Trauma resident exposure in Canada and operative numbers (TraumaRECON): a national multicentre retrospective review of operative and nonoperative trauma teaching.

BACKGROUND: General surgeons play an important role in the provision of trauma care in Canada and the current extent of their trauma experience during training is unknown. We sought to quantify the operative and nonoperative educational experiences among Canadian general surgery trainees. METHODS: We conducted a multicentre retrospective study of major operative exposures experienced by general surgery residents, as identified using institutional trauma registries and subsequent chart-level review, for 2008-2018. We also conducted a site survey on trauma education and structure. RESULTS: We collected data on operative exposure for general surgery residents from 7 programs and survey data from 10 programs. Operations predominantly occurred after hours (73% after 1700 or on weekends) and general surgery residents were absent from a substantial proportion (25%) of relevant trauma operations. The structure of trauma education was heterogeneous among programs, with considerable site-specific variability in the involvement of surgical specialties in trauma care. During their training, graduating general surgery residents each experienced around 4 index trauma laparotomies, 1 splenectomy, 1 thoracotomy, and 0 neck explorations for trauma. CONCLUSION: General surgery residents who train in Canada receive variable and limited exposure to operative and nonoperative trauma care. These data can be used as a baseline to inform the application of competency-based medical education in trauma care for general surgery training in Canada.

Toward an all-inclusive trauma system in Central South Ontario: development of the Trauma-System Performance Improvement and Knowledge Exchange (T-SPIKE) project.

Background: There is currently no integrated data system to capture the true burden of injury and its management within Ontario's regional trauma networks (RTNs), largely owing to difficulties in identifying these patients across the multiple health care provider records. Our project represents an iterative effort to create the ability to chart the course of care for all injured patients within the Central South RTN. Methods: Through broad stakeholder engagement of major health care provider organizations within the Central South RTN, we obtained research ethics board approval and established data-sharing agreements with multiple agencies. We tested identification of trauma cases from Jan. 1 to Dec. 31, 2017, and methods to link patient records between the various echelons of care to identify barriers to linkage and opportunities for administrative solutions. Results: During 2017, potential trauma cases were identified within ground paramedic services (23 107 records), air medical transport services (196 records), referring hospitals (7194 records) and the lead trauma hospital trauma registry (1134 records). Linkage rates for medical records between services ranged from 49% to 92%. Conclusion: We successfully conceptualized and provided a preliminary demonstration of an initiative to collect, collate and accurately link primary data from acute trauma care providers for certain patients injured within the Central South RTN. Administration-level changes to the capture and management of trauma data represent the greatest opportunity for improvement.

Contexte: On ne dispose actuellement d'aucun système intégré de gestion des données pour évaluer le fardeau réel des traumatismes et de leur gestion dans les réseaux régionaux de traumatologie (RRT) en Ontario, en bonne partie en raison de la difficulté d'identifier les cas parmi la multiplicité des dossiers d'intervenants médicaux. Notre projet représente un effort itératif pour créer la capacité de cartographier le parcours de soin de tous les polytraumatisés du RRT de la région Centre-Sud. Méthodes: Grâce à l'engagement général des intervenants des grandes organisations de santé du RRT de la région Centre-Sud, nous avons obtenu l'approbation d'un comité d'éthique de la recherche et conclu des accords de partage des données avec plusieurs agences. Nous avons testé l'identification des cas de traumatologie du 1er janvier au 31 décembre 2017 et les méthodes de liaison des dossiers de patients entre les divers échelons de soin pour identifier les obstacles à la liaison et leurs solutions administratives possibles. Résultats: Au cours de 2017, les cas de traumatologie potentiels ont été identifiés auprès des services ambulanciers terrestres (23 107 dossiers), des services de transport médical aérien (196 dossiers), des hôpitaux référents (7194 dossiers) et du registre hospitalier principal de traumatologie (1134 dossiers). Les taux de liaison entre les différents services pour les dossiers médicaux variaient de 49 % à 92 %. Conclusion: Nous avons conceptualisé et présenté avec succès la démonstration préliminaire d'un projet visant à recueillir, colliger et relier avec justesse les données primaires des intervenants en traumatologie aiguë pour certains patients blessés du RRT du Centre-Sud. Des changements administratifs centrés sur la saisie et la gestion des données de traumatologie représentent la meilleure voie vers une amélioration.

Cause for concern: Resident experience in operative trauma during general surgery residency at a Canadian centre.

BACKGROUND: The ability to provide competent operative trauma care is a core objective of general surgery training but recent publications question the ability of graduates to meet this standard. To assess the adequacy of operative trauma exposure during residency, we constructed and analyzed a retrospective trauma operative case log for general surgery residents at a Canadian trauma centre. METHODS: The Hamilton General Hospital Trauma Registry was used to identify all patients from July 2008 to June 2018 who underwent a trauma operation on the neck, chest, or abdomen. Medical records were reviewed to determine procedure type and resident presence. RESULTS: In our study, 417 patients underwent 570 operations (422 abdominal, 103 thoracic, and 45 neck). For the 35 residents that completed their general surgery residency during the study, the median number of trauma laparotomies was 5, with only 14/35 (40%) present for ≥10 trauma operations. Only 10 residents (29%) were exposed to a neck exploration and 18 (51%) exposed to a thoracic operation for trauma. CONCLUSIONS: Operative trauma exposure amongst general surgery residents at an academic Canadian trauma centre was limited. Cumulative operative trauma surgery exposure of a typical graduating resident was inadequate when compared to Canadian and American accrediting-body standards.

