All posts by The Trauma Pro

Performance Improvement

Blame The Trauma Surgeon?

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I found an interesting paper published a couple of years ago that purports to examine individual surgeon outcomes after trauma laparotomy. This was presented at the annual AAST meeting in 2021 and then published in the Journal the following year.

Everyone seems to be giving this paper a pass. I won’t be so easy on it. Let me provide some details.

The authors observe that the mortality in patients presenting in shock who require emergent laparotomy averages more than 40%, and hasn’t changed significantly in at least 20 years. They also note that this mortality varies widely from 11-46%, and therefore, “significant differences must exist at the level of the individual surgeon.” They go on to point out that damage control usage varies between individuals and trauma centers, which could lead to the same conclusion.

So the authors designed a retrospective cohort study of results from their hospital to try to look at the impact of individual surgeon performance on survival.

Here are the factoids:

  • Over the 15-month study period, there were over 7,000 trauma activations and 252 emergent laparotomies for hemorrhage control
  • There were 13 different trauma surgeons, and the number of laparotomies for each ranged from 7 to 31, with a median of 15
  • There were no differences in [crude, in my opinion] patient demographics, hemodynamics, or lab values preop
  • “Significant” differences in management and outcomes between surgeons were noted:
    • Median total OR time was significantly different, ranging from 120-197 minutes
    • Median operation time was also different, from 75-151 minutes across the cohort of surgeons
    • Some of the surgeons had a higher proportion of patients with ED LOS < 60 minutes and OR time < 120 minutes
    • Resuscitation with red cells and plasma varied “significantly” across the surgeons
  • Mortality rates “varied significantly” across surgeons at all time points (24-hour, and hospital stay)
  • There were no mortality differences based on surgeons’ volume of cases, age, or experience level

The authors acknowledged several limitations, included the study’s retrospective and single-center nature, the limited number of patients, and its limited scope. Yet despite this, they concluded that the study “suggests that differences between individual surgeons appear to affect patient care.” They urge surgeons to openly and honestly evaluated ourselves. And of course, they recommend a large, prospective, multicenter study to further develop this idea.

Bottom line: This study is an example of a good idea gone astray. Although the authors tried to find a way to stratify patient injury (using ISS and individual AIS scores and presence of specific injuries) and intervention times (time in ED, time to OR, time in OR, op time), these variables just don’t cut it. They are just too crude. The ability to meaningfully compare these number across surgeons is also severely limited by low patient numbers. 

The authors found some fancy statistical ways to demonstrate a significant difference. But upon closer inspection, many of these differences are not meaningful clinically. Here are some examples:

  • Intraoperative FFP ranged from 0-7 units between surgeons, with a p value of 0.03
  • Postoperative FFP ranged from 0-7 units, with a p value of 0.01
  • Intraoperative RBC usage was 0-6 units with the exception of one surgeon who used 15 in a case, resulting in a p value of 0.04

The claim that mortality rates varied significantly is difficult to understand. Overall p values were > 0.05, but they singled out one surgeon who had a significant difference from the rest in 22 of 25 mortality parameters listed. This surgeon also had the second highest patient volume, at 25.

The authors are claiming that they are able to detect significant variations in surgeon performance which impacts timing, resuscitation, and mortality. I don’t buy it! They believe that they are able to accurately standardize these patients using simple demographic and performance variables. Unfortunately, the variables selected are far too crude to accurately describe what is wrong inside the patient and what the surgeon will have to do to fix it.

Think about your last 10 trauma laparotomies where your patient was truly bleeding to death. How similar were they? Is there no difference between a patient with a mesenteric laceration with bleeding, an injury near the confluence of the superior mesenteric vessels, and a right hepatic vein injury? Of course there is. And this will definitely affect the parameters measured here and crude outcomes. Then add some unfavorable patient variables like obesity or previous laparotomy.

In my estimation, this paper completely misses the point because it’s not possible to retrospectively categorize all the possible variables impacting “surgeon performance.” This is particularly true of the patient variables that could not possibly be captured. The only way to do this right is to analyze each case as prospectively as possible, as close to the time of the procedure and as honestly as possible. And this is exactly what a good trauma M&M process does!

So forget the strained attempts at achieving statistical significance. Individual surgeon performance and variability will come to light at a proper morbidity and mortality conference, and should be evened out using the peer review and mentoring process. It’s not time to start blaming the surgeon!

