Professionalism of Admitting and Consulting Services and Trauma Patient Outcomes.

OBJECTIVE: To determine whether trauma patients managed by an admitting or consulting service with a high proportion of physicians exhibiting patterns of unprofessional behaviors are at greater risk of complications or death. SUMMARY BACKGROUND DATA: Trauma care requires high-functioning interdisciplinary teams where professionalism, particularly modeling respect and communicating effectively, is essential. METHODS: This retrospective cohort study used data from 9 level I trauma centers that participated in a national trauma registry linked with data from a national database of unsolicited patient complaints. The cohort included trauma patients admitted January 1, 2012 through December 31, 2017. The exposure of interest was care by 1 or more high-risk services, defined as teams with a greater proportion of physicians with high numbers of patient complaints. The study outcome was death or complications within 30 days. RESULTS: Among the 71,046 patients in the cohort, 9553 (13.4%) experienced the primary outcome of complications or death, including 1875 of 16,107 patients (11.6%) with 0 high-risk services, 3788 of 28,085 patients (13.5%) with 1 high-risk service, and 3890 of 26,854 patients (14.5%) with 2+ highrisk services (P < 0.001). In logistic regression models adjusting for relevant patient, injury, and site characteristics, patients who received care from 1 or more high-risk services were at 24.1% (95% confidence interval 17.2% to 31.3%; P < 0.001) greater risk of experiencing the primary study outcome. CONCLUSIONS: Trauma patients who received care from at least 1 service with a high proportion of physicians modeling unprofessional behavior were at an increased risk of death or complications.

Quality of Care Within a Trauma Center Is not Altered by Injury Type.

BACKGROUND: : Previous studies have demonstrated variations in severity-adjusted mortality between trauma centers. However, it is not clear if outcomes vary by the type of injury being treated. METHODS: : National Trauma Data Bank was used to identify patients 16 years or older with moderate to severe injuries (Abbreviated Injury score > or =3) treated at level I or II trauma centers (n = 127,439 patients, 105 centers). Observed-to-Expected mortality ratios (O/E ratios, 95% confidence interval [CI]) were calculated for each trauma center within each of the three injury types: blunt multisystem (two or more body regions; n = 27,980; crude mortality, 15%), penetrating torso (neck, chest, or abdomen; n = 9,486; crude mortality, 9%), and blunt single system (n = 89,973; crude mortality 5%). Multivariate logistic regression was used to adjust for age, gender, mechanism, transfer status, and injury severity (Glasgow Coma Scale, blood pressure). For each injury type, trauma centers' performance was ranked as high (O/E with 95% CI <1), low (O/E with 95% CI >1), or average performers (O/E overlapping 1). RESULTS: : Almost three quarters of the trauma centers achieved the same performance rank in each of the three injury categories. There were 14 low-performing trauma centers in blunt multisystem injuries, six in penetrating torso injuries, and nine in the blunt single system injuries group. None of these centers achieved high performance in any other type of injury. CONCLUSIONS: : Risk-adjusted outcomes are consistent within trauma centers across different types of injuries, suggesting that quality improvement efforts should measure, analyze, and focus on hospital-wide systems of care, rather than on isolated quality domains related to specific types of injury.

Is the use of pan-computed tomography for blunt trauma justified? A prospective evaluation.

