"SCIP"ping antibiotic prophylaxis guidelines in trauma: The consequences of noncompliance

Effect of Blood Product Resuscitation on Cefazolin Pharmacokinetics in Trauma Patients

Background: Antibiotics are frequently administered prophylactically to trauma patients with various injury patterns to prevent infectious complications. Trauma patients may also require large volume resuscitation with blood products. Limited data are available to support antibiotic dosing recommendations in this population. We hypothesized that we would be able to develop a population pharmacokinetic model of cefazolin, a frequently used antibiotic in the trauma scenario, from remnant blood samples by pharmacokinetic analysis of trauma patients. Methods: Remnant plasma from standard of care chemistry/hematology assessments was retrieved within 48 h of collection and assayed to determine cefazolin concentrations. Population pharmacokinetic analyses were conducted in Pmetrics using R. Linear regression was conducted to assess the effect of blood product resuscitation volume on cefazolin pharmacokinetic parameters. Results: Cefazolin concentrations best fitted a two-compartment model (Akaike information criterion: 443.9). The mean ± standard deviation parameters were total body clearance (4.3 ± 1.9L), volume of the central compartment (Vc: 7.7 ± 6.9L), and intercompartment transfer constants (k12: 1.3 ± 0.98 h-1, k21: 0.6 ± 0.45 h-1). No statistical relationships were observed between blood products, volume of blood products, and cefazolin clearance or Vc (R2: 0.0004-0.21, p = 0.08-0.95). Using a 5,000-patient Monte Carlo simulation, 2 g with repeated dosing every 2 h until end of surgery was required to achieve 93.2% probability of 100% free time above the minimum inhibitory concentration (MIC) (fT > MIC) at the ECOFF value for Staphylococcus aureus (2 mg/L). Conclusions: In these 15 trauma patients receiving blood transfusion, no relationship with blood volume resuscitation and cefazolin pharmacokinetics was observed. On the basis of this pharmacokinetic model, frequent cefazolin doses are required to maintain 100% fT > MIC.

Surgical and procedural antibiotic prophylaxis in the surgical ICU: an American Association for the Surgery of Trauma Critical Care Committee clinical consensus document

The use of prophylactic measures, including perioperative antibiotics, for the prevention of surgical site infections is a standard of care across surgical specialties. Unfortunately, the routine guidelines used for routine procedures do not always account for many of the factors encountered with urgent/emergent operations and critically ill or high-risk patients. This clinical consensus document created by the American Association for the Surgery of Trauma Critical Care Committee is one of a three-part series and reviews surgical and procedural antibiotic prophylaxis in the surgical intensive care unit. The purpose of this clinical consensus document is to provide practical recommendations, based on expert opinion, to assist intensive care providers with decision-making for surgical prophylaxis. We specifically evaluate the current state of periprocedural antibiotic management of external ventricular drains, orthopedic operations (closed and open fractures, silver dressings, local, antimicrobial adjuncts, spine surgery, subfascial drains), abdominal operations (bowel injury and open abdomen), and bedside procedures (thoracostomy tube, gastrostomy tube, tracheostomy).

Antibiotic prophylaxis in trauma: Global Alliance for Infection in Surgery, Surgical Infection Society Europe, World Surgical Infection Society, American Association for the Surgery of Trauma, and World Society of Emergency Surgery guidelines

Trauma is a complex disease, and the use of antibiotic prophylaxis (AP) in trauma patients is common practice. However, considering the increasing rates of antibiotic resistance, AP use should be questioned and limited only to specific cases. Antibiotic stewardship is of paramount importance in fighting resistance spread. Definitive rules or precise indications about AP in trauma remain unclear. The present article describes the indications of AP in traumatic lesions to the head, brain, torso, maxillofacial, extremities, skin, and soft tissues endorsed by the Global Alliance for Infection in Surgery, Surgical Infection Society Europe, World Surgical Infection Society, American Association for the Surgery of Trauma, and World Society of Emergency Surgery.

