Building lean improvement sckills at scale: an evaluation of a massive open online course in the English NHS.

BACKGROUND: Internationally, healthcare systems face challenges from population demographics and rising care costs. Systematic methods of quality improvement (QI) are considered key to delivering needed transformation and change. Large-scale training in QI skills is required.Massive open online courses (MOOCs) are an inexpensive strategy for QI training across large regions and countries. The Lean Fundamentals MOOC was developed in the English NHS to train health and care staff in Lean QI methods. It supported participants to learn and apply process improvement skills through a free-to-access, practical, learning-in-action approach. METHODS: Lean Fundamentals' cost-effectiveness and its impact on participants' knowledge and confidence to apply Lean to improve processes were assessed. Using the Kirkpatrick framework, participant reaction, knowledge and confidence change, results and overall return-on-investment (ROI) were evaluated. Quantitative data were collected via pre and postcourse surveys to analyse participants' knowledge and confidence change using the Wilcoxon signed rank test. Qualitative learning platform and postcourse survey data demonstrated participants' results from application. RESULTS: Over 18 months, Lean Fundamentals attracted 6617 enrolments and supported 3462 active participants. 97.6% (n=829) of participants completing the postcourse survey indicated Lean Fundamentals met their expectations and 97.2% (n=823) indicated they would recommend it. Self-reported changes in knowledge and confidence to apply Lean showed significant differences (p<0.001). Learning was applied to operational healthcare priorities (such as post-COVID recovery of services) and participants shared 511 project improvement reports. CONCLUSION: Lean Fundamentals helped large numbers of participants to develop Lean process improvement skills-avoiding costs associated with commercial Lean training in the range £1.7 m to £3.4 m and generating ROI of between £11 and £23 per every pound spent on delivery. This demonstrates that massive online is an effective and efficient method for building improvement knowledge and skills at scale.

Recovering staff, recovering services: massive-online support for recovering a paediatric service using Lean and compassionate communication.

The COVID-19 pandemic has infected tens of millions worldwide. Healthcare systems have been stretched caring for the most seriously ill and healthcare workers have struggled to maintain non-COVID services leading to backlogs.Strategies proposed to support the recovery of backlogs include additional administration support; waiting list data validation; enhanced patient communication; and use of systematic improvement methods to make rapid incremental improvements.As part of COVID-19 recovery, a hospital trust in northern England used the Lean systematic improvement approach to recover the waiting list of a paediatric service to pre-COVID levels. The intervention strategy used a massive-open-online-course (Lean Fundamentals) to support the improvement project lead to follow a structured improvement routine to apply Lean improvement techniques.By acknowledging that staff were overburdened by the requirements of COVID-19 and that patients were stuck in a system of disconnected processes, administrative activities were redesigned around an ethos of compassionate communication that put patients first.Over a period of 8 weeks, the project reduced the waiting list from 1109 to 212. Waiting times were reduced from a maximum of 36 months to a 70-day average.Lean is often described in terms of increasing process efficiency and productivity. It is not often associated with staff benefits. However, when seen in the context of unburdening staff to deliver patient care, Lean has potential to support the recovery of both staff and services. Lean Fundamentals, with its accessible massive-online design, may provide a means of supporting such improvement at scale.

Resuscitation with blood products in patients with trauma-related haemorrhagic shock receiving prehospital care (RePHILL): a multicentre, open-label, randomised, controlled, phase 3 trial.

