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Lammers D, Uhlich R, Rokayak O, Manley N, Betzold RD, Hu P. Comparison of military and civilian surgeon outcomes with emergent trauma laparotomy in a mature military-civilian partnership. Trauma Surg Acute Care Open 2024; 9:e001332. [PMID: 38440096 PMCID: PMC10910416 DOI: 10.1136/tsaco-2023-001332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 02/05/2024] [Indexed: 03/06/2024] Open
Abstract
Introduction Medical readiness is of paramount concern for active-duty military providers. Low volumes of complex trauma in military treatment facilities has driven the armed forces to embed surgeons in high-volume civilian centers to maintain clinical readiness. It is unclear what impact this strategy may have on patient outcomes in these centers. We sought to compare emergent trauma laparotomy (ETL) outcomes between active-duty Air Force Special Operations Surgical Team (SOST) general surgeons and civilian faculty at an American College of Surgeons verified level 1 trauma center with a well-established military-civilian partnership. Methods Retrospective review of a prospectively maintained, single-center database of ETL from 2019 to 2022 was performed. ETL was defined as laparotomy from trauma bay within 90 min of patient arrival. The primary outcome was to assess for all-cause mortality differences at multiple time points. Results 514 ETL were performed during the study period. 22% (113 of 514) of patients were hypotensive (systolic blood pressure ≤90 mm Hg) on arrival. Six SOST surgeons performed 43 ETL compared with 471 ETL by civilian faculty. There were no differences in median ED length of stay (27 min vs 22 min; p=0.21), but operative duration was significantly longer for SOST surgeons (129 min vs 110 min; p=0.01). There were no differences in intraoperative (5% vs 2%; p=0.30), 6-hour (3% vs 5%; p=0.64), 24-hour (5% vs 5%; p=1.0), or in-hospital mortality rates (5% vs 8%; p=0.56) between SOST and civilian surgeons. SOST surgeons did not significantly impact the odds of 24-hour mortality on multivariable analysis (OR 0.78; 95% CI 0.10, 6.09). Conclusion Trauma-related mortality for patients undergoing ETL was not impacted by SOST surgeons when compared with their civilian counterparts. Military surgeons may benefit from the valuable clinical experience and mentorship of experienced civilian trauma surgeons at high volume trauma centers without creating a deficit in the quality of care provided. Level of evidence Level IV, therapeutic/care management.
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Affiliation(s)
- Daniel Lammers
- Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Rindi Uhlich
- Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Omar Rokayak
- Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Nathan Manley
- Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Richard D Betzold
- Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Parker Hu
- Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Foppen W, Claassen Y, Falck D, van der Meer NJM. Trauma Patient Volume and the Quality of Care: A Scoping Review. J Clin Med 2023; 12:5317. [PMID: 37629358 PMCID: PMC10455163 DOI: 10.3390/jcm12165317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/09/2023] [Accepted: 08/14/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND Healthcare stakeholders in the Netherlands came to an agreement in 2022 to deal with present and future challenges in healthcare. Among others, this agreement contains clear statements regarding the concentration of trauma patients, including the minimal required number of annual severe trauma patients for Major Trauma Centers. This review investigates the effects of trauma patient volumes on several domains of the quality of healthcare. METHODS PubMed was searched; studies published during the last 10 years reporting quantitative data on trauma patient volume and quality of healthcare were included. Results were summarized and categorized into the quality domains of healthcare. RESULTS Seventeen studies were included with a total of 1,517,848 patients. A positive association between trauma patient volume and survival was observed in 11/13 studies with adjusted analyses. Few studies addressed other quality domains: efficiency (n = 5), safety (n = 2), and time aspects of care (n = 4). None covered people-centeredness, equitability, or integrated care. CONCLUSIONS Most studies showed a better survival of trauma patients when treated in high-volume hospitals compared to lower volume hospitals. However, the ideal threshold could not be determined. The association between trauma volume and other domains of the quality of healthcare remains unclear.
