Brian P. Smith

''SCIP''ping antibiotic prophylaxis guidelines in trauma: The consequences of noncompliance

OBJECTIVE The Surgical Care Improvement Project (SCIP) established surgical antibiotic prophylaxis guidelines as part of a national patient safety initiative aimed at reducing surgical complications such as surgical site infection (SSI). Although these antibiotic prophylaxis guidelines have become well established in surgical patients, they remain largely unstudied in patients with injury from trauma undergoing operative procedures. We sought to determine the role of these antibiotic prophylaxis guidelines in preventing SSI in patients undergoing trauma laparotomy. METHODS A retrospective review of all patients who underwent emergency trauma laparotomy at two Level I trauma centers (2007–2008) revealed 306 patients who survived more than 4 days after injury. Demographics and clinical risk SSI factors were analyzed, and patients were compared on the basis of adherence to the following SCIP guidelines: (1) prophylactic antibiotic given, (2) antibiotic received within 1 hour before incision, (3) correct antibiotic selection, and (4) discontinuation of antibiotic within 24 hours after surgery. The primary study end point was the development of SSI. RESULTS The study sample varied by age (mean [SD], 32 [16] years) and injury mechanism (gunshot wound 44%, stab wound 27%, blunt trauma 30%). When patients with perioperative antibiotic management complying with the four SCIP antibiotic guidelines (n = 151) were compared with those who did not comply (n = 155), no difference between age, shock, small bowel or colon resection, damage control procedures, and skin closure was detected (p > 0.05). After controlling for injury severity score, hypotension, blood transfusion, enteric injury, operative duration, and other potential confounding variables in a multivariate analysis, complete adherence to these four SCIP antibiotic guidelines independently decreased the risk of SSI (odds ratio, 0.43; 95% confidence interval, 0.20–0.94; p = 0.035). Patients adhering to these guidelines less often developed SSI (17% vs. 33%, p = 0.001) and had shorter overall hospital duration of antibiotics (4 [6] vs. 9 [11] days, p < 0.001) and hospital length of stay (14 [13] vs. 19 [23] days, p = 0.016), although no difference in mortality was detected (p > 0.05). CONCLUSIONS Our results suggest that SCIP antibiotic prophylaxis guidelines effectively reduce the risk of SSI in patients undergoing trauma laparotomy. Despite the emergent nature of operative procedures for trauma, efforts to adhere to these antibiotic guidelines should be maintained. LEVEL OF EVIDENCE Therapeutic study, level II.

A comparison of Injury Severity Score and New Injury Severity Score after penetrating trauma: a prospective analysis

BACKGROUND The Injury Severity Score (ISS) has been validated in numerous studies and has become one of the most common trauma scoring systems since its inception. The ISS equation was later modified to create the New Injury Severity Score (NISS). By using the three most severe injuries regardless of body region, the NISS seems well suited to describe patients of penetrating trauma, where injuries often cluster within a single body region. We hypothesized that NISS would better predict outcomes than ISS in penetrating trauma patients. METHODS An analysis (June 2008 to March 2009) of all severely injured (length of hospital stay ≥ 48 hours, intensive care unit admission, interhospital transfer, or death) penetrating trauma patients revealed final study sample of 256 patients. ISS and NISS were compared as predictors for both mortality and complications through area under the receiver operating characteristic curve, Hanley-McNeil test, multiple-variable logistic regression, and Hosmer-Lemeshow goodness-of-fit test analysis. RESULTS Of 256 study patients, 195 (76.2%) survived until discharge. The mean (ISS, 21.7 ± 21.1 vs. NISS, 27.4 ± 22.0; p < 0.001) and median (ISS, 14.0 vs. NISS, 21.0) ISS was lower than those of the NISS. Overall, 173 patients (67.6%) had discordant scores with 26% and 43% having scores greater than 25 (ISS and NISS, respectively, p < 0.01). The mortality area under the curve (AUC) for NISS was greater than the AUC for ISS in all penetrating patients (0.930 vs. 0.885, p = 0.008), those with penetrating torso injuries (NISS, 0.934 vs. ISS, 0.881, p < 0.001), and those with severe (score > 25) injuries (NISS, 0.845 vs. ISS, 0.761, p < 0.001). In patients surviving for more than 48 hours, the complications AUC for NISS was also greater than the AUC for ISS (NISS, 0.838 vs. ISS, 0.784; p = 0.023). CONCLUSION The NISS outperformed ISS as a predictor of both mortality and complications in civilian penetrating trauma patients. These results indicate that NISS is a superior scoring system for patients with penetrating injuries. LEVEL OF EVIDENCE Prognostic study, level III.

