more often female (52% versus 50%, P < 0.001), and more often white (73% versus 68%, P < 0.001). For ages 18-64, drug and alcohol abuse predominated (41%), whereas dementia and related disorders (48%) were the most common in adults ≥65 y. Mortality was lower for trauma patients with a psychiatric diagnosis compared to those who did not in both unadjusted and adjusted analysis (1.9% versus 2.8%; odds ratio: 0.56, P < 0.001).Psychiatric conditions are present in almost half of all hospitalized trauma patients in the United States; however, the types of conditions varied with age. The frequency of psychiatric conditions in the trauma population suggests efforts should be made to address this component of patient health.

  View details for PubMedID 28601311

• National Readmission Patterns of Isolated Splenic Injuries Based on Initial Management Strategy. JAMA surgery Rosenberg, G. M., Knowlton, L. n., Rajasingh, C. n., Weng, Y. n., Maggio, P. M., Spain, D. A., Staudenmayer, K. L. 2017; 152 (12): 1119–25

  Abstract

  Options for managing splenic injuries have evolved with a focus on nonoperative management. Long-term outcomes, such as readmissions and delayed splenectomy rate, are not well understood.To describe the natural history of isolated splenic injuries in the United States and determine whether patterns of readmission were influenced by management strategy.The Healthcare Cost and Utilization Project's Nationwide Readmission Database is an all-payer, all-ages, longitudinal administrative database that provides data on more than 35 million weighted US discharges yearly. The database was used to identify patients with isolated splenic injuries and the procedures that they received. Adult patients with isolated splenic injuries admitted from January 1 through June 30, 2013, and from January 1 through June 30, 2014, were included. Those who died during the index hospitalization or who had an additional nonsplenic injury with an Abbreviated Injury Score of 2 or greater were excluded. Univariate and mixed-effects logistic regression analysis controlling for center effect were used. Weighted numbers are reported.Initial management strategy at the time of index hospitalization, including nonprocedural management, angioembolization, and splenectomy.All-cause 6-month readmission rate. Secondary outcome was delayed splenectomy rate.A weighted sample of 3792 patients (2146 men [56.6%] and 1646 women [43.4%]; mean [SE] age, 48.5 [0.7] years) with 5155 admission events was included. During the index hospitalization, 825 (21.8%) underwent splenectomy, 293 (7.7%) underwent angioembolization, and 2673 (70.5%) had no procedure. The overall readmission rate was 21.1% (799 patients). Readmission rates did not differ based on initial management strategy (195 patients undergoing splenectomy [23.6%], 70 undergoing angioembolism [23.9%], and 534 undergoing no procedure [20%]; P = .33). Splenectomy was performed in 36 of 799 readmitted patients (4.5%) who did not have a splenectomy at their index hospitalization, leading to an overall delayed splenectomy rate of 1.2% (36 of 2967 patients). In mixed-effects logistic regression analysis controlling for patient, injury, clinical, and hospital characteristics, the choice of splenectomy (odds ratio, 0.93; 95% CI, 0.66-1.31) vs angioembolization (odds ratio, 1.19; 95% CI, 0.72-1.97) as initial management strategy was not associated with readmission.This national evaluation of the natural history of isolated splenic injuries from index admission through 6 months found that approximately 1 in 5 patients are readmitted within 6 months of discharge after an isolated splenic injury. However, the chance of readmission for splenectomy after initial nonoperative management was 1.2%. This finding suggests that the current management strategies used for isolated splenic injuries in the United States are well matched to patient need.

  View details for PubMedID 28768329

• Trends in open vascular surgery for trauma: implications for the future of acute care surgery. journal of surgical research Forrester, J. D., Weiser, T. G., Maggio, P., Browder, T., Tennakoon, L., Spain, D., Staudenmayer, K. 2016; 205 (1): 208-212

  Abstract

  Trauma patients with vascular injuries have historically been within a general surgeon's operative ability. Changes in training and decline in operative trauma have decreased trainees' exposure to these injuries. We sought to determine how frequently vascular procedures are performed at US trauma centers to quantify the need for general surgeons trained to manage vascular injuries.We conducted a retrospective analysis of the National Trauma Data Base (NTDB) from 2012 compared with 2002. Patients with general surgical and vascular procedures were identified using International Classification of Diseases, Ninth Revision, procedure codes 38.0-39.99, excluding 38.9-38.99.General surgery or vascular operations were performed on 12,099 (24%) of 50,248 severely injured adult patients in 2002 and 21,854 (16%) of 138,009 injured patients in 2012. Nineteen percent to 26% of all patients underwent vascular procedures. Patients with combined general surgery and vascular procedures were less likely to be discharged home and more likely to die. In 2002, 6% of severely injured adult trauma patients underwent open vascular procedures at level III/IV trauma centers; by 2012, only 1% of vascular surgery procedures were performed at level III/IV centers (P < 0.001).Need for emergent vascular surgery remains common for severely injured patients. Future trauma systems and surgical training programs will need to account for the need for open vascular skills. The findings suggest that there is already a trend away from open vascular procedures at level III/IV trauma centers, which may be a sign of system compensation for changes in the workforce.

  View details for DOI 10.1016/j.jss.2016.06.032

  View details for PubMedID 27621021

• Trends in the management of pelvic fractures, 2008-2010 JOURNAL OF SURGICAL RESEARCH Chu, C. H., Tennakoon, L., Maggio, P. M., Weiser, T. G., Spain, D. A., Staudenmayer, K. L. 2016; 202 (2): 335-340

  Abstract

  Bleeding from pelvic fractures can be lethal. Angioembolization (AE) and external fixation (EXFIX) are common treatments to control bleeding, but it is not known how frequently they are used. We hypothesized that AE would be increasingly more common compared with EXFIX over time.The National Trauma Data Bank for the years from 2008-2010 were used. Patients were included in the study if they had an International Classification of Diseases, ninth edition, Clinical Modification codes for pelvic fractures and were aged ≥18 y. Patients were excluded if they had isolated acetabular fractures, were not admitted, or had minor injuries. Outcomes included receiving a procedure and in-hospital mortality.A total of 22,568 patients met study criteria. AE and EXFIX were performed in 746 (3.3%) and 663 (2.9%) patients, respectively. AE was performed more often as the study period progressed (2.5% in 2007 to 3.7% in 2010; P < 0.001). This remained significant in adjusted analysis (odds ratio per year 1.15; P = 0.008). Having a procedure was associated with higher mortality in unadjusted analyses compared with those with no procedure (11.0% for no procedure versus 20.5% and 13.4% for AE or EXFIX, respectively; P < 0.001). In adjusted analyses, only AE remained associated with higher mortality (odds ratio 1.63; P < 0.001).AE in severely injured pelvic fracture patients is increasing. AE is associated with higher mortality, which may reflect the fact that it is used for patients at higher risk of death. The role of AE for bleeding should be examined in future studies.