MultiCenter Study of Intra-Abdominal Abscess Formation After Major Operative Hepatic Trauma

INTRODUCTION

One of the significant complications of operative liver trauma is intra-abdominal abscesses (IAA). The objective of this study was to determine risk factors associated with postoperative IAA in surgical patients with major operative liver trauma.

METHODS

A retrospective multi-institutional study was performed at 13 Level 1 and Level 2 trauma centers from 2012 to 2021. Adult patients with major liver trauma (grade 3 and higher) requiring operative management were enrolled. Univariate and multivariate analyses were performed.

RESULTS

Three hundred seventy-two patients were included with 21.2% (n = 79/372) developing an IAA. No difference was found for age, gender, injury severity score, liver injury grade, and liver resections in patients between the groups (P > 0.05). Penetrating mechanism of injury (odds ratio (OR) 3.42, 95% confidence interval (CI) 1.54-7.57, P = 0.02), intraoperative massive transfusion protocol (OR 2.43, 95% CI 1.23-4.79, P = 0.01), biloma/bile leak (OR 2.14, 95% CI 1.01-4.53, P = 0.04), hospital length of stay (OR 1.04, 95% CI 1.02-1.06, P < 0.001), and additional intra-abdominal injuries (OR 2.27, 95% CI 1.09-4.72, P = 0.03) were independent risk factors for IAA. Intra-abdominal drains, damage control laparotomy, total units of packed red blood cells, number of days with an open abdomen, total abdominal surgeries, and blood loss during surgery were not found to be associated with a higher risk of IAA.

CONCLUSIONS

Patients with penetrating trauma, massive transfusion protocol activation, longer hospital length of stay, and injuries to other intra-abdominal organs were at higher risk for the development of an IAA following operative liver trauma. Results from this study could help to refine existing guidelines for managing complex operative traumatic liver injuries.

Antibiotic Prophylaxis in Torso, Maxillofacial, and Skin Traumatic Lesions: A Systematic Review of Recent Evidence

Use of antibiotic prophylaxis (AP) in trauma patients is a common practice. However, considering the increasing rates of antibiotic resistance, AP use should be questioned and limited only to specific cases. We performed a systematic review of recent literature (from year 2000), aiming to summarize the state of the art on efficacy and appropriateness of AP in patients with traumatic injuries of torso, maxillofacial complex and skin (including burns). Twenty-six articles were selected. In thoracic trauma, AP could be useful in reducing infective complications in tube thoracostomy for penetrating trauma. In maxillo-facial trauma, AP could find a role in the peri-operative trauma setting in the case of a graft or prosthetic implant. In abdominal trauma, there is a lack of consensus on the definition of contamination, infection, antibiotic therapy, and prophylaxis. In burned patients, routine AP is not suggested. In the case of human bites to the extremities, AP could find an indication. Future studies should focus on the subcategories of patients at higher risk of infection, identifying those who would benefit from AP. Attention to antimicrobial stewardship and guidelines focused on AP in trauma are required, to reduce antibiotic abuse, and increase quality research.

The Effect of Pharmacist-Led Intervention on Surgical Antibacterial Prophylaxis (SAP) at an Orthopedic Unit

Perioperative antibiotic use is a common reason for antibiotic misuse. Evidence suggests that adherence to SAP guidelines may improve outcomes. The purpose of this study was to analyze the impact of pharmacist-led antibiotic stewardship interventions on SAP guideline compliance. The study was conducted at an Orthopedic Department of a tertiary care medical center. SAP compliance and antibiotic exposure in the pre-intervention and intervention period was compared using chi-square, Fisher exact, and Mann-Whitney tests, as appropriate. Prophylactic antibiotic use in orthopedic joint arthroplasties (overall guideline adherence: agent, dose, frequency, duration), clinical outcomes (length of stay-LOS, number of surgical site infections-SSIs), antibiotic exposure and direct antibiotic costs were compared between pre-intervention and intervention periods. Significant improvement in mean SAP duration (by 42.9%, 4.08 ± 2.08 vs. 2.08 ± 1.90 days, p ˂ 0.001), and overall guideline adherence regarding antibiotic use (by 56.2%, from 2% to 58.2%, p ˂ 0.001) were observed. A significant decrease was observed in antibiotic exposure in SAP (by 41%, from 6.07 ± 0.05 to 3.58 ± 4.33 DDD/patient, p ˂ 0.001), average prophylactic antibiotic cost (by 54.8%, 9278.79 ± 6094.29 vs. 3598.16 ± 3354.55 HUF/patient), and mean LOS (by 37.2%, from 11.22 ± 6.96 to 7.62 ± 3.02 days, p < 0.001); and a slight decrease in the number of confirmed SSIs was found between the two periods (by 1.8%, from 3% to 1.2%, p = 0.21). Continuous presence of the clinical pharmacist led to significant improvement in SAP guideline adherence, which was accompanied by decreased antibiotic exposure and cost.

