Characterizing trauma patients with delays in orthopedic process measures.

INTRODUCTION

Early operative intervention in orthopedic injuries is associated with decreased morbidity and mortality. Relevant process measures (e.g., femoral shaft fixation <24 hours) are used in trauma quality improvement programs to evaluate performance. Currently, there is no mechanism to account for patients who are unable to undergo surgical intervention (i.e., physiologically unstable). We characterized the factors associated with patients who did not meet these orthopedic process measures.

METHODS

A retrospective cohort study of patients from 35 American College of Surgeons Committee on Trauma-verified level 1 and level 2 trauma centers was performed using quality collaborative data (2017-2022). Inclusion criteria were adult patients (18 years or older), Injury Severity Score ≥5, and a closed femoral shaft or open tibial shaft fracture classified via the Abbreviated Injury Scale version 2005. Relevant factors (e.g., physiologic) associated with a procedural delay >24 hours were identified through a multivariable logistic regression, and the effect of delay on inpatient outcomes was assessed. A subanalysis characterized the rate of delay in "healthy patients."

RESULTS

We identified 5,199 patients with a femoral shaft fracture, and 87.5% had a fixation procedure, of which 31.8% had a delay, and 47.1% of those delayed were "healthy." There were 1,291 patients with an open tibial shaft fracture, 92.2% had fixation, 50.5% had an irrigation and debridement, and 11.2% and 18.7% were delayed, respectively. High Injury Severity Score, older age, and multiple medical comorbidities were associated with a delay in femur fixation, and those delayed had a higher incidence of complications.

CONCLUSION

There is a substantial incidence of surgical delays in some orthopedic trauma process measures that are predicted by certain patient characteristics, and this is associated with an increased rate of complications. Understanding these factors associated with a surgical delay, as well as effectively accounting for them, is key if these process measures are to be used appropriately in quality improvement programs.

LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.