CONTEXTE: La capacité d'offrir des soins de qualité en traumatisme opératoire est un objectif principal de la formation en chirurgie générale, mais des publications récentes contestent la capacité des diplômés à satisfaire cette norme. Pour évaluer le caractère adéquat de l'exposition à des traumatismes opératoires pendant la résidence, nous avons construit et analysé un registre rétrospectif des cas opératoires traumatologiques des résidents en chirurgie générale à un centre canadien de traumatologie. MÉTHODES: Le registre des traumatismes du Hamilton General Hospital a été utilisé pour identifier tous les patients de juillet 2008 à juin 2018 qui ont subi une chirurgie traumatologique au cou, au thorax ou à l'abdomen. Les dossiers médicaux ont été examinés pour établir le type de procédure et la présence de résidents. RÉSULTATS: Dans notre étude, 417 patients ont subi 570 opérations (422 à l'abdomen, 103 au thorax et 45 au cou). Pour les 35 résidents qui ont terminé leur résidence en chirurgie générale au cours de l'étude, le nombre médian de laparotomies traumatologiques a été de cinq, avec seulement 14/35 (40 %) présents pour dix opérations traumatologiques ou plus. Seulement 10 résidents (9 %) ont assisté à une exploration du cou et 18 (51 %) ont assisté à une chirurgie thoracique pour un trauma. CONCLUSIONS: L'exposition aux traumatismes opératoires chez les résidents en chirurgie générale à un centre universitaire canadien de traumatologie a été limitée. L'exposition cumulative à des chirurgies traumatologiques opératoires d'un résident diplômé type était inadéquate comparativement aux normes d'agrément des organismes canadiens et américains.

Trauma Resident Exposure in Canada and Operative Numbers (TraumaRECON): a study protocol for a national multicentre study of operative, nonoperative and structured educational exposures in Canada.

BACKGROUND: Canada's shift toward nonoperative trauma management, coupled with the implementation of competency-based medical education, has highlighted the lack of quantitative knowledge about the volume and quality of exposure to operative trauma training experiences among Canadian general surgery residents. We aim to quantify the exposure to specific operative trauma domains during residency over time and across participating Canadian training programs and to perform an environmental scan of the nonoperative clinical exposure and other formal and informal trauma education provided to general surgery residents across Canadian training programs. METHODS: Trauma Resident Exposure in Canada and Operative Numbers (TraumaRECON) is a retrospective, multicentre study of operative trauma procedures involving the participation of general surgery residents in Canada. Participating sites will populate a data abstraction form outlining operative trauma data points as abstracted from eligible trauma operative charts via each site's trauma registry. They will also complete a survey of the nonoperative clinical and other educational opportunities in trauma care to which general surgery residents are exposed in participating general surgery training programs. The primary outcome of this study will be the volume of operative trauma cases that general surgery residents are exposed to during their residency in Canada. Secondary outcomes will include the association between time of occurrence during the day for trauma operations and resident participation, operative volume stratified by postgraduate year of training, volume of missed operative trauma opportunities, volume of operative trauma cases by type, and the operative role of residents involved in trauma operations. INTERPRETATION: The need for competency in operative trauma management will always exist; however, with potentially limited operative trauma volume, this standard may prove difficult to achieve for the next generation of general surgery residents in Canada. Results of TraumaRECON will provide a quantitative commentary on the operative trauma volume experienced by general surgery residents in Canada to inform future teaching practices in the context of competency-based medical education.

A method to audit and score implementation of knowledge translation (KT) interventions in large health regions - an observational pilot study using rectal cancer surgery in Ontario.

BACKGROUND: Across Ontario, since the year 2006 various knowledge translation (KT) interventions designed to improve the quality of rectal cancer surgery have been implemented by the provincial cancer agency or by individual researchers. Ontario is divided administratively into 14 health regions. We piloted a method to audit and score for each region of the province the KT interventions implemented to improve the quality of rectal cancer surgery. METHODS: We interviewed stakeholders to audit KT interventions used in respective regions over years 2006 to 2014. Results were summarized into narrative and visual forms. Using a modified Delphi approach, KT experts reviewed these data and then, for each region, scored implementation of KT interventions using a 20-item KT Signature Assessment Tool. Scores could range from 20 to 100 with higher scores commensurate with greater KT intervention implementation. RESULTS: There were thirty interviews. KT experts produced scores for each region that were bimodally distributed, with an average score for 2 regions of 78 (range 73-83) and for 12 regions of 30.5 (range 22-38). CONCLUSION: Our methods efficiently identified two groups with similar KT Signature scores. Two regions had relatively high scores reflecting numerous KT interventions and the use of sustained iterative approaches in addition to those encouraged by the provincial cancer agency, while 12 regions had relatively low scores reflecting minimal activities outside of those encouraged by the provincial cancer agency. These groupings will be used for future comparative quantitative analyses to help determine if higher KT signature scores correlate with improved measures for quality of rectal cancer surgery.

Venous thromboembolism prophylaxis and the impact of a thrombosis service at a Canadian level 1 trauma centre

Background: Venous thromboembolism (VTE) is a common and serious complication seen in patients with trauma. Guidelines recommend the routine use of pharmacologic prophylaxis; however, compliance rates vary widely. The aim of this study was to describe the clinical practice related to VTE prophylaxis in the first 24 hours after injury at our level 1 Canadian trauma centre and the impact of a thrombosis consultation service. Methods: We performed a retrospective review of the health records of adult patients with trauma admitted between Jan. 1, 2012, and June 30, 2013. The rate of VTE was ascertained. The use of an initial prophylactic regimen, potential contraindications to prophylaxis and involvement of the thrombosis service were determined. Results: A total of 633 patients were included, 459 men and 174 women with a mean age of 47.4 years. The mean Injury Severity Score was 15.8. The overall VTE rate was 2.8%. A total of 514 patients (81.2%) received VTE prophylaxis, mechanical in 302 (47.7%) and pharmacologic in 231 (36.5%) (19 patients received both types). The thrombosis service was involved in the care of 164 patients (25.9%). Patients seen by the thrombosis service were more likely to receive VTE prophylaxis than those not seen by the service (145 [88.4%] v. 369 [78.7%], p < 0.01). Conclusion: Compliance with VTE prophylaxis administration was suboptimal, and opportunities for improvement exist. The involvement of a thrombosis consultation service appears to improve compliance with VTE prophylaxis, and augmented use of this service may improve clinical outcomes.