Risk Stratification for Superficial Surgical Site Infection after Emergency Trauma Laparotomy

Background: Superficial surgical site infections (S-SSIs) are common after trauma laparotomy, leading to morbidity, increased costs, and prolonged length of stay (LOS). Opportunities to mitigate S-SSI risks are limited to the intra-operative and post-operative periods. Accurate S-SSI risk stratification is paramount at the time of operation to inform immediate management. We aimed to develop a risk calculator to aid in surgical decision-making at the time of emergency laparotomy. Methods: A retrospective cohort study of patients requiring emergency trauma laparotomy between 2011 and 2017 at a single, level 1 trauma center was performed. Operative factors, skin management strategy, and outcomes were determined by chart review. Bayesian multilevel logistic regression was utilized to create a risk calculator with variables available upon closure of the laparotomy. Models were validated on a 30% test cohort and discrimination reported as an area under the receiver operating characteristics curve (AUROC). Results: Of 1,322 patients, the majority were male (77%) with median age of 33 years, injured by blunt mechanism (54%), and median injury severity score of 19. Eighty-eight (7%) patients developed an S-SSI. Patients who developed S-SSI had higher final lactate, blood loss, transfusion requirements, and wound classification. Patients with S-SSI more frequently had mesenteric or large bowel injury than those without S-SSI. Superficial SSI was associated with increased complications and prolonged length of stay (LOS). The S-SSI predictive model demonstrated moderate discrimination with an AUROC of 0.69 (95% confidence interval [CI], 0.56-0.81). Parameters contributing the most to the model were damage control laparotomy, full-thickness large bowel injury, and large bowel resection. Conclusion: A predictive model for S-SSI was built using factors available to the surgeon upon index emergency trauma laparotomy closure. This calculator may be used to standardize intra- and post-operative care and to identify high-risk patients in whom to test novel preventative strategies and improve overall outcomes for patients requiring emergency trauma laparotomy.

Impact of bodyweight-adjusted antimicrobial prophylaxis on surgical-site infection rates

Background

Antimicrobial prophylaxis (AMP) adjustment according to bodyweight to prevent surgical-site infections (SSI) is controversial. The impact of weight-adjusted AMP dosing on SSI rates was investigated here.

Methods

Results from a first study of patients undergoing visceral, vascular or trauma operations, and receiving standard AMP, enabled retrospective evaluation of the impact of bodyweight and BMI on SSI rates, and identification of patients eligible for weight-adjusted AMP. In a subsequent observational prospective study, patients weighing at least 80 kg were assigned to receive double-dose AMP. Risk factors for SSI, including ASA classification, duration and type of surgery, wound class, diabetes, weight in kilograms, BMI, age, and AMP dose, were evaluated in multivariable analysis.

Results

In the first study (3508 patients), bodyweight and BMI significantly correlated with higher rates of all SSI subclasses (both P < 0.001). An 80-kg cut-off identified patients receiving single-dose AMP who were at higher risk of SSI. In the prospective study (2161 patients), 546 patients weighing 80 kg or more who received only single-dose AMP had higher rates of all SSI types than a group of 1615 who received double-dose AMP (odds ratio (OR) 4.40, 95 per cent c.i. 3.18 to 6.23; P < 0.001). In multivariable analysis including 5021 patients from both cohorts, bodyweight (OR 1.01, 1.00 to 1.02; P = 0.008), BMI (OR 1.01, 1.00 to 1.02; P = 0.007) and double-dose AMP (OR 0.33, 0.23 to 0.46; P < 0.001) among other variables were independently associated with SSI rates.