  View details for DOI 10.1016/j.jss.2015.12.052

  View details for PubMedID 27229108

• The Triage of Injured Patients: Mechanism of Injury, Regardless of Injury Severity, Determines Hospital Destination AMERICAN SURGEON Staudenmayer, K., Wang, N. E., Weiser, T. G., Maggio, P., Mackersie, R. C., Spain, D., Hsia, R. Y. 2016; 82 (4): 356-361

  Abstract

  The target rate for trauma undertriage is <5 per cent, but rates are as high as 30 to 40 per cent in many trauma systems. We hypothesized that high undertriage rates were due to the tendency to undertriage injured elderly patients and a growing elderly population. We conducted a retrospective analysis of all hospital visits in California using the Office of Statewide Health Planning and Development Database over a 5-year period. All hospital admissions and emergency department visits associated with injury were longitudinally linked. The primary outcome was triage pattern. Triage patterns were stratified across three dimensions: age, mechanism of injury, and access to care. A total of 60,182 severely injured patients were included in the analysis. Fall-related injuries were frequently undertriaged compared with injuries from motor vehicle collisions (MVCs) and penetrating trauma (52% vs 12% and 10%, respectively). This pattern was true for all age groups. Conversely, MVCs and penetrating traumas were associated with high rates of overtriage (>70% for both). In conclusion, in contrast to our hypothesis, we found that triage is largely determined by mechanism of injury regardless of injury severity. High rates of undertriage are largely due to the undertriage of fall-related injuries, which occurs in both younger and older adults. Patients injured after MVCs and penetrating trauma victims are brought to trauma centers regardless of injury severity, resulting in high rates of overtriage. These findings suggest an opportunity to improve trauma system performance.

  View details for Web of Science ID 000377853800022

  View details for PubMedID 27097630

• Trauma center care is associated with reduced readmissions after injury. journal of trauma and acute care surgery Staudenmayer, K., Weiser, T. G., Maggio, P. M., Spain, D. A., Hsia, R. Y. 2016; 80 (3): 412-418

  Abstract

  Trauma center care has been associated with improved mortality. It is not known if access to trauma center care is also associated with reduced readmissions. We hypothesized that receiving treatment at a trauma center would be associated with improved care and therefore would be associated with reduced readmission rates.We conducted a retrospective analysis of all hospital visits in California using the Office of Statewide Health Planning and Development Database from 2007-2008. All hospital admissions and emergency department visits associated with injury were longitudinally linked. Regions were categorized by whether or not they had trauma centers. We excluded all patients younger than 18 years of age. We performed univariate and multivariate regression analyses to determine if readmissions were associated with patient characteristics, length of stay for initial hospitalization, trauma center access, and triage patterns.A total of 211,504 patients were included in the analysis. Of these, 5,094 (2%) died during the index hospitalization. Of those who survived their initial hospitalization, 79,123 (38%) experienced one or more readmissions to any hospital within one year. The majority of these were one-time readmissions (62%) but 38% experienced multiple readmissions. Over 67% of readmissions were unplanned and 8% of readmissions were for a trauma. After controlling for patient variables known to be associated with readmissions, primary triage to a trauma center was associated with a lower odds of readmission (OR 0.89, p<0.001). The effect of transport to a trauma center remained significantly associated with decreased odds of readmission at one year (OR 0.96, p<0.001).Readmissions after injury are common and are often unscheduled. While patient factors play a role in this, care at a trauma center is also associated with decreased odds for re-admission, even when controlling for severity of injury. This suggests that the benefits of trauma center care extend beyond improvements in mortality to improved long-term outcomes.Economic/Decision LEVEL OF EVIDENCE: Level IV.

  View details for DOI 10.1097/TA.0000000000000956

  View details for PubMedID 26713975

• Trauma center verification and a more inclusive system: identifying unnecessary criteria for level III/IV centers Forrester, J., Weiser, T. G., Maggio, P. M., Tennakoon, L., Spain, D. A., Staudenmayer, K. L. ELSEVIER SCIENCE INC. 2015: E31

  View details for DOI 10.1016/j.jamcollsurg.2015.08.379

  View details for Web of Science ID 000386899000071

• Improving and sustaining a reduction in iatrogenic pneumothorax through a multifaceted quality-improvement approach. Journal of hospital medicine Shieh, L., Go, M., Gessner, D., Chen, J. H., Hopkins, J., Maggio, P. 2015; 10 (9): 599-607

  Abstract

  The Agency for Healthcare Research and Quality has adopted iatrogenic pneumothorax (IAP) as a Patient Safety Indicator. In 2006, in response to a low performance ranking for IAP rate from the University Healthsystem Consortium (UHC), the authors established a multidisciplinary team to reduce our institution's IAP rate. Root-cause analysis found that subclavian insertion of central venous catheterization (CVC) was the most common procedure associated with IAP OBJECTIVE: Our short-term goal was a 50% reduction of both CVC-associated and all-cause IAP rates within 18 months, with long-term goals of sustained reduction.Observational study.Academic tertiary care hospital.Consecutive inpatients from 2006 to 2014.Our multifaceted intervention included: (1) clinical and documentation standards based on evidence, (2) cognitive aids, (3) simulation training, (4) purchase and deployment of ultrasound equipment, and (5) feedback to clinical services.CVC-associated IAP, all-cause IAP rate.We achieved both a short-term (years 2006 to 2008) and long-term (years 2006 to 2008-2014) reduction in our CVC-associated and all-cause IAP rates. Our short-term reduction in our CVC-associated IAP was 53% (P = 0.088), and our long-term reduction was 85% (P < 0.0001). Our short-term reduction in the all-cause IAP rate was 26% (P < 0.0001), and our long-term reduction was 61% (P < 0.0001).A multidisciplinary team, focused on evidence, patient safety, and standardization, can use a set of multifaceted interventions to sustainably improve patient outcomes for several years after implementation. Our hospital was in the highest performance UHC quartile for all-cause IAP in 2012 to 2014. Journal of Hospital Medicine 2015. © 2015 Society of Hospital Medicine.