Reference: It is time to look in the mirror: Individual surgeon outcomes after emergent trauma laparotomy. J Trauma 92(5):769-780, 2022.

Thorax

Can I Keep Patients With More Than Three Rib Fractures At My Level IV Trauma Center?

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Rib fractures are one of the most common thoracic injuries presenting to trauma centers. Traditionally, many state designation standards set limits on the number of rib fractures in patients to be admitted to Level IV trauma centers. The assumption was that these centers had limited surgical capabilities and might not have the expertise to manage them to achieve optimal patient outcomes. They were then forced to transfer these patients upstream to a higher-level trauma center.

And then, unfortunately, COVID came along, and things changed. Mainly for the worse. Due to reduced professional staffing throughout the entire continuum of health care, the upstream centers are saturated and have limited availability to absorb patients who don’t take advantage of their increased resources.

Both staffing and reimbursement issues strain rural EMS agencies. It is difficult to justify transferring a patient to a center that takes the only ambulance in the community out of service for a good portion of the day. Also, most current state trauma system standards do not fully appreciate non-surgeon clinicians’ interest and skill levels at those Level IV centers.

The Pennsylvania Trauma Systems Foundation recognized these issues at the centers in its state. In 2020, it opted to liberalize the number of rib fractures that could be treated at Level IV centers. It required hospitalists to be current in ATLS in order to admit these patients. The centers were also required to adhere to a chest injury guideline created for them.

To gauge the safety and effectiveness of this change, a retrospective state registry study was performed comparing patients admitted during the 2.5 years before the standards change to the 2.5 years after. Demographics, injury characteristics, length of stay, and mortality were compared between the groups. Patients were excluded if they had significant injuries in other body regions, were age < 18 years of age, or had complicated fractures (requiring supplemental oxygen on admission, concomitant pneumothorax or hemothorax, pulmonary contusion or laceration, or who did not require admission

Here are the factoids:

  • Over 4,000 patients were recorded in the registry during the 5 years, but 3350 were excluded due to the definition of complex rib fractures
  • A final total of 1,070 patients were included, with 710 admitted to Level III centers and 360 to Level IV centers
  • This left 132 Level III patients and 228 Level IV patients in the pre- and post-standard groups, respectively
  • The number of transfers out of the Level IV centers dropped significantly, from 56% to 21%
  • Patients with <3 rib fractures had the same length of stay as those with more than three (3 vs 2, respectively)
  • Mortality was extremely low and not significantly different based on the number of rib fractures

Bottom line: This study showed that the change in admission standards for rib fractures in Pennsylvania did not impact outcomes and resulted in significantly fewer transfers.

The key to a successful change like this involves education and protocols. The requirement that hospitalists be current in ATLS is beneficial because it gives them a better understanding of the physiologic effects and priorities in managing trauma patients. A well-designed practice guideline is critical so that all clinicians apply best practices in caring for these patients. 

This is an important paper, and should be considered in any state where local resources are being challenged, and hospital reimbursements are declining. This type of standards change may breathe new life into many of our Level IV centers.

Philosophy

Do I Have To Call My Trauma Team For Incoming Transfers?

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Some trauma centers receive a significant number of transfers from referring hospitals. Much of the time, the outside hospital has already done a portion of the workup. If the patient meets one or more of your trauma activation criteria, do you still need to activate your team when they arrive?

And the answer is: sometimes. But probably not that often.

Think about it. You should be activating your team because you suspect the patient may have an injury that demands rapid diagnosis and treatment. The purpose of any trauma activation is speed. Rapid evaluation. Fast lab results. Quick access to CT scan or OR. If a significant amount of time has already passed (transported to an outside hospital, worked up for an hour or two, then transported to you), then it is less likely that a trauma activation will benefit the patient.

There are four classes of trauma activation criteria. I’ll touch on each one and the need to activate in a delayed fashion if present, in priority order.

  • Physiologic. You must activate if there is a significant disturbance in vital signs while in transit to you (hypotension, tachycardia, respiratory problems, coma). Something else is going on that needs to be corrected as soon as the patient arrives. And remember the two mandatory ACS criteria that fall into this category: respiratory compromise/need for an emergent airway, and patients receiving blood to maintain vital signs. But a patient who needed an airway who is already intubated and no longer compromised does not need to be a trauma activation.
  • Anatomic. Most simple anatomic criteria (e.g., long bone or pelvic fractures) do not need a trauma activation unless the patient is beginning to show signs of physiologic compromise. However, anatomic criteria that require rapid treatment or access to the OR (proximal amputations, mangled or pulseless extremities, spinal cord injury) should be activated.
  • Mechanism. Most of the vague mechanistic criteria (falls, pedestrian struck, vehicle intrusion) do not require trauma activation after transfer to you. But once again, if the mechanism suggests a need for further rapid diagnosis or treatment (penetrating injury to abdomen), then activate.
  • Comorbidities. This includes underlying diseases, extremes of age, and pregnancy. In general, these will not require trauma activation after they arrive.