Conclusion

Double-dose AMP decreases SSI rates in patients weighing 80 kg or more.

Retrospective Identification of Bacterial Isolates From Emergency Laparotomy Surgical Site Infections in Horses

Surgical site infection (SSI) with multiresistant bacteria is an important cause of postoperative morbidity after laparotomy in horses. The objective of this study was to identify bacteria isolates and their antibiotic resistance patterns associated with the development of wound infection in horses after laparotomy. This is a retrospective case series. Medical records of horses that underwent ventral midline exploratory laparotomy in a four-year period at one equine hospital were reviewed. Results of microbiologic culture and susceptibility testing are described. The study group consisted of 183 (100%) horses that recovered from anesthesia after laparotomy. The prevalence of infection was 19% (24/124) after first surgery and 83% (19/23) after relaparotomy. The most common microbial isolates were bacteria of the family Enterobacteriaceae followed by Staphylococcus ssp., Enterococcus ssp., Streptococcus ssp., and Bacteroides ssp. Bacteria from the family Enterobacteriaceae showed the lowest resistance to amphenicols, cephalosporins, and quinolones groups of antibiotics. Coagulase-positive Staphylococci were sensitive to amphenicols and only 33% were resistant to trimethoprim/sulfamethoxazole. The most commonly used perioperative and postoperative antibiotics were gentamicin and amoxicillin. Limitations include poor control over exposure factors, covariates, and potential confounders during the surgery, recovery time, or period of hospitalization; relying on others for accurate outcome assessment and recordkeeping; lack of follow-up information once animals were discharged from the hospital. Despite 5 days of antibiotic prophylaxis, the rate of incisional infection is still high. The most common isolates from SSI belong to the family Enterobacteriaceae and the genus Staphylococcus, which showed high resistance to the antibiotics used before the gastrointestinal surgery.

Antimicrobial Prophylaxis Redosing Reduces Surgical Site Infection Risk in Prolonged Duration Surgery Irrespective of Its Timing

BACKGROUND

Long-duration surgery requires repeated administration of antimicrobial prophylaxis (amp). Amp "redosing" reduces incidence of surgical site infections (SSI) but is frequently omitted. Clinical relevance of redosing timing needs to be investigated. Here, we evaluated the effects of compliance with amp redosing and its timing on SSI incidence in prolonged duration surgery.

METHODS

Data from >9000 patients undergoing visceral, trauma, or vascular surgery with elective or emergency treatment in two tertiary referral Swiss hospitals were analyzed. All patients had to receive amp preoperatively and redosing, if indicated. Antibiotics used were cefuroxime (1.5 or 3 g, if weight >80 kg), or cefuroxime and metronidazole (1.5 and 0.5 g, or 3 and 1 g doses, if weight >80 kg). Alternatively, in cases of known or suspected allergies, vancomycin (1 g), gentamicin (4 mg/Kg), and metronidazole or clindamycin (300 mg) with or without ciprofloxacin (400 mg) were used. Association of defined parameters, including wound class, ASA scores, and duration of operation, with SSI incidence was explored.

RESULTS

In the whole cohort, SSI incidence significantly correlated with duration of surgery (ρ = 0.73, p = 0.031). In 593 patients undergoing >240 min long interventions, duration of surgery was the only parameter significantly (p < 0.001) associated with increased SSI risk, whereas wound class, ASA scores, treatment areas, and emergency versus elective hospital entry were not. Redosing significantly reduced SSI incidence as shown by multivariate analysis (OR 0.60, 95% CI 0.37-0.96, p = 0.034), but exact timing had no significant impact.

CONCLUSIONS

Long-duration surgery associates with higher SSI incidence. Irrespective of its exact timing, amp redosing significantly decreases SSI risk.

