John J. Fildes

Advanced trauma life support, 8th edition, the evidence for change.

The American College of Surgeons Committee on Traumas Advanced Trauma Life Support Course is currently taught in 50 countries. The 8th edition has been revised following broad input by the International ATLS subcommittee. Graded levels of evidence were used to evaluate and approve changes to the course content. New materials related to principles of disaster management have been added. ATLS is a common language teaching one safe way of initial trauma assessment and management.

Trauma: the leading cause of maternal death

The records of the Cook County Medical Examiner were reviewed for the period January, 1986, to December, 1989. Ninety-five maternal deaths were identified. The causes of maternal death were categorized as direct maternal, indirect maternal, or nonmaternal. Direct maternal causes of death (18.9%) were the result of complications of pregnancy, labor, delivery, or its management. Indirect maternal causes of death (12.6%) occurred when pre-existing health problems were exacerbated by pregnancy. All other maternal deaths were the result of nonmaternal causes. Nonmaternal causes of maternal death were further classified as traumatic or nontraumatic. Traumatic maternal deaths (46.3%) were attributed to homicide in 57% and suicide in 9%. The mechanism of injury in traumatic maternal deaths included gunshot wounds (22.7%), motor vehicle crashes (20.5%), stab wounds (13.6%), strangulation (13.6%), blunt head injuries (9.1%), burns (6.8%), falls (4.5%), toxic exposure (4.5%), drowning (2.3%), and iatrogenic injury (2.3%). Trauma was therefore the leading cause of maternal death, accounting for 46.3% of deaths in this series.

American Association for the Surgery of Trauma Organ Injury Scale I: spleen, liver, and kidney, validation based on the National Trauma Data Bank.

BACKGROUND This study attempts to validate the American Association for the Surgery of Trauma (AAST) Organ Injury Scale (OIS) for spleen, liver, and kidney injuries using the National Trauma Data Bank (NTDB). STUDY DESIGN All NTDB entries with Abbreviated Injury Scale codes for spleen, liver, and kidney were classified by OIS grade. Injuries were stratified either as an isolated intraabdominal organ injury or in combination with other abdominal injuries. Isolated abdominal solid organ injuries were additionally stratified by presence of severe head injury and survival past 24 hours. The patients in each grading category were analyzed for mortality, operative rate, hospital length of stay, ICU length of stay, and charges incurred. RESULTS There were 54,148 NTDB entries (2.7%) with Abbreviated Injury Scale-coded injuries to the spleen, liver, or kidney. In 35,897, this was an isolated abdominal solid organ injury. For patients in which the solid organ in question was not the sole abdominal injury, a statistically significant increase (p < or = 0.05) in mortality, organ-specific operative rate, and hospital charges was associated with increasing OIS grade; the exception was grade VI hepatic injuries. Hospital and ICU lengths of stay did not show substantial increase with increasing OIS grade. When isolated organ injuries were examined, there were statistically significant increases (p < or = 0.05) in all outcomes variables corresponding with increasing OIS grade. Severe head injury appears to influence mortality, but none of the other outcomes variables. Patients with other intraabdominal injuries had comparable quantitative outcomes results with the isolated abdominal organ injury groups for all OIS grades. CONCLUSIONS This study validates and quantifies outcomes reflective of increasing injury severity associated with increasing OIS grades for specific solid organ injuries alone, and in combination with other abdominal injuries.

Staged reconstruction after gunshot wounds to the abdomen.