  View details for DOI 10.1002/jhm.2388

  View details for PubMedID 26041246

• Improving and sustaining a reduction in iatrogenic pneumothorax through a multifaceted quality-improvement approach JOURNAL OF HOSPITAL MEDICINE Shieh, L., Go, M., Gessner, D., Chen, J. H., Hopkins, J., Maggio, P. 2015; 10 (9): 599-607

  Abstract

  The Agency for Healthcare Research and Quality has adopted iatrogenic pneumothorax (IAP) as a Patient Safety Indicator. In 2006, in response to a low performance ranking for IAP rate from the University Healthsystem Consortium (UHC), the authors established a multidisciplinary team to reduce our institution's IAP rate. Root-cause analysis found that subclavian insertion of central venous catheterization (CVC) was the most common procedure associated with IAP OBJECTIVE: Our short-term goal was a 50% reduction of both CVC-associated and all-cause IAP rates within 18 months, with long-term goals of sustained reduction.Observational study.Academic tertiary care hospital.Consecutive inpatients from 2006 to 2014.Our multifaceted intervention included: (1) clinical and documentation standards based on evidence, (2) cognitive aids, (3) simulation training, (4) purchase and deployment of ultrasound equipment, and (5) feedback to clinical services.CVC-associated IAP, all-cause IAP rate.We achieved both a short-term (years 2006 to 2008) and long-term (years 2006 to 2008-2014) reduction in our CVC-associated and all-cause IAP rates. Our short-term reduction in our CVC-associated IAP was 53% (P = 0.088), and our long-term reduction was 85% (P < 0.0001). Our short-term reduction in the all-cause IAP rate was 26% (P < 0.0001), and our long-term reduction was 61% (P < 0.0001).A multidisciplinary team, focused on evidence, patient safety, and standardization, can use a set of multifaceted interventions to sustainably improve patient outcomes for several years after implementation. Our hospital was in the highest performance UHC quartile for all-cause IAP in 2012 to 2014. Journal of Hospital Medicine 2015. © 2015 Society of Hospital Medicine.

  View details for DOI 10.1002/jhm.2388

  View details for Web of Science ID 000360836000007

• Septris: a novel, mobile, online, simulation game that improves sepsis recognition and management. Academic medicine Evans, K. H., Daines, W., Tsui, J., Strehlow, M., Maggio, P., Shieh, L. 2015; 90 (2): 180-184

  Abstract

  Annually affecting over 18 million people worldwide, sepsis is common, deadly, and costly. Despite significant effort by the Surviving Sepsis Campaign and other initiatives, sepsis remains underrecognized and undertreated.Research indicates that educating providers may improve sepsis diagnosis and treatment; thus, the Stanford School of Medicine has developed a mobile-accessible, case-based, online game entitled Septris (http://med.stanford.edu/septris/). Septris, launched online worldwide in December 2011, takes an innovative approach to teaching early sepsis identification and evidence-based management. The free gaming platform leverages the massive expansion over the past decade of smartphones and the popularity of noneducational gaming.The authors sought to assess the game's dissemination and its impact on learners' sepsis-related knowledge, skills, and attitudes. In 2012, the authors trained Stanford pregraduate (clerkship) and postgraduate (resident) medical learners (n = 156) in sepsis diagnosis and evidence-based practices via 20 minutes of self-directed game play with Septris. The authors administered pre- and posttests.By October 2014, Septris garnered over 61,000 visits worldwide. After playing Septris, both pre- and postgraduate groups improved their knowledge on written testing in recognizing and managing sepsis (P < .001). Retrospective self-reporting on their ability to identify and manage sepsis also improved (P < .001). Over 85% of learners reported that they would or would maybe recommend Septris.Future evaluation of Septris should assess its effectiveness among different providers, resource settings, and cultures; generate information about how different learners make clinical decisions; and evaluate the correlation of game scores with sepsis knowledge.This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License, where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially.

  View details for DOI 10.1097/ACM.0000000000000611

  View details for PubMedID 25517703

• A nurse-driven screening tool for the early identification of sepsis in an intermediate care unit setting. Journal of hospital medicine Gyang, E., Shieh, L., Forsey, L., Maggio, P. 2015; 10 (2): 97-103

  Abstract

  Use of a screening tool as a decision support mechanism for early detection of sepsis has been widely advocated, yet studies validating tool performance are scarce, especially in non-intensive care unit settings.For this pilot study we prospectively screened consecutive patients admitted to a medical/surgical intermediate care unit at an academic medical center over a 1-month period and retrospectively analyzed their clinical data. Patients were screened with a 3-tiered, paper-based, nurse-driven sepsis assessment tool every 8 hours. For patients screening positive for sepsis or severe sepsis, the primary treatment team was notified and the team's clinical actions were recorded. Results of the screening test were then compared to patient International Classification of Diseases, Ninth Revision (ICD-9) codes for sepsis, severe sepsis, and septic shock identified during the study time period, and performance of the screening test was assessed.A total of 2143 screening tests were completed in 245 patients (169 surgical, 76 medical). ICD-9 codes confirmed sepsis incidence was 9%. Of the 39 patients who screened positive, 51% were positive for sepsis, and 49% screened positive for severe sepsis. Screening tool sensitivity and specificity were 95% and 92%, respectively. Negative predictive value was 99% and positive predictive value was 54%. Overall test accuracy was 92%. There was no statistically significant difference in tool performance between medical and surgical patients.A simple screening tool for sepsis utilized as part of nursing assessment may be a useful way of identifying early sepsis in both medical and surgical patients in an intermediate care unit setting. Journal of Hospital Medicine 2014. © 2014 Society of Hospital Medicine.

