Surgeon decision-making is consistent in trauma patients despite time of day and patient injury

Dale Coffey; M Chance Spalding; Blake V Conklin; John Kuckelman; Michael S O'Mara

doi:10.4103/2455-5568.222475

ORIGINAL ARTICLE

Year : 2017 | Volume : 3 | Issue : 2 | Page : 243-247

Surgeon decision-making is consistent in trauma patients despite time of day and patient injury

Dale Coffey, M Chance Spalding, Blake V Conklin, John Kuckelman, Michael S O'Mara
Grant Medical Center, Columbus; Department of Surgery, Ohio University Heritage College of Osteopathic Medicine, Athens, Ohio, USA

Date of Web Publication

9-Jan-2018

Correspondence Address:
Dr. Michael S O'Mara
OhioHealth Grant Medical Center, 111 Grant Avenue, Columbus, Ohio 43215
USA

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/2455-5568.222475

Abstract

Background: Damage control laparotomy with temporary abdominal closure has become routine in trauma surgery. This technique is associated with complications. Increasing prevalence of this procedure leads to concern over abdomens being left open due to decision points other than patient factors, such as routine, time of day, or surgeon fatigue. We hypothesize that time of day contributes to the decision to leave the initial trauma laparotomy open.
Materials and Methods: This was a retrospective chart review of 527 patients over 5 years. Patients with emergent damage control laparotomies with fascia not closed were included in the open abdomen group. Those patients who had fascia primarily closed were used as the control group. Patient demographics, injury factors, time of operation, and time to fascial closure were evaluated.
Results: Time of day was not predictive of the decision to leave a patient open. In a logistic regression model of these factors, only patient age (P = 0.002), injury severity score (P < 0.0001), and the number of abdominal organs with an injury grade of three or more (P = 0.0014) predicted the abdomen would be left open. Of the patients with initially open abdomen, 101 (72.1%) survived and 77 (76.2%) of those achieved primary fascial closure. Mean time to closure was 3.7 days.
Conclusion: The decision to perform damage control surgery and leave an abdomen open appears to be consistent throughout the day and to be dependent on the patient factors. Time of day does not seem to be a contributing factor. Fascial closure, done on average 3.7 days after the initial procedure, does not vary based on the demographic or injury factors. It appears that closure occurs as part of a routine or on convenience. An opportunity may exist to identify a subset of the open abdomen patients that could return to the operating room for earlier definitive closure, thereby lowering the risk of complications.
The following core competencies are addressed in this article: Patient care, Practice based learning and improvement, and Systems-based practice.

Keywords: Abdominal, damage control, fatigue, open abdomen, surgeon, trauma

How to cite this article:
Coffey D, Spalding M C, Conklin BV, Kuckelman J, O'Mara MS. Surgeon decision-making is consistent in trauma patients despite time of day and patient injury. Int J Acad Med 2017;3:243-7

How to cite this URL:
Coffey D, Spalding M C, Conklin BV, Kuckelman J, O'Mara MS. Surgeon decision-making is consistent in trauma patients despite time of day and patient injury. Int J Acad Med [serial online] 2017 [cited 2020 Nov 28];3:243-7. Available from: https://www.ijam-web.org/text.asp?2017/3/2/243/222475

Introduction

The severely injured trauma patient often requires complex management with a multidisciplinary team. One of the life-saving maneuvers for the severely injured patient is the trauma laparotomy with damage control surgery (DCS). By leaving the abdomen open and transferring the patient to the Intensive Care Unit (ICU), correction of coagulopathy, metabolic acidosis, and hypothermia can be achieved.^[1] This scenario is the predominant reason that surgeons choose the open abdomen method.^[2] Other common reasons for using this surgical approach include planned second-look procedures, abdominal compartment syndrome (ACS), intra-abdominal sepsis, vascular and general surgery procedures, and as treatment for refractory intracranial hypertension.^[1],[3] The open abdomen technique has resulted in decreased immediate mortality.^[4],[5]

There are many temporary closure techniques described to decrease fluid and protein losses, protect from infection, and facilitate early or delayed primary fascial closure (DPFC). Neither the American College of Surgeons nor the Eastern Association for the Surgery of Trauma has endorsed a specific technique for temporary abdominal closure.^[6] Regardless of the temporary closure technique used, the open abdomen creates a new set of challenges for surgeons.^[6] Leaving the abdominal wall open with intra-abdominal contents exposed can lead to dynamic fluid and protein losses, sepsis, increased risk for enteroatmospheric fistulas, and large ventral hernias with lateral abdominal fascial retraction. The overall morbidity associated with the open abdomen has been reported at 25%,^[7] and early definitive closure may reduce the risk of these complications.^[8]

As DCS has become the standard of care for the severely injured abdominal trauma patient, concerns exist for an increasing prevalence of complications. While early definitive closure has proven to decrease overall morbidity associated with the open abdomen, leaving intra-abdominal contents exposed for any amount of time predisposes the patient to developing associated medical and surgical complications.^[8] Concerns have arisen that factors beyond the patient physiology, such as surgeon fatigue, routine, or time of the day, may increase the likelihood of using this strategy.