BACKGROUND: Time to treatment matters in traumatic haemorrhage but the optimal prehospital use of blood in major trauma remains uncertain. We investigated whether use of packed red blood cells (PRBC) and lyophilised plasma (LyoPlas) was superior to use of 0·9% sodium chloride for improving tissue perfusion and reducing mortality in trauma-related haemorrhagic shock. METHODS: Resuscitation with pre-hospital blood products (RePHILL) is a multicentre, allocation concealed, open-label, parallel group, randomised, controlled, phase 3 trial done in four civilian prehospital critical care services in the UK. Adults (age ≥16 years) with trauma-related haemorrhagic shock and hypotension (defined as systolic blood pressure <90 mm Hg or absence of palpable radial pulse) were assessed for eligibility by prehospital critial care teams. Eligible participants were randomly assigned to receive either up to two units each of PRBC and LyoPlas or up to 1 L of 0·9% sodium chloride administered through the intravenous or intraosseous route. Sealed treatment packs which were identical in external appearance, containing PRBC-LyoPlas or 0·9% sodium chloride were prepared by blood banks and issued to participating sites according to a randomisation schedule prepared by the co-ordinating centre (1:1 ratio, stratified by site). The primary outcome was a composite of episode mortality or impaired lactate clearance, or both, measured in the intention-to-treat population. This study is completed and registered with ISRCTN.com, ISRCTN62326938. FINDINGS: From Nov 29, 2016 to Jan 2, 2021, prehospital critical care teams randomly assigned 432 participants to PRBC-LyoPlas (n=209) or to 0·9% sodium chloride (n=223). Trial recruitment was stopped before it achieved the intended sample size of 490 participants due to disruption caused by the COVID-19 pandemic. The median follow-up was 9 days (IQR 1 to 34) for participants in the PRBC-LyoPlas group and 7 days (0 to 31) for people in the 0·9% sodium chloride group. Participants were mostly white (62%) and male (82%), had a median age of 38 years (IQR 26 to 58), and were mostly involved in a road traffic collision (62%) with severe injuries (median injury severity score 36, IQR 25 to 50). Before randomisation, participants had received on average 430 mL crystalloid fluids and tranexamic acid (90%). The composite primary outcome occurred in 128 (64%) of 199 participants randomly assigned to PRBC-LyoPlas and 136 (65%) of 210 randomly assigned to 0·9% sodium chloride (adjusted risk difference -0·025% [95% CI -9·0 to 9·0], p=0·996). The rates of transfusion-related complications in the first 24 h after ED arrival were similar across treatment groups (PRBC-LyoPlas 11 [7%] of 148 compared with 0·9% sodium chloride nine [7%] of 137, adjusted relative risk 1·05 [95% CI 0·46-2·42]). Serious adverse events included acute respiratory distress syndrome in nine (6%) of 142 patients in the PRBC-LyoPlas group and three (2%) of 130 in 0·9% sodium chloride group, and two other unexpected serious adverse events, one in the PRBC-LyoPlas (cerebral infarct) and one in the 0·9% sodium chloride group (abnormal liver function test). There were no treatment-related deaths. INTERPRETATION: The trial did not show that prehospital PRBC-LyoPlas resuscitation was superior to 0·9% sodium chloride for adult patients with trauma related haemorrhagic shock. Further research is required to identify the characteristics of patients who might benefit from prehospital transfusion and to identify the optimal outcomes for transfusion trials in major trauma. The decision to commit to routine prehospital transfusion will require careful consideration by all stakeholders. FUNDING: National Institute for Health Research Efficacy and Mechanism Evaluation.

Mass production methods for mass vaccination: improving flow and operational performance in a COVID-19 mass vaccination centre using Lean.

The COVID-19 pandemic has infected tens of millions of people worldwide causing many deaths. Healthcare systems have been stretched caring for the most seriously ill and lockdown measures to interrupt COVID-19 transmission have had adverse economic and societal impacts. Large-scale population vaccination is seen as the solution.In the UK, a network of sites to deploy vaccines comprised National Health Service hospitals, primary care and new mass vaccination centres. Due to the pace at which mass vaccination centres were established and the scale of vaccine deployment, some sites experienced problems with queues and waiting times. To address this, one site used the Lean systematic improvement approach to make rapid operational improvements to reduce process times and improve flow.The case example identifies obstacles to flow experienced by a mass vaccination centre and how they were addressed using Lean concepts and techniques. Process cycle times were used as a proxy metric for efficiency and flow. Based on daily demand volume and open hours, takt time was calculated to give a process completion rate to achieve flow through the vaccination centre.The mass vaccination centre achieved its aim of reducing process times and improving flow. Administrative and clinical cycle times were reduced sufficiently to increase throughput and the number of queues and queueing time were reduced improving client experience.The design and operational management of vaccination centre processes contribute to client experience, efficiency and throughput. Lean provides a systematic approach that can improve operational processes and facilitate client flow through mass vaccination centres.