  View details for DOI 10.1002/jhm.2291

  View details for PubMedID 25425449

• Septris: A Novel, Mobile, Online, Simulation Game That Improves Sepsis Recognition and Management Academic Medicine Evans, K. H., Daines, W. P., Tsui, J., Strehlow, M., Maggio, P., Shieh, L. 2015; Vol. 90, No. 2 (February 2015)

  Abstract

  Annually affecting over 18 million people worldwide, sepsis is common, deadly, and costly. Despite significant effort by the Surviving Sepsis Campaign and other initiatives, sepsis remains underrecognized and undertreated.Research indicates that educating providers may improve sepsis diagnosis and treatment; thus, the Stanford School of Medicine has developed a mobile-accessible, case-based, online game entitled Septris (http://med.stanford.edu/septris/). Septris, launched online worldwide in December 2011, takes an innovative approach to teaching early sepsis identification and evidence-based management. The free gaming platform leverages the massive expansion over the past decade of smartphones and the popularity of noneducational gaming.The authors sought to assess the game's dissemination and its impact on learners' sepsis-related knowledge, skills, and attitudes. In 2012, the authors trained Stanford pregraduate (clerkship) and postgraduate (resident) medical learners (n = 156) in sepsis diagnosis and evidence-based practices via 20 minutes of self-directed game play with Septris. The authors administered pre- and posttests.By October 2014, Septris garnered over 61,000 visits worldwide. After playing Septris, both pre- and postgraduate groups improved their knowledge on written testing in recognizing and managing sepsis (P < .001). Retrospective self-reporting on their ability to identify and manage sepsis also improved (P < .001). Over 85% of learners reported that they would or would maybe recommend Septris.Future evaluation of Septris should assess its effectiveness among different providers, resource settings, and cultures; generate information about how different learners make clinical decisions; and evaluate the correlation of game scores with sepsis knowledge.This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License, where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially.

  View details for DOI 10.1097/ACM.0000000000000611

• Restrictive blood transfusion practices are associated with improved patient outcomes. Transfusion Goodnough, L. T., Maggio, P., Hadhazy, E., Shieh, L., Hernandez-Boussard, T., Khari, P., Shah, N. 2014; 54 (10): 2753-2759

  Abstract

  Blood transfusion has been cited as one of the five most overutilized therapeutic procedures in the United States. We assessed the impact of clinical decision support at computerized physician order entry and education on red blood cell (RBC) transfusions and clinical patient outcomes at our institution.Clinical patient outcomes and RBC transfusions were assessed before and after implementation of a best practice alert triggered for transfusions when the hemoglobin level was higher than 7 g/dL for all inpatient discharges from January 2008 through December 2013. Retrospective clinical and laboratory data related to RBC transfusions were extracted: case-mix complexity, patient discharges and selected surgical volumes, and patient outcomes (mortality, 30-day readmissions, length of stay).There was a significant improvement in RBC utilization as assessed by RBC units transfused per 100 patient-days-at-risk. Concurrently, hospital-wide clinical patient outcomes showed improvement (mortality, p = 0.034; length of stay, p = 0.003) or remained stable (30-day readmission rates, p = 0.909). Outcome improvements were even more pronounced in patients who received blood transfusions, with decreased mortality rate (55.2 to 33.0, p < 0.001), length of stay (mean, 10.1 to 6.2 days, p < 0.001), and 30-day readmission rate (136.9 to 85.0, p < 0.001). The mean number of units transfused per patient also declined (3.6 to 2.7, p < 0.001). Acquisition costs of RBC units per 1000 patient discharges decreased from $283,130 in 2009 to $205,050 in 2013 with total estimated savings of $6.4 million and likely far greater impact on total transfusion-related costs.Improved blood utilization is associated with improved clinical patient outcomes.

  View details for DOI 10.1111/trf.12723

  View details for PubMedID 24995770

• Restrictive blood transfusion practices are associated with improved patient outcomes TRANSFUSION Goodnough, L. T., Maggio, P., Hadhazy, E., Shieh, L., Hernandez-Boussard, T., Khari, P., Shah, N. 2014; 54 (10): 2753-2759

  Abstract

  Blood transfusion has been cited as one of the five most overutilized therapeutic procedures in the United States. We assessed the impact of clinical decision support at computerized physician order entry and education on red blood cell (RBC) transfusions and clinical patient outcomes at our institution.Clinical patient outcomes and RBC transfusions were assessed before and after implementation of a best practice alert triggered for transfusions when the hemoglobin level was higher than 7 g/dL for all inpatient discharges from January 2008 through December 2013. Retrospective clinical and laboratory data related to RBC transfusions were extracted: case-mix complexity, patient discharges and selected surgical volumes, and patient outcomes (mortality, 30-day readmissions, length of stay).There was a significant improvement in RBC utilization as assessed by RBC units transfused per 100 patient-days-at-risk. Concurrently, hospital-wide clinical patient outcomes showed improvement (mortality, p = 0.034; length of stay, p = 0.003) or remained stable (30-day readmission rates, p = 0.909). Outcome improvements were even more pronounced in patients who received blood transfusions, with decreased mortality rate (55.2 to 33.0, p < 0.001), length of stay (mean, 10.1 to 6.2 days, p < 0.001), and 30-day readmission rate (136.9 to 85.0, p < 0.001). The mean number of units transfused per patient also declined (3.6 to 2.7, p < 0.001). Acquisition costs of RBC units per 1000 patient discharges decreased from $283,130 in 2009 to $205,050 in 2013 with total estimated savings of $6.4 million and likely far greater impact on total transfusion-related costs.Improved blood utilization is associated with improved clinical patient outcomes.

