Judy N. Mikhail

Is Delayed Laparotomy for Blunt Abdominal Trauma a Valid Quality Improvement Measure in the Era of Nonoperative Management of Abdominal Injuries

BACKGROUND Review of hemodynamically stable patients who undergo laparotomy for trauma greater than 4 hours after admission is an American College of Surgeons quality improvement filter. We reviewed our recent experience with patients who underwent laparotomy for trauma greater than 4 hours after admission to evaluate the reasons for delay, and to determine whether they were because of failure of nonoperative management or other causes. METHODS The registry at our Level I trauma center was searched from January 1998 through December 2000 for patients who required a laparotomy for trauma greater than 4 hours after admission. Of 3,369 admitted blunt trauma patients, 90 (2.7%) underwent laparotomy for trauma, of which 26 (29%) were identified as delayed laparotomies greater than 4 hours after admission. RESULTS The most common mechanism of injury was motor vehicle crash, the mean Injury Severity Score was 18, and 65% of the patients had significant distracting injuries. Five patients had laparotomy greater than 24 hours after admission. The average time to the operating room in the remaining patients was 8.6 hours. Clinical examination (61%) findings were the most common indication for operation. Gastrointestinal (GI) tract injury was the most common injury associated with delay in laparotomy (58%). CONCLUSION GI tract injuries are the predominant injury leading to delayed laparotomy for blunt trauma (58%). Failed nonoperative management of solid organ injuries occurred less frequently (15%). Future efforts should concentrate on earlier identification of GI tract injury. Delayed laparotomy for blunt abdominal trauma is a valid quality improvement measure.

Regional collaborative quality improvement for trauma reduces complications and costs

BACKGROUND Although evidence suggests that quality improvement to reduce complications for trauma patients should decrease costs, studies have not addressed this question directly. In Michigan, trauma centers and a private payer have created a regional collaborative quality initiative (CQI). This CQI program began as a pilot in 2008 and expanded to a formal statewide program in 2010. We examined the relationship between outcomes and expenditures for trauma patients treated in collaborative participant and nonparticipant hospitals. METHODS Payer claims and collaborative registry data were analyzed for 30-day episode payments and serious complications in patients admitted with trauma diagnoses. Patients were categorized as treated in hospitals that had different CQI status: (1) never participated (Never-CQI); (2) collaborative participant, but patient treated before CQI initiation (Pre-CQI); or (3) active collaborative participant (Post-CQI). DRG International Classification of Diseases—9th Rev. codes were crosswalked to Abbreviated Injury Scale (AIS) 2005 codes. Episode payment data were risk adjusted (age, sex, comorbidities, type/severity of injury, and year of treatment), and price was standardized. Outcome data were risk adjusted. A serious complication consisted of one or more of the following occurrences: acute lung injury/adult respiratory distress syndrome, acute kidney injury, cardiac arrest with cardiopulmonary resuscitation, decubitus ulcer, deep vein thrombosis, enterocutaneous fistula, extremity compartment syndrome, mortality, myocardial infarction, pneumonia, pulmonary embolism, severe sepsis, stroke/cerebral vascular accident, unplanned intubation, or unplanned return to operating room. RESULTS The risk-adjusted rate of serious complications declined from 14.9% to 9.1% (p < 0.001) in participating hospitals (Post-CQI, n = 26). Average episode payments decreased by

Midlevel practitioner role evolution in an American College of Surgeons-verified trauma surgery service: the 23-year experience at Hurley Medical Center.

2,720 (from

Unfractionated heparin versus low-molecular-weight heparin for venous thromboembolism prophylaxis in trauma

36,043 to

The Michigan Trauma Quality Improvement Program: Results from a collaborative quality initiative

33,323, p = 0.08) among patients treated in Post-CQI centers, whereas patients treated at Never-CQI institutions had a significant year-to-year increase in payments (from

Trauma Center Based Youth Violence Prevention Programs: An Integrative Review

23,547 to

The Association of Race, Socioeconomic Status, and Insurance on Trauma Mortality.