Operations management on the front line of COVID-19 vaccination: building capability at scale via technology-enhanced learning.

The globe is gripped by the COVID-19 pandemic. Mass population vaccination is seen as the solution. As vaccines become available, governments aim to deploy them as rapidly as possible. It is important, therefore, that the efficiency of vaccination processes is optimal.Operations management is concerned with improving processes and comprises systematic approaches such as Lean. Lean focuses explicitly on process efficiency through the elimination of non-value adding steps to optimise processes for those who use and depend on them.Technology-enhanced learning can be a strategy to build improvement capability at scale. A massive online programme to build capability in Lean has been developed by the regulator of England's National Health Service. Beta testing of this programme has been used by some test sites to refine their COVID-19 vaccination processes. The paper presents a case example of massive online learning supporting the use of Lean in the day-to-day operations management of COVID-19 vaccine processes.The case example illustrates the challenges that vaccination processes may present and the need for responsive and effective operations management. Building capability to respond rapidly and systematically in dynamic situations to optimise flow, safety and patient experience may be beneficial.Given the national imperative to achieve mass vaccination as rapidly as possible, systematic improvement methods such as Lean may have a contribution to make. Massive online programmes, such as that described here, may help with this effort by achieving timely knowledge transfer at large scale.

Capability building for large-scale transformational change: learning from an evaluation of a national programme.

BACKGROUND: The Long Term Plan presents an ambitious vision for England's National Health Service which will require a sustained programme of transformational change. The Virtual Academy of Large-Scale Change (VALSC) was developed to build capability in health and care system teams involved in transformation or redesign programmes. METHODS: To evaluate the VALSC, quantitative and qualitative data were collected and reviewed against the Kirkpatrick model. Quantitative data were collected via end-of-session surveys to assess individual knowledge before and after participating in capability-building interventions. Qualitative data were also collected and included post-intervention surveys and interviews. Interviews were transcribed and analysed using an inductive approach to identify themes that were subsequently assessed against the Kirkpatrick model. RESULTS: Results suggest that the VALSC programme has helped build capability for large-scale change in terms of learning, behaviour change and impact. Participants' ipsative self-assessment of knowledge demonstrated a significant change (p<0.001) and qualitative data suggested three broad themes in which the VALSC made an impact. First, participants were empowered with transformation and change skills which they applied to local health and care challenges. Second, VALSC helped strengthen connections within and between transformational change teams. Third, VALSC helped transformational change teams to engage more effectively with their stakeholders. CONCLUSIONS: The VALSC developed knowledge, skills, behavioural change and application impact that built capability in individuals and teams. Therefore, continuing to develop capability-building offers that empower and build agency in front-line staff working on service transformation and equip them with approaches, methods and tools to increase their chances of success, is recommended.

Outcomes following trauma laparotomy for hypotensive trauma patients: A UK military and civilian perspective.

BACKGROUND: The management of trauma patients has changed radically in the last decade, and studies have shown overall improvements in survival. However, reduction in mortality for the many may obscure a lack of progress in some high-risk patients. We sought to examine the outcomes for hypotensive patients requiring laparotomy in UK military and civilian cohorts. METHODS: We undertook a review of two prospectively maintained trauma databases: the UK Joint Theatre Trauma Registry for the military cohort (February 4, 2003, to September 21, 2014) and the trauma registry of the Royal London Hospital major trauma center (January 1, 2012, to January 1, 2017) for civilian patients. Adults undergoing trauma laparotomy within 90 minutes of arrival at the emergency department (ED) were included. RESULTS: Hypotension was present on arrival at the ED in 155 (20.4%) of 761 military patients. Mortality was higher in hypotensive casualties (25.8% vs. 9.7% in normotensive casualties; p < 0.001). Hypotension was present on arrival at the ED in 63 (35.7%) of 176 civilian patients. Mortality was higher in hypotensive patients (47.6% vs. 12.4% in normotensive patients; p < 0.001). In both cohorts of hypotensive patients, neither the average injury severity, the prehospital time, the ED arrival systolic blood pressure, nor mortality rate changed significantly during the study period. CONCLUSIONS: Despite improvements in survival after trauma for patients overall, the mortality for patients undergoing laparotomy who arrive at the ED with hypotension has not changed and appears stubbornly resistant to all efforts. Specific enquiry and research should continue to be directed at this high-risk group of patients. LEVEL OF EVIDENCE: Prognostic/Epidemiologic, level IV.

