Niklas Bobrovitz

Indications for use of thoracic, abdominal, pelvic, and vascular damage control interventions in trauma patients: A content analysis and expert appropriateness rating study.

BACKGROUND The use of abbreviated or damage control (DC) interventions may improve outcomes in severely injured patients when appropriately indicated. We sought to determine which indications for DC interventions have been most commonly reported in the peer-reviewed literature to date and evaluate the opinions of experts regarding the appropriateness (expected benefit-to-harm ratio) of the reported indications for use in practice. METHODS Two investigators used an abbreviated grounded theory method to synthesize indications for 16 different DC interventions reported in peer-reviewed articles between 1983 and 2014 into a reduced number of named, content-characteristic codes representing unique indications. For each indication code, an international panel of trauma surgery experts (n = 9) then rated the appropriateness of conducting the DC intervention of interest in an adult civilian trauma patient. RESULTS The 424 indications identified in the literature were synthesized into 101 unique indications. The panel assessed 12 (70.6%) of the coded indications for the 7 different thoracic, 47 (78.3%) for the 7 different abdominal/pelvic, and 18 (75.0%) for the 2 different vascular interventions to be appropriate for use in practice. These included indications for rapid lung-sparing surgery (pneumonorrhaphy, pulmonary tractotomy, and pulmonary wedge resection) (n = 1); pulmonary tractotomy (n = 3); rapid, simultaneously stapled pneumonectomy (n = 1); therapeutic mediastinal and/or pleural space packing (n = 4); temporary thoracic closure (n = 3); therapeutic perihepatic packing (n = 28); staged pancreaticoduodenectomy (n = 2); temporary abdominal closure (n = 12); extraperitoneal pelvic packing (n = 5); balloon catheter tamponade (n = 6); and temporary intravascular shunting (n = 11). CONCLUSION This study identified a list of candidate appropriate indications for use of 12 different DC interventions that were suggested by authors of peer-reviewed articles and assessed by a panel of independent experts to be appropriate. These indications may be used to focus future research and (in the interim) guide surgical practice while studies are conducted to evaluate their impact on patient outcomes.

Indications for use of damage control surgery and damage control interventions in civilian trauma patients: A scoping review.

BACKGROUND Variation in the use of damage control (DC) surgery across trauma centers may partially be driven by uncertainty as to when the procedure is indicated. We sought to scope the literature on DC surgery and DC interventions, identify their reported indications, and examine the content and evidence upon which they are based. METHODS We searched MEDLINE, EMBASE, PubMed, Scopus, Web of Science, and the Cochrane Library (1950–February 14, 2014) and the grey literature for original and nonoriginal citations reporting indications for DC surgery or DC interventions in civilian trauma patients. RESULTS Among 27,732 citations identified, we included 270 peer-reviewed articles in the scoping review. Of these, 156 (57.8%) represented original research, primarily (75.0%) cohort studies. The articles reported 1,099 indications for DC surgery and 418 indications for 15 different DC interventions. The majority of indications for DC interventions were for abdominal (56.5%) procedures, including therapeutic perihepatic packing (56.5%), temporary abdominal closure/open abdominal management (40.7%), and staged pancreaticoduodenectomy (2.8%). Most DC surgery indications were based on intraoperative findings (71.7%) and represented characteristics of the injured patient (94.5%), including their physiology (57.6%), injuries (38.9%), and/or the amount or type of resuscitation provided (14.3%). Others were dependent on characteristics of the treating surgeon (12.1%), the patient’s physiologic response to trauma care (9.6%), and/or the trauma care environment (1.5%). Approximately half (49.5%) included a decision threshold (e.g., pH < X) and, while most (74.7%) were based on a single clinical finding/injury, 25.3% required the presence of multiple findings concurrently. Only 87 indications were evaluated in original research studies and only 9 by more than one study. CONCLUSION The vast number, varying underlying content, and lack of original research relating to indications for DC suggests that substantial uncertainty exists around when the procedure is indicated and highlights the need to establish evidence-informed consensus indications.

Indications for Use of Damage Control Surgery in Civilian Trauma Patients: A Content Analysis and Expert Appropriateness Rating Study.

Objectives:To characterize and evaluate indications for use of damage control (DC) surgery in civilian trauma patients. Background:Although DC surgery may improve survival in select, severely injured patients, the procedure is associated with significant morbidity, suggesting that it should be used only when appropriately indicated. Methods:Two investigators used an abbreviated grounded theory method to synthesize indications for DC surgery reported in peer-reviewed articles between 1983 and 2014 into a reduced number of named, content-characteristic codes representing unique indications. An international panel of trauma surgery experts (n = 9) then rated the appropriateness (expected benefit-to-harm ratio) of the coded indications for use in surgical practice. Results:The 1107 indications identified in the literature were synthesized into 123 unique pre- (n = 36) and intraoperative (n = 87) indications. The panel assessed 101 (82.1%) of these indications to be appropriate. The indications most commonly reported and assessed to be appropriate included pre- and intraoperative hypothermia (median temperature <34°C), acidosis (median pH <7.2), and/or coagulopathy. Others included 5 different injury patterns, inability to control bleeding by conventional methods, administration of a large volume of packed red blood cells (median >10 units), inability to close the abdominal wall without tension, development of abdominal compartment syndrome during attempted abdominal wall closure, and need to reassess extent of bowel viability. Conclusions:This study identified a comprehensive list of candidate indications for use of DC surgery. These indications provide a practical foundation to guide surgical practice while studies are conducted to evaluate their impact on patient care and outcomes.