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Affiliation(s)
- Wouter Foppen
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht University, 3584 CS Utrecht, The Netherlands
| | - Yvette Claassen
- Department of Surgery, Leids Universitair Medisch Centrum, 2333 ZA Leiden, The Netherlands
| | - Debby Falck
- Department of Neurology, HagaZiekenhuis, 2545 AA The Hague, The Netherlands
| | - Nardo J. M. van der Meer
- Department of Medicine, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands
- TIAS School for Business and Society, 5037 AB Tilburg, The Netherlands
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Operative trauma volume is not related to risk-adjusted mortality rates among Pennsylvania trauma centers. J Trauma Acute Care Surg 2022; 93:786-792. [PMID: 36049153 DOI: 10.1097/ta.0000000000003534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Higher center-level operative volume is associated with lower mortality after complex elective surgeries, but this relationship has not been robustly demonstrated for operative trauma. We hypothesized that trauma centers in Pennsylvania with higher operative trauma volumes would have lower risk-adjusted mortality rates than lower volume institutions. METHODS We queried the Pennsylvania Trauma Outcomes Study database (2017-2019) for injured patients 18 years or older at Level I and II trauma centers who underwent an International Classification of Diseases, Tenth Revision (ICD-10), procedure code -defined operative procedure within 6 hours of admission. The primary exposure was tertile of center-level operative volume. The primary outcome of interest was inpatient mortality. We entered factors associated with mortality in univariate analysis (age, injury severity, mechanism, physiology) into multivariable logistic regression models with tertiles of volume accounting for center-level clustering. We conducted secondary analyses varying the form of the association between the volume and mortality to including dichotomous and fractional polynomial models. RESULTS We identified 3,650 patients at 29 centers meeting the inclusion criteria. Overall mortality was 15.9% (center-level range, 6.7-34.2%). Operative procedure types were cardiopulmonary (7.3%), vascular (20.1%), abdominopelvic (24.3%), and multiple (48.3%). The mean annual operative volume over the 3 years of data was 10 to 21 operations for low-volume centers, 22 to 47 for medium-volume centers, and 47 to 158 for high-volume centers. After controlling for patient demographics, physiology, and injury characteristics, there was no significant difference in mortality between highest and lowest tertile centers (odds ratio, 0.92; confidence interval, 0.57-1.49). Secondary analyses similarly demonstrated no relationship between center operative volume and mortality in key procedure subgroups. CONCLUSION In a mature trauma system, we found no association between center-level operative volume and mortality for patients who required early operative intervention for trauma. Efforts to standardize the care of seriously injured patients in Pennsylvania may ensure that even lower-volume centers are prepared to generate satisfactory outcomes. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
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Bentin JM, Possfelt-Møller E, Svenningsen P, Rudolph SS, Sillesen M. A characterization of trauma laparotomies in a scandinavian setting: an observational study. Scand J Trauma Resusc Emerg Med 2022; 30:43. [PMID: 35804389 PMCID: PMC9264678 DOI: 10.1186/s13049-022-01030-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 06/19/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite treatment advances, trauma laparotomy continuous to be associated with significant morbidity and mortality. Most of the literature originates from high volume centers, whereas patient characteristics and outcomes in a Scandinavian setting is not well described. The objective of this study is to characterize treatments and outcomes of patients undergoing trauma laparotomy in a Scandinavian setting and compare this to international reports. METHODS A retrospective study was performed in the Copenhagen University Hospital, Rigshospitalet (CUHR). All patients undergoing a trauma laparotomy within the first 24 h of admission between January 1st 2019 and December 31st 2020 were included. Collected data included demographics, trauma mechanism, injuries, procedures performed and outcomes. RESULTS A total of 1713 trauma patients were admitted to CUHR of which 98 patients underwent trauma laparotomy. Penetrating trauma accounted for 16.6% of the trauma population and 66.3% of trauma laparotomies. Median time to surgery after arrival at the trauma center (TC) was 12 min for surgeries performed in the Emergency Department (ED) and 103 min for surgeries performed in the operating room (OR). A total of 14.3% of the procedures were performed in the ED. A damage control strategy (DCS) approach was chosen in 18.4% of cases. Our rate of negative laparotomies was 17.3%. We found a mortality rate of 8.2%. The total median length of stay was 6.1 days. CONCLUSION The overall rates, findings, and outcomes of trauma laparotomies in this Danish cohort is comparable to reports from similar Western European trauma systems.
