Hospital factors associated with splenectomy for splenic injury: a national perspective.
ABSTRACT The management of patients with splenic injury has shifted from routine splenectomy to attempts at splenic salvage. Using the Healthcare Cost and Utilization Project's National Inpatient Sample (HCUP-NIS), we assessed the patterns of care for splenic trauma. We hypothesized that the processes of care in urban and rural hospitals would differ.
Generalized estimating equations were used to identify predictor variables associated with laparotomy and splenectomy from a national, population-based sample of inpatients (HCUP-NIS). Fourteen thousand nine hundred one patients with an International Classification of Diseases, Ninth Revision, Clinical Modification discharge diagnosis code of 865 were selected from the 1998 to 2000 HCUP-NIS data. Exclusion criteria included age greater than 80 years. Analyses were compared using all patients and excluding patients who died during the first 2 hospital days.
Eight thousand five hundred fifty-three patients were treated in urban teaching hospitals. Forty percent underwent a laparotomy and 28% underwent a splenectomy at that time. Another 4,461 patients were cared for in urban nonteaching hospitals. Of these, 46% had a laparotomy and 35% underwent a splenectomy. The remaining 1,887 patients were seen in rural hospitals. Forty-six percent had a laparotomy and 36% had a splenectomy. Patients in urban teaching hospitals had lower risk-adjusted odds of splenectomy in multivariate models controlling for confounders including overall injury severity. Overall splenic salvage increased from 1998 to 2000, primarily because of increased salvage rates among urban teaching hospitals.
The management of patients with splenic injury differs among urban teaching, urban nonteaching, and rural hospitals. Surgeons at urban teaching hospitals appear more willing to attempt splenic salvage by means of nonoperative management.
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ABSTRACT: Non-operative management (NOM) of hemodynamically stable patients with blunt splenic injury (BSI) is the standard of care, although it is associated with a potential risk of failure. Hemodynamically unstable patients should always undergo immediate surgery and avoid unnecessary CT scans. Angioembolization might help to increase the NOM rates, as well as NOM success rates. The aim of this study was to review and critically analyze the data from BSI cases managed at the Maggiore Hospital Trauma Center during the past 5 years, with a focus on NOM, its success rates and outcomes. A further aim was to develop a proposed clinical practical algorithm for the management of BSI derived from Clinical Audit experience. During the period between January 1, 2009 and December 31, 2013 we managed 293 patients with splenic lesions at the Trauma Center of Maggiore Hospital of Bologna. The data analyzed included the demographics, clinical parameters and characteristics, diagnostic and therapeutic data, as well as the outcomes and follow-up data. A retrospective evaluation of the clinical outcomes through a clinical audit has been used to design a practical clinical algorithm. During the five-year period, 293 patients with BSI were admitted, 77 of whom underwent immediate surgical management. The majority (216) of the patients was initially managed non-operatively and 207 of these patients experienced a successful NOM, with an overall rate of successful NOM of 70 % among all BSI cases. The success rate of NOM was 95.8 % in this series. All patients presenting with stable hemodynamics underwent an immediate CT-scan; angiography with embolization was performed in 54 cases for active contrast extravasation or in cases with grade V lesions even in absence of active bleeding. Proximal embolization was preferentially used for high-grade injuries. After a critical review of the cases treated during the past 5 years during a monthly clinical audit meeting, a clinical algorithm has been developed with the aim of standardizing the clinical management of BSI by a multidisciplinary team to include every patient within the correct diagnostic and therapeutic pathway, in order to improve the outcomes by potentially decreasing the NOM failure rates and to optimize the utilization of resources.Surgery Today 12/2014; DOI:10.1007/s00595-014-1084-0 · 1.21 Impact Factor
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ABSTRACT: Although studies have suggested that a relationship exists between hospital teaching status and quality improvement activities, it is unknown whether this relationship exists for trauma centres. We surveyed 249 adult trauma centres in the United States, Canada, Australia, and New Zealand (76% response rate) regarding their quality improvement programs. Trauma centres were stratified into two groups (teaching [academic-based or -affiliated] versus non-teaching) and their quality improvement programs were compared. All participating trauma centres reported using a trauma registry and measuring quality of care. Teaching centres were more likely than non-teaching centres to use indicators whose content evaluated treatment (18% vs. 14%, p < 0.001) as well as the Institute of Medicine aim of timeliness of care (23% vs. 20%, p < 0.001). Non-teaching centres were more likely to use indicators whose content evaluated triage and patient flow (15% vs. 18%, p < 0.001) as well as the Institute of Medicine aim of efficiency of care (25% vs. 30%, p < 0.001). While over 80% of teaching centres used time to laparotomy, pulmonary complications, in hospital mortality, and appropriate admission physician/service as quality indicators, only two of these (in hospital mortality and appropriate admission physician/service) were used by over half of non-teaching trauma centres. The majority of centres reported using morbidity and mortality conferences (96% vs. 97%, p = 0.61) and quality of care audits (94% vs. 88%, p = 0.08) while approximately half used report cards (51% vs. 43%, p = 0.22). Teaching and non-teaching centres reported being engaged in quality improvement and exhibited largely similar quality improvement activities. However, differences exist in the type and frequency of quality indicators utilized among teaching versus non-teaching trauma centres.BMC Surgery 12/2014; 14(1):112. DOI:10.1186/1471-2482-14-112 · 1.24 Impact Factor
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ABSTRACT: The incidence of splenectomy after trauma is institutionally dependent and varies from 18% to as much as 40%. This is important because variation in management influences splenic salvage. The aim of this study was to investigate whether differences exist between Dutch level 1 trauma centers with respect to the treatment of these injuries, and if variation in treatment was related to splenic salvage, spleen-related reinterventions, and mortality.Journal of Surgical Research 09/2014; 194(1). DOI:10.1016/j.jss.2014.08.063 · 2.12 Impact Factor