Self-monitoring blood pressure in hypertension, patient and provider perspectives: A systematic review and thematic synthesis.

OBJECTIVE To systematically review the qualitative evidence for patient and clinician perspectives on self-measurement of blood pressure (SMBP) in the management of hypertension focussing on: how SMBP was discussed in consultations; the motivation for patients to start self-monitoring; how both patients and clinicians used SMBP to promote behaviour change; perceived barriers and facilitators to SMBP use by patients and clinicians. METHODS Medline, Embase, PsycINFO, Cinahl, Web of Science, SocAbs were searched for empirical qualitative studies that met the review objectives. Reporting of included studies was assessed using the COREQ framework. All relevant data from results/findings sections of included reports were extracted, coded inductively using thematic analysis, and overarching themes across studies were abstracted. RESULTS Twelve studies were included in the synthesis involving 358 patients and 91 clinicians. Three major themes are presented: interpretation, attribution and action; convenience and reassurance v anxiety and uncertainty; and patient autonomy and empowerment improve patient-clinician alliance. CONCLUSIONS SMBP was successful facilitating the interaction in consultations about hypertension, bridging a potential gap in the traditional patient-clinician relationship. PRACTICE IMPLICATIONS Uncertainty could be reduced by providing information specifically about how to interpret SMBP, what variation is acceptable, adjustment for home-clinic difference, and for patients what they should be concerned about and how to act.

Lack of evidence for interventions offered in UK fertility centres

Carl Heneghan and colleagues call for better quality evidence to help people seeking assisted reproduction make informed choices

A protocol for a scoping and qualitative study to identify and evaluate indications for damage control surgery and damage control interventions in civilian trauma patients

Introduction Initial abbreviated surgery with planned reoperation (damage control surgery) is frequently used for major trauma patients to rapidly control haemorrhage while limiting surgical stress. Although damage control surgery may decrease mortality risk among the severely injured, it may also be associated with several complications when inappropriately applied. We seek to scope the literature on trauma damage control surgery, identify its proposed indications, map and clarify their definitions, and examine the content and evidence on which they are based. We also seek to generate a comprehensive list of unique indications to inform an appropriateness rating process. Methods and analysis We will search 11 electronic bibliographic databases, included article bibliographies and grey literature sources for citations involving civilian trauma patients that proposed one or more indications for damage control surgery or a damage control intervention. Indications will be classified into a predefined conceptual framework and categorised and described using qualitative content analysis. Constant comparative methodology will be used to create, modify and test codes describing principal findings or injuries (eg, bilobar liver injury) and associated decision variables (eg, coagulopathy) that comprise the reported indications. After a unique list of codes have been developed, we will use the organisational system recommended by the RAND/University of California, Los Angeles (RAND-UCLA) Appropriateness Rating Method to group principal findings or injuries into chapters (subdivided by associated decision variables) according to broader clinical findings encountered during surgical practice (eg, major liver injury). Ethics and dissemination This study will constitute the first step in a multistep research programme aimed at developing appropriate, evidence-informed indications for damage control in civilian trauma patients. With use of an integrated knowledge translation intervention that includes collaboration with surgical practice leaders, this research may allow for development of indications that are more likely to be relevant to and used by surgeons. Ethics approval is not required for this study.

A qualitative analysis of a consensus process to develop quality indicators of injury care.

BackgroundConsensus methodologies are often used to create evidence-based measures of healthcare quality because they incorporate both available evidence and expert opinion to fill gaps in the knowledge base. However, there are limited studies of the key domains that are considered during panel discussion when developing quality indicators.MethodsWe performed a qualitative content analysis of the discussions from a two-day international workshop of injury control and quality-of-care experts (19 panel members) convened to create a standardized set of quality indicators for injury care. The workshop utilized a modified RAND/UCLA Appropriateness method. Workshop proceedings were recorded and transcribed verbatim. We used constant comparative analysis to analyze the transcripts of the workshop to identify key themes.ResultsWe identified four themes in the selection, development, and implementation of standardized quality indicators: specifying a clear purpose and goal(s) for the indicators to ensure relevant data elements were included, and that indicators could be used for system-wide benchmarking and improving patient outcomes; incorporating evidence, expertise, and patient perspectives to identify important clinical problems and potential measurement challenges; considering context and variations between centers in the health system that could influence either the relevance or application of an indicator; and contemplating data collection and management issues, including availability of existing data sources, quality of data, timeliness of data abstraction, and the potential role for primary data collection.ConclusionOur study provides a description of the key themes of discussion among a panel of clinical, managerial, and data experts developing quality indicators. Consideration of these themes could help shape deliberation of future panels convened to develop quality indicators.