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Affiliation(s)
- Jakob Mejdahl Bentin
- Department of Anesthesia, Center of Head and Orthopedics, Rigshospitalet, Copenhagen, Denmark
| | - Emma Possfelt-Møller
- Department of Organ Surgery and Transplantation, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Peter Svenningsen
- Department of Surgical Gastroenterology, North Zealand Hospital, Hillerød, Denmark
| | - Søren Steemann Rudolph
- Department of Anesthesia, Center of Head and Orthopedics, Rigshospitalet, Copenhagen, Denmark
| | - Martin Sillesen
- Department of Organ Surgery and Transplantation, Copenhagen University Hospital, Rigshospitalet, Denmark. .,Institute of Clinical Medicine, University of Copenhagen, Blegdamsvej 3b, 2200, Copenhagen N, Denmark.
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Cardiac arrest centres: what, who, when, and where? Curr Opin Crit Care 2022; 28:262-269. [PMID: 35653246 DOI: 10.1097/mcc.0000000000000934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Cardiac arrest centres (CACs) may play a key role in providing postresuscitation care, thereby improving outcomes in out-of-hospital cardiac arrest (OHCA). There is no consensus on CAC definitions or the optimal CAC transport strategy despite advances in research. This review provides an updated overview of CACs, highlighting evidence gaps and future research directions. RECENT FINDINGS CAC definitions vary worldwide but often feature 24/7 percutaneous coronary intervention capability, targeted temperature management, neuroprognostication, intensive care, education, and research within a centralized, high-volume hospital. Significant evidence exists for benefits of CACs related to regionalization. A recent meta-analysis demonstrated clearly improved survival with favourable neurological outcome and survival among patients transported to CACs with conclusions robust to sensitivity analyses. However, scarce data exists regarding 'who', 'when', and 'where' for CAC transport strategies. Evidence for OHCA patients without ST elevation postresuscitation to be transported to CACs remains unclear. Preliminary evidence demonstrated greater benefit from CACs among patients with shockable rhythms. Randomized controlled trials should evaluate specific strategies, such as bypassing nearest hospitals and interhospital transfer. SUMMARY Real-world study designs evaluating CAC transport strategies are needed. OHCA patients with underlying culprit lesions, such as those with ST-elevation myocardial infarction (STEMI) or initial shockable rhythms, will likely benefit the most from CACs.
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Kishawi SK, Tseng ES, Adomshick VJ, Towe CW, Ho VP. Race and trauma mortality: The effect of hospital-level Black-White patient race distribution. J Trauma Acute Care Surg 2022; 92:958-966. [PMID: 35125445 PMCID: PMC9133009 DOI: 10.1097/ta.0000000000003538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Race-related health disparities have been well documented in the United States. In some settings, Black patients have better outcomes in hospitals that serve high proportions of Black patients. We hypothesized that Black trauma patients would have lower mortality in high Black-serving (H-BS) hospitals. METHODS We identified all adult patients with Black or White race and with an Injury Severity Score of ≥4 from the 2017 National Inpatient Sample. We collected hospital identifier, mechanism, age, sex, comorbidities, urban-rural location, insurance, zip code income quartile, and injury severity calculated from International Classification of Diseases, Tenth Revision, codes. We used a previously published method to group hospitals by proportion of Black patients served: HB-S (top 5%), medium Black serving (5-25%), and low Black serving (L-BS; bottom 75%). Adjusted logistic regression using an interaction variable between race and hospital service rank (reference: White patients in H-BS) was used to identify factors associated with mortality. RESULTS We analyzed 184,080 trauma patients (median age, 72 years [interquartile range, 55-84 years]; Injury Severity Score, 9 [4-10]), of whom 11.7% were Black. Overall mortality was 4%. Of 2,376 hospitals, 126 (5.3%) were H-BS and 469 (19.7%) were medium Black serving. Furthermore, 29.8% of Black and 3.6% of White patients were treated at H-BS hospitals, while 71.7% of White and 23.6% of Black patients were treated at L-BS hospitals (p < 0.001). Black patients had the lowest mortality at H-BS hospitals (odds ratio [OR], 0.76 [0.64-0.92]) and the highest mortality (OR, 1.43 [1.13-1.80]) at L-BS hospitals. White patients had the lowest mortality at L-BS hospitals (OR, 0.76 [0.64-0.92]). CONCLUSION After adjusting for patient and hospital factors, disparities exist such that Black and White patients have the best outcomes in hospitals that treat those patients most frequently, suggesting potential for racial bias at the institutional level. Further efforts must be made to promote equitable treatment at all hospitals and reduce these disparities. LEVEL OF EVIDENCE Prognostic and Epidemiologic; Level IV.