OBJECTIVE: Many trauma centers use the pan-computed tomography (CT) scan (head, neck, chest, and abdomen/pelvis) for the evaluation of blunt trauma. This prospective observational study was undertaken to determine whether a more selective approach could be justified. METHODS: We evaluated injuries in blunt trauma victims receiving a pan-CT scan at a level I trauma center. The primary outcome was injury needing immediate intervention. Secondary outcome was any injury. The perceived need for each scan was independently recorded by the emergency medicine and trauma surgery service before patients went to CT. A scan was unsupported if at least one of the physicians deemed it unnecessary. RESULTS: Between July, 1, 2007, and December, 28, 2007, 284 blunt trauma patients (average Injury Severity Score = 11) underwent a pan-CT after the survey form was completed. A total of 311 CT scans were judged to be unnecessary in 143 patients (27%), including scans of the head (62), neck (50), chest (116), and abdomen/pelvis (83). Of the 284 patients, 48 (17%) had injuries on 52 unsupported CT scans. An immediate intervention was required in 2 of the 48 patients (4%). Injuries that would have been missed included 5 of 62 unsupported head scans (8%), 2 of 50 neck scans (4%), 33 of 116 chest scans (28%), and 12 of 83 abdominal scans (14%). These missed injuries represent 5 of the 61 patients with closed head injuries (8%) in the series, 2 of the 23 with C-spine injuries (9%), 33 of the 112 with chest injuries (29%), and 12 of the 86 with abdominal injuries (14%). In 19 patients, none of the four CT scans was supported; nine of these had an injury identified, and six were admitted to the hospital (1 to the intensive care unit). Injuries that would have been missed included intraventricular and intracerebral hemorrhage (4), subarachnoid hemorrhage (2), cerebral contusion (1), C1 fracture (1), spinous and transverse process fractures (3), vertebral fracture (6), lung lacerations (1), lung contusions (14), small pneumothoraces (7), grade II-III liver and splenic lacerations (6), and perinephric or mesenteric hematomas (2). CONCLUSIONS: In this small sample, physicians were willing to omit 27% of scans. If this was done, two injuries requiring immediate actions would have been missed initially, and other potentially important injuries would have been missed in 17% of patients.

Trauma quality improvement using risk-adjusted outcomes.

PURPOSE: The National Surgical Quality Improvement Program has improved the quality of surgical care by tracking risk-adjusted patient outcomes. Unlike the National Surgical Quality Improvement Program, the trauma center verification program of the American College of Surgeons (ACS) focuses on availability of optimal resources, not outcomes. We hypothesized that significant variations in outcomes exist across similar level ACS-verified trauma centers despite availability of similar resources. METHODS: The National Trauma Data Bank was used to identify adult patients (age 16-99 years) who were treated at ACS-verified Level I trauma centers that submitted at least 1,000 patients during the 5-year study period (264,102 patients from 58 trauma centers, excluding dead upon arrival). Multivariate logistic regression was used to analyze expected survival for each patient, adjusted for age, gender, race, injury mechanism, transfer status, and injury severity. Observed-to-expected survival ratios (O/E ratios with 95% confidence intervals) were used to rank trauma centers as high performers (O/E ratio significantly larger than 1), low performers (O/E ratio significantly less than 1), or average performers (O/E ratio overlapping 1). RESULTS: Almost half the centers performed significantly different from their risk-adjusted expectation. Fourteen were high performers, 11 were low performers, and 33 were average performers. CONCLUSIONS: The trauma center verification process in its present form may not ensure optimal outcome across all verified centers. If further validated, these findings suggest significant room for trauma quality improvement by replicating structures and processes of high performing trauma centers.

The effect of hypertonic saline resuscitation on responses to severe hemorrhagic shock by the skeletal muscle, intestinal, and renal microcirculation systems: seeing is believing.

BACKGROUND: Decompensated hemorrhagic shock is often refractory to resuscitation, and we show here that it is associated with loss of vascular tone in skeletal muscle precapillary arterioles. We tested the hypothesis that microvascular derangements in the skeletal muscle, intestinal, and renal microcirculation systems would be reversed by initial hypertonic saline-dextran infusion. METHODS: Male Sprague-Dawley rats underwent precollicular brain stem transection without anesthesia for study. Parameters measured by in vivo videomicroscopy included cardiac output, mean arterial pressure, and microvascular responses in the skeletal muscle, ileum, and renal (i.e., the hydronephrotic kidney) microcirculation systems. Hemorrhaged was induced to a mean arterial pressure of 50 mmHg until decompensation occurred. The rats were then initially resuscitated with (1) 4 mL/kg 7.5% NaCl in 6% dextran 70, (2) 33 mL/kg .9% NaCl in 6% dextran 70, or (3) 33 mL/kg .9% NaCl. Twenty minutes later they received shed blood plus 33 mL/kg .9% NaCl to maintain mean arterial pressure at baseline levels. RESULTS: Decompensated hemorrhagic shock decreased cardiac output to between 24% and 35% of baseline values and profoundly decreased microvascular blood flow to between 10% and 19% of baseline. At the completion of resuscitation cardiac output increased to greater than baseline in all groups. Microvascular blood flow increased toward baseline transiently but then progressively deteriorated to between 36% and 69% of baseline in the 3 tissues. There was no significant difference between the three resuscitative fluids. CONCLUSIONS: Despite return of cardiac output to greater than baseline levels, muscle, intestinal, and renal microvascular blood flows remained significantly depressed. Hypertonic saline and/or dextran did not improve these deficits.