Surgeon-specific analyses have demonstrated the effect of shift work and its associated disturbed sleep patterns on cognitive and psychomotor abilities, particularly the morning after call.^{[9],[10],[11]} The goal of this study was to evaluate the during call time frame, to assess if the decision-making patterns of the attending surgeon differed during the on-call night. We hypothesize that time of day, rather than the patients' presenting physiologic parameters, contributes to the decision to leave the initial trauma laparotomy open between the hours of 2400 and 0600; we also hypothesize that the patients' physiologic parameters guide the decision to proceed with delayed fascial closure.

Materials and Methods

In this retrospective chart review, we compared clinical outcomes among patients undergoing trauma emergent laparotomy. Patients were assigned into two groups: patients who underwent laparotomy and the abdominal fascia was left open and those with primary fascial closure.

This retrospective chart review was approved by the Grant Medical Center Institutional Review Board. All trauma patients, 16-year-old and older, who were discharged from the trauma service (including deaths) at Grant Medical Center from January 1, 2010, to June 30, 2014, who underwent a laparotomy during their initial injury admission were included in this study. Patients who are <16-year-old were not included in the study.

Grant Trauma Services maintains a computer registry database for all patient records, and from this database and from individual review of the charts, the following data were extracted: the patient age, gender, mechanism of injury, hospital day and time of admission, time and date of operation, type of operation, reason if given for open abdomen, admitting diagnosis, injury severity score (ISS) abdominal abbreviated injury score (AIS), number of abdominal injuries with an AIS of three or more, mechanism of injury, days in the ICU, any associated injuries, timing of DPFC or definitive closure of the abdominal wall, mortality, weight, lactate, base deficit, pH, pCO₂, PaO₂, and ventilator days. After all the data were obtained, a random 10% error check was run to determine the validity of the chart extracted values obtained.

This study compared the percentage of abdomens left open based on the time of day of the operation. Times of day were divided into 6-h increments starting at midnight. This methodology was chosen to evaluate the possible role of physician fatigue and time of day on decision-making between the hours of 2400 and 0600, when Grant Medical Center's trauma surgeons had worked anywhere between a 16 and 22 h shift. Surgeons work a 24-h in hospital shift, with overlap time at the beginning and end of the shift for face-to-face handoff of patient care. Also evaluated was the relationship between the time of day of the operation and the abdominal closure rate as well as the time to definitive closure as influence by patient and physician factors.

Statistical analysis

Analyses were performed using SAS 9.2 (SAS Institute, Cary, NC, USA). Descriptive statistics were reported as mean and standard deviation for continuous variables and frequency (percentage) for dichotomous or categorical variables. Simple comparisons between independent groups were conducted using two-sample t- tests or Chi-square tests as appropriate. Logistic regression was used to model mortality as a function of a set of predictors; odds ratios are based on these logistic regression models, rather than on simple two-way associations, which do not control for other covariates.

Results

The decision to leave the abdomen open in trauma patients was not associated with the time of day of the operation [Table 1]. On univariate analysis, patient weight, ISS, the abdominal AIS, the number of abdominal injuries with AIS ≥3, and penetrating mechanism correlated with an increased likelihood of the abdomen being left open. Admission serum values assessing physiology were also significantly associated with increased the use of an open abdomen technique [Table 2]. When all of these variables were assessed together in a logistic regression model, the time of day did not predict the surgeon's decision to leave the abdomen open (P = 0.42). What did remain significant as “predictors” of the decision to use open abdomen strategy were patient age (P = 0.0005), ISS (P< 0.0001), the number of abdominal organs with an injury grade of three or more (P = 0.0014), and presentation lactate level (P< 0.0001).

Table 1: Demographic and injury factors

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Table 2: Physiologic measures on presentation

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When the charts were reviewed for documented decision-making to leave the abdomen open, 135 of the 140 open abdomens had stated reasoning. Of these, 103 (76.3%) were left open for damage control, 20 (14.8%) with plans for a second-look procedure, and 12 (8.9%) due to concerns for ACS. The mean time to operation in the open abdomen patients was 2.6 h (±6.8, range 0–51 h).

