All posts by TheTraumaPro

EAST 2019 #2: Utilization of Damage Control Laparotomy

The next paper presentation I’ll review from the upcoming EAST Annual Assembly is from a consortium of six US trauma programs, and appears to be under the direction of faculty at the McGovern Medical School in Houston. They recognized that rates of damage control laparotomy (DCL) vary widely throughout the US. In part, this is due to the lack of hard and fast indications for the application of this procedure. This procedure is used in cases where patient physiology (or trends in that physiology) would suggest that persisting with an open body cavity would lead to hypothermia, coagulopathy, additional injury, or death.

This study entailed the prospective review of every DCL performed at the centers over a one year period. Each was adjudicated by a majority faculty vote as to whether it would have been safe and appropriate to perform a definitive laparotomy (DL) instead. DL means that all injuries are fixed and the abdomen is closed.

Here are the factoids:

  • 872 trauma laparotomies were performed: 209 DCL and 639 DL. There were 24 intraoperative deaths.
  • There was no change in DCL rate compared to historical controls for 5 of the 6 centers (see diagram)
  • One center had an initial reduction in DCL rate, but this disappeared throughout the rest of the study
  • The voting group found consensus in recommending DCL with hemodynamic instability or if packing was required, but could not agree on the need for second look procedures

Overall, this intervention (reviewing each and every damage control procedure immediately after) did not decrease the DCL rate as hoped. The authors cited the second look laparotomy disagreement as a possible target to improve results.

Here are some questions for the authors and presenter to consider in advance to help them prepare for audience questions:

  • All DCLs are not the same. Six different centers were studied, each with their own DCL popluation. What was the blunt:penetrating mix for each? What were the specific mechanisms and injuries sustained? ISS? It could be that the study group was not homogeneous, making it more difficult to judge appropriateness.
  • Was the study powered well enough to detect differences? The total number of DCL cases was only 209, or 35 per center. And of course, some had more, some less. In our original DCL paper from Penn, the clinical significance first showed up only in the subset of most severely injured penetrating injury patients. Did you have enough patients?
  • What exactly was the intervention that would drive down the DCL rate? Although this is (kind of) a prospective project, the analysis of each case and the consensus vote took place after each procedure. Was this done at each institution, or only by the research group at the mother ship? How did the results get disseminated to all surgeons so that they could apply the findings to their next trauma laparotomy?
  • Look at the outlier. This is always valuable. Why was center #4 so much lower at the beginning of the study period compared to the one year historical control? Were their laparotomy numbers lower? Patient/injury mix different? Did you interview that group to see what their insights were? This is one of the most interesting findings, in my opinion.

I’ll be sitting in the front row for this one!

Reference: Better understanding the utilization of damage control laparotomy: a multiinstitutional quality improvement project. EAST 2019, Paper #12.

EAST 2019 #1: Predicting Outcome After Brain Injury

Here’s the first abstract I’ll review from the EAST 2019 Annual Assembly in January.

This one comes to us from the University of Arizona system, and specifically from Tucson. The senior author has an interest in traumatic brain injury (TBI) and geriatric trauma, so it’s not surprising to see this abstract that fuses the two. The aim was to create a new tool to predict mortality in patients who had sustained a TBI.

The authors devised a score, the Brain Trauma Outcome Score (BTOS) using three variables: age, injury severity score (ISS), and presence of blood transfusion. Furthermore, this was used to create a Brain Trauma Outcome Score (BTOS), by dividing the BTOS by the GCS. These equations were developed and tested using data sets from two years worth of TQIP data. I know, lots of acronyms, but stay with me. After generating the equations for GTOS and BTOS from one TQIP dataset and testing against another, both of these systems were checked for discriminatory power by generating receiving operator characteristic curves.

The authors found that the tested BTOS was better at predicting mortality than the tested GTOS. They concluded that “BTOS can accurately predict in-hospital mortality in all TBI patients.” Seems like a pretty bold assertion.

Here are some questions for the authors and presenter to consider in advance to help them prepare for audience questions:

  • Be aware that some typos crept into the final copy. When preparing abstracts, try not to use special characters (i.e. +) as they may not be generic enough for the commercial printing software used to prepare final copy. This is similar to avoiding video or links to YouTube videos in slide sets. I was able to figure out what the question marks really were (I think), but make sure the audience does, too.
  • Why did you even think to create this model? Some new “systems” are just wild guesses, and sometimes it’s even possible to find one that appears to have a significant correlation with reality. What was the rationale that prompted you to combine ISS, age, blood, and GCS? Did your clinical experience suggest this? Papers on related prediction systems? Then what?
  • Is validating your test data using other patients from the same dataset legitimate? Shouldn’t they be very similar since they are in the same 2-years of data? This could make the system less accurate when applied to a very different patient cohort.
  • The GCS range studied was very high and narrow. If I read the abstract correctly, the median was 14-ish with a range from 12-15. These are mostly mild TBIs, so why were they dying anyway? And if the formula for GTOS was derived using predominantly mild TBI data, how can it possibly work well for moderate and severe? And I still worry that patients were dying of problems unrelated to TBI.
  • Make sure you clearly explain your methods to the audience. Some are not well versed in ROC curves, and many will not understand the nuances and potential pitfalls of developing and validating numerical systems like this. It’s easy to lose them, so make sure you are clear and concise in your explanations.
  • How do you see a system like this being used in the future? It’s nice to have some appreciation of the practicality, and an assurance that this isn’t just an academic exercise.