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Affiliation(s)
- Sami K. Kishawi
- MetroHealth Medical Center, Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, 2500 MetroHealth Drive, Cleveland, OH 44109
- University Hospitals Cleveland Medical Center, Department of Surgery, 11100 Euclid Avenue, Lakeside 7 Floor, Cleveland, OH 44106
- Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH 44106
| | - Esther S. Tseng
- MetroHealth Medical Center, Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, 2500 MetroHealth Drive, Cleveland, OH 44109
- Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH 44106
| | - Victoria J. Adomshick
- Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH 44106
| | - Christopher W. Towe
- University Hospitals Cleveland Medical Center, Department of Surgery, 11100 Euclid Avenue, Lakeside 7 Floor, Cleveland, OH 44106
- Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH 44106
| | - Vanessa P. Ho
- MetroHealth Medical Center, Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, 2500 MetroHealth Drive, Cleveland, OH 44109
- Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH 44106
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Hu P, Jansen JO, Uhlich R, Hashmi ZG, Gelbard RB, Kerby J, Cox D, Holcomb JB. It is time to look in the mirror: Individual surgeon outcomes after emergent trauma laparotomy. J Trauma Acute Care Surg 2022; 92:769-780. [PMID: 35045057 DOI: 10.1097/ta.0000000000003540] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Multiple quality indicators are used by trauma programs to decrease variation and improve outcomes. However, little if any provider level outcomes related to surgical procedures are reviewed. Emergent trauma laparotomy (ETL) is arguably the signature case that trauma surgeons perform on a regular basis, but few data exist to facilitate benchmarking of individual surgeon outcomes. As part of our comprehensive performance improvement program, we examined outcomes by surgeon for those who routinely perform ETL. METHODS A retrospective cohort study of patients undergoing ETL directly from the trauma bay by trauma faculty from December 2019 to February 2021 was conducted. Patients were excluded from mortality analysis if they required resuscitative thoracotomy for arrest before ETL. Surgeons were compared by rates of damage control and mortality at multiple time points. RESULTS There were 242 ETL (7-32 ETLs per surgeon) performed by 14 faculties. Resuscitative thoracotomy was performed in 7.0% (n = 17) before ETL. Six patients without resuscitative thoracotomy died intraoperatively and damage-control laparotomy was performed on 31.9% (n = 72 of 226 patients). Mortality was 4.0% (n = 9) at 24 hours and 7.1% (n = 16) overall. Median Injury Severity Score (p = 0.21), new injury severity score (p = 0.21), and time in emergency department were similar overall among surgeons (p = 0.15), while operative time varied significantly (40-469 minutes; p = 0.005). There were significant differences between rates of individual surgeon's mortality (range [hospital mortality], 0-25%) and damage-control laparotomy (range, 14-63%) in ETL. CONCLUSION Significant differences exist in outcomes by surgeon after ETL. Benchmarking surgeon level performance is a necessary natural progression of quality assurance programs for individual trauma centers. Additional data from multiple centers will be vital to allow for development of more granular quality metrics to foster introspective case review and quality improvement. LEVEL OF EVIDENCE Therapeutic/care management, level III.
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Affiliation(s)
- Parker Hu
- From the Division of Acute Care Surgery (P.H., J.O.J., Z.G.H., R.B.G., J.K., D.C., J.B.H.), Department of Surgery and Department of Surgery (R.U.), University of Alabama at Birmingham, Birmingham, Alabama
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Comment on Prospective Observational Evaluation of the ER-REBOA Catheter at 6 U.S. Trauma Centers. Ann Surg 2021; 274:e867. [PMID: 33443894 DOI: 10.1097/sla.0000000000004743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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