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The use of intravenous (IV) acetaminophen (APAP) postoperatively in older adults may be a beneficial strategy. We implemented a multimodal pain management approach in our hospital in 2015, with IV APAP being the first-line therapy. This was a retrospective, single-center, observational cohort study of polytrauma, orthopedic surgical patients aged ≥50 y. Patients admitted in 2017, postimplementation of pain protocol, were categorized as the exposed patients. Patients in the year 2014 served as the historical cohort. The two primary outcomes evaluated were postoperative opioid consumption in morphine milligram equivalents (MMEs) and patient pain scores. In total, 121 eligible patients were identified for this study; 22 historical control patients and 99 exposed patients. We observed a significant reduction in postoperative opioid use up to 48 h postoperatively (20.9 ± 27 versus 4.3 ± 12.4 MME [ P < 0.05] at 24 h and 19.8 ± 31.2 versus 2.1 ± 11.3 MME [ P < 0.05] at 48 h, respectively). The mean opioid consumption remained significantly lower in patient subgroup of age ≥74 y with no difference in the mean pain scores (1.5 ± 1.5 versus 1.9 ± 1.6 [ P = 0.48] at 24 h and 1.5 ± 1.8 versus 2.0 ± 1.5 [ P = 0.21] at 48 h postoperatively in the historical versus exposed cohort, respectively). Exposed patients had a shorter hospital length of stay than control patients (5.0 [3, 7] versus 6.5 [5, 9.5] d; P = 0.01). The use of multimodal pain management with IV APAP as first-line therapy was associated with reduced opioid use in the perioperative setting for older adults with polytrauma. • Multimodal pain management strategy is preferred for perioperative pain. • Using intravenous acetaminophen is an effective strategy in older adults. • Intravenous acetaminophen can reduce opioid consumption. • Intravenous acetaminophen may be effective in reducing adverse events associated with opioid use. [ABSTRACT FROM AUTHOR]

Contralateral pneumothorax after percutaneous central venous catheter placement has not been previously reported. Three patients who required intubation and mechanical ventilation for acute respiratory failure due to COVID-19 were identified with a new pneumothorax on routine post-placement chest roentgenogram on the side opposite the catheter placement. Retrospective review of charts, radiographs, and laboratory studies. No causative relationship was identified between the percutaneous placement of the central venous catheters and the subsequent pneumothoraces identified on the contralateral side, other than the presence of active COVID-19 viral pneumonia. The timing of the contralateral pneumothoraces were coincidental the placement of the central venous catheters. We believe these pneumothoraces were a consequence of the pulmonary pathology of the COVID-19 virus. [ABSTRACT FROM AUTHOR]

Background: Catheter-associated urinary tract infection (CAUTI) is a noted complication among geriatric hip fracture patients. This complication results in negative outcomes for both the patients and the institution providing care. Screening measures to identify predisposing factors, with early diagnosis and treatment of urinary tract infection (UTI) present on admission, may lead to reduced rates of CAUTI. Objective: The goals of this study were to determine the prevalence of UTI on admission among geriatric hip fracture patients and whether routine screening for UTI or predisposing factors at presentation resulted in reduced rates of CAUTI. Methods: A retrospective observational study of geriatric hip fracture patients from January 2017 to December 2018 at a Level I trauma center was performed. Rates of UTI on admission and CAUTI were calculated using routine admission urinalysis. Results: Of the 183 patients in the sample, 36.1% had UTI on admission and 4.4% of patients developed CAUTI. There were no significant differences in patient demographics, comorbidities, and complications between those with UTI on admission and those without. Conclusions: Urinary tract infection on admission may be present among a large portion of geriatric hip fracture patients, leading to increased rates of CAUTI. Routine screening for UTI and its predisposing factors at admission can identify these patients earlier and lead to earlier treatments and prevention of CAUTI. JTRAN Journal of Trauma Nursing 1078-7496 Wolters Kluwer Health, Inc. 10.1097/JTN.0000000000000603 00003 3 RESEARCH Reducing Catheter-Associated Urinary Tract Infection: The Impact of Routine Screening in the Geriatric Hip Fracture Population Singh Shridevi MD ssingh5@numc.edu Angus L. D. George MD langus@numc.edu Munnangi Swapna PhD smunnang@numc.edu Shaikh Dooniya MD dshaikh@numc.edu Digiacomo Jody C. MD jdigiac1@numc.edu Angara Vivek C. DO vangara@numc.edu Brown Aaron MD Aaron.brown.nyee@gmail.com Akadiri Tayo MD tayoakadiri234@gmail.com Department of Surgery, Nassau University Medical Center, East Meadow, New York. Correspondence: L. D. George Angus, MD, Department of Surgery, Nassau University Medical Center, East Meadow, NY 11554 (langus@numc.edu). The content of this article does not substantially overlap with previously published or submitted work, to the best of the authors' knowledge. Authors Shridevi Singh, MD, and Swapna Munnangi, PhD, had full access to all the data in this study and take responsibility for the integrity of the data and the accuracy of the data analysis. The data that support the findings of this study are available from the corresponding author L.D. George Angus, MD, upon reasonable request. The authors declare no conflicts of interest. September/October 2021 28 5 290 297 © 2021 Society of Trauma Nurses 2021 Background: Catheter-associated urinary tract infection (CAUTI) is a noted complication among geriatric hip fracture patients. This complication results in negative outcomes for both the patients and the institution providing care. Screening measures to identify predisposing factors, with early diagnosis and treatment of urinary tract infection (UTI) present on admission, may lead to reduced rates of CAUTI. Objective: The goals of this study were to determine the prevalence of UTI on admission among geriatric hip fracture patients and whether routine screening for UTI or predisposing factors at presentation resulted in reduced rates of CAUTI. Methods: A retrospective observational study of geriatric hip fracture patients from January 2017 to December 2018 at a Level I trauma center was performed. Rates of UTI on admission and CAUTI were calculated using routine admission urinalysis. Results: Of the 183 patients in the sample, 36.1% had UTI on admission and 4.4% of patients developed CAUTI. There were no significant differences in patient demographics, comorbidities, and complications between those with UTI on admission and those without. Conclusions: Urinary tract infection on admission may be present among a large portion of geriatric hip fracture patients, leading to increased rates of CAUTI. Routine screening for UTI and its predisposing factors at admission can identify these patients earlier and lead to earlier treatments and prevention of CAUTI. Catheter-associated urinary tract infections CAUTI Complications Elderly Geriatric Hip fracture Hospital costs Trauma Urinary tract infections INTRODUCTION: Geriatric hip fracture patients are susceptible to a higher rate of complications, with rates ranging from 7% to 40% (Bliemel et al., 2017; Różańska, Wałaszek, Wolak, & Bulanda, 2016; Thakker et al., 2018). One such complication is catheter-associated urinary tract infection (CAUTI). Risk factors inherent to this population include surgical procedures, immobility, age, and the routine utilization of indwelling urinary catheters in the perioperative period (Detweiler, Mayers, & Fletcher, 2015; Hälleberg Nyman et al., 2013; Zielinski et al., 2015). This complication negatively impacts both the patient and the institution providing care. It is reported that 15.5% of hospitalized patients older than 65 years have urinary tract infections (UTIs) (Centers for Disease Control and Prevention [CDC], 2019; Foxman, 2010). Moreover, 6.2% of infectious disease-related deaths are due to UTIs (Alpay, Aykin, Korkmaz, Gulduren, & Caglan, 2018). Implementation of various measures has led to a reduction in the incidence of UTIs; however, UTIs are still prevalent, placing an enormous financial burden on institutions (Polites et al., 2014; Rebmann & Greene, 2010). The Centers for Medicare & Medicaid has deemed that CAUTI is a "reasonably preventable" inhospital complication and has terminated reimbursements for these events since 2008 (CDC, 2019). The mean cost of UTI is $862 to $1007 per UTI (Bail et al., 2015; CDC, 2019; Scott, 2010), whereas a systematic review found that the mean cost of CAUTI can exceed $10,000 per CAUTI based on the clinical status of the patient (Hollenbeak & Schilling, 2018). A vast majority of patients who suffer hip fractures undergo a surgical repair after admission (Bliemel et al., 2017; Johnstone, Morgan, Wilkinson, & Chissell, 1995; Wallace et al., 2019). These repairs have an elevated risk of causing postoperative urinary retention due to the use of anesthesia, patient immobility, and long duration of surgery (Johnstone et al., 1995; Polites et al., 2014; Rowe & Juthani-Mehta, 2013). It is also common practice at some institutions, including our own, to routinely place an indwelling urinary catheter for bladder drainage during the perioperative period (Bliemel et al., 2017; Hälleberg Nyman et al., 2013). Geriatric trauma patients are a unique patient population with numerous intrinsic risk factors for UTI (Bohl et al., 2017; Magill et al., 2014; Monaghan et al., 2011). Some of these risk factors include female sex, falls, head injury, and altered mental status (Aubron et al., 2012; Bliemel et al., 2017; Zielinski et al., 2015). Elderly patients tend to be institutionalized with lower