What fluids are given during air ambulance treatment of patients with trauma in the UK, and what might this mean for the future? Results from the RESCUER observational cohort study.

OBJECTIVES: We investigated how often intravenous fluids have been delivered during physician-led prehospital treatment of patients with hypotensive trauma in the UK and which fluids were given. These data were used to estimate the potential national requirement for prehospital blood products (PHBP) if evidence from ongoing trials were to report clinical superiority. SETTING: The Regional Exploration of Standard Care during Evacuation Resuscitation (RESCUER) retrospective observational study was a collaboration between 11 UK air ambulance services. Each was invited to provide up to 5 years of data and total number of taskings during the same period. PARTICIPANTS: Patients with hypotensive trauma (systolic blood pressure <90 mm Hg or absent radial pulse) attended by a doctor. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was the number of patients with hypotensive trauma given prehospital fluids. Secondary outcomes were types and volumes of fluids. These data were combined with published data to estimate potential national eligibility for PHBP. RESULTS: Of 29 037 taskings, 729 (2.5%) were for patients with hypotensive trauma attended by a physician. Half were aged 21-50 years; 73.4% were male. A total of 537 out of 729 (73.7%) were given fluids. Five hundred and ten patients were given a single type of fluid; 27 received >1 type. The most common fluid was 0.9% saline, given to 486/537 (90.5%) of patients who received fluids, at a median volume of 750 (IQR 300-1500) mL. Three per cent of patients received PHBP. Estimated projections for patients eligible for PHBP at these 11 services and in the whole UK were 313 and 794 patients per year, respectively. CONCLUSIONS: One in 40 air ambulance taskings were manned by physicians to retrievepatients with hypotensive trauma. The most common fluid delivered was 0.9% saline. If evidence justifies universal provision of PHBP, approximately 800 patients/year would be eligible in the UK, based on our data combined with others published. Prospective investigations are required to confirm or adjust these estimations.

An adapted Clavien-Dindo scoring system in trauma as a clinically meaningful nonmortality endpoint.

BACKGROUND: There is no consensus on reporting nonmortality trauma complications in a graded manner. The Clavien-Dindo scale of complications was originally for elective surgery and requires adaptation to provide meaningful data for trauma patients. In particular, the original score does not account for those treated without surgery. We report an adapted Clavien-Dindo in trauma (ACDiT) scale and apply it to patients managed operatively and nonoperatively. METHODS: A combined prospective and retrospective international multicenter observational study was undertaken to apply the ACDiT scale to 484 trauma patients at three university teaching hospitals (Birmingham, England (n = 303); Houston, Texas (n = 113); and Glasgow, Scotland (n = 68)). These included both intensive care unit (ICU) and non-ICU-managed patients. The Clavien-Dindo scoring system was adapted for trauma patients based on consensus amongst an international collaboration of trauma specialists at these sites. Data included whether initial patients were managed operatively or nonoperatively. Complication grades were compared with hospital-free and ICU-free days as other outcome measures of patient morbidity. RESULTS: Two hundred seventeen (44.8%) of 484 patients experienced complications, of whom 61 (28.1%) of 217 died (grade V). The remainder consisted of grades I (n = 20), II (n = 60), III (n = 24), and IV (n = 52). There was a strong association between higher ACDiT grade category and lower number of hospital-free and ICU-free days (p < 0.01). Eighty-eight patients with complications did not require surgery, validating the score's usefulness in patients managed nonoperatively. CONCLUSION: The ACDiT scale can be used to grade the severity of posttrauma complications in patients managed both operatively and nonoperatively. It provides clinically meaningful data for morbidity and mortality meetings and other quality improvement exercises. LEVEL OF EVIDENCE: Prognostic, level IV.

Deployed skills training for whole blood collection by a special operations expeditionary surgical team.