Temporary arterial shunts in damage control: Experience and outcomes.

BACKGROUND Arterial shunting is a well-described method to control hemorrhage and rapidly reestablish flow, but optimal shunt dwell times remain controversial. We hypothesized that prolonged shunt dwell times of more than 6 hours are related to adverse outcomes after major arterial injury. METHODS A review (2005–2013) of all patients with arterial shunts placed after traumatic injury at our urban Level I trauma center was undertaken. Patients who died prior to shunt removal (n = 7) were excluded. Shunt complications were defined as dislodgement, thrombosis, and distal ischemia. Patients were compared on the basis of shunt complications with respect to clinical parameters. RESULTS The 42 patients who underwent arterial shunting after major vascular injury were primarily young (median, 26 years; interquartile range [IQR], 22–31 years) males (97.6%), severely injured (Injury Severity Score, 17.5 [IQR, 14–29]; shunted vessel Abbreviated Injury Scale score, 4 [IQR, 3–4]) by gunshot (85.7%) requiring neck/torso (33.3%) or upper-extremity (19.1%) or lower-extremity (47.6%) shunts. Thirty-five patients survived until shunt removal, and 5 (14.3%) of 35 developed shunt complications. Demographics and clinical characteristics were compared between those with shunt dwell times of less than 6 hours (n = 19) and more than 6 hours (n = 16). While patients appeared to have a greater injury burden overall in the group with dwell times of more than 6 hours, there were no statistical differences between groups with respect to age, gender, initial systolic blood pressure or hemodynamics during the shunt dwell period, use of vasopressors, Abbreviated Injury Scale score of the shunted vessel, Injury Severity Score, or outcomes including limb amputation or mortality. No patients (0/19) with shunt dwell times of less than 6 hours developed complications, whereas 5 (31.3%) of 16 patients with dwell times of more than 6 hours developed shunt complications (p = 0.05). CONCLUSIONS In this civilian series, 14% of patients with arterial shunts developed shunt complications. Our data suggest that limiting shunt dwell times to less than 6 hours when clinically feasible may decrease adverse outcomes. LEVEL OF EVIDENCE Therapeutic/care management study, level IV.

Defining the optimal time to the operating room may salvage early trauma deaths.