mobility or have medical comorbidities such as hypertension, diabetes, stroke, or dementia that predispose these patients to bladder or bowel incontinence and UTI (Foxman, 2014; Mody & Juthani-Mehta, 2014; Woodford & George, 2009). In addition, less attention to sanitary precautions further predisposes this specific patient population to high rates of UTIs (Alpay et al., 2018). Although current guidelines do not recommend treating asymptomatic bacteriuria (Zalmanovici Trestioreanu, Lador, Sauerbrun-Cutler, & Leibovici, 2015), this specific population subset may not be able to vocalize or validate symptoms due to altered mental status and communication incapability as a result of dementia, stroke, etc. (Tsuda et al., 2015). Hence, we presume that in this specific patient population, UTI is a missed diagnosis because of the missed clinical correlation needed as per current UTI diagnostic criteria guidelines (CDC, 2019; Rowe & Juthani-Mehta, 2014). Failure in early diagnosis and treatment in this specific elderly patient population results in morbid outcomes for patients and significant financial penalties for institutions (Detweiler et al., 2015; Thakker et al., 2018; Zielinski et al., 2014). However, the question arises whether a CAUTI diagnosis is truly the progression of asymptomatic bacteriuria due to the indwelling catheter or is rather a result of comorbid UTI at admission. Therefore, we propose that by screening geriatric hip fracture patients with a urinalysis (UA) within 24 hr of an indwelling urinary catheter that is placed at admission, we will find there is a significant frequency of patients who present with either UTI on admission or with UA findings that could predispose patients to a UTI with an indwelling urinary catheter. METHODS: A retrospective observational study of patients at an urban Level I trauma center, as verified by the American College of Surgeons, was performed. The trauma center is a 500-bed public safety-net hospital that serves 1.4 million people, with approximately 75,000 emergency department visits and approximately 1,700 trauma admissions each year. After obtaining approval from the Institutional Review Board (19-205), the trauma registry was queried by using ICD-10 codes S72.001-S72.26 for hip fracture for all patients 65 years and older from January 1, 2017, through December 31, 2018, which were the first 2 years that routine screening UA was included as a component of the multidisciplinary geriatric hip fracture comanagement protocol at this institution (Wallace et al., 2019). Routine screening UAs were obtained within 24 hr of admission. Demographic information, comorbid conditions, preinjury medications, mechanism of injury, vital signs, Abbreviated Injury Score, Injury Severity Score, Revised Trauma Score, Glasgow Coma Scale, admission disposition, hospital course, intensive care unit (ICU) length of stay, hospital length of stay, complications, disposition, and outcome were extracted from the trauma registry supplemented by direct review of the electronic medical record. Initially, 193 patient records were identified. However, 10 of these patient records were deemed incomplete and were excluded, as they either did not have at least one of the above data points available or the screening UA performed, leaving 183 patients for the final sample. There was no historical control group, as the frequency of UTI and asymptomatic bacteriuria at the time of admission were the variables of interest. All patients were admitted to the ICU as part of our institution's protocol for geriatric hip fracture patients. Urinary tract infection is a clinical diagnosis with symptoms of dysuria, urinary frequency, urinary urgency, or suprapubic pain. Catheter-associated urinary tract infection is defined as a UTI in the setting of an indwelling urinary catheter that has been in place for more than 2 consecutive days in an inpatient location, with the catheter being present either the day of UTI diagnosis or removed the day before (CDC, 2021). Urinalysis can be used as a diagnostic tool to reinforce the clinical diagnosis of a UTI with positive results for leukocyte esterase or nitrites in a midstream-void specimen (Schulz, Hoffman, Pothof, & Fox, 2016; Simati, Kriegsman, & Safranek, 2013; Stovall et al., 2013). Leukocyte esterase is specific (94%–98%) and sensitive (75%–96%) for detecting uropathogens equivalent to 100,000 colony-forming units (CFU) per ml of urine (Devillé et al., 2004; Nicolle et al., 2005; Simati et al., 2013). Negative nitrite tests do not rule out a UTI because the causative organism can also be non-nitrate-reducing (e.g., Enterococci species, Staphylococcus saprophyticus, and Acinetobacter species). Therefore, the sensitivity of nitrite tests ranges from 35% to 85%, but with a specificity of 95% (Devillé et al., 2004; Nicolle et al., 2005; Simati et al., 2013). Nitrite tests can also be falsely negative if the urine specimen is too diluted (Devillé et al., 2004; Nicolle