Contexte: La thromboembolie veineuse (TEV) est une complication grave et fréquente chez les patients vus en traumatologie. Les lignes directrices recommandent l'utilisation systématique d'une prophylaxie pharmacologique; par contre, les taux de conformité aux lignes directrices varient beaucoup. Le but de cette étude était de décrire la pratique clinique en matière de thromboprophylaxie dans notre centre de traumatologie canadien de niveau 1 au cours des 24 premières heures suivant un traumatisme et l'impact d'un service de prévention des thromboses. Méthodes: Nous avons procédé à une revue rétrospective des dossiers médicaux de patients adultes hospitalisés en traumatologie entre le 1er janvier 2012 et le 30 juin 2013. Le taux de TEV a été mesuré et nous avons vérifié si un schéma prophylactique initial avait été utilisé, s'il y avait des contre-indications potentielles à la prophylaxie et si le service de prévention des thromboses avait été mis à contribution. Résultats: En tout, 633 patients ont été inclus, 459 hommes et 174 femmes âgés en moyenne de 47,4 ans. L'indice moyen de gravité de la blessure (IGB) était de 15,8. Le taux global de TEV a été de 2,8 %. En tout 514 patients (81,2 %) ont reçu une thromboprophylaxie (mécanique chez 302 [47,7 %] et pharmacologique chez 231 [36,5 %]; 19 patients ont reçu les 2 types de prophylaxie). Le service de prévention des thromboses a été impliqué dans 164 dossiers (25,9 %). Les patients vus par le service de prévention des thromboses étaient plus susceptibles que les autres patients de recevoir une thromboprophylaxie (145 [88,4 %] c. 369 [78,7 %], p < 0,01). Conclusion: La conformité aux lignes directrices sur la thromboprophylaxie a été sous-optimale, et il est possible de l'améliorer. L'implication d'un service de prévention des thromboses semble améliorer la conformité aux lignes directrices sur la thromboprophylaxie et y faire appel plus souvent pourrait améliorer les résultats cliniques.

Selective nonoperative management of penetrating abdominal trauma at a level 1 Canadian trauma centre: a quest for perfection

Background: Many patients who sustain penetrating abdominal trauma can be managed nonoperatively. The Eastern Association for the Surgery of Trauma (EAST) has published guidelines on selective nonoperative management (SNOM), and this approach is well established. The purpose of this study is to assess the management of penetrating abdominal trauma, including the selection of patients for SNOM and the use of this approach, at a Canadian level 1 trauma centre. Methods: We used the Hamilton Health Sciences trauma registry to compile data on patients aged 16 years and older who sustained penetrating abdominal trauma from Jan. 1, 2011, to Dec. 31, 2017. Hemodynamically stable, nonperitonitic patients without evisceration or impalement were considered potentially eligible for SNOM. We compared the SNOM group of patients with the immediate operative (IOR) group. Our primary outcome was SNOM failure; secondary outcomes included length of stay, repeat imaging, computed tomography (CT) protocol, laparoscopy in left thoracoabdominal trauma, and nontherapeutic and negative laparotomies. Results: We included 191 patients with penetrating abdominal trauma; 123 underwent SNOM and 68 underwent IOR. Of the 68 patients in the IOR group, 4 underwent nontherapeutic laparotomies. Of the 123 patients in the SNOM group, this approach failed in 7 (5.7%). Patients who were successfully managed with SNOM had an average length of stay of 25.4 hours (7.9­43.0 h), with no repeat imaging in 34/35 (97.1%). Only 5 of the 47 patients with flank/back wounds had a CT scan that included luminal contrast. Only 3 of the 58 patients with left thoracoabdominal wounds underwent same-admission laparoscopy, all demonstrating diaphragmatic defects. Conclusion: Our study demonstrates a high rate of compliance with the EAST SNOM guidelines, including minimal failure rate of SNOM and an efficient use of resources as demonstrated by reduced length of stay and minimal use of reimaging. We identified 2 opportunities for improvement: improved use of luminal contrast CT in patients with flank/back wounds and improved use of diagnostic laparoscopy in patients with left thoracoabdominal wounds.

