Unplanned Return to OR in a Level 1 Trauma Center Elizabeth D. Fox, MD; Elizabeth V. Atkins, MSN, RN, CCRN-K; Christopher J. Dente, MD GSACS Day of Trauma & Annual Meeting August 18th, 2017

Definition “Unplanned return to the Operating Room after initial operative management for a similar or related procedure”

Unplanned return to OR Several studies in Neurosurgery, Orthopaedic, and General Surgery patients, but overall literature is limited Approximately 3% of operations (0.5-10%) Associated with patient comorbidities, acuity of operation, type of operation, technical aspects1 Pujol N et al. 2015 1Lin Y et al. Am J Surg. 2016; S0002-9610(16)30956-4

Unplanned return to OR among trauma patients There are no studies looking specifically at unplanned return to OR among trauma patients.

Unplanned return to OR among trauma patients There are no studies looking specifically at unplanned return to OR among trauma patients. Questions: What factors are associated with unplanned return to OR among trauma patients? What can be done to prevent this event?

Methods Retrospective analysis of data from Grady Memorial Hospital Trauma Registry Patients admitted after trauma January 1st, 2016 – March 31st, 2017 Charts were reviewed for Patient factors (age, gender, comorbidities, mechanism of trauma, ISS, injuries sustained) Specifics of all operative interventions Outcomes (ventilator days, ICU LOS, hospital LOS, complications, mortality)

Methods Definition of “Unplanned return to OR” (UROR) group “Unplanned return to the Operating Room after initial operative management for a similar or related procedure”

Methods Patients were identified as “Not truly unplanned” if The return was, in fact, planned The return was for anesthesia support for a non- operative procedure (i.e. ERCP) The return was unrelated to a previous operation The operation was related to a previous comorbidity (i.e. AVR in aortic stenosis patient), not part of trauma management

Overall numbers 1/1/2016 – 3/31/2017 Patients identified from Trauma Registry 86 Not truly unplanned 10 True UROR 76 Unplanned returns 82

Not truly unplanned Return was planned Washout/debridement after fasciotomy, n = 2 Washout/debridement after I&D, n = 1 Definitive fixations after ex-fix, n = 1 Return was for anesthesia support ERCP for bile leak or pancreatic leak, n = 2 Tracheostomy exchange, n = 1 Return was unrelated to previous operation Bronchoscopy after imaging, n = 1 ORIF of different extremity fracture, n = 1 Original operation was for a previous comorbidity Bleed after AVR, n = 1

Not truly unplanned: Documentation Planned reoperation was the most common reason for return to OR, but plan was not always explicit in the operative note “Ex-fix to remain in place” For both fasciotomy cases, no indication in op note that further washout/closure would be required One patient underwent planned postoperative radiographic workup, but this plan was not noted in the original operative note

True unplanned return to OR: Patient characteristics Variable True Unplanned (n=76) Age (mean) 39 years Male gender 84% (n = 64) Comorbidities Obesity 9% (n = 7) Coronary artery disease 7% (n = 5) Diabetes HIV/AIDS 2.6% (n = 2) Anticoagulant/antiplatelet use Blunt trauma 51% (n = 39) ISS (mean) 22.4

True unplanned return to OR: Services Number of cases (n=82) Trauma Surgery 65% (n = 53) Orthopaedic Surgery 13% (n = 11) Neurosurgery 9.8% (n = 8) Vascular Surgery 4.9% (n = 4) Neurosurgery (Spine) 2.4% (n =2) Orthopaedics (Hand) 1.2% (n = 1) PRS (Face) OMFS (Face) PRS (Hand)

Overall outcomes Outcome True UROR (n = 76 patients) Ventilator days ICU LOS 13.1 days Hospital LOS 27 days Mortality 13.2% (10/76 patients) Discharge to rehab or longterm care facility 28.8% (19/66 patients)

Reasons for unplanned return to OR Site Reason # cases Service for Index Case Cranial Hematoma VP shunt malfunction Wound infection Hydrocephalus 3 1 Neurosurgery Neck Bleed s/p tracheostomy Missed vascular injury Submental hematoma Anastomotic leak Failed percutaneous tracheostomy 2 Trauma Surgery PRS (Face) Thorax Empyema Retained hemothorax Thrombosed vascular repair Vascular Surgery

Reasons for unplanned return to OR Site Reason # cases Service for Index Case Abdomen Hemorrhage Missed injury Evisceration Ureteral injury Compartment syndrome Graft infection Dislodged or malpositioned PEG Anastomotic leak 4 3 2 1 Trauma Surgery Extremity Evacuation of hematoma Wound dehiscence Wound infection Hardware infection Hardware malposition Missed vascular injury Necrosis Pseudoaneurysm Orthopaedics, Trauma Surgery PRS (Hand), Trauma, Orthopaedics Orthopaedics Orthopaedics (Hand) Vascular Surgery Spine Epidural hematoma Neurosurgery Spine

Most common reasons for unplanned return to OR Characteristic Bleeding Event (n=21) Surgical Site Event (n=20) Missed Injury (n=11) Age 36.9 years 41.8 years 38.3 years Male gender 91% 67% 82% Blunt mechanism 52% 60% 27% ISS 25.1 19.3 25.2 Anti-coagulant/ anti-platelet 10% 0% Emergent OR? 76% (n = 16) 60% (n = 12) 100% (n = 12) Hospital LOS 33.6 days 28.8 days 26.7 days Ventilator days 10.1 days 8.8 days 4.8 days ICU LOS 17.3 days 13.6 days 10.7 days Mortality 9.5% (n = 2) 5% (n = 1) 9.1% (n =1)

Further analysis: Emergent Operation Initial operation was emergent in 72% of patients (n = 57) “Emergent” defined as ED Dispo to Operating Room This group may be at higher risk of unplanned return to OR given hemodynamic instability and/or limited initial diagnostic workup

Emergent Operation (ED to OR) Characteristic No UROR (n = 1315) True UROR (n = 57) p value Age 37.6 years 37.3 years 0.85 Male gender 78% (n = 1030) 84% (n = 48) 0.32 Penetrating injury 39% (n = 511) 65% (n = 37) 0.001 ISS 14 24.6 <0.0001 Ventilator days 2.1 days 7.6 days ICU LOS 4 days 13.2 days Hospital LOS 11.5 days 25.9 days Mortality 5.6% (n = 74) 14% (n = 8) 0.0172

Unplanned return to OR Summary Improved documentation of plan for return to OR may improve accuracy of detecting unplanned return to OR The most common reasons for unplanned return to OR were bleeding events (24%) surgical site complications (dehiscence and infection; 23%) missed injury (13%) There were no unplanned return to OR events for unintended retained surgical item or hardware failure

Unplanned return to OR Summary Initial operation was emergent in the vast majority of patients who had UROR for bleeding events and missed injury Among patients requiring emergent operation, UROR was associated with more severe injury and higher rates of penetrating injury UROR affects outcomes, with UROR patients having longer hospitalization and higher mortality rates

Unplanned return to OR Future directions Evaluation of complications among unplanned return to OR patients Further comparison of outcomes versus patients who did not have unplanned returns to OR Track service-specific occurrences and outcomes State-wide review of unplanned returns to OR

Unplanned Return to OR in a Level 1 Trauma Center Elizabeth D. Fox, MD; Elizabeth V. Atkins, MSN, RN, CCRN-K; Christopher J. Dente, MD GSACS Day of Trauma & Annual Meeting August 18th, 2017