et al., 2005; Simati et al., 2013). In addition, microscopic hematuria may be present in 40%–60% of patients with UTI (Devillé et al., 2004). The diagnosis of UTI in this study was made based on the following UA results regardless of clinical symptoms: white blood cells >10/high-power field (hpf), +nitrites, +bacteria. Comparisons of outcomes were then compared to subgroups within the data collected. Patients diagnosed with UTI were treated with antibiotics. Statistical Analysis: Descriptive statistics were used to summarize the demographic and clinical variables in the study sample. Continuous variables were summarized by presenting mean and standard deviation. Categorical variables were summarized using frequency and percentages. The study sample was stratified into two groups based on whether or not the patient had a UTI upon admission. Continuous variables were compared using unpaired Student's t-test. The Fisher exact test or Pearson χ2 test was used to examine the association of categorical variables with UTI on admission. A p value <.05 was considered statistically significant. Statistical analysis was performed using SAS version 9.4 (SAS Institute, Cary, NC). RESULTS: The study sample consisted of 183 hip fracture patients who met the inclusion criteria. Of these 183 patients, 36.07% had a UTI on admission, and 63.93% did not. Table 1 depicts the baseline clinical and demographic characteristics of the study sample stratified by the UTI status upon admission. The average age of the patients was 84.9 years (M = 84.9, SD = 8). The majority (76.5%) were female. Fall from the same level was the most common mechanism of injury (77%). The mortality rate was 4.4%. Advance directives were in place for 8.2% of the patients. The median ICU length of stay was 3 days (interquartile range [IQR] = 1), and median hospital length of stay was 4 days (IQR = 4). Overall, eight patients, or 4.4% of the study sample, had CAUTI, six of whom were female. A Foley catheter was in place for a median of 2 days (IQR = 1). Acute rehabilitation was the most common discharge disposition (49.7%). There was a statistically significant increase in median ICU length of stay in those with UTI on admission compared with those without. All other demographic and clinical characteristics did not demonstrate any statistically significant difference between the two groups. TABLE 1 Demographic and Clinical Characteristics: Variable Total Sample (n = 183) n (%) UTI on Admission (n = 66; 36.07%) n (%) No UTI on Admission (n = 117; 63.93%) n (%) p Value Age, M (SD), year 84.9 (8.0) 86.2 (7.5) 84.2 (8.3).108 Sex Female 140 (76.5) 53 (80.3) 87 (74.4).363 Male 43 (23.5) 13 (19.7) 30 (25.6) Mechanism of injury .715 Fall from bed 5 (2.7) 1 (1.5) 4 (3.4) Fall from chair 10 (5.5) 3 (4.5) 7 (6.0) Fall from stairs 19 (10.4) 7 (10.6) 12 (10.3) Fall from toilet 2 (1.1) 2 (1.1) 1 (0.8) Fall same level 141 (77.0) 50 (75.8) 91 (77.8) Fall unspecified 2 (1.0) 1 (1.5) 1 (0.8) Other 4 (2.2) 3 (4.5) 1 (0.8) Mortality 8 (4.4) 4 (6.1) 4 (3.4).401 ICU length of Stay, Mdn (IQR), day 3 (1.0) 3 (3.0) 2 (1.0).004 Hospital length of stay, Mdn (IQR), day 4 (4.0) 5 (5.0) 4 (3.0).118 CAUTI 8 (4.4) 0 (0.0) 8 (6.8) Foley days, Mdn (IQR), day 2 (1.0) 2 (1.0) 2 (1.0).593 Injury Severity Score, M (SD) 9.9 (2.9) 10.2 (3.1) 9.7 (2.8).307 Glasgow Coma Scale, M (SD) 14.7 (1.2) 14.5 (1.6) 14.8 (.88).219 Hospital disposition .806 Acute rehabilitation 91 (49.7) 29 (43.9) 62 (53.0) Died full code/withdrawal of care 8 (4.4) 4 (6.1) 4 (3.4) Home 4 (2.2) 2 (3.0) 2 (1.7) Skilled nursing facility 15 (8.2) 6 (9.1) 9 (7.7) Subacute rehabilitation 61 (33.3) 24 (36.4) 37 (31.6) Other nursing facility 4 (2.2) 1 (1.5) 3 (2.6) Note. CAUTI = catheter-associated urinary tract infection; ICU = intensive care unit; IQR = interquartile range; UTI = urinary tract infection. Comorbidities in the study sample were summarized in Table 2. Hypertension was the most common comorbid condition in the overall study sample and the groups stratified by UTI status on admission. There were no significant differences in the comorbid conditions between those who had a UTI on admission and those who did not. The inhospital complications in the study sample were summarized in Table 3. Unplanned returns to the operating room (2.2%) and ICU (2.3%) were the most common inhospital complications observed in the study sample. The inhospital complications were not significantly different between those who had a UTI on admission and those who did not. TABLE 2 Comorbidities: Comorbidity Total Sample (n = 183) n (%) UTI on Admission (n = 66; 36.07%) n (%) No UTI on Admission (n = 117; 63.93%) n (%) p Value Anticoagulation 48 (26.2) 20 (30.3) 28 (23.9).347 Bleeding disorder 3 (1.6) 1 (1.5) 2 (1.7).920 CHF 37 (20.2) 14 (21.2) 23 (19.7).802 Chronic renal failure 15 (8.2) 5 (7.6) 10 (8.5).217 Cirrhosis 2 (1.1) 0 (0.0) 2 (1.7).536 Congenital anomaly 1 (0.5) 0 (0.0) 1 (0.8).639 COPD 12 (6.6) 7 (10.6) 5 (4.3).064 Dementia 43 (23.5) 