Date Published: July 5, 2017
Publisher: Public Library of Science
Author(s): James P. Byrne, Avery B. Nathens, David Gomez, Daniel Pincus, Richard J. Jenkinson, Martin Schreiber
Abstract: BackgroundFemoral shaft fractures are common in major trauma. Early definitive fixation, within 24 hours, is feasible in most patients and is associated with improved outcomes. Nonetheless, variability might exist between trauma centers in timeliness of fixation. Such variability could impact outcomes and would therefore represent a target for quality improvement. We evaluated variability in delayed fixation (≥24 hours) between trauma centers participating in the American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) and measured the resultant association with important clinical outcomes at the hospital level.Methods and findingsA retrospective cohort study was performed using data derived from the ACS TQIP database. Adults with severe injury who underwent definitive fixation of a femoral shaft fracture at a level I or II trauma center participating in ACS TQIP (2012–2015) were included. Patient baseline and injury characteristics that might affect timing of fixation were considered. A hierarchical logistic regression model was used to identify predictors of delayed fixation. Hospital variability in delayed fixation was measured using 2 approaches. First, the random effects output of the hierarchical model was used to identify outlier hospitals where the odds of delayed fixation were significantly higher or lower than average. Second, the median odds ratio (MOR) was calculated to quantify heterogeneity in delayed fixation between hospitals. Finally, complications (pulmonary embolism, deep vein thrombosis, acute respiratory distress syndrome, pneumonia, decubitus ulcer, and death) and hospital length of stay were compared across quartiles of risk-adjusted delayed fixation.We identified 17,993 patients who underwent definitive fixation at 216 trauma centers. The median injury severity score (ISS) was 13 (interquartile range [IQR] 9–22). Median time to fixation was 15 hours (IQR 7–24 hours) and delayed fixation was performed in 26% of patients. After adjusting for patient characteristics, 57 hospitals (26%) were identified as outliers, reflecting significant practice variation unexplained by patient case mix. The MOR was 1.84, reflecting heterogeneity in delayed fixation across centers. Compared to hospitals in the lowest quartile of delayed fixation, patients treated at hospitals in the highest quartile of delayed fixation suffered 2-fold higher rates of pulmonary embolism (2.6% versus 1.3%; rate ratio [RR] 2.0; 95% CI 1.2–3.2; P = 0.005) and required greater length of stay (7 versus 6 days; RR 1.15; 95% CI 1.1–1.19; P < 0.001). There was no significant difference with respect to mortality (1.3% versus 0.8%; RR 1.6; 95% CI 1.0–2.8; P = 0.066). The main limitations of this study include the inability to classify fractures by severity, challenges related to the heterogeneity of the study population, and the potential for residual confounding due to unmeasured factors.ConclusionsIn this large cohort study of 216 trauma centers, significant practice variability was observed in delayed fixation of femoral shaft fractures, which could not be explained by differences in patient case mix. Patients treated at centers where delayed fixation was most common were at significantly greater risk of pulmonary embolism and required longer hospital stay. Trauma centers should strive to minimize delays in fixation, and quality improvement initiatives should emphasize this recommendation in best practice guidelines.
Partial Text: Femoral shaft fractures are common in major trauma, often occurring in patients with blunt multiple-system injuries . Early definitive stabilization, within 24 hours, has been associated with decreased risk of thromboembolism, pulmonary complications, and shorter length of stay as compared to delayed fixation [2–4]. While decision-making in patients with severe multiple-system injuries is complex, early definitive care is feasible and safe in the majority of patients . For this reason, surgical fixation within 24 hours is conditionally recommended in current practice management guidelines .
In this retrospective study of patients with femoral shaft fractures, we found significant variability between trauma centers in rates of delayed surgical fixation. This variability did not appear to be explained by differences in patient case mix between hospitals, indicating that differences in processes of care might exist that influence the timing of fixation. These differences were associated with patient outcomes, with significantly higher observed rates of PE and greater lengths of stay at trauma centers with the greatest tendency for performing delayed fixation.
In this large cohort study of 216 trauma centers, significant variability in delayed fixation of femoral shaft fractures was observed between hospitals that was not explained by patient case mix. Patients treated at centers in which delayed fixation was most common were at significantly greater risk of PE and required longer hospital stay. Trauma centers should strive to minimize delays in fixation and quality-improvement initiatives should emphasize this recommendation in best practice guidelines.