MSS009: RESUSCITATION RULES: ANALYSIS OF DCR QUALITY METRICS ON THE BATTLEFIELD
Reed D Koldenhoven, OMSIII1; Jonathan D Stallings, PhD2; Darshan S Thota, MD, MSCICPT2; Jan-Michael Van Gent, DO2; Stephen F Flaherty, MD, FACS2; Jennifer M Gurney, MD, FACS2; 1Rocky Vista University College of Osteopathic Medicine; 2Joint Trauma System, JBSA Fort Sam Houston, Texas
Introduction: The Joint Trauma System (JTS) mission is to improve trauma readiness and outcomes through evidence-driven medical performance improvement (MPO). The DoD Trauma Registry (DoDTR) is systematically reviewed to provide data-driven recommendations to healthcare service members through clinical practice guidelines (CPG) and evaluation of metrics according to an established performance improvement plan. Here, we (1) evaluate the Damage Control Resuscitation (DCR) populations and CPG-specific metrics and (2) establish standardized benchmarking to better inform performance improvements (PI).
Methods: Patients > 17 years old with a documented conflict-related injuries and battles status, with valid data in sex, mechanism of injury, injury type, military injury severity score (ISS), beneficiary status, and discharge vital status. Subpopulations included (P1) all patients who receive blood product transfusions within three hours of injury, (P2) all severely injured patients with ISS >16 and > 2 body regions with > 2 Abbreviated Injury Score severity and pre-hospital or ED triggers for SBP < 100 or HR > 100 or HCT <32% or pH <7.25, and (P3) all mass transfusion (MT) patients ( 10 Red Blood Cells [RBC] + Whole Blood [WB] within 24 hours). We analyzed balanced resuscitation, tranexamic acid (TXA) administration, calcium administration, WB utilization, and >1L prehospital fluid resuscitation.
Results: Of 75,629 unique records, P1 included 14,836 patients, of which 15.1% received TXA, <1% received calcium, 9.2% received WB, and 0.8% received crystalloids. P2 included 9,811, of which 11.2% received TXA, 0.9% received calcium, 7.5% received WB, and 1.1% received crystalloids. P3 included 3,717 patients, of which 26.4% received TXA, and 1.6% received calcium. Further, 66.3% received cryoprecipitate or WB and 82.3% received platelet or WB. In MT patients, 88.6% received a balanced transfusion. Over time, utilization of WB increased from 17.8% to 78.1% at role 2 and 5.1% to 65.5% at role 3. At role 3, TXA improved 30.7% and calcium improved 20.7%. Patients with >1L pre-hospital crystalloid were up to 3-fold higher odds of mortality at Role 3.
Conclusion: The analysis of DCR CPG metrics in a systematic manner enables JTS to establish benchmarks to better inform system-level PI. While documentation remains a significant limitation for certain populations and metrics, dramatically improvement over the last two decades of war, resulting in better clinical outcomes.