18 (27.3) 25 (21.4).366 DOH status 28 (15.3) 9 (13.6) 19 (16.2).639 Cancer 10 (5.5) 2 (3.0) 8 (6.8).277 Hypertension 131 (71.6) 45 (68.1) 86 (73.5).443 Major psychiatric illness 3 (1.6) 1 (1.5) 2 (1.7).921 Mental personal disorder 8 (4.4) 2 (3.0) 6 (5.1).505 Myocardial infarction 1 (0.5) 0 (0.0) 1 (0.8).639 Respiratory disease 6 (3.3) 4 (6.0) 2 (1.7).113 PAD 9 (4.9) 5 (7.6) 4 (3.4).128 SP CVA 9 (4.9) 4 (6.0) 5 (4.3).233 Smoker 13 (7.1) 6 (9.0) 7 (6.0).168 Steroid use 1 (0.5) 0 (0.0) 1 (0.8).639 PNA 1 (0.5) 0 (0.0) 1 (0.8).639 ARDS 1 (0.5) 0 (0.0) 1 (0.8).639 Note. ARDS = acute respiratory distress syndrome; CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease; DOH = Department of Health; PAD = peripheral arterial disease; PNA = pneumonia; SP CVA = status post cerebrovascular accident; UTI = urinary tract infection. TABLE 3 Inhospital Complications: Complication Total Sample (n = 183) n (%) UTI on Admission (n = 66; 36.07%) n (%) No UTI on Admission (n = 117; 63.93%) n (%) p Value Cardiac arrest with CPR 2 (1.0) 1 (1.5) 1 (0.8).464 Myocardial infarction 1 (0.5) 0 (0.0) 1 (0.8).639 Unplanned intubation 4 (2.2) 2 (3.0) 2 (1.7).322 Unplanned return to OR 4 (2.2) 0 (0.0) 4 (3.4).164 Unplanned return to ICU 1 (0.5) 1 (1.5) 0 (0.0).361 Acute renal failure 3 (1.6) 1 (1.5) 2 (1.7).446 Severe sepsis 3 (1.6) 0 (0.0) 3 (2.6).259 Coagulopathy 1 (0.5) 0 (0.0) 1 (0.8).639 Acute renal injury 1 (0.5) 1 (1.5) 0 (0.0).361 Other 1 (0.5) 0 (0.0) 1 (0.8).639 Note. CPR = cardiopulmonary resuscitation; ICU = intensive care unit; OR = operating room; UTI = urinary tract infection. DISCUSSION: The elimination of all CAUTI is not attainable; however, it is necessary to take "reasonable preventive" measures to mitigate this inhospital complication that also has a significant financial burden on institutions. By ceasing reimbursements for hospital-acquired UTI, there has been a reduction in UTI rates (CDC, 2019). Yet, there is still a significant prevalence of hospital-acquired UTIs that is burdensome to the host institution (Chenoweth, Gould, & Saint, 2014; Gould et al., 2010; Hassan, Tuckman, Patrick, Kountz, & Kohn, 2010). This study looked at a specific patient population with two important characteristics that deem them at high risk for UTI at admission or postadmission: age and fractured hip. This study aimed to assess the frequency of a positive UA at admission in elderly hip fracture patients, which was found to be 36%. Bliemel et al. (2017) found that 24% of their elderly hip fracture patients sustained an inhospital UTI. The patients in Bliemel et al.'s study were assessed with a UA and urine culture after indwelling catheter removal in those who had clinical symptoms specific for UTI or diffuse symptoms of fatigue, fever, or weakness (Bliemel et al., 2017). In our study, we screened and treated patients based on UA results at admission as per our inhospital protocol for elderly hip fractures. By doing so, rates of CAUTI may have been reduced. In our study period, eight of 183 (4.4%, Table 4) patients developed CAUTI during their hospital course, and 66 of 183 (36%, Table 1) patients had UTI on admission. The increased incidence of CAUTI seen in previous studies compared to our data supports the theory that the colonization of urine with bacteria might have already been present and untreated. It is generally recommended that patients with asymptomatic bacteriuria should not be treated, and for the nonelderly hip fracture patient, we agree. The limitation in obtaining symptomatology history in this specific patient population due to their comorbidities (e.g., dementia) and the significant incidence of positive UA at admission in this study supports the theory that the clinical diagnosis of UTI should be assessed objectively and thus treated appropriately in elderly hip fracture patients. TABLE 4 Comorbidities With CAUTI But No UTI on Admission: Comorbidity CAUTI (n =8; 4.4%) n (%) No UTI on Admission Excluding CAUTI (n = 109) n (%) Anticoagulation 4 (50) 24 (22.0) Bleeding disorder 0 (0.0) 2 (1.83) CHF 3 (37.5) 20 (18.3) Chronic renal failure 0 (0.0) 10 (9.2) Cirrhosis 1 (12.5) 1 (0.9) Congenital anomaly 0 (0.0) 1 (0.9) COPD 0 (0.0) 5 (4.6) Dementia 3 (37.5) 22 (20.2) DOH status 5 (62.5) 14 (12.8) Cancer 2 (25.0) 6 (5.5) Hypertension 6 (75.0) 80 (73.4) Major psychiatric illness 0 (0.0) 2 (1.8) Mental personal disorder 0 (0.0) 6 (5.5) Myocardial infarction 1 (12.5) 0 (0.0) Respiratory disease 0 (0.0) 2 (1.8) PAD 0 (0.0) 4 (3.7) SP CVA 0 (0.0) 5 (4.6) Smoker 0 (0.0) 7 (6.4) Steroid use 0 (0.0) 1 (0.9) PNA 0 (0.0) 1 (0.9) ARDS 0 (0.0) 1 (0.9) Note. ARDS = acute respiratory distress syndrome; CAUTI = catheter-associated urinary tract infection; CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease; DOH = Department of Health; PAD = peripheral arterial disease; PNA = pneumonia; SP CVA = status post cerebrovascular accident; UTI = urinary tract infection. Study Limitations: The retrospective design of the study is a