28,446, p < 0.001). A savings of

Noncompliance with American College of Surgeons Committee on Trauma recommended criteria for full trauma team activation is associated with undertriage deaths

6.5 million in total episode payments from 2010 to 2011 was achieved for payer-covered Post-CQI treated patients. CONCLUSION This study confirms our hypothesis that participation in a regional CQI program improves outcomes and reduces costs for trauma patients. Support of a regional CQI for trauma represents an effective investment to achieve health care value. LEVEL OF EVIDENCE Economic/value-based evaluation, level III.

Association of Hospital Participation in a Regional Trauma Quality Improvement Collaborative With Patient Outcomes

The purpose of this study was to evaluate our 23-year experience with midlevel practitioners in an American College of Surgeons–verified trauma surgery service in the absence of a surgical residency. A retrospective review of the utilization of trauma surgery midlevel practitioners was performed at a community hospital American College of Surgeons–verified trauma center from 1985 to 2007. The trauma surgery service has expanded in volume, acuity, and services offered over the 23-year period. This model has allowed us to establish effective and efficient surgical coverage while growing the trauma program, as well as general surgery and bariatric services.

Injury severity scoring: influence of trauma surgeon involvement on accuracy.

BACKGROUND Venous thromboembolism (VTE) is a common complication in trauma patients. Pharmacologic prophylaxis is utilized in trauma patients to reduce their risk of a VTE event. The Eastern Association for the Surgery of Trauma guidelines recommend use of low-molecular-weight heparin (LMWH) as the preferred agent in these patients. However, there is literature suggesting that unfractionated heparin (UFH) is an acceptable, and less costly, alternative VTE prophylaxis agent with equivalent efficacy in trauma patients. We examined data from the Michigan Trauma Quality Improvement Program to perform a comparative effectiveness study of UFH versus LMWH on outcomes for trauma patients. METHODS We conducted an analysis of the Michigan Trauma Quality Improvement Program data from January 2012 to December 2014. The data set contains information on date, time, and drug type of the first dose of VTE prophylaxis. Thirty-seven thousand eight hundred sixty-eight patients from 23 hospitals were present with an Injury Severity Score of 5 or greater and hospitalization for more than 24 hours. Patients were excluded if they died within 24 hours or received no pharmacologic VTE prophylaxis or agents other than UFH or LMWH while admitted to the hospital. We compared patients receiving LMWH to those receiving UFH. Outcomes assessed were VTE event, pulmonary embolism, deep vein thrombosis, and mortality during hospitalization. We used a generalized estimating equation approach to fit population-averaged logistic regression models with the type of first dose of VTE prophylaxis as the independent variable. Unfractionated heparin was considered the reference value. Timing of the first dose of VTE prophylaxis was entered into the model in addition to standard covariates. Odds ratios were generated for each of the dependent variables of interest. RESULTS The analysis cohort consisted of 18,010 patients. Patients administered LMWH had a decreased risk of mortality (odds ratio, 0.64; confidence interval, 0.49–0.83), VTE (odds ratio, 0.67; confidence interval, 0.53–0.84), pulmonary embolism (odds ratio, 0.53; confidence interval, 0.35–0.79), and deep vein thrombosis (odds ratio, 0.73; confidence interval, 0.57–0.95) when compared with UFH following risk adjustment and accounting for hospital effect. The reduced risk of a VTE event for patients receiving LMWH was most pronounced for patients in the lower injury-severity categories. CONCLUSIONS In our examination of VTE prophylaxis drug effectiveness, LMWH was found to be superior to UFH in reducing the incidence of mortality and VTE events among trauma patients. Therefore, LMWH should be the preferred VTE prophylaxis agent for use in hospitalized trauma patients. LEVEL OF EVIDENCE Therapeutic, level III.