WAIKOLOA, HI. – If you openly share your institution’s use of damage control laparotomy, it is possible to safely decrease use of the procedure, according to results from a 2-year, single-center quality improvement project.
“Damage control laparotomy (DCL) is currently overused, both in trauma and general surgery,” John A. Harvin, MD, said in an interview in advance of the annual meeting of the American Association for the Surgery of Trauma. “One of the barriers to discussing the overuse is that no one knows what the ‘right’ rate of DCL should be. The vast majority of papers reporting findings regarding DCL fail to provide a denominator, thus actual rates of DCL across the country are not known. It is only by word of mouth that the overuse comes out.”
In a quality improvement (QI) project designed to decrease the rate of DCL at the University of Texas Health Science Center, Houston, Dr. Harvin and his associates prospectively evaluated all emergent laparotomies performed at the institution from November 2013 to October 2015. During year 1 of the QI project, trauma faculty completed report cards immediately following every DCL. During year 2, the researchers collectively reviewed DCLs every other month to determine which patients may have safely undergone definitive laparotomy. They prospectively compared the morbidity and mortality of patients in the quality improvement group with that of a published historical cohort group of patients who underwent emergent laparotomy between January 2011 and October 2013 (Am. J. Surg. 2016;212:34-9).
Dr. Harvin of the division of acute care surgery at the university, reported that the rate of DCL among the historical control group was 39%. Soon after the QI project was implemented the DCL rate fell to 23% (P less than .05), and it declined further following completion of the project, to 18%. “This was accomplished by open discussion among our faculty on who and why DCL was done,” he said. “Over the course of the 2-year QI project, approximately 70 DCLs were avoided without an increase in complications or mortality.”
Many of the findings surprised the researchers, including the fact that the indications for DCL did not differ before and after implementation of the QI project. “So, surgeons did not necessarily abandon certain indications but used all indications more selectively,” Dr. Harvin noted. “That being said, we were able to identify a few indications for DCL that may or may not be necessary. Lastly, despite a significant reduction in the overall use of DCL, we saw no change in rates of complications. This flies in the face of many papers reporting an association between DCL and all kinds of morbidities.”
He acknowledged certain limitations of the study, including the fact that the researchers identified a Hawthorne effect after implementation of the QI intervention. “Despite this, there was a sustained reduction in the rate of DCL that persisted following termination of the project,” Dr. Harvin said. “Additionally, this is not a randomized clinical trial, but a before and after trial which is subject to the usual methodological flaws such as confounding by temporal change and differences in baseline characteristics of the patient populations.” He reported having no financial disclosures.