limitation in itself. Our data were collected by analyzing medical records, which intrinsically lends itself to systematic bias. The validity of data relating to such things as laboratory values and interpretation can therefore not be fully guaranteed. Our sample size was also small, and we hope to elaborate with future studies. However, as a pilot study, we believe that publishing our findings will engage the academic community and help determine future study parameters. Furthermore, as a descriptive, observational study, there are limitations as there are no control groups, and interpretation of results is therefore theoretical. CONCLUSIONS: Based on our findings, we strongly believe that if an admission UA was conducted for elderly hip fracture patients and positive results were treated accordingly, there would be a significant reduction in the diagnosis of CAUTI. An indwelling urinary catheter is commonly placed in elderly hip fracture patients, increasing their inherent risk for a UTI based on catheter placement alone. This study has also demonstrated the increased incidence of positive UA as an additional theoretical risk factor for CAUTI in these patients. Because of potential for serious complications, mortality, and financial burden on institutions, early identification of urinary tract infection or asymptomatic bacteriuria should be identified and treated in a protocolized manner in elderly hip fracture patients. These protocols can lower the incidence of CAUTI and improve outcomes in this susceptible and high-risk population. Although routine screening for urinary tract infection is a common measure adopted in geriatric wards, it has not been common practice among elderly trauma patients. This article brings forward the need to adopt this common practice to reduce the likelihood of a CAUTI being attributed to institutions, given the high risk of infection/colonization in the geriatric population. Therefore, we recommend that all elderly hip fracture patients be screened at admission with a UA and be treated appropriately. KEY POINTS: Catheter-associated urinary tract infections (CAUTIs) are a well-known complication among the geriatric hip fracture population. CAUTI has negative consequences for both the patient and the institution and may be due to urinary tract infection (UTI) present on admission. This study observed outcomes in geriatric hip fracture patients who underwent routine UTI screening on admission. The results of this study suggest reduced rates of CAUTI compared to previously published literature. The results suggest there may be a role in routine UTI screening for geriatric hip fracture patients. Acknowledgments: We thank the patients at Nassau University Medical Center for trusting us with their care. We also thank the staff of the trauma department at Nassau University Medical Center for their continued commitment to patient care. REFERENCES: Alpay Y. Aykin N. Korkmaz P. Gulduren H. M. Caglan F. C. (2018). Urinary tract infections in the geriatric patients. Pakistan Journal of Medical Sciences , 34 (1), 67 – 72. doi:10.12669/pjms.341.14013 Aubron C. Huet O. Ricome S. Borderie D. Pussard E. Leblanc P.-E. Duranteau J. (2012). Changes in urine composition after trauma facilitate bacterial growth. 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Background: Heitzer and Duret described the surgical creation of colostomy in the 1700s, more than a century before the introduction of anesthesia. With the ever increasing degree of frailty in patients of advanced age who require surgical intervention, a simplified methodology for the creation of a colostomy based on their original reports is described and the advantages for use in high risk patients and the critical care setting is discussed. Methods: Eleven patients underwent simplified colostomy under local anesthesia, without complication. Results: All colostomies functioned normally within hours. There were no bleeding or infectious complications, nor peri-operative adverse events. Conclusions: Colostomy formation can be safely performed under local anesthesia when the patient is considered too high risk to undergo general anesthesia. [ABSTRACT FROM AUTHOR]

Objective: To assess the impact of preassigning a single bed in the surgical intensive care unit (SICU) for the next trauma admission. Background: Prolonged emergency department (ED) dwell time before admission to a critical care unit has an adverse effect on patient outcomes and is often due to the lack of an available bed in the intensive care unit (ICU). Methods: A "Bed Ahead" policy was instituted at an urban level 1 Trauma Public Safety Net Teaching Hospital to preassign 1 SICU bed for the next trauma patient who warrants a critical care admission. A retrospective review of all trauma patients admitted to the SICU before and after implementation of this policy was performed to assess the impact on ED dwell time, ICU and hospital lengths of stay, complications, and in-hospital mortality. Results: ED length of stay (ED-LOS); ICU length of stay (ICU-LOS); hospital length of stay (HLOS); complications; and in-hospital mortality were compared before (PRE) and after (POST)implementation of the Bed Ahead policy. Statistically significant improvements were seen in the POST period for ED-LOS, HLOS, complications, and in-hospital mortality. Conclusions: Preassigning 1 ICU for the yet to arrive next injured patient decreases ED dwell times, complications, HLOS, and in-hospital mortality. [ABSTRACT FROM AUTHOR]