Contexte: Il est possible de traiter non chirurgicalement bon nombre de traumatismes abdominaux pénétrant. L'Eastern Association for the Surgery of Trauma (EAST) a publié des lignes directrices sur une approche bien établie : le traitement non chirurgical sélectif (« selective nonoperative management ¼, ou SNOM). Le but de cette étude est d'évaluer le traitement des traumatismes abdominaux pénétrants, y compris la sélection des patients en vue du SNOM et l'utilisation de cette approche dans un centre de traumatologie canadien de niveau 1. Méthodes: Nous avons utilisé le registre de traumatologie du Hamilton Health Sciences Centre pour compiler les données sur les patients de 16 ans et plus ayant subi un traumatisme abdominal pénétrant entre le 1er janvier 2011 et le 31 décembre 2017. Les patients hémodynamiquement stables, indemmes de péritonite, d'éviscération ou d'empalement ont été considérés pour le SNOM. Nous avons comparé les patients du groupe soumis au SNOM à ceux du groupe soumis à une intervention chirurgicale immédiate. Notre paramètre principal était l'échec du SNOM; les paramètres secondaires incluaient la durée du séjour, la reprise des épreuves d'imagerie, le protocole de tomodensitométrie (TDM), la laparoscopie dans les cas de traumatisme thoracoabdominal gauche et les laparotomies non thérapeutiques et négatives. Résultats: Nous avons inclus 191 patients ayant subi un traumatisme abdominal pénétrant; 123 ont été soumis à l'approche SNOM et 68 à un une intervention chirurgicale immédiate. Parmi ces 68 patients, 4 ont subi des laparotomies non thérapeutiques. Parmi les 123 patients du groupe SNOM, l'approche a échoué chez 7 (5,7 %). Les patients traités avec succès par le SNOM ont séjourné en moyenne 25,4 heures (7,9­43,0 h), sans reprise d'imagerie chez 34/35 (97,1 %). Seulement 5 patients sur les 47 victimes de traumatisme au côté ou au dos ont subi une TDM avec contraste endoluminal. Seulement 3 patients sur 58 patients ayant une plaie thoraco-abdominale gauche ont subi des laparoscopies le jour même de l'admission et elles ont toutes révélé des anomalies diaphragmatiques. Conclusion: Notre étude a démontré un taux élevé de conformité aux lignes directrices de l'EAST concernant le SNOM, y compris un taux minime d'échecs avec cette approche et une utilisation à bon escient des ressources, comme en témoignent l'abrègement des séjours et le recours minime à la reprise des épreuves d'imagerie. Nous avons relevé deux secteurs à améliorer, soit l'emploi plus judicieux de la TDM avec contraste endoluminal chez les victimes d'un traumatisme au dos ou au côté et de la laparoscopie chez les victimes d'un traumatisme thoraco-abdominal gauche.

Role of the status of the mesorectal fascia in the selection of patients with rectal cancer for preoperative radiation therapy: a retrospective cohort study

Background: Patients with rectal cancer in whom the mesorectal fascia is threatened by tumour are more likely than all patients with stage II/III disease to benefit from preoperative radiotherapy (RT). The objective of this study was to assess whether the status of the mesorectal fascia versus a stage II/III designation can best inform the use of preoperative RT in patients undergoing major rectal cancer resection. Methods: We reviewed the charts of consecutive patients with primary rectal cancer treated by a single surgeon at McMaster University, Hamilton, Ontario, between March 2006 and December 2012. The status of the mesorectal fascia was assessed by digital rectal examination, pelvic computed tomography and, when needed, pelvic magnetic resonance imaging (MRI). Patients whose mesorectal fascia was threatened or involved by tumour received preoperative RT. The study outcomes were rates of positive circumferential radial margin (CRM) and local tumour recurrence. Results: A total of 153 patients were included, of whom 76 (49.7%) received preoperative RT because of concerns of a compromised mesorectal fascia. The median length of follow-up was 4.5 years. The number of CRM-positive cases in the RT and no-RT groups was 16 (22%) and 1 (1%), respectively (p < 0.01), and the number of cases of local tumour recurrence was 5 (7%) and 2 (3%), respectively (p = 0.2). Rates were similar when only patients with stage II/III tumours were included. Overall, 26 patients (17.0%) received MRI. Conclusion: The status of the mesorectal fascia, not tumour stage, may best identify patients for preoperative RT.

Contexte: Plus que tous les patients présentant une maladie de stade II/III, les patients atteints d'un cancer du rectum dont le fascia mésorectal est menacé par la tumeur sont de bons candidats à la radiothérapie (RT) préopératoire. L'objectif de cette étude était d'évaluer ce qui, entre l'état du fascia mésorectal et une désignation de stade II/III, permet le mieux de confirmer le bien-fondé d'une RT préopératoire chez les patients qui doivent subir une résection majeure pour cancer du rectum. Méthodes: Nous avons passé en revue les dossiers de patients consécutifs atteints d'un cancer rectal primaire traités par un seul chirurgien à l'Université McMaster, à Hamilton, en Ontario, entre mars 2006 et décembre 2012. L'état du fascia mésorectal a été évalué par toucher rectal, tomodensitométrie pelvienne et, au besoin, imagerie par résonnance magnétique (IRM) pelvienne. Les patients dont le fascia mésorectal était menacé ou affecté par la tumeur ont reçu une RT préopératoire. Les paramètres de l'étude étaient : taux de positivité de la marge radiale circonférentielle (MRC) et récurrence de la tumeur locale. Résultats: En tout, 153 patients ont été inclus, dont 76 (49,7 %) ont reçu une RT préopératoire en raison d'une atteinte du fascia mésorectal. La durée moyenne du suivi a été de 4,5 ans. Dans les groupes soumis et non soumis à la RT, les nombres de cas MRC-positifs ont été respectivement de 16 (22 %) et de 1 (1 %), (p < 0,01), et les nombres de cas de récurrence de la tumeur locale ont été respectivement de 5 (7 %) et de 2 (3 %) (p = 0,2). Les taux étaient similaires lorsque seuls les patients présentant des tumeurs de stade II/III étaient inclus. Globalement, 26 patients (17,0 %) ont subi l'IRM. Conclusion: C'est l'état du fascia mésorectal et non le stade de la tumeur qui peut le mieux permettre d'identifier les candidats à une RT préopératoire.

Independent Heath Facility Meets Cancer Care Ontario and Canadian Association of Gastroenterology Guidelines for Endoscopic Procedure Wait Times While Meeting Quality Indicators: A Retrospective Review.