I enjoyed the abstract, and look forward to hearing it in person next month!

Reference: The Brain Trauma Outcome Score (BTOS): Estimating mortality after a traumatic brain injury. EAST 2019, Paper #6.

Starting Next Week: EAST 2019!

The 32nd Annual Assembly of the Eastern Association for the Surgery of Trauma (EAST) is just around the corner. The meeting starts January 15 in Austin, TX.

I traditionally choose some of the abstracts to presented that I find particularly interesting. I’ll dissect them here on the blog, and provide suggestions to the authors on how to prepare for questions they might receive from the audience at the meeting.

Starting next Monday, and continuing through the meeting in Mid-January, I’ll be posting one critique per day. Tune in and enjoy!

Trauma Morning Report – A Best Practice?

Hospital medicine in general, and inpatient trauma care specifically, is now characterized by a series of handoffs. These occur between physicians, trainees, nurses, and a host of other trauma professionals. Many trauma centers have implemented a “morning report” type of handoff, which formalizes part of the process and frequently adds a teaching component.

The group at the University of Arkansas studied the impact of implementing a morning report process on length of stay and care planning. Prior to the study, residents handed off care post-call to other residents without attending surgeon involvement. The morning report process added the presence of the post-call surgeon, and the trauma and emergency general surgery attendings coming on duty. Advanced practice nurses collected information on care plan changes.

Here are the factoids:

  • Problem: There is mention of a survey with 79% response rate detailing 219 trauma admissions during the 90 day study period. This is not explained anywhere else in the abstract, so it is not clear if the data presented represents all admissions.
  • 69% of patients were admitted to a ward bed, and 31% to ICU
  • Change to the care plan occurred during morning report in 20% of patients
  • The most common care plan changes were: addition of a procedure in 45%, medication change in 34% (typically pain management)
  • Mean hospital length of stay decreased from 10 to 6 days (!)

Bottom line: This small, prospective study quantifies a few of the benefits of a formal “morning report” process. The fact that just a little bit of trauma attending oversight decreased length of stay by a whopping 4 days suggests that the residents really needed the increased supervision. Discharge planning is a multidisciplinary activity, and should be a major part of the rounding routine as well.

Formalizing the handoff process is always a good thing. Yes, it takes time and planning, but as this and other studies have shown, it is well worth the effort!

References:

  1. Morning report decreases length of stay in trauma patients by changing care plans in 20% of patients. AAST 2016, Poster 124.
  2. Morning report decreases length of stay in trauma patients. Trauma Surg Acute Care Open 3(1):e185, 2018.

Nuances Of The “Unanticipated Mortality” Classification

All trauma centers verified by the American College of Surgeons (ACS) are required to classify trauma patient deaths into one of three categories: unanticipated mortality, mortality with opportunity for improvement, or mortality without opportunity for improvement. I’ve provided some details about each of those over the past several posts. But I do want to provide a little more detail for the much dreaded “unanticipated mortality.”

You may have noticed that unanticipated mortality does not seem to come in the same two flavors as the anticipated mortality: with and without opportunity for improvement. Why is this? Does this imply that all unanticipated mortalities have some opportunity or another? I actually used to think so.

But over time, I’ve changed my mind. It is true that the vast majority of unanticipated mortalities involve one, and many times, several opportunities that may improve the outcome for similar patients in the future. But I have personally seen at least two that did not.

How can this be, you say? Let me give you a far-fetched example. A healthy young male is involved in a car crash, sustaining fractures of a few ribs which are very painful. He is admitted for pain control, and is treated with your usual regimen of analgesics, mobilization, and pulmonary toilet. He admits to no significant medical or surgical history and is taking no medications. As he is sitting in his room waiting for his ride on the day of discharge, a small meteorite plunges through his window and strikes him in the head, killing him instantly.

So where’s the opportunity? Put meteorite shielding around your entire hospital? I think not. Don’t be ridiculous, you say, that’s not a realistic example. But what if, on the day of discharge, he stands up in his room and keels over in PEA arrest? An autopsy is performed, and a massive pulmonary embolism is identified. And let’s say that this patient somehow met your DVT prophylaxis criteria and he was receiving appropriate management per your practice guideline. And when you convey these findings to the family, they seem to recall a pattern of pulmonary embolism deaths and DVT complications in other family members. But nobody mentioned this to you during the history and physical exam. And you treated them exactly according to your protocol.

So what do you think now? Is there an opportunity? I still think not! But you must still pick apart every bit of the patient’s care, trying to identify anything that was not done according to plan or protocol that may have led to this (extremely) adverse outcome. But be aware that over your career as a trauma professional, you will likely run into one or more of these cases that are unanticipated but completely nonpreventable!