Characterizing Trauma Patients with Delays in Orthopaedic Process Measures

Nishant Gohel; Pranav Khambete; Laura Gerhardinger; Anna N Miller; Philip Wolinsky; Molly Jarman; John W Scott; Rahul Vaidya; Mark R Hemmila; Bryant W Oliphant

doi:10.1097/TA.0000000000004346

Characterizing Trauma Patients with Delays in Orthopaedic Process Measures

J Trauma Acute Care Surg. 2024 Apr 30. doi: 10.1097/TA.0000000000004346. Online ahead of print.

Authors

Nishant Gohel¹, Pranav Khambete², Laura Gerhardinger, Anna N Miller³, Philip Wolinsky⁴, Molly Jarman⁵, John W Scott⁶, Rahul Vaidya², Mark R Hemmila, Bryant W Oliphant

Affiliations

¹ Department of Orthopaedic Surgery, Penn State University, Hershey, PA.
² Department of Orthopaedic Surgery, Wayne State University, Detroit, MI.
³ Department of Orthopaedic Surgery, Washington University in St. Louis, MO.
⁴ Department of Orthopaedic Surgery, Dartmouth Health, Lebanon, NH.
⁵ Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA.
⁶ Department of Surgery, University of Washington, Seattle, WA.

PMID: 38685206
DOI: 10.1097/TA.0000000000004346

Abstract

Introduction: Early operative intervention in orthopaedic injuries is associated with decreased morbidity and mortality. Relevant process measures (e.g. femoral shaft fixation <24 hours) are used in trauma quality improvement programs to evaluate performance. Currently, there is no mechanism to account for patients who are unable to undergo surgical intervention (i.e. physiologically unstable). We characterized the factors associated with patients who did not meet these orthopaedic process measures.

Methods: A retrospective cohort study of patients from 35 ACS-COT verified Level 1 and Level 2 trauma centers was performed utilizing quality collaborative data (2017-2022). Inclusion criteria were adult patients (≥18 years), ISS ≥5, and a closed femoral shaft or open tibial shaft fracture classified via the Abbreviated Injury Scale version 2005 (AIS2005). Relevant factors (e.g. physiologic) associated with a procedural delay >24 hours were identified through a multivariable logistic regression and the effect of delay on inpatient outcomes was assessed. A sub-analysis characterized the rate of delay in "healthy patients".

Results: We identified 5,199 patients with a femoral shaft fracture and 87.5% had a fixation procedure, of which 31.8% had a delay, and 47.1% of those delayed were "healthy." There were 1,291 patients with an open tibial shaft fracture, 92.2% had fixation, 50.5% had an irrigation and debridement and 11.2% and 18.7% were delayed, respectively. High ISS, older age and multiple medical comorbidities were associated with a delay in femur fixation, and those delayed had a higher incidence of complications.

Conclusions: There is a substantial incidence of surgical delays in some orthopaedic trauma process measures that are predicted by certain patient characteristics, and this is associated with an increased rate of complications. Understanding these factors associated with a surgical delay, and effectively accounting for them, is key if these process measures are to be used appropriately in quality improvement programs.

Level of evidence: Level III; Therapeutic/Care Management.