Background: Canadian independent health facilities (IHFs) have been implemented to reduce hospital endoscopy volume and expedite endoscopic evaluations for patients suspected to have underlying colorectal cancer. Methods: We conducted a retrospective review of a prospective database at a large-volume urban IHF. The primary outcomes were wait times, and the secondary outcomes were colonoscopy quality indicators and complication rates. Results: Median wait times from referral to colonoscopy met the recommendations set out by the Canadian Association of Gastroenterology and Cancer Care Ontario for all indications: chronic abdominal pain: 43 days; new onset change in bowel habits: 36 days; bright red rectal bleeding: 42 days; documented iron-deficiency anemia: 43 days; fecal occult blood test positive: 38 days; cancer likely based on imaging or physical exam: 23 days; chronic diarrhea and chronic constipation: 42 days; and screening colonoscopies: 55 days. Secondary outcomes of quality indicators and complication rates all met or exceeded the CCO and CAG recommendations. Conclusions: This IHF met the recommended wait times for all indications for colonoscopy while maintaining high procedural quality and safety. IHFs are one solution to help meet the increasing demand for colonoscopy in Ontario.

Quality of preoperative pelvic computed tomography (CT) and magnetic resonance imaging (MRI) for rectal cancer in a region in Ontario: A retrospective population-based study.

BACKGROUND AND OBJECTIVES: Treatment decisions for rectal cancer rely on preoperative staging with CT and MRI scans. We assessed the quality of such scans in a region of Ontario. METHODS: We retrospectively collected data for patients undergoing rectal cancer surgery between July 2011 and December 2014. We measured three aspects of quality: use; comprehensiveness of reporting T-category, N-category, mesorectal fascia (MRF) status; and in non-radiated patients sensitivity and specificity of reports for relevant elements. RESULTS: A total of 559 patients underwent major rectal cancer surgery. Preoperative staging with CT and MRI was performed in 93% and 50% of patients. CT scan reports provided information on T-category, N-category, and MRF status in 41%, 92%, and 16% of cases. These same elements were reported on MRI in 88%, 93%, and 62% of cases. CT scan sensitivity and specificity was 80% and 80% for T-category, and 85% and 39% for N-category. MRI sensitivity and specificity was 75% and 81% for T-category, 79% and 37% for N-category, and 33% and 89% for MRF status. CONCLUSION: In this region of Ontario, pre-operative MRI was underutilized, CT reporting of MRF status was low, and when reported sensitivity and specificity of T- and N-category were similar for CT and MRI.

Beta blockers in critically ill patients with traumatic brain injury: Results from a multicenter, prospective, observational American Association for the Surgery of Trauma study.

BACKGROUND: Beta blockers, a class of medications that inhibit endogenous catecholamines interaction with beta adrenergic receptors, are often administered to patients hospitalized after traumatic brain injury (TBI). We tested the hypothesis that beta blocker use after TBI is associated with lower mortality, and secondarily compared propranolol to other beta blockers. METHODS: The American Association for the Surgery of Trauma Clinical Trial Group conducted a multi-institutional, prospective, observational trial in which adult TBI patients who required intensive care unit admission were compared based on beta blocker administration. RESULTS: From January 2015 to January 2017, 2,252 patients were analyzed from 15 trauma centers in the United States and Canada with 49.7% receiving beta blockers. Most patients (56.3%) received the first beta blocker dose by hospital day 1. Those patients who received beta blockers were older (56.7 years vs. 48.6 years, p < 0.001) and had higher head Abbreviated Injury Scale scores (3.6 vs. 3.4, p < 0.001). Similarities were noted when comparing sex, admission hypotension, mean Injury Severity Score, and mean Glasgow Coma Scale. Unadjusted mortality was lower for patients receiving beta blockers (13.8% vs. 17.7%, p = 0.013). Multivariable regression determined that beta blockers were associated with lower mortality (adjusted odds ratio, 0.35; p < 0.001), and propranolol was superior to other beta blockers (adjusted odds ratio, 0.51, p = 0.010). A Cox-regression model using a time-dependent variable demonstrated a survival benefit for patients receiving beta blockers (adjusted hazard ratio, 0.42, p < 0.001) and propranolol was superior to other beta blockers (adjusted hazard ratio, 0.50, p = 0.003). CONCLUSION: Administration of beta blockers after TBI was associated with improved survival, before and after adjusting for the more severe injuries observed in the treatment cohort. This study provides a robust evaluation of the effects of beta blockers on TBI outcomes that supports the initiation of a multi-institutional randomized control trial. LEVEL OF EVIDENCE: Therapeutic/care management, level III.

Are We Missing Traumatic Bowel and Mesenteric Injuries?

PURPOSE: Traumatic bowel and mesenteric injury (TBMI), although an uncommon entity, can be lethal if not detected and treated in a timely manner. The purpose of our study was to evaluate the diagnostic accuracy of 64-slice multidetector computed tomography (MDCT) for the detection of TBMI in patients at our level 1 trauma centre. METHODS: We used our hospital's trauma registry to identify patients with a diagnosis of TBMI from January 1, 2006, to June 30, 2013. Only patients who had a 64-slice MDCT scan at presentation and subsequently underwent laparotomy or laparoscopy were included in the study cohort. Using the surgical findings as the gold standard, the accuracy of prospective radiology reports was analyzed. RESULTS: Of the 4781 trauma patients who presented to our institution, 44 (0.92%) had surgically proven TBMI. Twenty-two of 44 were excluded as they did not have MDCT before surgery. The study cohort consisted of 14 males and 8 females with a median age of 41.5 years and a median injury severity score of 27. In total 17 of 22 had blunt trauma and 5 of 22 had penetrating injury. A correct preoperative imaging diagnosis of TBMI was made in 14 of 22 of patients. The overall sensitivity of the radiology reports was 63.6% (95% confidence interval [CI]: 41%-82%), specificity was 79.6% (95% CI: 67%-89%), PPV was 53.9% (95% CI: 33%-73%), and the NPV was 85.5% (95% CI: 73%-94%). Accuracy was calculated at 75.3%. However, only 59% (10 of 17) of patients with blunt injury had a correct preoperative diagnosis. Review of the findings demonstrated that majority of patients with missed blunt TBMI (5 of 7) demonstrated only indirect signs of injury. CONCLUSION: The detection of TBMI in trauma patients on 64-slice MDCT can be improved, especially in patients presenting with blunt injury. Missed cases in this population occurred because the possibility of TBMI was not considered despite the presence of indirect imaging signs. The prospective diagnosis of TBMI remains challenging despite advances in CT technology and widespread use of 64-slice MDCT.

