Avery B. Nathens

Several indicators of quality pediatric trauma care have been proposed including low in-hospital mortality, nonoperative management of blunt splenic injury, use of intracranial pressure monitors after severe traumatic brain injury, and craniotomy for children with severe subdural or epidural hematomas. It is not known if center-level performance is consistent in each of these metrics. We evaluated whether center performance in one area of quality predicted similar performance in other areas of quality. We reviewed patients 18 years or younger who were hospitalized with an injury Abbreviated Injury Scale (AIS) score of 2 or greater from 2010 to 2011 at trauma centers (n = 150) participating in the Trauma Quality Improvement Program. Random-intercept multilevel modeling was used to generate center-specific adjusted odds ratios for each quality indicator. We evaluated correlations between center-specific adjusted odds ratios of each quality indicator and mortality using Pearson correlation coefficients. Weighted κ statistics were used to test multiple pairwise agreements between indicators and the overall agreement across all four indicators. Among 84,880 children identified for analysis, 3,603 had blunt splenic injury, 3,503 had severe traumatic brain injury, and 1,286 had an epidural or subdural hematoma. A negative correlation between center-specific odds of mortality and craniotomy was present (Pearson correlation coefficient, -0.18; p = 0.03). There were no significant correlations between other indicators. Although κ statistics showed slight agreement for the pairwise comparison of odds of mortality and craniotomy (0.17, 0.02-0.32), there was no agreement for all other pairwise comparisons or the overall comparison of all four indicators (-0.01, -0.07 to 0.06). Our findings demonstrate a lack of concordance in center-level performance across the four pediatric trauma quality indicators we evaluated. These findings should be considered by pediatric trauma quality improvement initiatives to allow for comprehensive measurement of hospital quality as opposed to benchmarking using a single indicator.

A gap exists between the best evidence and practice with regards to surgical site infection (SSI) prevention. Awareness of evidence is the first step in knowledge translation. A web-based survey was distributed to 59 general surgeons and 68 residents at University of Toronto teaching hospitals. Five domains pertaining to SSI prevention with questions addressing knowledge of prevention strategies, efficacy of antibiotics, strategies for changing practice and barriers to implementation of SSI prevention strategies were investigated. Seventy-six individuals (60%) responded. More than 90% of respondents stated there was evidence for antibiotic prophylaxis and perioperative normothermia and reported use of these strategies. There was a discrepancy in the perceived evidence for and the self-reported use of perioperative hyperoxia, omission of hair removal and bowel preparation. Eighty-three percent of respondents felt that consulting published guidelines is important in making decisions regarding antibiotics. There was also a discrepancy between what respondents felt were important strategies to ensure timely administration of antibiotics and what strategies were in place. Checklists, standardized orders, protocols and formal surveillance programs were rated most highly by 75%-90% of respondents, but less than 50% stated that these strategies were in place at their institutions. Broad-reaching initiatives that increase surgeon and trainee awareness and implementation of multifaceted hospital strategies that engage residents and attending surgeons are needed to change practice.

Although injuries are a leading cause of morbidity and mortality in the USA, few prior studies exist on the costs of trauma care. This article estimates treatment costs of care for 12 months follow...

Background: Evaluation of trauma center performance has been limited to comparisons of observed versus expected mortality using trauma and injury severity score methodology. Few studies have focused on identifying top performers. In part, this is due to the perceived need for extensive data required to adequately risk adjust. We set out to identify the patient and injury-related factors that most affect case-mix across centers and thus are most likely to alter assessments of hospital performance. Methods: One hundred ninety trauma centers contributing data to the National Trauma Databank (NTDB) during 2004 to 2005 were used for hospital rankings (n = 169,929 patients). Trauma centers were ranked by crude mortality. We then added variables [injury severity score {ISS}, systolic blood pressure {SBP}, mechanism, age, gender, comorbidities, body region abbreviated injury scale {AIS}] singly to a risk-adjustment model to obtain adjusted probability of death. Trauma centers were then ranked again. The variable that affected rankings the greatest was kept and the process was repeated in an iterative fashion until the incremental change in ranks was minimal. Results: ISS accounted for the most variation in mortality rates across trauma centers, shown by the large rank change with addition of ISS to the model. Specifically, when ISS was taken into consideration, 92% of trauma centers changed their rank by ≥3 and almost half their quartile rank by at least 1. In lesser order of importance, age, SBP, head AIS, mechanism, gender, and abdominal AIS were relevant to adjust for case mix. Conclusions: Trauma center rankings are affected by few parameters, reflecting their relationship to mortality and their relative frequencies. Complex risk adjustment methodology is not required to address differences in case mix. Data abstraction for the purpose of comparing trauma center performance should focus on ensuring that at minimum, these variables are collected with a high degree of accuracy.

