June 2023 - Quality, Safety and Outcomes
June 2023
EAST Monthly Literature Review
"Keeping You Up-to-Date with Current Literature"
Brought to you by the EAST Manuscript and Literature Review Committee
This issue was prepared by EAST Quality, Safety and Outcomes Committee Members Anthony J. DeSantis, MD and A.J. Bethurum.
Thank you to Haemonetics for supporting the EAST Monthly Literature Review.
In This Issue: Quality, Safety and Outcomes
Scroll down to see summaries of these articles
Article 1 reviewed by Anthony J. DeSantis, MD
Retrospective value assessment of a dedicated, trauma hybrid operating room. Balch JA, Loftus TJ, Ruppert MM, Rosenthal MD, Mohr AM, Efron PA, Upchurch GR Jr, Smith RS. J Trauma Acute Care Surg. 2023 Jun 1;94(6):814-822.
Article 2 reviewed by A.J. Bethurum
Contemporary Management and Outcomes of Penetrating Colon Injuries: Validation of the 2020 AAST Colon Organ Injury Scale. Zeineddin, Ahmad MD, Tominaga, Gail T. MD, Crandall, Marie MD, MPH, et al. J. Trauma Acute Care Surg. 2023 April 19.
Article 1
Retrospective value assessment of a dedicated, trauma hybrid operating room. Balch JA, Loftus TJ, Ruppert MM, Rosenthal MD, Mohr AM, Efron PA, Upchurch GR Jr, Smith RS. J Trauma Acute Care Surg. 2023 Jun 1;94(6):814-822.
As endovascular techniques continue to be developed and implemented across the spectrum of surgery, some of these techniques have been found to be very helpful in obtaining early hemorrhage control in the traumatically injured patient. The use of portable C-arm fluoroscopy can at times be cumbersome, and transfer of patients from an operating room to an angiography suite has the potential for delays in care and complications. For these reasons many high-volume trauma centers have moved towards the construction of dedicated trauma hybrid operating rooms, with some literature suggesting decreased time to hemorrhage control and reduced transfusion requirements when a hybrid OR is available. What remains to be fully elucidated is the cost impact of the creation of these ORs, and how this effects value at the healthcare delivery macroenvironment. The authors of this study set out to quantify and describe the cost-utility and value of a dedicated hybrid trauma operating room as seen from the perspective of their healthcare system.
This is a retrospective single-center study of outcomes before and after the development of a dedicated trauma hybrid OR at an academic level-1 trauma center. The authors collected data on 292 consecutive trauma patients, all of whom required operative exploration for hemorrhage control within 4 hours of presentation. The initial 106 patients presented in the 42 months prior to the development of the facility’s trauma hybrid OR and served as controls. The remaining 186 patient presented in the 42 months following construction of the OR. Exclusion criteria included patients under the age of 18, those who underwent a surgical procedure at an outside facility prior to transfer, and blunt traumatic arrest within the emergency department or the pre-hospital setting. Patient characteristics were statistically similar across cohorts with the only differences being the hybrid cohort actually had a lower starting hemoglobin, as well as a higher rate of normal thrombelastography. There was not a statistically significant difference in injury severity score, mechanism of injury, GCS, presenting vital signs, field intubation rate, and FAST findings. Value was defined as a measure of clinical outcomes relative to resource usage and was calculated using both clinical outcome measures and hospital costs for each patient. A cost-utility ratio was developed, where incremental cost was calculated by subtracting median cost of a standard admission of the median cost of a hybrid admission, and incremental utility was calculated by subtracting health outcomes of a standard admission from those of a hybrid admission. Incremental cost was then divided by incremental utility to produce the ratio. Value was defined as the inverse of the percentage of serious adverse event divided by median cost. The hybrid OR was created by converting a former angiography suite, at a total construction cost of 1.6 million dollars.