Background: An occult pneumothorax is identified by computed tomography but not visualized by a plain film chest X-ray. The optimal management remains unclear.Methods: A retrospective review of an urban level I trauma center's trauma registry was conducted to identify patients with occult pneumothorax over a 2-year period. Factors predictive of chest tube placement were identified using univariate and multivariate logistic regression analysis.Results: A total of 131 patients were identified, of whom 100 were managed expectantly with an initial period of observation. Ultimately, 42 (32.0%) patients received chest tubes and 89 did not. The patients who received chest tubes had larger pneumothoraces at initial assessment, a higher incidence of rib fractures, and an increased average number of rib fractures, of which significantly more were displaced.Conclusions: Displaced rib fractures and moderate-sized pneumothoraces are significant factors associated with chest tube placement in a victim of blunt trauma with occult pneumothorax. The optimal timing for the first follow-up chest X-ray remains unclear. [ABSTRACT FROM AUTHOR]

In the past, injuries to the adrenal glands due to blunt trauma were considered rare, and were reported to be associated with high Injury Severity Scores (ISSs) and high mortality. Recent reports have reported a much high incidence associated with lower ISS and lower mortality. The purpose of this study was to assess the incidence of adrenal gland injuries due to blunt trauma in a large state trauma registry and determine whether these injuries are associated with a higher ISS and increased risk for mortality. A retrospective review was performed on the New York State Trauma Registry comparing blunt injured adults with adrenal injuries to those who did not. Concurrent organ injuries, ISS, and inhospital mortality were compared. Three hundred thirty-nine patients with adrenal gland injuries were identified. Concurrent liver and kidney injuries were more prevalent in the adrenal injured group, and concurrent injuries to the small and large intestine and spleen were more prevalent in the nonadrenal injured group. There was no difference in ISS or mortality between the adrenal injured and nonadrenal injured populations. The results of this study are consistent with recent smaller studies which identified incidence rates which were higher than previously reported and that ISS and mortality risk were unchanged by the presence of blunt adrenal gland injuries. Adrenal gland injuries due to blunt trauma are not uncommon, with an incidence rate of 0.61 per cent. Adrenal gland injuries are not associated with higher ISS or an increased risk of mortality. [ABSTRACT FROM AUTHOR]

Background: Alcohol-related trauma remains high among underserved patients despite ongoing preventive measures. Geographic variability in prevalence of alcohol-related injury has prompted reexamination of this burden across different regions. We sought to elucidate demographic and socioeconomic factors influencing the prevalence of alcohol-related trauma among underserved patients and determine alcohol effects on selected outcomes.Methods: A retrospective analysis examined whether patients admitted to a suburban trauma center differed according to their blood alcohol concentration (BAC) on admission. Patients were stratified based on their BAC into four categories (undetectable BAC, BAC 1-99mg/dL, BAC 100-199mg/dL, and BAC ≥ 200mg/dL). T-tests and X2 tests were used to detect differences between BAC categories in terms of patient demographics and clinical outcomes. Multivariate linear and logistic regressions were used to investigate the association between patient variables and selected outcomes while controlling for confounders.Results: One third of 738 patients analyzed were BAC-positive, mean (SD) BAC was 211.4 (118.9) mg/dL, 80% of BAC-positive patients had levels ≥ 100mg/dL. After risk adjustments, the following patient characteristics were predictive of having highly elevated BAC (≥200mg/dL) upon admission to the Trauma Center; Hispanic patients (adjusted odds ratio (OR)=1.91, 95% confidence interval (CI): 1.14-3.21), unemployment (OR=1.74, 95% CI: 1.09-2.78), Medicaid beneficiaries (OR=3.59, 95% CI: 1.96-6.59), and uninsured patients (OR=2.86, 95% CI: 1.60-5.13). Patients with BAC of 100-199mg/dL were likely to be more severely injured (P=0.016) compared to undetectable-BAC patients. There was no association between being intoxicated, and being ICU-admitted or having differences in length of ICU or hospital stay.Conclusion: Demographic and socioeconomic factors underlie disparities in the prevalence of alcohol-related trauma among underserved patients. These findings may guide targeted interventions toward specific populations to help reduce the burden of alcohol-related injury. [ABSTRACT FROM AUTHOR]