BACKGROUND Early trauma deaths have the potential for salvage with immediate surgery. We studied time from injury to death in this group to qualify characteristics and quantify time to the operating room, yielding the greatest opportunity for salvage. METHODS The Pennsylvania Trauma Outcomes Study (PTOS) is a comprehensive registry including all Pennsylvania trauma centers. PTOS was queried for adult trauma patients from 1999 to 2010 dying within 4 hours of injury. The distribution of time to death (TD) was examined for subgroups according to mechanism of injury, hypotension (defined as systolic blood pressure ⩽ 90 mm Hg), and operation required. The 5th percentile (TD5) and the 50th percentile (TD50) were calculated from the distributions and compared using the Mann-Whitney U-test. RESULTS The PTOS yielded 6,547 deaths within 4 hours of injury. The overall TD5 and TD50 were 0:23 (hour:minute) and 0:59, respectively. Median penetrating injury times were significantly shorter than blunt injury times (TD5/TD50, 0:19/0:43 vs. 0:29/1:10). Median time was significantly shorter for hypotensive versus normotensive patients (TD5/TD50, 0:22/0:52 vs. 0:43/2:18). Operative subgroups had different TD5/TD50 (abdominal surgery [n = 607], 1:07/2:26; thoracic surgery [n = 756] 0:25/1:25; vascular surgery [n = 156], 0:35/2:15; and cranial surgery [n = 18], 1:20/2:42). CONCLUSION Early trauma deaths have the potential for salvage with immediate surgery. We found TD to vary based on mechanism of injury, presence of hypotension, and type of surgery needed. With the use of TD5 and TD50 benchmarks in these subgroups, a trauma system may determine if decreased time to the operating room decreases mortality. Trauma systems can use these data to further improve prehospital and initial hospital phases of care for this subset of early death trauma patients. LEVEL OF EVIDENCE Epidemiologic study, level III.

Skin closure after trauma laparotomy in high-risk patients: opening opportunities for improvement.

BACKGROUND Although many surgeons leave laparotomy incisions open after colon injury to prevent surgical site infection (SSI), other injured patient subsets are also at risk. We hypothesized that leaving trauma laparotomy skin incisions open in high-risk patients with any enteric injury or requiring damage control laparotomy (DCL) would not affect superficial SSI and fascial dehiscence rates. METHODS Patients who underwent trauma laparotomy (2004–2008) at two Level I centers were reviewed. To ensure a high-risk sample, only patients with transmural enteric injuries or need for DCL surviving 5 days or more were included. SSIs were categorized by the CDC (Centers for Disease Control and Prevention) criteria and risk factors were analyzed by skin closure (open vs. any closure). Significant (p < 0.05) univariate variables were applied to two multivariate analyses examining superficial SSI and fascial dehiscence. RESULTS Of 1,501 patients who underwent laparotomy, 503 met inclusion criteria. Patients were young (median, 28.0 years; range, 22.0–40.0 years) with penetrating (74%) or enteric (80%) injuries, and DCL (36%) and SSI (44%; superficial, 25%; deep, 3%; organ/space, 25%) were common. While no difference in superficial SSI after loose (n = 136) or complete skin closure (n = 224) was detected (p = 0.64), superficial SSIs were less common with open skin incisions (9.8%), despite multiple risk factors, than with any skin closure (31.1%, p < 0.001). Predictors of superficial SSIs and fascial dehiscence were each evaluated with multiple-variable logistic regression analysis. After adjusting for multiple potential confounding variables, any skin closure increased the risk of superficial SSIs approximately nine times (odds ratio, 8.6; p < 0.001) and fascial dehiscence six times (odds ratio, 5.7; p = 0.013). CONCLUSION Management of skin incisions takes careful consideration like any other step of a laparotomy. Our results suggest that the decision to leave skin open is one simple method to improve outcomes in high-risk patients. LEVEL OF EVIDENCE Therapeutic study, level III.

Contemporary management of high-grade renal trauma: Results from the American Association for the Surgery of Trauma Genitourinary Trauma study