  View details for DOI 10.1111/trf.12723

  View details for Web of Science ID 000343821100023

• Improved blood utilization using real-time clinical decision support. Transfusion Goodnough, L. T., Shieh, L., Hadhazy, E., Cheng, N., Khari, P., Maggio, P. 2014; 54 (5): 1358-1365

  Abstract

  We analyzed blood utilization at Stanford Hospital and Clinics after implementing real-time clinical decision support (CDS) and best practice alerts (BPAs) into physician order entry (POE) for blood transfusions.A clinical effectiveness (CE) team developed consensus with a suggested transfusion threshold of a hemoglobin (Hb) level of 7 g/dL, or 8 g/dL for patients with acute coronary syndromes. The CDS was implemented in July 2010 and consisted of an interruptive BPA at POE, a link to relevant literature, and an "acknowledgment reason" for the blood order.The percentage of blood ordered for patients whose most recent Hb level exceeded 8 g/dL ranged at baseline from 57% to 66%; from the education intervention by the CE team August 2009 to July 2010, the percentage decreased to a range of 52% to 56% (p = 0.01); and after implementation of CDS and BPA, by end of December 2010 the percentage of patients transfused outside the guidelines decreased to 35% (p = 0.02) and has subsequently remained below 30%. For the most recent interval, only 27% (767 of 2890) of transfusions occurred in patients outside guidelines. Comparing 2009 to 2012, despite an increase in annual case mix index from 1.952 to 2.026, total red blood cell (RBC) transfusions decreased by 7186 units, or 24%. The estimated net savings for RBC units (at $225/unit) in purchase costs for 2012 compared to 2009 was $1,616,750.Real-time CDS has significantly improved blood utilization. This system of concurrent review can be used by health care institutions, quality departments, and transfusion services to reduce blood transfusions.

  View details for DOI 10.1111/trf.12445

  View details for PubMedID 24117533

• Logistics of transfusion support for patients with massive hemorrhage CURRENT OPINION IN ANESTHESIOLOGY Goodnough, L. T., Spain, D. A., Maggio, P. 2013; 26 (2): 208-214

  Abstract

  Traditionally, trauma resuscitation protocols have advocated sequential administration of therapeutic components, beginning with crystalloid solutions infused to replace lost intravascular volume. However, rapid restoration of the components of blood is essential for ensuring adequate tissue perfusion and for preventing acidosis, coagulopathy, and hypothermia, referred to as the 'lethal triad' in trauma settings. The review summarizes practical approaches for transfusion support of patients with massive hemorrhage.Massive transfusion protocols for blood transfusion support are reviewed, including practical considerations from our own. We maintain an inventory of thawed, previously frozen plasma (four units each of blood group O and A), which can be issued immediately for patients in whom the blood type is known. As frozen plasma requires 45 min to thaw, liquid AB plasma (26 day outdate) functions as an excellent alternative, particularly for patients with unknown or blood group B or AB types.Close monitoring of bleeding and coagulation in trauma patients allows goal-directed transfusions to optimize patients' coagulation, reduce exposure to blood products, and to improve patient outcomes. Future studies are needed to understand and demonstrate improved patient outcomes.

  View details for DOI 10.1097/ACO.0b013e32835d6f8f

  View details for PubMedID 23446185

• Payer status is associated with the use of prophylactic inferior vena cava filter in high-risk trauma patients SURGERY Pickham, D. M., Callcut, R. A., Maggio, P. M., Mell, M. W., Spain, D. A., Bech, F., Staudenmayer, K. 2012; 152 (2): 232-237

  Abstract

  It is controversial whether patients at high risk for pulmonary embolism (PE) should receive prophylactic inferior vena cava filters (IVC) filters. This lack of clarity creates the potential for variability and disparities in care. We hypothesized there would be differential use of prophylactic IVC filters for patients at high risk for PE on the basis of insurance status.We performed a retrospective analysis using the National Trauma Databank (2002-2007). We included adult patients at high risk for PE (traumatic brain injury or spinal cord injury) and excluded patients with a diagnosis of deep venous thrombosis (DVT) or PE. Logistic regression was performed to control for confounders and a hierarchical mixed effects model was used to control for center.A prophylactic filter was placed in 3,331 (4.3%) patients in the study cohort. Patients without insurance had an IVC filter placed less often compared with those with any form of insurance (2.7% vs 4.9%, respectively). After adjusting for confounders, we found that patients without insurance were less likely to receive a prophylactic IVC filter, even when we controlled for center (OR 5.3, P < .001).When guidelines lack clarity, unconscious bias has the potential to create a system with different levels of care based on socioeconomic disparities.

  View details for DOI 10.1016/j.surg.2012.05.041

  View details for Web of Science ID 000307157500013

  View details for PubMedID 22828145

• Early outcomes of deliberate nonoperative management for blunt thoracic aortic injury in trauma JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Caffarelli, A. D., Mallidi, H. R., Maggio, P. M., Spain, D. A., Miller, D. C., Mitchell, R. S. 2010; 140 (3): 598-605

  Abstract

  Traumatic blunt aortic injury has traditionally been viewed as a surgical emergency, whereas nonoperative therapy has been reserved for nonsurgical candidates. This study reviews our experience with deliberate, nonoperative management for blunt thoracic aortic injury.A retrospective chart review with selective longitudinal follow-up was conducted for patients with blunt aortic injury. Surveillance imaging with computed tomography angiography was performed. Nonoperative patients were then reviewed and analyzed for survival, evolution of aortic injury, and treatment failures.During the study period, 53 patients with an average age of 45 years (range, 18-80 years) were identified, with 28% presenting to the Stanford University School of Medicine emergency department and 72% transferred from outside hospitals. Of the 53 patients, 29 underwent planned, nonoperative management. Of the 29 nonoperative patients, in-hospital survival was 93% with no aortic deaths in the remaining patients. Survival was 97% at a median of 1.8 years (range, 0.9-7.2 years). One patient failed nonoperative management and underwent open repair. Serial imaging was performed in all patients (average = 107 days; median, 31 days), with 21 patients having stable aortic injuries without progression and 5 patients having resolved aortic injuries.This experience suggests that deliberate, nonoperative management of carefully selected patients with traumatic blunt aortic injury may be a reasonable alternative in the polytrauma patient; however, serial imaging and long-term follow-up are necessary.