Massive transfusion policies at trauma centers participating in the American College of Surgeons Trauma Quality Improvement Program.

BACKGROUND: Massive transfusion protocols (MTPs) have been developed to implement damage control resuscitation (DCR) principles. A survey of MTP policies from American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) participants was performed to establish which MTP activation, hemostatic resuscitation, and monitoring aspects of DCR are included in the MTP guidelines. METHODS: On October 10, 2013, ACS-TQIP administration administered a cross-sectional electronic survey to 187 ACS-TQIP participants. RESULTS: Seventy-one percent (132 of 187) of responses were analyzed, with 62% designated as Level I and 38% designated as Level II ACS-TQIP trauma centers. Sixty-nine percent of sites indicated that they have plasma immediately available for MTP activation. By policy, in the first group of blood products administered, 88% of sites target high (≥1:2) plasma-to-red blood cell (RBC) ratios and 10% target low ratios. Likewise, 79% of sites target high platelet-to-RBC ratios and 16% target low ratios. Eighteen percent of sites reported incorporating point-of-care thromboelastogram into MTP policies. The most common intravenous hemostatic adjunct incorporated into MTPs was tranexamic acid (49%). Thirty-four percent of sites reported that some or all of their emergency medical service agencies have the ability to administer blood products or hemostatic agents during prehospital transport. There were minimal differences in MTP policies or capabilities between Level I and II sites. CONCLUSION: The majority of ACS-TQIP participants reported having MTPs that support the use of DCR principles including high plasma-to-RBC and platelet-to-RBC ratios. Immediate availability of plasma and product use by emergency medical services are becoming increasingly common, whereas the incorporation of point-of-care thromboelastogram into MTP policies remains low.

Negative appendectomy in pregnant women is associated with a substantial risk of fetal loss.

BACKGROUND: The preoperative diagnosis of acute appendicitis is often inaccurate in pregnant women, and complicated appendicitis is associated with a high rate of fetal loss. The study objective was to evaluate rates of fetal loss and early delivery in pregnant patients undergoing appendectomy, using a large population-based database. STUDY DESIGN: Using the California Inpatient File, we retrospectively analyzed all women undergoing appendectomy between 1995 and 2002 for pregnancy, diagnosis, operative technique, fetal loss, and early delivery during the same hospitalization as appendectomy. RESULTS: Of 94,789 women who underwent appendectomy, 3,133 were pregnant. Complicated appendicitis was found in 30% of pregnant women and 29% of nonpregnant women (p=NS). The rate of negative appendectomy was considerably higher in pregnant compared with nonpregnant women (23% versus 18%, p < 0.05). Rates of fetal loss and early delivery were considerably higher in women with complex appendicitis (6% and 11% respectively; p < 0.05) in comparison with negative (4% and 10%) and simple (2% and 4%) appendicitis. Using multivariate logistic regression, complicated and negative appendicitis (odds ratio [OR] 2.69 and 1.88 respectively, compared with simple) remained major positive predictors of fetal loss. Also, laparoscopy was associated with a higher rate of fetal loss compared with open appendectomy (odds ratio=2.31). CONCLUSIONS: The current approach to possible acute appendicitis in pregnant women puts 23% at risk for fetal loss, even though they have a normal appendix. These data indicate that reducing fetal loss in pregnant women suspected of having acute appendicitis will require more accurate diagnosis to avoid unnecessary operation.