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. 2017 Aug;225(2):200-209.
doi: 10.1016/j.jamcollsurg.2017.04.010. Epub 2017 Apr 23.

Decreasing the Use of Damage Control Laparotomy in Trauma: A Quality Improvement Project

John A Harvin  1 , Lillian S Kao  2 , Mike K Liang  2 , Sasha D Adams  3 , Michelle K McNutt  2 , Joseph D Love  2 , Laura J Moore  3 , Charles E Wade  3 , Bryan A Cotton  3 , John B Holcomb  3
Affiliations

Decreasing the Use of Damage Control Laparotomy in Trauma: A Quality Improvement Project

John A Harvin et al. J Am Coll Surg. 2017 Aug.

Erratum in

  • Correction.
    [No authors listed] [No authors listed] J Am Coll Surg. 2017 Nov;225(5):689. doi: 10.1016/j.jamcollsurg.2017.07.1064. J Am Coll Surg. 2017. PMID: 29106847 No abstract available.

Abstract

Background: Our institution has published damage control laparotomy (DCL) rates of 30% and documented the substantial morbidity associated with the open abdomen. The purpose of this quality improvement (QI) project was to decrease the rate of DCL at a busy, Level I trauma center in the US.

Study design: A prospective cohort of all emergent trauma laparotomies from November 2013 to October 2015 (QI group) was followed. The QI intervention was multifaceted and included audit and feedback for every DCL case. Morbidity and mortality of the QI patients were compared with those from a published control (control group: emergent laparotomy from January 2011 to October 2013).

Results: A significant decrease was observed immediately on beginning the QI project, from a 39% DCL rate in the control period to 23% in the QI group (p < 0.001). This decrease was sustained over the 2-year study period. There were no differences in demographics, Injury Severity Score, or transfusions between the groups. No differences organ/space infection (control 16% vs QI 12%; p = 0.15), fascial dehiscence (6% vs 8%; p = 0.20), unplanned relaparotomy (11% vs 10%; p = 0.58), or mortality (9% vs 10%; p = 0.69) were observed. The reduction in use resulted in a decrease of 68 DCLs over the 2-year period. There was a further reduction in the rate of DCL to 17% after completion of the QI project.

Conclusions: A QI initiative rapidly changed the use of DCL and improved quality of care by decreasing resource use without an increase morbidity or mortality. This decrease was sustained during the QI period and further improved upon after its completion.

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Figures

Figure 1
Figure 1
Rate of damage control laparotomy (DCL) from January 2011 to June 2016. (A) DCL rate during historical control period was 38%. (B) After initiation of quality improvement (QI) project, there was an immediate and sustained decrease in the DCL rate to 23% (p<0.001). (C) After completion of the QI project, the DCL rate continued to decrease, averaging 18% in the subsequent 8 months.
Figure 2
Figure 2
Surgeon-specific rates of damage control laparotomy (DCL) during the control period (01/2011–10/2013) and the quality improvement period (11/2013–10/2015). Most surgeons had a decrease in the rate of DCL between the 2 periods with varying degrees of change. Two surgeons had an increase in the rate of DCL between the 2 periods.
See this image and copyright information in PMC

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