  View details for DOI 10.1016/j.jtcvs.2010.02.056

  View details for PubMedID 20579668

• Outcomes and complications of open abdomen technique for managing non-trauma patients. Journal of emergencies, trauma, and shock Kritayakirana, K., M Maggio, P., Brundage, S., Purtill, M., Staudenmayer, K., A Spain, D. 2010; 3 (2): 118-122

  Abstract

  Damage control surgery and the open abdomen technique have been widely used in trauma. These techniques are now being utilized more often in non-trauma patients but the outcomes are not clear. We hypothesized that the use of the open abdomen technique in non-trauma patients 1) is more often due to peritonitis, 2) has a lower incidence of definitive fascial closure during the index hospitalization, and 3) has a higher fistula rate.Retrospective case series of patients treated with the open abdomen technique over a 5-year period at a level-I trauma center. Data was collected from the trauma registry, operating room (OR) case log, and by chart review. The main outcome measures were number of operations, definitive fascial closure, fistula rate, complications, and length of stay.One hundred and three patients were managed with an open abdomen over the 5-year period and we categorized them into three groups: elective (n = 31), urgent (n = 35), and trauma (n = 37). The majority of the patients were male (69%). Trauma patients were younger (39 vs 53 years; P < 0.05). The most common indications for the open abdomen technique were intraabdominal hypertension in the elective group (n = 18), severe intraabdominal infection in the urgent group (n = 19), and damage control surgery in the trauma group (n = 28). The number of abdominal operations was similar (3.1-3.7) in the three groups, as was the duration of intensive care unit (ICU) stay (average: 25-31 days). The definitive fascial closure rates during initial hospitalization were as follows: 63% in the elective group, 60% in the urgent group, and 54% in the trauma group. Intestinal fistula formation occurred in 16%, 17%, and 11%, respectively, in the three groups, with overall mortality rates of 35%, 31%, and 11%.Intra-abdominal infection was a common reason for use of the open abdomen technique in non-trauma patients. However, the definitive fascial closure and fistula rates were similar in the three groups. Despite differences in indications, damage control surgery and the open abdomen technique have been successfully transitioned to elective and urgent non-trauma patients.

  View details for DOI 10.4103/0974-2700.62106

  View details for PubMedID 20606786

  View details for PubMedCentralID PMC2884440

• Massive Transfusion Protocols: The Role of Aggressive Resuscitation Versus Product Ratio in Mortality Reduction JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Riskin, D. J., Tsai, T. C., Riskin, L., Hernandez-Boussard, T., Purtill, M., Maggio, P. M., Spain, D. A., Brundage, S. I. 2009; 209 (2): 198-205

  Abstract

  Exsanguinating hemorrhage necessitating massive blood product transfusion is associated with high mortality rates. Recent data suggest that altering the fresh frozen plasma to packed red blood cell ratio (FFP:PRBC) results in significant mortality reductions. Our purpose was to evaluate mortality and blood product use in the context of a newly initiated massive transfusion protocol (MTP).In July 2005, our American College of Surgeons-verified Level I trauma center implemented an MTP supporting a 1:1.5 FFP:PRBC ratio, improved communications, and enhanced systems flow to optimize rapid blood product availability. During the 4 years surrounding protocol implementation, we reviewed data on trauma patients directly admitted through the emergency department and requiring 10 or more units PRBCs during the first 24 hours.For the 2 years before and subsequent to MTP initiation, there were 4,223 and 4,414 trauma activations, of which 40 and 37 patients, respectively, met study criteria. The FFP:PRBC ratios were identical, at 1:1.8 and 1:1.8 (p = 0.97). Despite no change in FFP:PRBC ratio, mortality decreased from 45% to 19% (p = 0.02). Other significant findings included decreased mean time to first product: cross-matched RBCs (115 to 71 minutes; p = 0.02), FFP (254 to 169 minutes; p = 0.04), and platelets (418 to 241 minutes; p = 0.01).MTP implementation is associated with mortality reductions that have been ascribed principally to increased plasma use and decreased FFP:PRBC ratios. Our study found a significant reduction in mortality despite unchanged FFP:PRBC ratios and equivalent overall mean numbers of transfusions. Our data underscore the importance of expeditious product availability and emphasize that massive transfusion is a complex process in which product ratio and time to transfusion represent only the beginning of understanding.

  View details for DOI 10.1016/j.jamcollsurg.2009.04.016

  View details for Web of Science ID 000268747300006

  View details for PubMedID 19632596

• Commitment to COT Verification Improves Patient Outcomes and Financial Performance 67th Annual Meeting of the American-Association-for-the-Surgery-of-Trauma/Meeting of the Association-for-Acute-Medicine Maggio, P. M., Brundage, S. I., Hernandez-Boussard, T., Spain, D. A. LIPPINCOTT WILLIAMS & WILKINS. 2009: 190–95

  Abstract

  After an unsuccessful American College of Surgery Committee on Trauma visit, our level I trauma center initiated an improvement program that included (1) hiring new personnel (trauma director and surgeons, nurse coordinator, orthopedic trauma surgeon, and registry staff), (2) correcting deficiencies in trauma quality assurance and process improvement programs, and (3) development of an outreach program. Subsequently, our trauma center had two successful verifications. We examined the longitudinal effects of these efforts on volume, patient outcomes and finances.The Trauma Registry was used to derive data for all trauma patients evaluated in the emergency department from 2001 to 2007. Clinical data analyzed included number of admissions, interfacility transfers, injury severity scores (ISS), length of stay, and mortality for 2001 to 2007. Financial performance was assessed for fiscal years 2001 to 2007. Data were divided into patients discharged from the emergency department and those admitted to the hospital.Admissions increased 30%, representing a 7.6% annual increase (p = 0.004), mostly due to a nearly fivefold increase in interfacility transfers. Severe trauma patients (ISS >24) increased 106% and mortality rate for ISS >24 decreased by 47% to almost half the average of the National Trauma Database. There was a 78% increase in revenue and a sustained increase in hospital profitability.A major hospital commitment to Committee on Trauma verification had several salient outcomes; increased admissions, interfacility transfers, and acuity. Despite more seriously injured patients, there has been a major, sustained reduction in mortality and a trend toward decreased intensive care unit length of stay. This resulted in a substantial increase in contribution to margin (CTM), net profit, and revenues. With a high level of commitment and favorable payer mix, trauma center verification improves outcomes for both patients and the hospital.