You are asked to be involved in organizing a trauma service for a major urban center. You are asked to make a decision on whether the services general approach to trauma in the city (which does have a well-established trauma center) will be scoop and run (minimal resuscitation at the scene with a goal to getting the patient to a trauma center as quickly as possible) or on-the-scene resuscitation with transfer following some degree of stabilization.

Background: There is an increased emphasis on benchmarking of trauma mortality outcomes as a measure of quality. Differences in approaches to end-of-life care or perceptions of salvageability might account for some of the variability in outcomes across centers. We postulated that these differences in perceptions or practice might lead to significant variation in the use of do not resuscitate (DNR) orders and sought to identify institutional characteristics associated with their use. Methods: Patients surviving >24 hours and admitted to an intensive care unit (ICU) in one of 68 centers across the United States were identified from a large prospective cohort study of severely injured patients. Independent predictors of a DNR order at both the patient and institutional level were identified using multivariate hierarchical modeling stratified by age <55 or ≥55. Results: Of 6,765 patients, 7% had a DNR order, of whom 88% died. The proportion of patients in each center with a DNR order ranged from 0% to 57%. Independent patient-level predictors associated with a DNR order were increasing age, preinjury comorbidity burden, severe injury, and organ failure. Institutional predictors of DNR orders differed by age. Care in an open ICU was associated with a DNR order (odds ratio, 1.7; 95% confidence interval, 1.0–3.0) in the elderly, whereas care in a combined medical-surgical ICU (vs. surgical or trauma ICU) was associated with greater likelihood (odds ratio, 2.0; 95% confidence interval, 1.1–4.1) of a DNR order in the young. Conclusions: DNR orders are relatively common in seriously injured trauma patients, and there is significant variability in their use across centers. Given the institutional characteristics independently associated with DNR status, it is likely that both differences in the ethos of end-of-life care and perceptions of salvageability affect decision making.

The incidence of venous thromboembolism (VTE) without prophylaxis is as high as 80% after major trauma. Initiation of prophylaxis is often delayed because of concerns of injury-associated bleeding. As the effect of delays in the initiation of prophylaxis on VTE rates is unknown, we set out to evaluate the relationship between late initiation of prophylaxis and VTE. Data were derived from a multicenter prospective cohort study evaluating clinical outcomes in adults with hemorrhagic shock after injury. Analyses were limited to patients with an Intensive Care Unit length of stay ≥7 days. The rate of VTE was estimated as a function of the time to initiation of pharmacologic prophylaxis. A multivariate stepwise logistic regression model was used to evaluate factors associated with late initiation. There were 315 subjects who met inclusion criteria; 34 patients (11%) experienced a VTE within the first 28 days. Prophylaxis was initiated within 48 hours of injury in 25% of patients, and another one-quarter had no prophylaxis for at least 7 days after injury. Early prophylaxis was associated with a 5% risk of VTE, whereas delay beyond 4 days was associated with three times that risk (risk ratio, 3.0, 95% CI [1.4–6.5]). Factors associated with late (>4 days) initiation of prophylaxis included severe head injury, absence of comorbidities, and massive transfusion, whereas the presence of a severe lower extremity fracture was associated with early prophylaxis. Clinicians are reticent to begin timely VTE prophylaxis in critically injured patients. Patients are without VTE prophylaxis for half of all days within the first week of admission and this delay in the initiation of prophylaxis is associated with a threefold greater risk of VTE. The relative risks and benefits of early VTE prophylaxis need to be defined to better direct practice in this high-risk population.