The development and testing of a survey to measure patient and family experiences with injury care

BACKGROUND To deliver patient-centered trauma care, we must capture patient and family experiences with the services they receive. We developed and pilot tested a survey to measure patient and family experiences with major injury care. METHODS We conducted a structured literature review and focus groups to generate survey items. We pilot tested the survey at a Level I trauma center and assessed feasibility of implementation and construct validity with Spearman’s correlation coefficients. Open ended questions were qualitatively analyzed to explore whether responses corroborated survey content. RESULTS We developed a survey with two parts: acute care component (46 items) and post–acute care component (27 items) with nine domains. We offered the survey (acute care component offered before hospital discharge, post–acute care component offered 1–7 months after discharge) to 170 patients/families, of whom 134 (79%) responded. Patients were primarily male (73%) with major injuries (median Injury Severity Score, 18; interquartile range, 16–25). Overall, respondents for both the acute care and post–acute care components of the survey reported being completely (47% vs. 26%), very (37% vs. 38%), or mostly (16% vs. 21%) satisfied with their injury care, whereas a minority reported being slightly (0% vs. 9%) or very (0% vs. 6%) dissatisfied (p = 0.002 Fischer’s exact test). Most survey items were significantly correlated with overall satisfaction (46 of 60 items). Almost all qualitatively identified themes matched survey domains, adding support to the survey content. CONCLUSION This pilot study demonstrates the feasibility of implementing a survey to capture patient and family experiences associated with major injury care and provides preliminary evidence of the instrument’s content and construct validity. LEVEL OF EVIDENCE Epidemiologic study, level III.

Multicenter validation of the Quality of Trauma Care Patient-Reported Experience Measure (QTAC-PREM).

BACKGROUND Incorporating patient and family perspectives into injury care quality assessment is a necessary part of comprehensive quality improvement. However, tools to measure patient and family perspectives of injury care are lacking. Therefore, our objective was to assess the psychometric properties of the Quality of Trauma Care Patient-Reported Experience Measure (QTAC-PREM), the first measure developed to assess patient experiences with overall injury care. METHODS We conducted a prospective multicenter cohort study of adult injury patients recruited from three trauma centers. Patients or surrogates completed an acute care survey measure in the hospital and a post–acute care survey measure after hospital discharge. RESULTS Four hundred participants (78%) completed the acute care measure, and 207 (59%) completed the post–acute care measure. We identified three subscales on the acute measure and two subscales on the post–acute measure. All subscales and items had evidence of construct validity. Four subscales had good internal consistency, and three were independent predictors of participants’ overall ratings of injury care quality. The majority of items demonstrated suitable test-retest reliability. Comparison of QTAC-PREM scores with those of an existing patient experience tool, the Hospital version of the Consumer Assessment of Healthcare Providers and Systems (HCAHPS), demonstrated evidence of appropriate divergent and convergent validity. CONCLUSION This study demonstrates that the QTAC-PREM is feasible to implement at trauma centers and provides evidence of validity and reliability. The tool may be useful to incorporate patient perspectives into trauma care quality measurement and improvement.

Protocol for an overview of systematic reviews of interventions to reduce unscheduled hospital admissions among adults

Introduction Unscheduled hospital admissions are an increasing burden on health systems worldwide. To date, initiatives to reduce admissions have had limited success as it is unclear which strategies effectively reduce admissions and are supported by a strong evidence-base. Therefore, we will conduct an overview to find, assess and summarise all published peer-reviewed systematic reviews of randomised controlled trials that examine the effect of an intervention on unplanned admissions among adults. Methods and analysis This is a protocol for a systematic overview of reviews. We will search four databases: Ovid MEDLINE, PubMed, Cochrane Database of Systematic Reviews and the Cochrane Database of Abstracts of Reviews of Effects. We will consider systematic reviews and meta-analyses of randomised controlled trials in adults (≥16 years old) evaluating the effect of any intervention on unscheduled hospital admissions including those to treat, monitor, diagnose or prevent a health problem. We will only include reviews that identified unscheduled hospitalisations as a prespecified outcome. Two authors will independently screen articles for inclusion using a priori criteria. We will assess the quality of included reviews and extract ratings of the quality of evidence from within each review. We will create a hierarchical list of interventions based on estimates of absolute admission reductions and the quality of the evidence. Presentation of results will align with guidelines in the Cochrane Handbook of Systematic Reviews of Interventions and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. Ethics and dissemination Ethics approval is not required. We will submit the results of this study for peer-review publication. The results will inform future research and could be used by healthcare managers, administrators and policymakers to guide resource allocation decisions and inform local implementation and optimisation of interventions to reduce unscheduled hospital admissions.