Despite similar patient characteristics and rates of open operative techniques, the hybrid group had statistically significant decreases in time from admission to hemorrhage control (135 vs 104 minutes, p=0.005) and time from operation start to hemorrhage control (60 vs 49 minutes, p<0.001). Hemorrhage control was defined as a sustained systolic blood pressure at or exceeding 100 mmHg without ongoing vasopressor requirements or blood product transfusion. Additionally, the hybrid cohort was found to have statistically significant decreases in overall median transfusions of both red blood cells and plasma in the 4-to-24-hour prior following hemorrhage control. Postoperative outcomes were similar between groups, to include overall complication rate, mortality, discharge disposition, and length of stay. The hybrid cohort had statistically significant reductions in infectious complications, primarily due to a reduced rate of pneumonia. Regarding total charges and total costs between the hybrid and traditional OR groups, there were no significant differences identified in this study. The incremental cost of an admission in the hybrid OR cohort was $4,717 ($54,740 minus $50,773), while the incremental utility in terms of median grade of overall complications was -2.0 (0.0 minus 2.0). Using the above-described definition of value, the pre-hybrid control was set to a value of 1.0, with the hybrid cohort registering at 1.07.
In summary, the authors of this paper demonstrate how the development of a dedicated trauma hybrid operating room at their center resulted in improved clinical outcomes (such as decreased time to hemorrhage control and decreased blood product transfusion rates), while not resulting in significantly increased costs to care for these patients. However, it is worth pointing out that this was after the initial 1.6-million-dollar investment to repurpose the room from a prior angiography suite. Investigation into the relationships between cost, outcome, and value in traumatically injured patients is inherently challenging due to the number and nature of potential confounding variables in this patient population and across the variety of different healthcare settings where this care is delivered. This study contributes to this growing body of literature and provides further perspective on the use of hybrid operating rooms.
Article 2
Contemporary Management and Outcomes of Penetrating Colon Injuries: Validation of the 2020 AAST Colon Organ Injury Scale. Zeineddin, Ahmad MD, Tominaga, Gail T. MD, Crandall, Marie MD, MPH, et al. J. Trauma Acute Care Surg. 2023 April 19.
Structured objective scoring systems, such as the various AAST Injury Scoring Scales, have historically provided useful guidelines in the assessment and management of trauma patients. In 2020, the AAST Organ Injury Scale (OIS) was updated to include a separate scale for penetrating colon injuries. While the original OIS for generalized colon injury, established in 1990, included operative and pathologic findings, this updated scale includes imaging parameters to reflect advances in diagnostic technology. To analyze the accuracy of the updated OIS, this retrospective multicenter study aimed to describe the modern management of penetrating colon injuries and compare patterns of operative management, complications, and outcomes with those described by the OIS.
The authors begin by describing the evolution of operative management in this patient population, recounting the progression from mandatory diversion to the increased implementation of primary anastomosis. Moreover, they define new factors affecting patient outcomes such as the widespread usage of damage-control laparotomy. The authors go on to explain how these shifts in paradigm warrant the creation of this updated OIS in order to more accurately guide decision-making in the treatment of penetrating colon injuries.
In this study, patients aged 16 years or older presenting with penetrating injury of the colon at 12 Level 1 trauma centers between the years 2016 and 2020 were identified, excluding those with serious injury to any other body region or those who expired within 24 hours of admission. AAST OIS operative grade was documented in all patients included. Primary outcome was defined as the correlation of OIS grade with clinical outcomes such as surgical management and complications. Bivariate analysis was used to describe the relationship between patient demographics, surgical management, and outcomes with OIS grade.
Authors noted that, of the 573 patients who met inclusion criteria, 88% were male and gunshot injury was the mechanism in 79%. Operative management was significantly different when comparing injuries of different OIS operative grade. The authors found that increasing OIS grade was associated with lower rate of primary repair and higher rates of resection with anastomosis (p<0.001) or diversion (p<0.001). In addition, increasing OIS grade was associated with higher rates of abscess, anastomotic leak, and extra-abdominal infection, even when adjusted for an array of demographic and perioperative factors. Preoperative imaging was performed in 27% of patients. Interestingly, imaging grade was found to be a poor predictor of operative grade (Kappa Coeff. 0.13), with operative grade matching preoperative imaging grade in only 39% of cases.
This multicenter analysis provides validation for the use of the updated OIS for penetrating colon injuries as a guide in the operative management of this patient population while presenting a unique database that highlights the increasing prevalence of primary repair and resection with anastomosis compared to diversion. Through robust adjustment, the authors additionally demonstrated the correlation between increasing OIS grade and postoperative complications. While confirming the reliability of OIS’s operative grade, this study intriguingly reports on the weak predictive value of imaging-based preoperative grading and suggests refinement before allowing this aspect of the OIS to guide practice.