Of the patients with an initially open abdomen, 101 (72.1%) survived and 77 (76.2%) of those achieved primary fascial closure (the other 34 underwent closure with synthetic or biologic mesh). Mean time to closure was 3.7 ± 3.7 (range: 1–21 days). None of the presenting demographic or injury factors predicted time to primary fascial closure by independent or model analysis (all P > 0.1). When the presenting injury, physiology, and intervention variables were placed in a logistic regression model to predict time to definitive closure of the abdomen, only the time interval to initial operation (P = 0.021, longer times to operation predicted longer times to closure), and time of day of initial operation (P = 0.046, operations done between midnight and 0600 were associated with longer intervals to closure) were associated with the time to closure. By Pearson correlation, these two factors still account for <10% of the total variation in days to closure.

Discussion

The tenets of DCS were first described in 1993 by Rotondo et al., as control of hemorrhage and contamination, intraperitoneal packing and temporary closure, followed by resuscitation in the ICU.^[12] DCS with open abdomen therapy has since become the standard of care for critically injured trauma patients when appropriate. The complications of the open abdomen pose both medical and surgical challenges to the trauma surgeon, raising concerns about the frequency with which this procedure is performed. This presented an opportunity to assess if this surgical procedure was utilized consistently at all times of the day.

A recent study of trauma surgeons determined that mortality of patients undergoing an exploratory laparotomy did not increase between the hours of midnight and 6 a.m.^[13] In this study, we evaluated the same time frame as an independent variable to determine if surgeon fatigue played a role in the decision to leave a patient's abdomen open after the initial exploratory laparotomy. We found that the decision to perform DCS and leave an abdomen open appears to be consistent throughout the day and to be dependent on patient factors as evaluated by the operating surgeon. Fatigue and time of day do not seem to be contributing factors to this decision.

Patient factors that were predictive of the physician's decision to leave a patient's abdomen open included older patient age, injury severity (ISS, abdomen AIS, abdominal injuries with an AIS ≥3), and serum lactate. The significant logistic regression analysis of abdominal injuries with AIS ≥3 can be explained by its close association of greater ISS, abdomen AIS, and blunt mechanism, and as this is a clinical decision by the surgeon, it is easy to understand how more organs with greater injury would incline the operating surgeon to choose a damage control strategy. The delay to abdominal closure associated with time of day of initial operation and delay to initial operation are interesting. The delay of the initial operation is easily seen as a predictor of increased difficulty with closure (injury progress, longer resuscitation period). The time of operation, by our evaluation, may be a factor of the desire for daytime operation. The next day would seem too early to operate, and in most cases the patients' physiologic derangements would not yet be corrected. This would cause the case to spill over to the next day. This could put the patient at risk for increased complications as they wait for a daytime operation despite being physiologically ready for attempted closure. This concept will bear further evaluation in the future.

One limitation of this paper is the definition and assumption of physician fatigue and its link to the hours of 2400–6000. This assumption was predicated on the Grant Medical Center's trauma surgeons having worked a 16 h shift by the hour of 2400. A meta-analysis exists that supports the detrimental effect of short-term sleep deprivation on mood and cognitive measures, as well as performance on long, complex tasks.^[14] In addition, a recent study on shift work in on-call surgeons demonstrated that surgeons' circadian rhythm is disrupted;^[15] variations in this normal rhythm may be implicated in impaired cognitive function.^[16] Another potential limitation of the study is the assumption that both the Grant Medical Center laparotomy patient population and physician makeup is representative of all Level 1 trauma centers. This is a retrospective analysis of an inaction decision-making process, and as such, we cannot say with certainty the reasons for all open abdomens. This was intended to have been accounted for (with respect to the patient population) by the recording of patient demographics and physiologic parameters.

While this study demonstrated that surgeon decision to leave an abdomen open is based on presenting physiologic parameters of the patient and not influenced by physician fatigue, the same cannot be said of the decision of when to achieve DPFC. Mean time to closure was 3.7 days, and this value was not predicted by any of the presenting demographic or physiologic factors rather by logistic factors associated with clinician decision-making. This suggests the possibility that time to DPFC is a procedure completed on a protocol basis, or based on convenience, rather than a decision based on the presenting physiologic parameters of each patient. An opportunity may exist to identify a subset of the open abdomen patients that could return to the operating room for earlier definitive closure, thereby decreasing the risk of complications.

Thus, the decision to leave an abdomen open appeared to be a consistent one throughout the day and likely based on the patient factors. The timing of closure was likely a combination of patient, physician, and facility factors and may leave opportunity for improved time to closure, potentially reducing complications.

Conclusion

The decision to perform damage control surgery and leave an abdomen open appears to be consistent throughout the day and to be dependent on the patient factors. Time of day does not seem to be a contributing factor. Fascial closure does not vary based on the demographic or injury factors. It appears that closure occurs as part of a routine or on convenience. An opportunity may exist to identify a subset of the open abdomen patients that could return to the operating room for earlier definitive closure, thereby lowering the risk of complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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