BACKGROUND: Noncompressible hemorrhage is the leading cause of potentially preventable battlefield death. Combining casualty retrieval from the battlefield and damage control resuscitation (DCR) within the "golden hour" increases survival. However, transfusion requirements may exceed the current blood component stocks held by forward surgical teams. Warm fresh whole blood (WFWB) is an alternative. We report WFWB transfusion training developed by and delivered to a US Golden Hour Offset Surgical Treatment Team and the resulting improvement in confidence with WFWB transfusion. METHODS: A bespoke instructional package was derived from existing operational clinical guidelines. All Golden Hour Offset Surgical Treatment Team personnel completed initial training, reinforced through ongoing casualty simulations. A record of blood types and donor eligibility was established to facilitate rapid identification of potential WFWB donors. Self-reported confidence in seven aspects of the WFWB transfusion process was assessed before and after training using a five-point Likert scale. Personnel were analyzed by groups consisting of those whose operational role includes WFWB transfusion ("transfusers"), clinical personnel without such responsibilities ("nontransfusers") and nonclinical personnel (other). Comparisons within and between groups were made using appropriate nonparametric tests. RESULTS: Data were collected from 39 (89%) of 44 training participants: 24 (62%) transfusers, 12 (31%) nontransfusing clinicians, and 3 (8%) other personnel. Transfusers and nontransfusers reported increased comfort with all practical elements of WFWB transfusion. The confidence of other personnel also increased, but (likely due to small numbers) was not statistically significant. CONCLUSION: WFWB transfusion is an integral part of modern deployed military remote DCR. Our in-theater training program rapidly and reproducibly enhanced the comfort in WFWB transfusion in providers from a range of backgrounds and skill-mixes. This model has the potential to improve both safety and effectiveness of WFWB remote DCR in the far-forward deployed setting. LEVEL OF EVIDENCE: Therapeutic/care management study, level IV.

Safety and feasibility of sublingual microcirculation assessment in the emergency department for civilian and military patients with traumatic haemorrhagic shock: a prospective cohort study.

OBJECTIVES: Sublingual microcirculatory monitoring for traumatic haemorrhagic shock (THS) may predict clinical outcomes better than traditional blood pressure and cardiac output, but is not usually performed until the patient reaches the intensive care unit (ICU), missing earlier data of potential importance. This pilot study assessed for the first time the feasibility and safety of sublingual video-microscopy for THS in the emergency department (ED), and whether it yields useable data for analysis. SETTING: A safety and feasibility assessment was undertaken as part of the prospective observational MICROSHOCK study; sublingual video-microscopy was performed at the UK-led Role 3 medical facility at Camp Bastion, Afghanistan, and in the ED in 3 UK Major Trauma Centres. PARTICIPANTS: There were 15 casualties (2 military, 13 civilian) who presented with traumatic haemorrhagic shock with a median injury severity score of 26. The median age was 41; the majority (n=12) were male. The most common injury mechanism was road traffic accident. PRIMARY AND SECONDARY OUTCOME MEASURES: Safety and feasibility were the primary outcomes, as measured by lack of adverse events or clinical interruptions, and successful acquisition and storage of data. The secondary outcome was the quality of acquired video clips according to validated criteria, in order to determine whether useful data could be obtained in this emergency context. RESULTS: Video-microscopy was successfully performed and stored for analysis for all patients, yielding 161 video clips. There were no adverse events or episodes where clinical management was affected or interrupted. There were 104 (64.6%) video clips from 14 patients of sufficient quality for analysis. CONCLUSIONS: Early sublingual microcirculatory monitoring in the ED for patients with THS is safe and feasible, even in a deployed military setting, and yields videos of satisfactory quality in a high proportion of cases. Further investigations of early microcirculatory behaviour in this context are warranted. TRIAL REGISTRATION NUMBER: NCT02111109.

Prehospital Blood Product Resuscitation for Trauma: A Systematic Review.