BACKGROUND The rarity of renal trauma limits its study and the strength of evidence-based guidelines. Although management of renal injuries has shifted toward a nonoperative approach, nephrectomy remains the most common intervention for high-grade renal trauma (HGRT). We aimed to describe the contemporary management of HGRT in the United States and also evaluate clinical factors associated with nephrectomy after HGRT. METHODS From 2014 to 2017, data on HGRT (American Association for the Surgery of Trauma grades III-V) were collected from 14 participating Level-1 trauma centers. Data were gathered on demographics, injury characteristics, management, and short-term outcomes. Management was classified into three groups—expectant, conservative/minimally invasive, and open operative. Descriptive statistics were used to report management of renal trauma. Univariate and multivariate logistic mixed effect models with clustering by facility were used to look at associations between proposed risk factors and nephrectomy. RESULTS A total of 431 adult HGRT were recorded; 79% were male, and mechanism of injury was blunt in 71%. Injuries were graded as III, IV, and V in 236 (55%), 142 (33%), and 53 (12%), respectively. Laparotomy was performed in 169 (39%) patients. Overall, 300 (70%) patients were managed expectantly and 47 (11%) underwent conservative/minimally invasive management. Eighty-four (19%) underwent renal-related open operative management with 55 (67%) of them undergoing nephrectomy. Nephrectomy rates were 15% and 62% for grades IV and V, respectively. Penetrating injuries had significantly higher American Association for the Surgery of Trauma grades and higher rates of nephrectomy. In multivariable analysis, only renal injury grade and penetrating mechanism of injury were significantly associated with undergoing nephrectomy. CONCLUSION Expectant and conservative management is currently utilized in 80% of HGRT; however, the rate of nephrectomy remains high. Clinical factors, such as surrogates of hemodynamic instability and metabolic acidosis, are associated with nephrectomy for HGRT; however, higher renal injury grade and penetrating trauma remain the strongest associations. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III; Therapeutic study, level IV.

Venous thromboembolism after major venous injuries: Competing priorities

BACKGROUND Venous thromboembolism (VTE) after major vascular injury (MVI) is particularly challenging because the competing risk of thrombosis and embolization after direct vessel injury must be balanced with risk of bleeding after surgical repair. We hypothesized that venous injuries, repair type, and intraoperative anticoagulation would influence VTE formation after MVI. METHODS A multi-institution, retrospective cohort study of consecutive MVI patients was conducted at three urban, Level I centers (2005–2013). Patients with MVI of the neck, torso, or proximal extremities (to elbows/knees) were included. Our primary study endpoint was the development of VTE (DVT or pulmonary embolism [PE]). RESULTS The 435 major vascular injury patients were primarily young (27 years) men (89%) with penetrating (84%) injuries. When patients with (n = 108) and without (n = 327) VTE were compared, we observed no difference in age, mechanism, extremity injury, tourniquet use, orthopedic and spine injuries, damage control, local heparinized saline, or vascular surgery consultation (all p > 0.05). VTE patients had greater Injury Severity Score (ISS) (17 vs. 12), shock indices (1 vs. 0.9), and more torso (58% vs. 35%) and venous (73% vs. 48%) injuries, but less often received systemic intraoperative anticoagulation (39% vs. 53%) or postoperative enoxaparin (47% vs. 61%) prophylaxis (all p < 0.05). After controlling for ISS, hemodynamics, injured vessel, intraoperative anticoagulation, and postoperative prophylaxis, multivariable analysis revealed venous injury was independently predictive of VTE (odds ratio, 2.7; p = 0.002). Multivariable analysis of the venous injuries subset (n = 237) then determined that only delay in starting VTE chemoprophylaxis (odds ratio, 1.3/day; p = 0.013) independently predicted VTE after controlling for ISS, hemodynamics, injured vessel, surgical subspecialty, intraoperative anticoagulation, and postoperative prophylaxis. Overall, 3.4% of venous injury patients developed PE, but PE rates were not related to their operative management (p = 0.72). CONCLUSION Patients with major venous injuries are at high risk for VTE, regardless of intraoperative management. Our results support the immediate initiation of postoperative chemoprophylaxis in patients with major venous injuries. LEVEL OF EVIDENCE Therapeutic/care management, level IV.