Background: Indirect calorimetry (IC) is the gold standard for determining energy requirement. Due to lack of availability in many institutions, predictive equations are used to estimate energy requirements. The purpose of this study is to determine the accuracy of predictive equations (ie, Harris-Benedict equation (HBE), Mifflin-St Jeor equation (MSJ), and Penn State University equation (PSU)) used to determine energy needs for critically ill, ventilated patients compared with measured resting energy expenditure (mREE)., Methods: The researchers examined data routinely collected as part of clinical care for patients within intensive care units (ICUs). The final sample consisted of 68 patients. All studies were recorded during a single inpatient stay within an ICU., Results: Patients, on average, had an mREE of 33.9 kcal/kg using IC. The estimated energy requirement when using predictive equations was 24.8 kcal/kg (HBE×1.25), 24.0 kcal/kg (MSJ×1.25), and 26.8 kcal/kg (PSU)., Discussion: This study identified significant differences between mREE and commonly used predictive equations in the ICU., Level of Evidence: III., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Blunt injuries to the adrenal glands are considered rare, associated with severe injury, and highly mortal, based on autopsy series and earlier retrospective reviews. Recent studies have reported higher incidence rates associated with lower injury severity and mortality rates., Methods: A 3-year review of the Pennsylvania Trauma Outcomes Study Registry of adults with intra-abdominal injuries after blunt trauma was performed and associated organ injuries, injury parameters and in-hospital mortality were compared between those with and those without adrenal gland injury., Results: 5679 patient records were identified, 439 with adrenal gland injuries and 5240 without. The liver and the kidney were the intra-abdominal organs most frequently associated with injuries to an adrenal gland, and the spleen was the intra-abdominal organ most frequently injured in those without an adrenal gland injury. There was no difference in mortality rates., Discussion: Injuries to the adrenal gland occur with an incidence of 0.43% after blunt force trauma. The presence of a blunt adrenal gland injury is not a marker of severe injury or associated with an increased mortality rate., Level of Evidence: II, Retrospective Study., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The newest CT scanners provide resolution comparable to MRIs leading many to question when and whether cervical spine MRIs are warranted., Methods: An 8 year retrospective review identified 241 patients who underwent CT scan and MRI of the cervical spine. The initial clinical examination, cervical spine CT scan, and cervical spine MRI were compared to identify cervical spine injuries that would have been missed had the MRI not been performed., Results: The CT scans were normal in 153 patients, and abnormal in 88. Of the 88 abnormal CT scans, the MRIs were abnormal in 65, and normal in the other 23. The indications for MRI in patients with normal CT scans were neck pain, an abnormal neurologic examination, and/or altered mental status. Of the 13 patients with abnormal MRIs, none were pain free with a normal clinical examination., Conclusion: In the absence of focal signs of neurologic injury, the cervical spine can be cleared without a clinical exam or MRI if the cervical CT scan does not demonstrate injury or abnormality., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Increased life expectancy has resulted in more older patients at trauma centers. Traditional assessments of injuries alone may not be sufficient; age, comorbidities, and medications should be considered., Methods: 446 older trauma patients were analyzed in two groups, 45-65 years and <65, using Injury Severity Score (ISS), the Charlson Comorbidity Index (CCI), and Comorbidity-Polypharmacy Score (CPS)., Results: CCI and CPS were associated with HLOS in patients <65. In patients aged 45-65, only CPS was associated with HLOS. CPS was inversely associated with in-hospital mortality in patients <65, but not patients aged 45-65. CCI score was not associated with in-hospital mortality in either group., Conclusion: Increased CCI and CPS were associated with increased HLOS. In patients over 65, increased CPS was associated with decreased mortality. This could be due to return toward physiologic normalcy in treated patients not seen in their peers with undiagnosed or untreated comorbidities., (Published by Elsevier Inc.)