INTRODUCTION: Administration of high ratios of plasma to packed red blood cells is a routine practice for in-hospital trauma resuscitation. Military and civilian emergency teams are increasingly carrying prehospital blood products (PHBP) for trauma resuscitation. This study systematically reviewed the clinical literature to determine the extent to which the available evidence supports this practice. METHODS: Bibliographic databases and other sources were searched to July 2015 using keywords and index terms related to the intervention, setting, and condition. Standard systematic review methodology aimed at minimizing bias was used for study selection, data extraction, and quality assessment (protocol registration PROSPERO: CRD42014013794). Synthesis was mainly narrative with random effects model meta-analysis limited to mortality outcomes. RESULTS: No prospective comparative or randomized studies were identified. Sixteen case series and 11 comparative studies were included in the review. Seven studies included mixed populations of trauma and non-trauma patients. Twenty-five of 27 studies provided only very low quality evidence. No association between PHBP and survival was found (OR for mortality: 1.29, 95% CI: 0.84-1.96, P = 0.24). A single study showed improved survival in the first 24 h. No consistent physiological or biochemical benefit was identified, nor was there evidence of reduced in-hospital transfusion requirements. Transfusion reactions were rare, suggesting the short-term safety of PHBP administration. CONCLUSIONS: While PHBP resuscitation appears logical, the clinical literature is limited, provides only poor quality evidence, and does not demonstrate improved outcomes. No conclusions as to efficacy can be drawn. The results of randomized controlled trials are awaited.

Iron-induced gastric ulceration with radiological and endoscopic appearance of carcinoma.

Erosive injury of the upper gastrointestinal tract resulting from therapeutic oral iron supplements is an uncommon phenomenon. We present a case of a large gastric ulcer with clinical, endoscopic and radiological features suggestive of malignancy, which resolved completely on cessation of iron therapy.

Interobserver Variability in Injury Severity Scoring After Combat Trauma: Different Perspectives, Different Values?

BACKGROUND: Anatomic measures of injury burden provide key information for studies of prehospital and in-hospital trauma care. The military version of the Abbreviated Injury Scale [AIS(M)] is used to score injuries in deployed military hospitals. Estimates of total trauma burden are derived from this. These scores are used for categorization of patients, assessment of care quality, and research studies. Scoring is normally performed retrospectively from chart review. We compared data recorded in the UK Joint Theatre Trauma Registry (JTTR) and scores calculated independently at the time of surgery by the operating surgeons to assess the concordance between surgeons and trauma nurse coordinators in assigning injury severity scores. METHODS: Trauma casualties treated at a deployed Role 3 hospital were assigned AIS(M) scores by surgeons between 24 September 2012 and 16 October 2012. JTTR records from the same period were retrieved. The AIS(M), Injury Severity Score (ISS), and New Injury Severity Score (NISS) were compared between datasets. RESULTS: Among 32 matched casualties, 214 injuries were recorded in the JTTR, whereas surgeons noted 212. Percentage agreement for number of injuries was 19%. Surgeons scored 75 injuries as "serious" or greater compared with 68 in the JTTR. Percentage agreement for the maximum AIS(M), ISS, and NISS assigned to cases was 66%, 34%, and 28%, respectively, although the distributions of scores were not statistically different (median ISS: surgeons: 20 [interquartile range (IQR), 9-28] versus JTTR: 17.5 [IQR, 9-31.5], p = .7; median NISS: surgeons: 27 [IQR, 12-42] versus JTTR: 25.5 [IQR, 11.5-41], p = .7). CONCLUSION: There are discrepancies in the recording of AIS(M) between surgeons directly involved in the care of trauma casualties and trauma nurse coordinators working by retrospective chart review. Increased accuracy might be achieved by actively collaborating in this process.

Scanning and War: Utility of FAST and CT in the Assessment of Battlefield Abdominal Trauma.

OBJECTIVE: To determine utilization and accuracy of focused assessment with sonography for trauma (FAST) and computed tomography (CT) in a mature military trauma system to inform service provision for future conflicts. BACKGROUND: FAST and CT scans undertaken by attending radiologists contribute to surgical decision making for battlefield casualties at the Joint Force, Role 3 Medical Treatment Facility at Camp Bastion (R3), Afghanistan. METHODS: Registry data for abdominally injured casualties treated at R3 from July to November 2012 were matched to radiological and surgical records to determine diagnostic accuracy for FAST and CT and their influence on casualty management. RESULTS: A total of 468 casualties met inclusion criteria, of whom 85.0% underwent FAST and 86.1% abdominal CT; 159 (34.0%) had abdominal injuries. For detection of intra-abdominal injury, FAST sensitivity (Sn) was 0.56, specificity (Sp) 0.98, positive predictive value (PPV) 0.87, negative predictive value (NPV) 0.90, and accuracy (Acc) 0.89. For CT, Sn was 0.99, Sp 0.99, PPV 0.96, NPV 1.00, and Acc 0.99. Forty-six solid organ injuries were identified in 38 patients by CT; 17 were managed nonoperatively. A further 61 patients avoided laparotomy after CT confirmed extra-abdominal wounds only. The negative laparotomy rate was 3.9%. CONCLUSIONS: FAST and CT contribute to triage, guide surgical management, and reduce nontherapeutic laparotomy. When imaging is available, these data challenge current doctrine about inadvisability of nonoperative management of abdominal injury after combat trauma.