Does proximity to violence negatively influence attitudes toward exception from informed consent in emergency research

BACKGROUND Trauma research has been limited by perceived patient reluctance to participate in exception from informed consent (EFIC) studies. We hypothesized that race, socioeconomic status, and proximity to violence influence willingness to participate in and perception of EFIC research among at-risk populations. METHODS Trauma patients, families, and community members ranked statements regarding attitude toward EFIC in the context of an upcoming trial and willingness to participate in emergency research using a 5-point Likert scale during a community consultation. Higher total scores reflected a more positive attitude regarding EFIC (range, 6–30; neutral, 18) and willingness (range, 23–115; neutral, 69). Subject zip code was used to calculate median income, as an estimate for socioeconomic status, and proximity to the five most violent city zip codes. Linear regression, Spearman’s correlation, and Kruskal-Wallis tests (p < 0.05) were used to evaluate relationships between estimated socioeconomic status, race, mechanism of injury, proximity to violence, and attitudes toward EFIC. RESULTS A total of 179 subjects participated including trauma patients (n = 99), families (n = 33), and community members (n = 47). Overall, participants were supportive of EFIC and reported high scores in willingness to participate (median, 24; interquartile range, 21–25; median 89, interquartile range, 82–95, respectively). Proximity to violence did correlate with race (p = 0.03) but was not associated with violent mechanism of injury, perception of EFIC, or willingness to participate in emergency research. Estimated socioeconomic status and race did not correlate with perception of or willingness to participate in EFIC. CONCLUSION Based on our data, there is no correlation between either proximity to violence or estimated socioeconomic status and willingness to participate in EFIC research. Given this lack of correlation, researchers should partner with at-risk communities to conduct EFIC studies without concern for limited participation. LEVEL OF EVIDENCE Epidemiologic/prognostic study, level III.

Leveraging Telemedicine Infrastructure to Monitor Quality of Operating Room to Intensive Care Unit Handoffs.

Purpose To analyze in-room video recordings of operating room (OR) to intensive care unit (ICU) handoffs to determine tempo and quality of team interactions on nights and weekends compared with weekdays, and to demonstrate how existing telemedicine technology can be used to evaluate handoffs. Method This prospective observational study of OR-to-ICU bedside handoffs was conducted in the surgical ICU of the Hospital of the University of Pennsylvania in July 2014–January 2015. Handoff video recordings were obtained for quality improvement purposes using existing telemedicine cameras. Evaluators used adapted validated in-person assessment measures to analyze basic characteristics and quality measures (timing, report types, report duration, presence of physical exam, teamwork skills, engagement, report delivery skills, listening skills, interruptions, unprofessional comments or actions). Results Sixteen weekday and 16 night and weekend handoffs were compared. There were no significant differences in basic characteristics. Most quality measures were similar on weekdays compared with nights and weekends. Surgeons demonstrated better report delivery skills and engagement on nights and weekends (P = .002 and P = .04, respectively), whereas OR anesthesiologists’ scores were similar during both time frames. Conclusions This study presents a novel approach of assessing handoff quality in OR-to-ICU handoffs using an existing telemedicine infrastructure. Using this approach, quality measures of night and weekend handoffs were found to be no worse—and sometimes better—than those during weekdays. Video analysis may emerge as an ideal unobtrusive quality improvement methodology to monitor handoffs and improve education and compliance with institutional handoff policies.

Handoffs in the Intensive Care Unit: Are Off Hours a Vulnerable Time?

Operating room (OR) to intensive care unit (ICU) handoffs are complex and known to be associated with adverse events and patient harm. The authors hypothesized that handoff quality diminishes during nights/weekends and that bedside handoff practices are similar between ICUs of the same health system. Bedside OR-to-ICU handoffs were directly observed in 2 surgical ICUs with different patient volumes. Handoff quality measures were compared within the ICUs on weekdays versus nights/weekends as well as between the high- and moderate-volume ICUs. In the high-volume ICU, transmitter delivery scores were significantly better during off hours, while other measures were not different. High-volume ICU scores were consistently better than those in the moderate-volume ICU. Bedside handoff practices are not worse during off hours and may be better in ICUs used to a higher patient volume. Specific handoff protocols merit evaluation and training to ensure consistent practices in different ICU models and at different times.