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Brandon C. Gabel, Joel Martin, John R. Crawford, and Michael Levy

intraoperative complications are sent to the floor postoperatively, assuming the patient is extubated in the postanesthesia care unit and does not have new neurological deficits. The aim of this study is to address the frequency and reasons why transfer to an ICU level of care, after elective admission to the floor, may be necessary. Methods Study Population Following approval by the University of California, San Diego, institutional review board and Rady Children's Hospital, data on pediatric patients undergoing elective craniotomy for a diagnosis of brain tumor

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Megan M. Finneran, Sarah Graber, Kim Poppleton, Allyson L. Alexander, C. Corbett Wilkinson, Brent R. O’Neill, Todd C. Hankinson, and Michael H. Handler

regular basis, using a 10-point verbal pain score, revised Face, Legs, Activity, Cry, Consolability (rFLACC) scale score, or Faces Pain Scale, 6 – 8 according to preferences of the nurses caring for the patients. Pain was scored on the day of the operation when patients were fully awake, on postoperative day (POD) 1, POD 2, and days thereafter. Days thereafter were less consistently recorded by nurses, as patients were discharged. Patients who were deemed medically complex and in need of ICU level of care included those who were emergently admitted with CM

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Raymond Fang, Gina R. Dorlac, Patrick F. Allan, and Warren C. Dorlac

T he “mobile patient” is a reality. 5 No longer capable of indefinitely maintaining comprehensive medical care facilities throughout the world, the US military developed a worldwide trauma care system focused on making the patient the moving part of the system. Life-saving interventions are performed early, and essential care is delivered at forward, austere locations. Patients then proceed successively through increasingly capable levels of care, culminating with arrival at permanent facilities in the US for definitive care and rehabilitation. The safe and

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Jacob S. Young, Andrew K. Chan, Jennifer A. Viner, Sujatha Sankaran, Alvin Y. Chan, Sarah Imershein, Aldea Meary-Miller, Philip V. Theodosopoulos, Line Jacques, Manish K. Aghi, Edward F. Chang, Shawn L. Hervey-Jumper, Tracy Ward, Liz Gibson, Mariann M. Ward, Peter Sanftner, Stacy Wong, Dominic Amara, Stephen T. Magill, Joseph A. Osorio, Brinda Venkatesh, Ralph Gonzales, Catherine Lau, Christy Boscardin, Michael Wang, Kim Berry, Laurie McCullagh, Mary Reid, Kayla Reels, Sara Nedkov, Mitchel S. Berger, and Michael W. McDermott

at a higher risk for requiring an ICU level of postoperative care. 7 In addition, the authors found that only 140 (35.0%) of 400 patients actually required an ICU level of care and that only 33 (8.3%) required care other than intravenous medications for blood pressure control. It is unclear whether patients who are otherwise healthy, have small structural brain lesions, and/or undergo short operations can bypass the ICU and transition directly to a lower level of care postoperatively. We developed a Safe Transitions Pathway (STP) at our institution, through

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Brianna C. Theriault, Julia Pazniokas, Anusha S. Adkoli, Edward K. Cho, Naina Rao, Meic Schmidt, Chad Cole, Chirag Gandhi, William T. Couldwell, Fawaz Al-Mufti, and Christian A. Bowers

frailty for patients harboring cranial tumors. 11–13 These studies demonstrated an increase in mortality, 11–13 complications, 11–13 length of stay (LOS), 12 , 13 and discharge to a higher level of care 13 in frailer patients following tumor resection. TABLE 1. Variables covered in the modified Frailty Index 1 Functional status 2 (not independent) 2 History of diabetes mellitus 3 History of COPD or pneumonia 4 History of myocardial infarction 5 History of PCI, PCS, or angina 6 History of congestive heart failure 7 History of hypertension requiring medication 8

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Jacob K. Greenberg, Donna B. Jeffe, Christopher R. Carpenter, Yan Yan, Jose A. Pineda, Angela Lumba-Brown, Martin S. Keller, Daniel Berger, Robert J. Bollo, Vijay M. Ravindra, Robert P. Naftel, Michael C. Dewan, Manish N. Shah, Erin C. Burns, Brent R. O’Neill, Todd C. Hankinson, William E. Whitehead, P. David Adelson, Mandeep S. Tamber, Patrick J. McDonald, Edward S. Ahn, William Titsworth, Alina N. West, Ross C. Brownson, and David D. Limbrick Jr.

, including key questions such as the appropriate level of care and role of repeat neuroimaging. These questions have particular salience in the management of children with mTBI complicated by intracranial injury (ICI), where available evidence suggests that admission practices vary across specialties and that level-of-care decisions often fail to correlate with patients’ evidence-based risk. 18 , 42 While there are emerging evidence-based tools to help guide level-of-care decisions, 18 it remains unclear what considerations currently influence physician decision making

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Jeffrey E. Florman, Deborah Cushing, Lynne A. Keller, and Anand I. Rughani

between the 2 groups of patients sent to the floor and those that went to a higher level of care using the Fisher's exact test. PACU neurological status and length of observation before transfer to the floor was collected. All daily progress notes, nursing notes, and discharge summaries were studied in detail on all patients transferred from floor beds into a higher level of care. Postoperative complications were assessed for the entire hospital stay, and length of stay was collected. Escalation of care was defined as transfer from the floor to either the step-down unit

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Shirley I. Stiver and Geoffrey T. Manley

poorer survival rates if they are treated at Level II adult trauma centers. 123 Disaster and Mass Casualty Events Recent world events, political and natural, have heightened the awareness and need for prehospital care of the highest standards for mass casualty events. The levels of trauma care in the Iraq war are a model for mass casualty and disaster trauma programs. 3 In Iraq there are 5 levels of care—3 in the combat zone, 2 outside the combat zone. In the combat zone, levels of care progress from first aid in battle (Level I), to mobile resuscitation

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Rafael De la Garza Ramos, Christine Park, Edwin McCray, Meghan Price, Timothy Y. Wang, Tara Dalton, César Baëta, Melissa M. Erickson, Norah Foster, Zach Pennington, John H. Shin, Daniel M. Sciubba, Khoi D. Than, Isaac O. Karikari, Christopher I. Shaffrey, Muhammad M. Abd-El-Barr, Reza Yassari, and C. Rory Goodwin

Emergency Medical Treatment and Active Labor Act. 15 While there are no official guidelines or criteria defining a hospital’s resources, expertise, or clinical criteria for transfer, this system aims to transfer patients in need of a higher level of care to hospitals capable of delivering said care. The decision to transfer must therefore weigh the benefits of transfer to a higher level of care against the downsides of a delay in care. This cost-benefit analysis has been explored in other realms of neurosurgery, notably in patients with general or neurological

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Adam T. Leibold, Jonathan Weyhenmeyer, and Albert Lee

similar level of care after this procedure, with a median hospital stay of 7 days. In each case the infection was effectively treated without reinfection of the new pump system. Three patients experienced an infection within the first 4 months after the Turner switch procedure. None of these patients experienced an infection of the new pump and catheter; all 3 infections involved the old pump site and/or the residual catheter that was left in place. Our small sample size limits our ability to comment on the infection rate of the newly implanted pump, but having no