Management and Outcomes of Acute Surgical Patients at a District Hospital in Uganda with Non-physician Emergency Clinicians

INTRODUCTION

Acute surgical care services in rural Sub-Saharan Africa suffer from human resource and systemic constraints. Developing emergency care systems and task sharing aspects of acute surgical care addresses many of these issues. This paper investigates the degree to which specialized non-physicians practicing in a dedicated Emergency Department contribute to the effective and efficient management of acute surgical patients.

METHODS

This is a retrospective review of an electronic quality assurance database of patients presenting to an Emergency Department in rural Uganda staffed by non-physician clinicians trained in emergency care. Relevant de-identified clinical data on patients admitted directly to the operating theater from 2011 to 2014 were analyzed in Microsoft Excel.

RESULTS

Overall, 112 Emergency Department patients were included in the analysis and 96% received some form of laboratory testing, imaging, medication, or procedure in the ED, prior to surgery. 72% of surgical patients referred by ED received preoperative antibiotics, and preoperative fluid resuscitation was initiated in 65%. Disposition to operating theater was accomplished within 3 h of presentation for 73% of patients. 79% were successfully followed up to assess outcomes at 72 h. 92% of those with successful follow-up reported improvement in their clinical condition. The confirmed mortality rate was 5%.

CONCLUSION

Specialized non-physician clinicians practicing in a dedicated Emergency Department can perform resuscitation, bedside imaging and laboratory studies to aid in diagnosis of acute surgical patients and arrange transfer to an operating theater in an efficient fashion. This model has the potential to sustainably address structural and human resources problems inherent to Sub-Saharan Africa's current acute surgical care model and will benefit from further study and expansion.

Variation in Postinjury Antibiotic Prophylaxis Patterns Over Five Years in a Combat Zone

In 2008, a clinical practice guideline (CPG) was developed for the prevention of infections among combat casualties and was later revised in 2011. We evaluated utilization of antimicrobials within 48 hours following injury in the combat zone over a 5-year period (June 2009 through May 2014) with regard to number of regimens, type of antimicrobial, and adherence to the 2011 CPG. The study population consisted of 5,196 wounded military personnel. Open fractures and skin and soft-tissue injuries were the most frequent injuries. Closed injuries had the highest overall compliance (83%), whereas open fractures and maxillofacial injuries had significant improvement in compliance from 2009-2010 (34 and 50%, respectively) to 2013-2014 (73 and 76%, respectively; p < 0.05). Part of the improvement with open fractures was a significant reduction of expanded Gram-negative coverage (61% received it in 2009-2010 compared to 7% in 2013-2014; p < 0.001). Use of Gram-negative coverage with maxillofacial injuries also significantly declined (37-12%; p = 0.001). Being injured during 2011-2014 compared to 2009-2010 was associated with CPG compliance (p < 0.001), while high injury severity scores (≥10) and admission to the intensive care unit in Germany were associated with noncompliance (p < 0.001). Our analysis demonstrates an increasing trend toward CPG compliance with significant reduction of expanded Gram-negative coverage.

Prolonged Operative Duration Increases Risk of Surgical Site Infections: A Systematic Review

Background: The incidence of surgical site infection (SSI) across surgical procedures, specialties, and conditions is reported to vary from 0.1% to 50%. Operative duration is often cited as an independent and potentially modifiable risk factor for SSI. The objective of this systematic review was to provide an in-depth understanding of the relation between operating time and SSI.

Patients and Methods: This review included 81 prospective and retrospective studies. Along with study design, likelihood of SSI, mean operative times, time thresholds, effect measures, confidence intervals, and p values were extracted. Three meta-analyses were conducted, whereby odds ratios were pooled by hourly operative time thresholds, increments of increasing operative time, and surgical specialty.

Results: Pooled analyses demonstrated that the association between extended operative time and SSI typically remained statistically significant, with close to twice the likelihood of SSI observed across various time thresholds. The likelihood of SSI increased with increasing time increments; for example, a 13%, 17%, and 37% increased likelihood for every 15 min, 30 min, and 60 min of surgery, respectively. On average, across various procedures, the mean operative time was approximately 30 min longer in patients with SSIs compared with those patients without.

Conclusions: Prolonged operative time can increase the risk of SSI. Given the importance of SSIs on patient outcomes and health care economics, hospitals should focus efforts to reduce operative time.