The Need for Consensus and Transparency in Assessing Population-Based Rates of Positive Circumferential Radial Margins in Rectal Cancer: Data from Consecutive Cases in a Large Region of Ontario, Canada.

BACKGROUND: A positive circumferential radial margin (CRM) after rectal cancer surgery is an important predictor of local recurrence. The definition of a positive CRM differs internationally, and reported rates vary greatly in the literature. This study used time-series population-based data to assess positive CRM rates in a region over time and to inform future methods of CRM analysis in a defined geographic area. METHODS: Chart reviews provided relevant data from consecutive patients undergoing rectal cancer surgery between 2006 and 2012 in all hospitals of the authors' region. Outcomes included rates for pathologic examination of CRM, CRM distance reporting, and positive CRM. The rate of positive CRM was calculated using various definitions. The variations included positive margin cutoffs of CRM at 1 mm or less versus 2 mm or less and inclusion or exclusion of cases without CRM assessment. RESULTS: In this study, 1222 consecutive rectal cancer cases were analyzed. The rate for pathology reporting of CRM distance increased from 54.7 to 93.2 % during the study. Depending on how the rate of positive CRM was defined, its value varied 8.5 to 19.4 % in 2006 and 6.0 to 12.5 % in 2012. Using a pre-specified definition, the rate of positive CRM decreased over time from 14.0 to 6.3 %. CONCLUSIONS: A marked increase in CRM distance reporting was observed, whereas the rates of positive CRM dropped, suggesting improved pathologist and surgeon performance over time. Changing definitions greatly influenced the rates of positive CRM, indicating the need for more transparency when such population-based rates are reported in the literature.

Imaging of Traumatic Diaphragmatic Rupture: Evaluation of Diagnostic Accuracy at a Level 1 Trauma Centre.

PURPOSE: Traumatic diaphragmatic rupture (TDR) is an uncommon injury that can be associated with significant morbidity if not detected and treated in a timely manner. The purpose of our study was to evaluate the diagnostic accuracy of 64-slice multidetector computed tomography (64-MDCT) for the detection of TDR in patients at our level 1 trauma centre. METHODS: We used our hospital's trauma registry to identify patients with a diagnosis of TDR from January 1, 2008, to December 31, 2012. Only patients with a 64-MDCT scan at presentation who subsequently underwent laparotomy/laparoscopy were included in the study cohort. Using surgical findings as the gold standard, the accuracy of the prospective radiology reports was analyzed. RESULTS: Of the 3225 trauma patients who presented to our institution, 38 (1.2%) had a TDR. Fourteen of the 38 were excluded as they did not have MDCT before surgery. The study cohort consisted of 20 males and 4 females with a median age of 34.5 years and a median Injury Severity Score (ISS90) of 26. Fifteen had blunt trauma while 9 had a penetrating injury. The overall sensitivity of the radiology reports was 66.7% (95% confidence interval [CI]: 46.7%-82.0%), specificity was 100% (95% CI: 94.1%-100%), positive predictive value was 100% (95% CI: 80.6%-100%), negative predictive value was 88.4% (95% CI: 78.8%-94.0%), and accuracy was 90.6% (95% CI: 82.5%-95.2%). However, only 3 of 9 patients with penetrating injury had a correct preoperative diagnosis. Two of the 6 missed penetrating trauma cases had only indirect signs of injury. CONCLUSIONS: The detection of TDR in trauma patients on 64-MDCT can be improved, especially in patients presenting with penetrating injury. A careful search for subtle diaphragmatic defects and indirect evidence of injury is important to avoid missing the diagnosis.

An Internet-Based Collaborative Cancer Conference for Rectal Cancer Influenced Surgeon Treatment Recommendations.

INTRODUCTION: In many jurisdictions geographic and resource constraints are barriers to multidisciplinary cancer conference review of all patients undergoing cancer surgery. We piloted an internet-based collaborative cancer conference (I-CCC) for rectal cancer to overcome these barriers in the LHIN4 region of Ontario (population 1.4 million). METHODS: Surgeons practicing at one of 10 LHIN4 hospitals were invited to participate in I-CCC reviews. A secure internet audio and visual link facilitated review of cross-sectional images and case details. Before review, referring surgeons detailed initial treatment plans. Main treatment options included preoperative radiation, straight to surgery, and plan uncertain. Changes were noted following I-CCC review from initial to final treatment plan. Major changes included: redirect patient to preoperative radiation from straight to surgery or plan uncertain; and redirect patient to straight to surgery from preoperative radiation or plan uncertain. Minor changes included: change type of neoadjuvant therapy; request additional tests (e.g., pelvic MRI); or formal MCC review. RESULTS: From November 2010 to May 2012, 20 surgeons (7 academic and 13 community) submitted 57 rectal cancer cases for I-CCC review. After I-CCC review, 30 of 57 (53 %) cases had treatment plan changes: 17 major and 13 minor. No patient or tumour factors predicted for treatment plan change. CONCLUSIONS: An I-CCC for rectal cancer in a large geographic region was feasible and influenced surgeon treatment recommendations in 53 % of cases. Because no factor predicted for treatment plan change, it is likely prudent that all rectal cancer patients undergo some form of collaborative review.

Product analysis and initial reliability testing of the total mesorectal excision-quality assessment instrument.

