A Surgical Endovascular Trauma Service Increases Case Volume and Decreases Time to Hemostasis

Jonathan J. Morrison, PhD, FRCS; Marta J. Madurska, MD; Anna Romagnoli, MD; Marcus Ottochian, MD; Sakib Adnan, MD, BS; William Teeter, MD; Tiffany Kuebler, PA-C; Melanie R. Hoehn, MD; Megan L. Brenner, MD; Joseph J. DuBose, MD; Thomas M. Scalea, MD

Disclosures

Annals of Surgery. 2019;270(4):612-619. 

In This Article

Abstract and Introduction

Abstract

Objectives: The aim of this study was to evaluate the effect of a recently active endovascular trauma service (ETS) on case volume and time to hemostasis, as a complement to an existing interventional radiology (IR) service.

Summary Background Data: Endovascular techniques are vital for trauma care, but timely access can be a challenge. There is a paucity of data on the effect of a multispecialty team for delivery of endovascular hemorrhage control.

Methods: The electronic medical record of trauma patients undergoing endovascular procedures between 2013 and 2018 was queried for provider type (IR or ETS). Case volume and rates were expressed per 100 monthly admissions, normalizing for seasonal variation. Interrupted time series analysis was used to model the case rate pre- and post-introduction of the ETS. Admission-to-procedure-time data were collected for pelvic angioembolization as a marker of patients requiring emergency hemostasis.

Results: During 6 years, 1274 admission episodes required endovascular interventions. Overall case volume increased from 2.7 to 3.6 at a rate of 0.006 (P = 0.734) after introduction of the ETS. IR case volume decreased from 3.3 to 2.6 at a rate of 0.03 (P = 0.063). ETS case volume increased at a rate of 0.048 (P < 0.001), which was significantly different from the IR trend (P < 0.001). Median (interquartile range) time-to-procedure (hours) was significantly shorter for pelvic angioembolization [3.0 (4.4) vs 4.3 (3.6); P < 0.001] when ETS was compared to IR.

Conclusion: A surgical ETS increases case volume and decreases time to hemostasis for trauma patients requiring time sensitive interventions. Further work is required to assess patient outcome following this change.

Introduction

Bleeding is a significant problem following traumatic injury, which can be a presenting feature or a secondary issue complicating the original injury or treatment.[1] Hemorrhage control is vital, which may be required immediately or as a prophylactic maneuver. Although open operation was once the only method to control bleeding, methods to accomplish hemostasis have become more varied and sophisticated.

Trauma surgeons are trained to deliver operative hemostasis; however, the role for open exploration in some injuries is diminishing, largely as endovascular catheter-based techniques have demonstrated efficacy and durability.[2] For example, endoluminal stenting of the thoracic aorta has essentially replaced operative repair in blunt thoracic aortic injury.[3] Angioembolization has become the standard of care for managing traumatic vascular lesions in solid organ injury[4] not requiring laparotomy and arterial bleeding in pelvic fractures.[5]

Between 1997 and 2003 there was a 27-fold increase in the use of endovascular techniques in trauma reported from the National Trauma Data Bank (NTDB).[6] This trend has continued unabated, with 13.2% of blunt vascular injury recorded in the NTDB treated by endovascular means in 2010.[7] Despite a compelling evidence base, timely access can be a challenge because endovascular intervention is usually provided by an interventional radiology service (IRS).[8,9] In addition to trauma cases, the IRS has to prioritize other emergency and elective commitments, sometimes across multiple sites.

In recognition of this issue, our institution developed an endovascular trauma service (ETS) to complement the existing IRS.[10] The ETS is staffed by dual trained trauma and vascular surgeons and facilitates early access to endovascular intervention. The aim of this study is to evaluate the impact of the ETS on case volume and time to intervention (Figs. 1 and 2).

Figure 1.

Overall number of endovascular interventions performed per 100 trauma admissions. The red dotted line demonstrates the regression line at 2.65 cases per 100 admission. This increased to 3.55 cases per 100 admissions following the implementation of the endovascular trauma service as denoted by the green line.

Figure 2.

The case rate by service: IR (red line) and ETS (green line). The IR case rate decreased at a rate 0.042 cases (P = 0.008) and the ETS rate increased at a rate of 0.048 (P < 0.001). The difference between these rates was significantly different (P < 0.001).

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