  View details for DOI 10.1097/TA.0b013e3181a51b2f

  View details for Web of Science ID 000267953100035

  View details for PubMedID 19590334

• Intensive insulin therapy is associated with reduced infectious complications in burn patients 65th Annual Meeting of the Central-Surgical-Association Hemmila, M. R., Taddonio, M. A., Arbabi, S., Maggio, P. M., Wahl, W. L. MOSBY-ELSEVIER. 2008: 629–37

  Abstract

  Intensive insulin therapy to control blood glucose levels has reduced mortality in surgical, but not medical, intensive care unit (ICU) patients. Control of blood glucose levels has also been shown to reduce morbidity in surgical ICU patients. There is very little data for use of intensive insulin therapy in the burn patient population. We sought to evaluate our experience with intensive insulin therapy in burn-injured ICU patients with regard to mortality, morbidity, and use of hospital resources.Burn patients admitted to our American College of Surgeons verified burn center ICU from 7/1/2004 to 6/30/2006 were studied. An intensive insulin therapy protocol was initiated for ICU patients admitted starting 7/1/2005 with a blood glucose target of 100-140 mg/dL. The 2 groups of patients studied were control (7/1/2004 to 6/30/2005) and intensive insulin therapy (7/1/2005 to 6/30/2006). All glucose values for the hospitalization were analyzed. Univariate and multivariate analyses were performed.Overall, 152 ICU patients admitted with burn injury were available for study. No difference in mortality was evident between the control and intensive insulin therapy groups. After adjusting for patient risk, the intensive insulin therapy group was found to have a decreased rate of pneumonia, ventilator-associated pneumonia, and urinary tract infection. In patients with a maximum glucose value of greater than 140 mg/dL, the risk for an infection was significantly increased (OR 11.3, 95% CI 4-32, P-value < .001). The presence of a maximum glucose value greater than 140 mg/dL was associated with a sensitivity of 91% and specificity of 62% for an infectious complication.Intensive insulin therapy for burn-injured patients admitted to the ICU was associated with a reduced incidence of pneumonia, ventilator-associated pneumonia, and urinary tract infection. Intensive insulin therapy did not result in a change in mortality or length of stay when adjusting for confounding variables. Measurement of a blood glucose level greater than 140 mg/dL should heighten the clinical suspicion for the presence of an infection in patients with burn injury.

  View details for DOI 10.1016/j.surg.2008.07.001

  View details for Web of Science ID 000259751000020

  View details for PubMedID 18847648

  View details for PubMedCentralID PMC3571713

• Real money: Complications and hospital costs in trauma patients SURGERY Hemmila, M. R., Jakubus, J. L., Maggio, P. M., Wahl, W. L., Dimick, J. B., Campbell, D. A., Taheri, P. A. 2008; 144 (2): 307-316

  Abstract

  Major postoperative complications are associated with a substantial increase in hospital costs. Trauma patients are known to have a higher rate of complications than the general surgery population. We used the National Surgical Quality Improvement Program (NSQIP) methodology to evaluate hospital costs, duration of stay, and payment associated with complications in trauma patients.Using NSQIP principles, patient data were collected for 512 adult patients admitted to the trauma service for > 24 hours at a Level 1 trauma center (2004-2005). Patients were placed in 1 of 3 groups: no complications (none), >or=1 minor complication (minor, eg, urinary tract infection), or >or=1 major complication (major, eg, pneumonia). Total hospital charges, costs, payment, and duration of stay associated with each complication group were determined from a cost-accounting database. Multiple regression was used to determine the costs of each type of complication after adjusting for differences in age, sex, new injury severity score, Glasgow coma scale score, maximum head abbreviated injury scale, and first emergency department systolic blood pressure.A total of 330 (64%) patients had no complications, 53 (10%) had >or= 1 minor complication, and 129 (25%) had >or= 1 major complication. Median hospital charges increased from $33,833 (none) to $81,936 (minor) and $150,885 (major). The mean contribution to margin per day was similar for the no complication and minor complication groups ($994 vs $1,115, P = .7). Despite higher costs, the patients in the major complication group generated a higher mean contribution to margin per day compared to the no complication group ($2,168, P < .001). The attributable increase in median total hospital costs when adjusted for confounding variables was $19,915 for the minor complication group (P < .001), and $40,555 for the major complication group (P < .001).Understanding the costs associated with traumatic injury provides a window for assessing the potential cost reductions associated with improved quality care. To optimize system benefits, payers and providers should develop integrated reimbursement methodologies that align incentives to provide quality care.

  View details for DOI 10.1016/j.surg.2008.05.003

  View details for Web of Science ID 000258308400026

  View details for PubMedID 18656640

  View details for PubMedCentralID PMC2583342

• Mean glucose values predict trauma patient mortality 66th Annual Meeting of the American-Association-for-the-Surgery-of-Trauma Wahl, W. L., Taddonio, M., Maggio, P. M., Arbabi, S., Hemmila, M. R. LIPPINCOTT WILLIAMS & WILKINS. 2008: 42–47

  Abstract

  Tight glycemic control in a mixed surgical intensive care unit patient population has been associated with improved survival. We postulated targeted therapy to achieve glucose levels <140 mg/dL would reduce infectious complications and mortality in trauma patients admitted to the intensive care unit (ICU).Adult trauma patients admitted to our American College of Surgeons Level I Trauma Center ICU from July 2004 through June 30, 2006 were studied. Insulin therapy was instituted for ICU patients admitted after July 1, 2005 with glucose >140 mg/dL. Data on infections and all glucose values were collected. Multivariate analysis adjusting for age, Injury Severity Score, Glasgow Coma Scale Score, admit blood pressure, and intubation status was performed.Five thirty-one ICU patients were admitted with a mean Injury Severity Score of 23 +/- 13 and mean age of 45 years +/- 19 years. The admission, mean, and maximum glucoses were 141, 129, and 192 respectively. In multivariate analyses, increases in all three glucose values were associated with a significantly higher mortality, with the best model achieved using mean glucose with a receiver operating curve of 0.90. For mean glucose categories of >200 mg/dL, 141 mg/dL to 200 mg/dL, and

  View details for DOI 10.1097/TA.0b013e318176c54e

  View details for Web of Science ID 000257767300007

  View details for PubMedID 18580507

• Restrictive red blood cell transfusion: not just for the stable intensive care unit patient AMERICAN JOURNAL OF SURGERY Wahl, W. L., Hemmila, M. R., Maggio, P. M., Arbabi, S. 2008; 195 (6): 803-806

