1. 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

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

3. 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; S (16)

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

5. 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?

6. 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)

7. 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”

8. 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

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

10. 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

11. 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

12. 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

13. 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)

14. 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)

15. 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

16. 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

17. 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)

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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