BACKGROUND: Product analysis of rectal cancer resection specimens before specimen fixation may provide an immediate and relevant evaluation of surgical performance. We tested the interrater reliability (IRR) of a product analysis tool called the Total Mesorectal Excision-Quality Assessment Instrument (TME-QA). METHODS: Participants included two gold standard raters, five pathology assistants, and eight pathologists. Domains of the TME-QA reflect total mesorectal excision principles including: (1) completeness of mesorectal margin; (2) completeness of mesorectum; (3) coning of distal mesorectum; (4) physical defects; and (5) overall specimen quality. Specimens were scored independently. We used the generalizability theory to assess the tool's internal consistency and IRR. RESULTS: There were 39 specimens and 120 ratings. Mean overall specimen quality scores for the gold standard raters, pathologists, and assistants were 4.43, 4.43, and 4.50, respectively (p > 0.85). IRR for the first nine items was 0.68 for the full sample, 0.62 for assistants alone, 0.63 for pathologists alone, and 0.74 for gold standard raters alone. IRR for the item overall specimen quality was 0.67 for the full sample, 0.45 for assistants, 0.80 for pathologists, and 0.86 for gold standard raters. IRR increased for all groups when scores were averaged across two raters. CONCLUSIONS: Assessment of surgical specimens using the TME-QA may provide rapid and relevant feedback to surgeons about their technical performance. Our results show good internal consistency and IRR when the TME-QA is used by pathologists. However, for pathology assistants, multiple ratings with the averaging of scores may be needed.

Results of a surgeon-directed quality improvement project on breast cancer surgery outcomes in South-Central Ontario.

BACKGROUND: Gaps in breast cancer (BC) surgical care have been identified. We have completed a surgeon-directed, iterative project to improve the quality of BC surgery in South-Central Ontario. METHODS: Surgeons performing BC surgery in a single Ontario health region were invited to participate. Interventions included: audit and feedback (A&F) of surgeon-selected quality indicators (QIs), workshops, and tailoring interviews. Workshops and A&F occurred yearly from 2005-2012. QIs included: preoperative imaging; preoperative core biopsy; positive margin rates; specimen orientation labeling; intraoperative specimen radiography of nonpalpable lesions; T1/T2 mastectomy rates; reoperation for positive margins; sentinel lymph node biopsy (SLNB) rates, number of sentinel lymph nodes; and days to receive pathology report. Semistructured tailoring interviews were conducted to identify facilitators and barriers to improved quality. All results were disseminated to all surgeons performing breast surgery in the study region. RESULTS: Over 6 time periods, 1,828 BC charts were reviewed from 12 hospitals (8 community and 4 academic). Twenty-two to 40 participants attended each workshop. Sustained improvement in rates of positive margins, preoperative core biopsies, specimen orientation labeling, and SLNB were seen. Mastectomy rates and overall axillary staging rates did not change, whereas time to receive pathology report increased. The tailoring interviews concerning positive margins, SLNB, and reoperation for positive margins identified facilitators and barriers relevant to surgeons. CONCLUSIONS: This surgeon-directed, regional project resulted in meaningful improvement in numerous QIs. There was consistent and sustained participation by surgeons, highlighting the importance of integrating the clinicians in a long-term, iterative quality improvement strategy in BC surgery.

The implementation of a surgeon-directed quality improvement strategy in breast cancer surgery.

BACKGROUND: The investigators designed a sustained, surgeon-directed, iterative project to improve the quality of breast cancer surgery in south central Ontario. METHODS: The strategy included audit and feedback of surgeon-selected quality indicators, workshops, and tailoring interviews. Workshops were held to discuss quality improvement strategies, select quality indicators, review audited results, and select interventions for subsequent implementation. Semistructured tailoring interviews were conducted to identify facilitators and barriers to improved quality. All presentations and results were disseminated to all surgeons performing breast surgery in the study region. RESULTS: Forty-four surgeons performing breast surgery across 12 hospitals are involved in the project. Five workshops have been held since 2005. Surgeons' enthusiasm and involvement in the project have been positive. Interim results demonstrated that over 4 audit cycles (2006-2010), the preoperative core biopsy rate increased from 73% to 92%. The tailoring interviews indicated that 18 of 21 surgeons performed preoperative core biopsies. CONCLUSIONS: This project highlights the feasibility of a surgeon-directed, iterative quality improvement strategy in breast cancer surgery. Interim results demonstrate consistent improvements in a key selected quality indicator.

Uptake of an innovation in surgery: observations from the cluster-randomized Quality Initiative in Rectal Cancer trial.

BACKGROUND: Theory suggests the uptake of a medical innovation is influenced by how potential adopters perceive innovation characteristics and by characteristics of potential adopters. Innovation adoption is slow among the first 20% of individuals in a target group and then accelerates. The Quality Initiative in Rectal Cancer (QIRC) trial assessed if rectal cancer surgery outcomes could be improved through surgeon participation in the QIRC strategy. We tested if traditional uptake of innovation concepts applied to surgeons in the experimental arm of the trial. METHODS: The QIRC strategy included workshops, access to opinion leaders, intraoperative demonstrations, postoperative questionnaires, and audit and feedback. For intraoperative demonstrations, a participating surgeon invited an outside surgeon to demonstrate optimal rectal surgery techniques. We used surgeon timing in a demonstration to differentiate early and late adopters of the QIRC strategy. Surgeons completed surveys on perceptions of the strategy and personal characteristics. RESULTS: Nineteen of 56 surgeons (34%) requested an operative demonstration on their first case of rectal surgery. Early and late adopters had similar perceptions of the QIRC strategy and similar characteristics. Late adopters were less likely than early adopters to perceive an advantage for the surgical techniques promoted by the trial (p = 0.023). CONCLUSION: Most traditional diffusion of innovation concepts did not apply to surgeons in the QIRC trial, with the exception of the importance of perceptions of comparative advantage.

