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Better understanding the utilization of damage control laparotomy

A multi-institutional quality improvement project

Harvin, John A. MD, MS; Sharpe, John P. MD; Croce, Martin A. MD; Goodman, Michael D. MD; Pritts, Timothy A. MD, PhD; Dauer, Elizabeth D. MD; Moran, Benjamin J. MD; Rodriguez, Rachel D. MD; Zarzaur, Ben L. MD, MPH; Kreiner, Laura A. MD; Claridge, Jeffrey A. MD; Holcomb, John B. MD

Journal of Trauma and Acute Care Surgery: July 2019 - Volume 87 - Issue 1 - p 27–34
doi: 10.1097/TA.0000000000002288
2019 EAST PODIUM PAPER
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BACKGROUND Rates of damage control laparotomy (DCL) vary widely and consensus on appropriate indications does not exist. The purposes of this multicenter quality improvement (QI) project were to decrease the use of DCL and to identify indications where consensus exists.

METHODS In 2016, six US Level I trauma centers performed a yearlong, QI project utilizing a single QI tool: audit and feedback. Each emergent trauma laparotomy was prospectively reviewed. Damage control laparotomy cases were adjudicated based on the majority vote of faculty members as being appropriate or potentially, in retrospect, safe for definitive laparotomy. The rate of DCL for 2 years prior (2014 and 2015) was retrospectively collected and used as a control. To account for secular trends of DCL, interrupted time series was used to effectiveness of the QI interventions.

RESULTS Eight hundred seventy-two emergent laparotomies were performed: 73% definitive laparotomies, 24% DCLs, and 3% intraoperative deaths. Of the 209 DCLs, 162 (78%) were voted appropriate, and 47 (22%) were voted to have been potentially safe for definitive laparotomy. Rates of DCL ranged from 16% to 34%. Common indications for DCL for which consensus existed were packing (103/115 [90%] appropriate) and hemodynamic instability (33/40 [83%] appropriate). The only common indication for which primary closure at the initial laparotomy could have been safely performed was avoiding a planned second look (16/32 [50%] appropriate).

CONCLUSION A single faceted QI intervention failed to decrease the rate of DCL at six US Level I trauma centers. However, opportunities for improvement in safely decreasing the rate of DCL were present. Second look laparotomy appears to lack consensus as an indication for DCL and may represent a target to decrease the rate of DCL after injury.

LEVEL OF EVIDENCE Epidemiological study with one negative criterion, level III.

From the Department of Surgery, the University of Texas McGovern Medical School at Houston (J.A.H., J.B.H.), Houston, Texas; the Department of Surgery, the University of Tennessee Health Science Center (J.P.S., M.A.C.), Memphis, Tennessee; the Department of Surgery, the University of Cincinnati College of Medicine (M.D.G.), Cincinnati, Ohio; the Department of Surgery, Temple University School of Medicine (E.D.D., B.J.M.), Philadelphia, Pennsylvania; the Department of Surgery, Indiana University School of Medicine (R.D.R., B.L.Z.), Indianapolis, Indiana; and the Department of Surgery, MetroHealth System (L.A.K., J.A.C.), Cleveland, Ohio.

Submitted: December 1, 2018, Revised: March 9, 2019, Accepted: March 13, 2019.

Address for reprints: John A. Harvin, MD, 6431 Fannin St, MSB 4.264, Houston, TX 77030; email: john.harvin@uth.tmc.edu.

This article is to be presented in oral form at the 32nd Eastern Association for the Surgery of Trauma, January 17, 2019 in Austin, Texas.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (www.jtrauma.com).

Online date: April 5, 2019

© 2019 Lippincott Williams & Wilkins, Inc.