Bottom line: In many cases, the patient transferred in from another hospital will not need to be a trauma activation, especially if they have been reasonably assessed there. The patient should be rapidly eyeballed by your emergency physicians, and if there is any doubt about their condition, activate then.

However, if little workup was done at the outside hospital (my preference), and the injuries are “fresh” (less than a few hours old), then definitely call your team. 

And finally, if the patient meets any of the ACS hard criteria for activation (this includes hypotension, transfusing blood, and respiratory compromise), don’t hesitate to trigger the activation!

Equipment, Prehospital

Cool EMS Stuff: The Backboard Washer!

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Backboards are made to get messy. Every time your friendly EMS provider brings you a patient, they invariably have to swab it down to give the next patient a reasonably sanitary surface to lie on. But sometimes the boards get downright nasty, and the cleanup job is a major production.

Enter… the backboard washer. I saw one of these for the first time at a Level III hospital in Ohio. Fascinating! Pop the board inside and seven minutes later it’s clean. And I mean really squeaky clean. You may think it looks clean after a good hand wash, but the effluent water coming out of this washer after inserting a hand-cleaned board is still nasty!

These units use standard 100V 20A power and only require a hot water hookup and a drain. They can wash two boards at once.

Hospitals in the know should locate one of these next to a work area for completing EMS paperwork and some free food. What could be better?

Note: I have no financial interest in this company, and I definitely do not have one in my garage.

Reference: Aqua Phase A-8000 spec sheet. Click to download.

Head

Are Prophylactic Antibiotics Needed For Facial Fractures?

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The use of prophylactic antibiotics in patients with facial fractures has been controversial since forever. Some trauma professionals argue that these fractures, many of which involve a sinus or the mouth, should be considered as open fractures.

Several studies on the use of antibiotics prophylactically, preoperatively, and postoperatively have shown a significant amount of variability. A few have shown no benefit from the use of short-, long-, or no antibiotics. In fact, the Surgical Infection Society issued a practice guideline on antibiotic use in facial fractures. Essentially, they recommended that antibiotics not be administered to patients who do not require surgery. And for operative fractures, they recommended against pre- or post-operative antibiotics.

A recently published study examined current practices regarding antibiotic administration, timing, and adverse events. The null hypothesis was that prophylactic antibiotics would not reduce facial fracture-associated infectious complications in nonoperative facial fractures.

The AAST Facial Fracture Study Group performed a prospective, observational study of adult patients who did not undergo operative repair of their facial fractures. Patients receiving antibiotics for other causes,  those who were immunocompromised, and patients with bowel injuries were excluded. The primary outcome was any related infection, drainage, or follow-up visit requiring antibiotics. Secondary outcomes included demographic indicators such as length of stay, ventilator time, discharge disposition, and readmission within 30 days.

Here are the factoids:

  • A total of 1,835 patients were studied, and two-thirds (64%) did not receive any antibiotics
  • Infections developed in 0.7% of patients without antibiotics and 1.7% with
  • The vast majority of fractures in all patients (84%) were not considered open (no mucosal exposure)
  • Antibiotic administration had a significant association with infectious complications, although the duration of antibiotics did not seem to make a difference

The authors concluded that infection rates were very low despite the majority of patients receiving no antibiotics.

Bottom line: This study provides another set of data points that show us that antibiotics are not necessary in many facial fractures. This is an observational study, so there were wide variations in practice patterns that make the study more difficult to interpret.

There was a relatively small number of patients with “open fractures” that involved exposure to the mucosa. This weakens the study conclusions for this group.

This study joins a growing number that would indicate that nonoperatively managed facial fractures do not require antibiotics. For those that do need surgery, the usual perioperative antibiotic rules still apply.

Reference: Prophylactic antibiotic use in trauma patients with non-operative facial fractures: A prospective AAST multicenter trial. Journal of Trauma and Acute Care Surgery 98(4):p 557-564, April 2025.