CONTEXTE: Selon une théorie, 2 facteurs influencent l'adoption de nouvelles pratiques en médecine, soit la façon dont les adeptes potentiels perçoivent les caractéristiques novatrices et les caractéristiques propres aux adeptes potentiels eux-mêmes. L'adoption des nouvelles pratiques se fait lentement chez les premiers 20 % des individus d'un groupe cible, puis va en s'accélérant. L'étude QIRC (Quality Initiative in Rectal Cancer) a voulu vérifier si la participation des chirurgiens à la stratégie QIRC pouvait améliorer l'issue de la chirurgie pour cancer du rectum. Nous avons vérifié si les modes habituels d'adoption des nouvelles pratiques s'appliquaient aux chirurgiens dans le groupe expérimental de l'étude. MÉTHODES: La stratégie QIRC incluait des ateliers, l'accès à des meneurs d'opinion, des démonstrations peropératoires et des questionnaires postopératoires, suivis de vérifications et de commentaires. Pour les démonstrations peropératoires, un chirurgien participant invitait un chirurgien de l'extérieur à faire une démonstration de techniques chirurgicales rectales optimales. Nous avons utilisé les délais d'adoption des nouvelles pratiques par les chirurgiens pour faire ressortir la distinction entre les adeptes précoces et tardifs de la stratégie QIRC. Les chirurgiens ont répondu à des questionnaires sur leurs perceptions à l'endroit de la stratégie et sur leurs caractéristiques personnelles. RÉSULTATS: Dix-neuf chirurgiens sur 56 (34 %) ont demandé une démonstration opératoire lors de leur premier cas de chirurgie rectale. Les adeptes précoces et tardifs avaient des perceptions similaires de la stratégie QIRC et des caractéristiques personnelles similaires. Les adeptes tardifs étaient moins susceptibles que les adeptes précoces de percevoir l'avantage des techniques chirurgicales préconisées dans le cadre de l'étude (p = 0,023). CONCLUSION: La plupart des modes habituels de diffusion des nouvelles pratiques ne s'appliquaient pas aux chirurgiens de l'essai QIRC, à l'exception de l'importance des perceptions à l'endroit des avantages comparatifs.

Patterns of use and outcomes for radiation therapy in the Quality Initiative in Rectal Cancer (QIRC) trial.

BACKGROUND: The Quality Initiative in Rectal Cancer (QIRC) trial targeted surgeon intraoperative technique and not radiation therapy (RT) use. We performed a post hoc analysis of RT use among patients in the QIRC trial, not by arm of trial but rather for the entire group. We wished to identify associations between local recurrence risk and use of preoperative, postoperative or no RT. METHODS: We compared demographic, tumour and process of care measures among patients receiving preoperative, postoperative or no RT. A multivariable Cox regression model assessed local recurrence risk. RESULTS: The QIRC trial enrolled 1015 patients at 16 hospitals between 2002 and 2004. Radiation therapy use did not differ between trial arms, and median follow-up was 3.6 years. For the preoperative, postoperative and no RT groups, respectively, the percentage of patients was 12.8%, 19.3% and 67.9%; the percentage of stage II/III tumours was 57.0%, 88.7% and 48.1%; and the local recurrence rate was 5.3%, 10.2% and 5.5% (p = 0.05). After controlling for patient and tumour characteristics, including tumour stage, the hazard ratio (HR) for local recurrence was increased in the postoperative RT versus the no RT group (HR 1.64, 95% confidence interval 1.04-2.58, p = 0.027). CONCLUSION: Use of preoperative RT was low; most patients with stage II/III disease did not receive RT and, as expected, the postoperative RT group had the highest risk of local recurrence. Our results suggest opportunities to improve rectal cancer RT use in Ontario.

CONTEXTE: L'essai QIRC (Quality Initiative in Rectal Cancer) portait sur la technique peropératoire des chirurgiens et non sur l'utilisation de la radiothérapie (RT). Nous avons effectué une analyse rétrospective de l'utilisation de la RT chez les patients inclus dans l'essai QIRC, non pas en fonction des différents groupes de l'essai, mais en fonction de sa population entière. Nous avons voulu vérifier les liens entre le risque de récurrences locales et l'utilisation préopératoire ou postopératoire de la RT ou l'abstention de toute RT. MÉTHODES: Nous avons comparé les paramètres démographiques, les caractéristiques de la tumeur et le processus de soins chez les patients soumis à une RT préopératoire ou postopératoire, ou non traités par RT. Un modèle de régression multivariée de Cox a permis d'évaluer le risque de récurrences locales. RÉSULTATS: L'essai QIRC a regroupé 1015 patients de 16 hôpitaux entre 2002 et 2004. Le recours à la radiothérapie n'a pas différé entre les groupes de l'essai, et le suivi médian a été de 3,6 ans. Pour ce qui est des groupes soumis à une RT préopératoire ou postopératoire, ou non soumis à la RT, respectivement, le pourcentage de patients était de 12,8 %, 19,3 % et 67,9 %; le pourcentage de tumeurs de stade II/III était de 57,0 %, 88,7 % et 48,1 %, et le taux de récurrences locales, de 5,3 %, 10,2 % et 5,5 % (p = 0,05). Après ajustement pour tenir compte des caractéristiques des patients et des tumeurs, y compris le stade de la tumeur, le risque relatif (RR) de récurrences locales a augmenté dans le groupe soumis à une RT postopératoire par rapport au groupe non soumis à la RT (RR 1,64; intervalle de confiance de 95 %, 1,04­2,58, p = 0,027). CONCLUSION: Le recours à la RT préopératoire a été faible; la plupart des patients atteints d'une maladie de stade II/III n'ont pas reçu de RT et comme prévu, le groupe soumis à une RT postopératoire a présenté le risque le plus élevé de récurrences locales. Nos résultats indiquent qu'il serait possible d'améliorer l'utilisation de la RT pour le cancer rectal en Ontario.