A prospective observational study of abdominal injury management in contemporary military operations: damage control laparotomy is associated with high survivability and low rates of fecal diversion.

OBJECTIVE: This study describes the cause, management, and outcomes of abdominal injury in a mature deployed military trauma system, with particular focus on damage control, hollow visceral injury (HVI), and stoma utilization. BACKGROUND: Damage control laparotomy (DCL) is established in military and civilian practice. However, optimal management of HVI during military DCL remains controversial. METHODS: We studied abdominal trauma managed over 5 months at the Joint Force Combat Support Hospital, Camp Bastion, Afghanistan (Role 3). Data included demographics, wounding mechanism, injuries sustained, prehospital times, location of first laparotomy (Role 3 or forward), use of DCL or definitive laparotomy, subsequent surgical details, resource utilization, complications, and mortality. RESULTS: Ninety-four of 636 trauma patients (15%) underwent laparotomy. Military injury mechanisms dominated [44 gunshot wounds (47%), 44 blast (47%), and 6 blunt trauma (6%)]. Seventy-two of 94 patients (77%) underwent DCL. Four patients were palliated. Seventy of 94 (74%) sustained HVI; 44 of 70 (63%) had colonic injury. Repair or resection with anastomosis was performed in 59 of 67 therapeutically managed HVI patients (88%). Six patients were managed with fecal diversion, and 6 patients were evacuated with discontinuous bowel. Anastomotic leaks occurred in 4 of 56 HVI patients (7%) with known outcomes. Median New Injury Severity Score for DCL patients was 29 (interquartile range: 18-41) versus 19.5 (interquartile range: 12-34) for patients undergoing definitive laparotomy (P = 0.016). Overall mortality was 15 of 94 (16%). CONCLUSIONS: Damage control is now used routinely for battlefield abdominal trauma. In a well-practiced Combat Support Hospital, this strategy is associated with low mortality and infrequent fecal diversion.

Protocol for a systematic review of the clinical effectiveness of pre-hospital blood components compared to other resuscitative fluids in patients with major traumatic haemorrhage.

BACKGROUND: There is growing interest in the use of blood components for pre-hospital resuscitation of patients with major traumatic haemorrhage. It has been speculated that early resuscitation with blood components may have benefits in terms of treating trauma-induced coagulopathy, which in turn may influence survival. The proposed systematic review will evaluate the evidence on the clinical effectiveness of pre-hospital blood components (red blood cells and/or plasma or whole blood), in both civilian and military settings, compared with other resuscitation strategies in patients with major traumatic haemorrhage. METHODS/DESIGN: Standard systematic review methods aimed at minimising bias will be employed for study identification, selection and data extraction. General medical and specialist databases will be searched; the search strategy will combine terms for the population, intervention and setting. Studies will be selected for review if the population includes adult patients with major traumatic haemorrhage who receive blood components in a pre-hospital setting (civilian or military). Systematic reviews, randomised and non-randomised controlled trials and controlled observational studies will be included. Uncontrolled studies will be considered depending on the volume of controlled evidence. Quality assessment will be tailored to different study designs. Both patient related and surrogate outcomes will be considered. Synthesis is likely to be primarily narrative, but meta-analyses and subgroup analyses will be undertaken where clinical and methodological homogeneity exists. DISCUSSION: Given the increasing use by emergency services of blood components for pre-hospital resuscitation, this is a timely systematic review, which will attempt to clarify the evidence base for this practice. As far as the authors are aware, the proposed systematic review will be the first to address this topic. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42014013794.