Detecting the blind spot: complications in the trauma registry and trauma quality improvement

The National Surgical Quality Improvement Program (NSQIP) has reduced complications for surgery patients in the Department of Veterans Affairs Healthcare System. The American College of Surgeons Committee on Trauma maintains the National Trauma Data Bank (NTDB) to track injured patient comorbidities, complications, and mortality. We sought to apply the NSQIP methodology to collect comorbidity and outcome data for trauma patients. Data were compared to the NTDB to determine the benefit and validity of using the NSQIP methodology for trauma.

Utilizing the NSQIP methodology, data were collected from August 1, 2004 to July 31, 2005 on all adult patients admitted to the trauma service at a level 1 trauma center. NSQIP data were collected for general surgery patients during the same time period from the same institution. Data were also extracted from v5.0 of the NTDB for patients >or=18 years old admitted to level 1 trauma centers. Comparisons between University of Michigan (UM) NSQIP Trauma and UM NSQIP General Surgery patients and between UM NSQIP Trauma and NTDB (2004) patients were performed using univariate and multivariate analysis.

Before risk adjustment, there was a difference in mortality between the UM NSQIP Trauma and NTDB (2004) groups with univariate analysis (8.4% vs 5.7%; odds ratio [OR], 0.7; 95% confidence interval [CI] 0.5-0.9; P = .01). This survival advantage reversed to favor the UM NSQIP Trauma patient group when risk adjustment was performed (OR, 2.3; 95% CI, 1.6-3.4; P < .001). The UM NSQIP Trauma group had more complications than the UM NSQIP general surgery patients. Despite having a lower risk-adjusted rate of mortality, the UM NSQIP Trauma patients had significantly higher rates of complications (wound infection, wound disruption, pneumonia, urinary tract infection, deep vein thrombosis, and sepsis) than the NTDB (2004) patients in both univariate and multivariate analyses.

Complications occurred more frequently in trauma patients than general surgery patients. The UM NSQIP Trauma patients had higher rates of complications than reported in the NTDB. The NTDB data potentially underreport important comorbidity and outcome data. Application of the NSQIP methodology to trauma may present an improved means of effectively tracking and reducing adverse outcomes in a risk-adjusted manner.