  Abstract

  Multiple studies report that patients receiving red blood cell (RBC) transfusion in the intensive care unit (ICU) are more likely to experience complications. Despite these findings, surgical patients are frequently transfused for operative procedures, trauma, and burns. We hypothesized that a RBC transfusion guideline would safely decrease our use of RBC transfusions in the ICU and lower the hematocrit at which our trauma and burn patients were transfused, both in the stable and symptomatic patient.For each episode of RBC transfusion, the pretransfusion vital signs and reasons for transfusion were recorded prospectively from August 2003 through April 2004. Before institution of the transfusion guideline, which stressed withholding transfusion for hematocrit over 23 in asymptomatic patients, intensive education of all caregivers occurred. Data from all transfusions during 2005 were also reviewed for long-term compliance with the guideline.Eighty-two of 316 ICU patients (26%) had 315 RBC transfusion events during the initial study period. Mean transfusion hematocrits decreased from 26.6 +/- 4.7 to 23.9 +/- 2.6 (P < .0003) for all patients. For the follow-up period in 2005, 94 of 523 patients (18%) were transfused in the ICU at a mean transfusion hematocrit of 24.1 for symptomatic (P < .0001) and 22.5 for asymptomatic patients (P < .0001). Low hematocrit was the most frequently cited reason for transfusion for all patients in the first part of the study, whereas hemodynamic instability (n = 91 events) and perioperative losses (n = 49 events) ranked highest for symptomatic patients.A transfusion guideline accompanied by intensive education is effective in reducing RBC transfusions in a trauma-burn ICU. A lower hematocrit was well tolerated in both the symptomatic and asymptomatic groups of surgical patients. With education and follow-up, the changes in transfusion practices were durable and affected transfusion practices for both asymptomatic and symptomatic patients.

  View details for DOI 10.1016/j.amjsurg.2007.05.047

  View details for Web of Science ID 000256585700014

  View details for PubMedID 18355792

• Trauma center downstream revenue: The impact of incremental patients within a health system JOURNAL OF TRAUMA-INJURY INFECTION AND CRITICAL CARE Taheri, P. A., Maggio, P. M., Dougherty, J., Neil, C., Fetyko, S., Harkins, D. R., Butz, D. A. 2007; 62 (3): 615-619

  Abstract

  The purpose of this study is to assess the downstream clinical and financial impact of a trauma, burn, and emergency surgery service at an academic Level I trauma center.All patients admitted to the trauma, burn, and emergency surgery service from fiscal years 2002 to 2004 were identified. Clinical and financial data including inpatient and outpatient activity were analyzed for 365 days (downstream) after initial service admission. Data were divided into total service, trauma and burn, inpatient, outpatient, hospital, and professional revenue.In all, 3,679 patients were admitted during the study period with total initial revenue approaching $103 million. Of these, 1,566 patients were subsequently admitted for downstream inpatient activity, resulting in almost $26 million in subsequent inpatient revenue. The initial patient admissions resulted in over 17,000 clinic visits during the course of the 3 study years. Professional revenue resulted in over $14 million for the initial admission and $6.1 million in downstream revenue during the study period.Trauma, burn, and emergency surgical services result in both substantial initial and downstream revenue for the hospital (inpatient and outpatient) and professional components. Services committed to caring for the injured and emergent patients substantially contribute to the institutional financial strength.

  View details for DOI 10.1097/TA.0b013e31802ee532

  View details for Web of Science ID 000244877300013

  View details for PubMedID 17414337

• Extracorporeal life support for massive pulmonary embolism JOURNAL OF TRAUMA-INJURY INFECTION AND CRITICAL CARE Maggio, P., Hemmila, M., Haft, J., Bartlett, R. 2007; 62 (3): 570-576

  Abstract

  Massive pulmonary embolism is frequently lethal because of acute irreversible pulmonary and cardiac failure. Extracorporeal life support (ECLS) has been used for cardiopulmonary failure in our institution since 1988, and we reviewed our experience with its use in the management of massive pulmonary emboli.We reviewed our complete experience with ECLS for massive pulmonary emboli from January 1992 through December 2005. The records of 21 patients were examined and data extracted.During the study period, 21 patients received ECLS for massive pulmonary emboli. All patients were on vasoactive drugs, acidemic, and hypoxic at the time of institution of ECLS. Eight were in active cardiac arrest. Five were trauma patients, eight had recently undergone an operation, and six had a hypercoagulable disorder. Nineteen of the 21 patients were cannulated for venoarterial bypass and two were placed on venovenous bypass. The average duration of support for survivors was 5.4 days, ranging from 5 hours to 12.5 days. Emboli resolved with anticoagulation in 10 of 13 survivors and 4 of 13 survivors underwent surgical pulmonary embolectomy. Catastrophic neurologic events were the most common cause of mortality in our series; four patients died from intracranial hemorrhage. The overall survival rate was 62% (13/21).We conclude that emergent ECLS provides an opportunity to improve the prognosis of an otherwise near-fatal condition, and should be considered in the algorithm for management of a massive pulmonary embolism in an unstable patient.

  View details for DOI 10.1097/TA.0b013e318031cd0c

  View details for Web of Science ID 000244877300005

  View details for PubMedID 17414330

• Perioperative issues: Myocardial ischemia and protection - Beta-blockade SURGICAL CLINICS OF NORTH AMERICA Maggio, P. M., Taheri, P. A. 2005; 85 (6): 1091-?

  Abstract

  Approximately one third of patients undergoing noncardiac surgery have coronary artery disease, and cardiovascular complications are an important cause of perioperative morbidity and mortality. Several algorithms are available to assess the risk for peri-operative cardiac events. Although preoperative risk assessment is useful in identifying patients at greatest risk for cardiac complications, recent investigations have provided additional guidance in choosing interventions to improve perioperative outcomes. These investigations show that perioperative beta-blockers significantly reduce morbidity and mortality in noncardiac surgery and appear to offer the greatest benefit to high-risk patients. Because of the lower complication rate in intermediate- and low-risk patients and the absence of large randomized controlled trials, the role of beta-blockers in this population is less well-defined.

  View details for DOI 10.1016/j.suc.2005.09.016

  View details for Web of Science ID 000234386500005

  View details for PubMedID 16326195