Article 1
Prospective validation of the Rib Injury Guidelines for traumatic rib fractures. Nelson A, Reina R, Northcutt A, Obaid O, Castanon L, Ditillo M, Gries L, Bible L, Anand T, Joseph B. J Trauma Acute Care Surg. 2022 Jun 1;92(6):967-973.
Nelson and colleagues conducted a study to evaluate triage effectiveness of an institutional rib injury guideline (RIG) for patients with rib fractures. In this study, the authors address gaps in the literature not addressed by previous scoring systems. Specifically, more emphasis was placed on physiologic factors and the patient population was not limited to ICU bound patients or geriatric admissions. This retrospective study was completed using a prospectively managed database at a Level I trauma center between October 2017 and January 2020, and included patients with at least one rib fracture identified on admission CT imaging. Patients transferred from another institution, receiving emergent interventions, or dying in the ED were excluded. In all, 336 patients were managed using RIG. Within the guideline, patients were stratified into three groups (RIG 1,2,3) based on a RIG Score using a combination of demographic, physiologic, and morphologic factors. Primary outcomes were based on escalation of care (readmission for RIG 1, ICU admission for RIG 2). Secondary outcomes were hospital LOS, and in-hospital mortality. Multivariate regression was performed to assess impact of RIG when adjusting for multiple factors felt to have clinical significance. The investigators found that no RIG 1 patients required readmission and only two RIG 2 patients required upgrade to ICU level care. No difference in mortality was found when compared to a pre-RIG period. The authors suggest dissemination of the RIG to triage patients with rib fractures as they were found to be safe when compared to a pre-RIG period.
The appropriate triage of patients with rib fractures is a timeless endeavor, although changing rapidly with the advances in management of chest wall injury. The authors present a concise and easy score that can be calculated on presentation. The RIG scoring is consistent with other published work, with a heavy emphasis placed on age and performance on incentive spirometry. The simplicity of the RIG contributes to its efficacy by predicting those who DO NOT need high level of care, but also limits use by not specifying WHICH ICU therapies are needed for those scoring high (RIG 3). It is likely that this study will serve as a basis for local triage guidelines at many institutions as they provide a firm foundation that can be tailored to the needs and specialty services of each institution. Comparison of RIG to your own institutional guidelines is a worthwhile activity.
Article 2
Time to OR for patients with abdominal gunshot wounds: A potential process measure to assess the quality of trauma care? Thomas AC, Campbell BT, Subacius H, Bilimoria KY, Stey AM, Hamad D, Nasca B, Nathens AB. J Trauma Acute Care Surg. 2022 Apr 1;92(4):708-716.
Thomas and colleagues conducted a retrospective review time to OR impact on mortality for patients presenting in hemorrhagic shock. In an attempt to establish appropriate measures of quality, the authors investigated if time to OR outlier status, as defined by outlier status, was associated with mortality. A North American, trauma quality database (TQIP) was used to stratify institutions based on time to OR. Patients included in the study presented in hemorrhagic shock following abdominal gunshot wounds. A total of 4,027 patients across 230 centers comprised the cohort after inclusion and exclusion criteria. Cutoffs at the 25th and 75th percentile for median time to OR was used to identify centers performing outside the 95th percentile. Authors controlled for number of cases using process-control methods. High outliers were then compared to low outliers to determine association with mortality. No such association was found between high and low outliers. Fast performing centers were more closely associated with Level I status and teaching institutions. The authors concluded that time to OR for severely injured patients should be utilized by centers as a process measure.
As the authors note, previous studies have examined time to OR and associated mortality. The specific gap addressed here is profound hypotension (<90mmHg) in the setting of penetrating abdominal trauma (opposed to blunt and penetrating). While previous studies have demonstrated improved outcomes with decreased time to OR, the authors DID NOT show a difference in mortality or major complications between Fast, Normal, and Slow centers. The authors’ framework is notable and demonstrate process-control techniques use to link process to outcomes. However, the findings are limited as evidenced by inclusion of laparoscopy and use of diagnostic codes (ICD9,10) to identify abdominal cases. Additionally, it is impossible to control for all heterogeneity in penetrating abdominal trauma. In summary, this study is an excellent investigation of a proposed metric using a large database collected across multiple sites. It also speaks to the need for additional research of firearm injuries to better understand and control for mechanism and morphology of injury.
Article 3
It is time to look in the mirror: Individual surgeon outcomes after emergent trauma laparotomy. Hu P, Jansen JO, Uhlich R, Hashmi ZG, Gelbard RB, Kerby J, Cox D, Holcomb JB. J Trauma Acute Care Surg. 2022 May 1;92(5):769-780.
Performance Improvement (PI) is a critical component of most if not all trauma programs across the county. While large institutional datasets such as TQIP exist to allow centers to benchmark themselves against the collective trauma community, there does not exist much research or data relating to impact of an individual trauma surgeon’s performance on the outcomes of the overall trauma center or as compared to their peers. The authors of this study set out to investigate exactly this perspective, retrospectively examining the outcomes of individual trauma surgeons performing emergent trauma laparotomy (ETL) at their level one tertiary referral center.
Acknowledging that the delivery of care to the traumatically injured patient is a team-based endeavor where the effects of a single surgeon can be “diluted” out over the course of an admission, ETL was selected as the procedure of investigation, as its high-acuity nature would potentially have the greatest ability to highlight the effect of a single surgeon’s variability on morbidity and mortality. The authors retrospectively identified ETLs occurring at their center over a 15-month study period, and examined them for patient demographics, injury characteristics, intra-operative variables (Time to OR, negative laparotomy rate, operative durations, fluid requirements, etc.), and mortality at various timepoints (intraoperative death, death within 4 hours, 24 hours, 7 days, and during the admission). Patients who had undergone resuscitative thoracotomy prior to arrival in the OR were excluded given the significant mortality associated with this clinical scenario.
225 ETLs were identified and included in the final analysis. Of these cases, there was a 2% intraoperative mortality rate, with 4% dying within 24 hours and 7% during the admission. Approximately 66% of patients had a penetrating mechanism of injury. The median number of ETLs per surgeon was 15, with no significant differences between surgeons regarding patient demographics, initial hemodynamics, and preoperative lab values (lactate, INR, etc.). However, management and outcome variables across surgeons did vary in some important ways. There was a difference seen in median operative time, time from ED arrival to OR discharge, median values of resuscitative blood products transfused, and mortality at all studied time points.
A number of papers have been published investigating the relationship of individual surgeon performance and outcome, however most are in elective surgical settings. The authors of this study provide important data on how individual surgeon performance is varied in the high-acuity surgical setting. These findings are not important just for the study of surgical care across a population but provide direct tangible feedback to the surgeons studied themselves. In an example provided by the authors, a surgeon identified with higher operative mortality was also found to have longer times from the ER to the operating room. While understanding that correlation does not mean causation, this feedback provided the surgeon in question with honest data that highlighted this variability and provided an opportunity to tailor the delivery of their care, and potentially alter their practice patterns and surgical outcomes. While the authors readily acknowledge the limitations of this work, the fact remains that further investigation of the role and potential variability displayed by individual surgeons has the potential to improve outcomes and care across all levels, from the surgeon themselves to the healthcare system collectively.