Practice Patterns for the Use of Antibiotic Agents in Damage Control Laparotomy and Its Impact on Outcomes

BACKGROUND

The purpose of this study was to identify practice patterns associated with the use of antimicrobial agents with damage control laparotomy (DCL) and the relationship with post-operative intra-abdominal infection (IAI) rates.

PATIENTS AND METHODS

The study was a retrospective review of trauma patients undergoing laparotomy at a Level 1 trauma center in 2010. Patients undergoing DCL versus those primarily closed (PCL) were compared for antimicrobial use (ABX) and its correlation with IAI rates (p < 0.05). Deaths with length of stay <5 days were excluded.

RESULTS

A total of 121 patients were identified (28 DCL, 93 PCL). The DCL group was more severely injured (Injury Severity Score [ISS]: 31.4 ± 15 DCL vs. 18 ± 12.7 PCL, p < 0.001) with more small and large bowel injuries (SLBI), although not statistically significant (53.6% DCL vs. 35.5% PCL, p = 0.12). Practice patterns of ABX administration in terms of pre-operative (94.6% PCL vs. 69.2% DCL, p = 0.0012) and post-operative administration (PCL: 50.5% none, 21.5% one day, 28% long term >1 d; DCL: 21.4% none, 25.0% one day, 53.6% long term >1 day, p = 0.0130) were significant. Regression analyses demonstrated that neither ISS nor DCL was an independent predictor of infection, but pre-operative ABX was a negative predictor (odds ratio [OR] 0.20, 95% confidence interval [CI] 0.05-0.91, p = 0.037), while post-operative ABX (OR 6.7, 95%CI 1.33-33.8, p = 0.044) and SLBI (OR 3.45, CI 1.03-11.5, p = 0.02) were positive predictors of infection with an receiver operating characteristic of 0.81.

CONCLUSION

Significant variations exist in the use of ABX in DCL and PCL. These variations may lead to deleterious results from both lack of initial pre-operative coverage and prolonged ABX use. The decrease in infection rates with pre-operative ABX yet significant increase with continued post-operative use even in the presence of SLBI suggests the need for a more standardized approach. With the increase in DCL and the open abdomen, more research is needed to clearly establish ABX protocols in this patient population.

Intra-abdominal packing with laparotomy pads and QuikClot™ during damage control laparotomy: A safety analysis

BACKGROUND

Intra-abdominal packing with laparotomy pads (LP) is a common and rapid method for hemorrhage control in critically injured patients. Combat Gauze™ and Trauma Pads™ ([QC] Z-Medica QuikClot^®) are kaolin impregnated hemostatic agents, that in addition to LP, may improve hemorrhage control. While QC packing has been effective in a swine liver injury model, QC remains unstudied for human intra-abdominal use. We hypothesized QC packing during damage control laparotomy (DCL) better controls hemorrhage than standard packing and is safe for intracorporeal use.

METHODS

A retrospective review (2011-2014) at a Level-I Trauma Center reviewed all patients who underwent DCL with intentionally retained packing. Clinical characteristics, intraoperative and postoperative parameters, and outcomes were compared with respect to packing (LP vs. LP+QC). All complications occurring within the patients' hospital stays were reviewed. A p≤0.05 was considered significant.

RESULTS

68 patients underwent DCL with packing; (LP n=40; LP+QC n=28). No difference in age, BMI, injury mechanism, ISS, or GCS was detected (Table 1, all p>0.05). LP+QC patients had a lower systolic blood pressure upon ED presentation and greater blood loss during index laparotomy than LP patients. LP+QC patients received more packed red blood cell and fresh frozen plasma resuscitation during index laparotomy (both p<0.05). Despite greater physiologic derangement in the LP+QC group, there was no difference in total blood products required after index laparotomy until abdominal closure (LP vs LP+QC; p>0.05). After a median of 2days until abdominal closure in both groups, no difference in complications rates attributable to intra-abdominal packing (LP vs LP+QC) was detected.