Immediate closure of abdominal incisions after exploration and treatment of gunshot wounds is not always feasible or advisable. Significant bowel edema after massive fluid resuscitation might preclude primary closure, whereas any attempt to close under tension might result in complications ranging from wound dehiscence, infection, and necrosis to the abdominal compartment syndrome with abdominal, cardiopulmonary, and renal complications. For these difficult cases, the open technique has been recommended. The abdomen is left open and is closed when the patients condition permits. When immediate wound approximation is not possible, temporary coverage can be achieved with a mesh, patch, or a split‐thickness skin graft and the definitive reconstruction is deferred for a more optimal time. The purpose of this retrospective study is to report the authors’ experience with staged abdominal wall reconstruction after gunshot wounds. From 1989 to 1998, 1933 patients underwent exploratory laparotomy for penetrating wounds to the abdomen. Twenty‐nine patients in grave condition and with multiple medical problems were comanaged by the Trauma and Plastic Surgery Services at Cook County Hospital with the following protocol: The abdomen was initially left open and exposed viscera were covered with a variety of methods, including a Gore‐Tex patch (W. L. Gore and Associates, Inc., Flagstaff, Ariz.). A split‐thickness graft was subsequently placed on the granulation tissue over viscera at an average of 14 days after the last laparotomy. These planned ventral hernias were definitively treated at an average of 7 months after the skin grafting procedure, primarily using the components separation technique. In 24 patients, the fascia was closed primarily without tension, while five patients required the use of synthetic mesh to restore fascial continuity. Nine patients underwent closure of a colostomy or repair of fistulas simultaneously with abdominal wall reconstruction. One patient developed a postoperative hernia, two developed superficial wound dehiscence that healed without further surgery, and one required re‐exploration for a failed anastomosis after colostomy closure. All but one patient maintained a stable abdominal wall after the reconstruction. The authors concluded that staged abdominal wall reconstruction should be primarily recommended for patients with complex abdominal wounds and a compromised general condition that precludes primary closure. With this treatment protocol, patients can recover faster from their trauma surgery and the risk of perioperative complications can be reduced. After final reconstruction, the continuity, stability, and strength of the abdominal wall are maintained in the vast majority of cases with the use of autogenous tissue and without the need for alloplastic material. With close cooperation between the trauma team and the plastic surgeon and appropriate timing and planning of each stage, the success rate of the technique is high and the incidence of complications limited. (Plast. Reconstr. Surg. 108: 83, 2001.)

Trauma quality improvement using risk-adjusted outcomes.

PURPOSE The National Surgical Quality Improvement Program has improved the quality of surgical care by tracking risk-adjusted patient outcomes. Unlike the National Surgical Quality Improvement Program, the trauma center verification program of the American College of Surgeons (ACS) focuses on availability of optimal resources, not outcomes. We hypothesized that significant variations in outcomes exist across similar level ACS-verified trauma centers despite availability of similar resources. METHODS The National Trauma Data Bank was used to identify adult patients (age 16-99 years) who were treated at ACS-verified Level I trauma centers that submitted at least 1,000 patients during the 5-year study period (264,102 patients from 58 trauma centers, excluding dead upon arrival). Multivariate logistic regression was used to analyze expected survival for each patient, adjusted for age, gender, race, injury mechanism, transfer status, and injury severity. Observed-to-expected survival ratios (O/E ratios with 95% confidence intervals) were used to rank trauma centers as high performers (O/E ratio significantly larger than 1), low performers (O/E ratio significantly less than 1), or average performers (O/E ratio overlapping 1). RESULTS Almost half the centers performed significantly different from their risk-adjusted expectation. Fourteen were high performers, 11 were low performers, and 33 were average performers. CONCLUSIONS The trauma center verification process in its present form may not ensure optimal outcome across all verified centers. If further validated, these findings suggest significant room for trauma quality improvement by replicating structures and processes of high performing trauma centers.

Methodology and analytic rationale for the American College of Surgeons Trauma Quality Improvement Program.

Received June 12, 2012; Revised August 12, 2012; Accepte 2012. From the Center for Policy and Research in Emergency Medi ment of Emergency Medicine, Oregon Health & Science Uni land, OR (Newgard), Department of Surgery, University of Vegas, NV (Fildes), American College of Surgeons, Chica Neal, Goble), Department of Surgery, University of Mich System, Ann Arbor, MI (Hemmila), Center for Clinical and Research, Departments of Surgery and Pediatrics, Childre Medical Center, Washington, DC (Burd), Intermountain In Research Center, University of Utah, Salt Lake City, UT (Ma ment of Surgery, University of Texas Southwestern Medical Sc TX (Shafi), Department of Surgery, Maine Medical Center, P (Clark), and Department of Surgery, University of Toron Ontario, Canada (Nathens). Correspondence address: Craig D Newgard, MD, MPH, FAC ment of Emergency Medicine, Center for Policy and Resea gency Medicine, Oregon Health & Science University, 31 Jackson Park Rd, Mail Code CR-114, Portland, OR 97239newgardc@ohsu.edu

The American College of Surgeons Trauma Quality Improvement Program

The American College of Surgeons Trauma Quality Improvement Program (ACS TQIP) is a recent addition to the many quality improvement collaboratives that have been established in surgery. On the background of a well-established trauma center and its performance improvement activities, ACS TQIP offers the potential to advance trauma care and offers participating centers the opportunity to better understand their strengths and areas for improvement. The rationale for ACS TQIPs development, implementation challenges, and potential for advancing the quality of trauma care are described.

