Open extremity fractures: impact of delay in operative debridement and irrigation.

BACKGROUND: Early (<8 hours) operative debridement and irrigation (D&I) of open fractures are considered essential to reduce the risk of deep infection. With the advent of powerful antimicrobials, this axiom has been challenged. The current study evaluates the rates of deep infections of open fractures in relation to the time to the first D&I. METHODS: A list of all blunt open fractures during a 6-year period was obtained from the trauma registry. Patients were evaluated for age, Injury Severity Score (ISS), physiologic derangement (systolic blood pressure, lactate, Revised Trauma Score [RTS]), and fracture type (Gustilo). Time to the first D&I was calculated. All patients received appropriate prophylactic antimicrobials. Infection rates were calculated and correlated to the time to the first D&I (<8 hours vs. >8 hours). Regression analysis was performed to identify independent predictors of infection. RESULTS: During the 72-month study period, 404 patients met entry criteria, with 415 open extremity fractures (upper, 129; lower, 287). Early (<8 hours) and delayed (>8 hours) groups were well matched, although the age was lower and ISS was higher in the group with greater than 8 hours. The rates of infection were 35 (11%) of 328 (<8 hour) and 17 (19%) of 87 (>8 hours) (p < 0.05). When fractures were subgrouped by extremity, for the lower extremity, both a delay of greater than 8 hours and higher Gustilo type correlated with the development of infection. In the upper extremity, only higher Gustilo type correlated, and a delay to the first D&I did not increase the incidence of infection. Regression analysis revealed that higher ISS (odd ratio [OR], 1.052; 95% confidence interval [CI], 1.019-1.086), Gustilo grade, and a delay of greater than 8 hours (OR, 2.035; 95% CI, 1.022-4.054) were independent predictors of infection for the all-extremity model. Separate models for upper and lower extremities showed that the same three parameters were independent predictors for the lower extremity (ISS: OR, 1.045; 95% CI, 1.004-1.087; Gustilo type and >8-hour delay: OR, 3.006; 95% CI, 1.280-7.059), but none for the upper extremity. CONCLUSION: Delay of greater than 8 hours to the first D&I for open fractures of the lower extremity increases the likelihood of infection but not for the upper extremity. Higher Gustilo type open fractures have a higher incidence of infection for both upper and lower extremities. The results have important implications in an era of decreasing surgeon availability, especially in off hours. LEVEL OF EVIDENCE: Therapeutic study, level IV.

What are we missing: results of a 13-month active follow-up program at a level I trauma center.

BACKGROUND: Poor follow-up by patients with trauma results in a lack of knowledge of postdischarge health-related issues. This study reports on postdischarge health-related issues discovered by a program of active postdischarge contact or follow-up. METHODS: All patients discharged home from the trauma service were followed up in the following manner: within 4 weeks of discharge, telephonic follow-up was attempted three times followed by scanning of electronic records. Failing that, other physicians (specialists or primary care) were contacted. Once contact was established, the patient, family member, or physician was questioned about the general well-being, any specific health-related issue, and the resolution. RESULTS: During the 13-month study period ending September 2007, a total of 1,353 patients met entry criteria. Contact was established with 692 (51%). Of these, 116 (17%) were found to have significant health issues: (1) severe uncontrolled pain, 45; (2) missed injury, 17 (spine fractures, 4; clavicle or hand or foot fractures, 6; facial bone fractures, 3; soft tissue, 3; hematuria, 1); (3) wound infections, 17; (4) other infections, 17 (urinary, 8; pulmonary, 7; blood stream, 2) (5) venous thromboembolism, 10; and (6) other, 9 (psychiatric, 6; nontraumatic, 3). One patient died at home within 24 hours of discharge. The issues were significant enough for the patients to seek medical care (outpatient, 39; emergency department visits, 52; hospitalization, 24). CONCLUSION: A significant proportion of patients with trauma have moderate to severe health-related issues postdischarge that are often not found by the trauma team or the trauma registry. Active follow-up can identify the nature of the medical issues and help in designing system changes to reduce or eliminate them.

Patient safety in trauma: maximal impact management errors at a level I trauma center.

BACKGROUND: The Division of Research at JCAHO developed a taxonomy (common terminology and classification schema) to promote consistency in reporting and facilitate root cause analysis. We undertook a review of trauma management errors at our institution with maximal impact (death). The analysis was based on the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) taxonomy. METHODS: Trauma deaths between 2001 and 2006 at our Level I trauma were peer-reviewed to identify errors in management. The errors are classified according to type, domain, and cause. RESULTS: Seventy-six (9.9%) of 764 deaths had management errors contributing to potentially preventable deaths in 60 (errors in management might have contributed to death) and preventable deaths (management errors definitely contributed to death) in 16 patients. Questionable resuscitation was the commonest type and involved poor treatment in the majority. Errors were made in all domains but most commonly in the emergency department and the operating room and in the resuscitative phase. Human errors predominated. CONCLUSIONS: Management errors in the basics of trauma care continue even in established trauma centers, despite guidelines, protocols, and continuous performance improvement. Standardized reporting such as the taxonomy may result in progressive collection of patient safety data and lead to innovations to minimize these errors.