CONCLUSION

While the addition of QC to LP packing did not confer additional benefit to standard packing, there was no additional morbidity identified with its use. The surgeons at our institution now select augmented packing with QC for sicker patients, as we believe this may have additional advantage over standard LP packing. A randomized controlled trial is warranted to further evaluate the intra-abdominal use of advanced hemostatic agents, like QC, for both hemostasis and associated morbidity.

Results of a statewide survey of surgeons' care practices for emergency Hartmann's procedure

BACKGROUND

Emergency general surgery is associated with high morbidity and mortality but has seldom been targeted for practice improvement. The goal of this study was to determine whether perioperative practices vary among surgeons for emergency Hartmann's procedures and whether perioperative care practices are associated with hospitals' complication rates.

MATERIALS AND METHODS

We conducted a survey of surgeons at 27 Michigan hospitals. Questionnaires focused on preoperative, intraoperative, and postoperative care practices. Hospitals were divided into quartiles of risk-adjusted complication rates. Responses of surgeons at hospitals with the lowest complication rates were compared to those with the highest, to determine whether there were systematic differences. Qualitative content analysis was performed for open-ended questions.

RESULTS

A total of 106 surgeons returned questionnaires (response rate 49%). We identified variation in use of bowel preparation, ostomy site marking, rectal stump management, ostomy protrusion, skin closure method, antibiotics duration, and ambulation/physical therapy practices. Surgeons from hospitals with low complication rates were more likely to use a clean instrument tray during wound closure (61% versus 11%, P = 0.001) and reported greater use of laparoscopic lavage without resection for emergency diverticulitis cases (31% versus 6%, P = 0.05). Surgeons in the lower complication rate hospitals listed more modifiable care factors in their open-ended responses to questions about reasons for complications.

CONCLUSIONS

Surgeons' practices vary for emergency Hartmann's procedure. This study serves as a proof of concept that studying surgeons' practices is feasible within a quality collaborative setting. Such data can be used to generate testable hypotheses for performance improvement aimed in high-risk, emergency surgery.

Improving trauma care in low- and middle-income countries by implementing a standardized trauma protocol

BACKGROUND

Standardized trauma protocols (STPs) have reduced morbidity and mortality in mature trauma systems. Most hospitals in low- and middle-income countries (LMICs) have not yet implemented such protocols, often due to financial and logistic limitations. We report preliminary findings from a trauma quality improvement (QI) initiative, using and evaluating the impact of a low-cost STP in an LMIC university hospital.

METHODS

We developed an STP based on generally accepted best practices and damage control resuscitation. It was designed for the resources available at the test institution. The Neiva University Hospital (NUH) is a tertiary care hospital and level I trauma center in Neiva, Colombia. As in most LMIC hospitals, there was no trauma information data system at NUH. Therefore, we adapted an administrative electronic database to capture clinically relevant information of adult patients who were hospitalized or died in the emergency department (ED) between August 2010 and June 2012 with an International Classification of Diseases, 10th revision (ICD-10) diagnoses indicating trauma (S00-Y98). Interventions that were recommended in the STP were compared in these two groups. Length of hospital stay (LOS) and mortality were also examined.

RESULTS

A total of 4,324 patients were included, of whom, 2,457 patients were in the pre-protocol period and 1,867 were in the post-protocol period. The use of several interventions increased: blood product transfusions in the ED (1.0 vs. 2.7%; p < 0.001), use of hypertonic fluids in hypotensive patients (3.2 vs. 8.9 %; p < 0.001), placement of Foley catheters (11.1 vs. 13.8%; p = 0.007), arterial blood gas draws (16.6 vs. 26.4%; p < 0.001), tetanus vaccinations (19.3 vs. 26.0%; p < 0.001), placement of multiple large bore peripheral catheters (29.5 vs. 34.7%; p < 0.001), prophylactic antibiotics (34.9 vs. 38.0%; p = 0.035), and the use of analgesics (64.5 vs. 68.0%; p = 0.016). Other interventions also trended upwards. Length of stay (LOS) decreased for both surgical and non-surgical patients (surgical 13.4 vs. 11.8 days; p = 0.017; non-surgical 4.4 vs. 3.8 days; p = 0.059). All-cause mortality of trauma patients decreased (3.9 vs. 2.9%; p = 0.088).