Very hot intravenous fluid in the treatment of hypothermia.

The efficacy and safety of very hot (65 degrees C/149 degrees F) intravenous fluid (IVF) were compared with those of conventional warm (38 degrees C/100.4 degrees F) IVF in the treatment of hypothermia. Eight anesthetized beagles (11-20 kg) were studied. Blood pressure (BP), pulse (P), and core temperature (cT degrees) were recorded at baseline, during hypothermia, and during rewarming. The plasma free hemoglobin (PFHg) was measured to assess hemolysis. Each subject was cooled to 32 degrees C/89.6 degrees F and assigned to receive either 65 degrees C or 38 degrees C IVF via a specially designed multiport balloon-tipped catheter in the superior vena cava (SVC). The IV fluid rate was 80% of the blood volume per hour. Conventional rewarming methods were used in all subjects. After 2 hours the subjects were killed and the SVC was examined for injury. The rate of rewarming was 2.9 degrees C/hour in the 65 degrees C IVF group and 1.25 degrees C/hour in the 38 degrees C IVF group. The cT degrees was significantly different in all subjects after 1 (35.2 degrees +/- 1.03 degrees C vs. 33.2 degrees +/- 0.5 degrees C; p < 0.006) and 2 (37.6 degrees +/- 1.17 degrees C vs. 34.3 degrees +/- 0.9 degrees C; p < 0.004) hours of rewarming. The BP, P, and PFHg were not different. Visual examination of the SVC revealed two lesions in the 65 degrees C IVF group and one in the 38 degrees C group. Mechanical or thermal injury could not be differentiated.(ABSTRACT TRUNCATED AT 250 WORDS)

Health care reform at trauma centers--mortality, complications, and length of stay.

OBJECTIVE The Trauma Quality Improvement Program has demonstrated existence of significant variations in risk-adjusted mortality across trauma centers. However, it is unknown whether centers with lower mortality rates also have reduced length of stay (LOS), with associated cost savings. We hypothesized that LOS is not primarily determined by unmodifiable factors, such as age and injury severity, but is primarily dependent on the development of potentially preventable complications. METHODS The National Trauma Data Bank (2002-2006) was used to include patients (older than 16 years) with at least one severe injury (Abbreviated Injury Scale score ≥ 3) from Level I and II trauma centers (217,610 patients, 151 centers). A previously validated risk-adjustment algorithm was used to calculate observed-to-expected mortality ratios for each center. Poisson regression was used to determine the relationship between LOS, observed-to-expected mortality ratios, and complications while controlling for confounding factors, such as age, gender, mechanism, insurance status, comorbidities, and injuries and their severity. RESULTS Large variations in LOS (median, 4-8 days) were observed across trauma centers. There was no relationship between mortality and LOS. The most important predictor of LOS was complications, which were associated with a 62% increase. Injury severity score, shock, gunshot wounds, brain injuries, intensive care unit admission, and comorbidities were less important predictors of LOS. CONCLUSION Quality improvement programs focusing on mortality alone may not be associated with reduced LOS. Hence, the Trauma Quality Improvement Program should also focus on processes of care that reduce complications, thereby shortening LOS, which may lead to significant cost savings at trauma centers.

Centers for medicare and medicaid services quality indicators do not correlate with risk-adjusted mortality at trauma centers

OBJECTIVES The Centers for Medicare and Medicaid Services (CMS) publicly reports hospital compliance with evidence-based processes of care as quality indicators. We hypothesized that compliance with CMS quality indicators would correlate with risk-adjusted mortality rates in trauma patients. METHODS A previously validated risk-adjustment algorithm was used to measure observed-to-expected mortality ratios (O/E with 95% confidence interval) for Level I and II trauma centers using the National Trauma Data Bank data. Adult patients (>or=16 years) with at least one severe injury (Abbreviated Injury Score >or=3) were included (127,819 patients). Compliance with CMS quality indicators in four domains was obtained from Hospital Compare website: acute myocardial infarction (8 processes), congestive heart failure (4 processes), pneumonia (7 processes), surgical infections (3 processes). For each domain, a single composite score was calculated for each hospital. The relationship between O/E ratios and CMS quality indicators was explored using nonparametric tests. RESULTS There was no relationship between compliance with CMS quality indicators and risk-adjusted outcomes of trauma patients. CONCLUSIONS CMS quality indicators do not correlate with risk-adjusted mortality rates in trauma patients. Hence, there is a need to develop new trauma-specific process of care quality indicators to evaluate and improve quality of care in trauma centers.