CONCLUSIONS

The institution of an STP at a university hospital in an LMIC has increased the use of vital interventions while decreasing overall LOS for all-cause trauma patients.

Adherence to published antimicrobial prophylaxis guidelines for wounded service members in the ongoing conflicts in Southwest Asia

In 2008, a clinical practice guideline (CPG) was developed for the prevention of infections among military personnel with combat-related injuries. Our analysis expands on a prior 6-month evaluation and assesses CPG adherence with respect to antimicrobial prophylaxis for U.S. combat casualties medically evacuated to Landstuhl Regional Medical Center over a 1-year period (June 2009 through May 2010), with an eventual goal of continuously monitoring CPG adherence and measuring outcomes as a function of compliance. We classified adherence to the CPG as receipt of recommended antimicrobials within 48 hours of injury. A total of 1106 military personnel eligible for CPG assessment were identified and 74% received antimicrobial prophylaxis. Overall, CPG compliance within 48 hours of injury was 75%. Lack of antimicrobial prophylaxis contributed 2 to 22% to noncompliance varying by injury category, whereas receipt of antibiotics other than preferred was 11 to 30%. For extremity injuries, antimicrobial prophylaxis adherence was 60 to 83%, whereas it was 80% for closed injuries and 68% for penetrating abdominal injuries. Overall, the results of our analysis suggest an ongoing need to improve adherence, monitor CPG compliance, and assess effectiveness.

A survey to examine patient awareness, knowledge, and perceptions regarding the risks and consequences of surgical site infections

We surveyed patients to determine awareness and knowledge regarding risks and consequences of and prevention of surgical site infection (SSI), and we found that 26% of respondents thought that education for SSI prevention could be improved and that 16% could not recall discussing SSI risks and prevention with a health care worker at all. Only 60% of patients recalled receiving an informational flyer in the hospital. Our results show that better educational and engagement interventions incorporating patient preferences are needed to promote awareness and patient engagement regarding SSI prevention.

Skin closure after trauma laparotomy in high-risk patients: opening opportunities for improvement

BACKGROUND

Although many surgeons leave laparotomy incisions open after colon injury to prevent surgical site infection (SSI), other injured patient subsets are also at risk. We hypothesized that leaving trauma laparotomy skin incisions open in high-risk patients with any enteric injury or requiring damage control laparotomy (DCL) would not affect superficial SSI and fascial dehiscence rates.

METHODS

Patients who underwent trauma laparotomy (2004-2008) at two Level I centers were reviewed. To ensure a high-risk sample, only patients with transmural enteric injuries or need for DCL surviving 5 days or more were included. SSIs were categorized by the CDC (Centers for Disease Control and Prevention) criteria and risk factors were analyzed by skin closure (open vs. any closure). Significant (p < 0.05) univariate variables were applied to two multivariate analyses examining superficial SSI and fascial dehiscence.

RESULTS

Of 1,501 patients who underwent laparotomy, 503 met inclusion criteria. Patients were young (median, 28.0 years; range, 22.0-40.0 years) with penetrating (74%) or enteric (80%) injuries, and DCL (36%) and SSI (44%; superficial, 25%; deep, 3%; organ/space, 25%) were common. While no difference in superficial SSI after loose (n = 136) or complete skin closure (n = 224) was detected (p = 0.64), superficial SSIs were less common with open skin incisions (9.8%), despite multiple risk factors, than with any skin closure (31.1%, p < 0.001). Predictors of superficial SSIs and fascial dehiscence were each evaluated with multiple-variable logistic regression analysis. After adjusting for multiple potential confounding variables, any skin closure increased the risk of superficial SSIs approximately nine times (odds ratio, 8.6; p < 0.001) and fascial dehiscence six times (odds ratio, 5.7; p = 0.013).

CONCLUSION

Management of skin incisions takes careful consideration like any other step of a laparotomy. Our results suggest that the decision to leave skin open is one simple method to improve outcomes in high-risk patients.

LEVEL OF EVIDENCE

Therapeutic study, level III.