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Clinical practice guideline adherence during Operation Inherent Resolve
Timothy P Plackett1, Darren C Cherry, Gerald Delk
1Womack Army Medical Center (T.P.P.), Fort Bragg, North Carolina; Robert E. Bush Naval Hospital (D.C.C.), Naval Medical Center Portsmouth, Portsmouth, Virginia; Cedar Park Medical Center (G.D.), Austin, Texas; Bassett Army Community Hospital (S.S.), Fort Wainwright, Arkansas; Tripler Army Medical Center (J.T.), Honolulu, Hawaii; William Beaumont Army Medical Center (D.M.), Fort Bliss, Texas; Martin Army Community Hospital (J.M.), Fort Benning, GA; and Joint Trauma System (S.A.S.), Fort Sam Houston, Texas.
Background:
The Joint Trauma System (JTS) clinical practice guidelines (CPGs) contributed to the decrease in battlefield mortality over the past 15 years. However, it is unknown to what degree the guidelines are being followed in current military operations.
Methods:
A retrospective review was performed of all patients treated at three separate US Army Role II facilities during the first 10 months of Operation Inherent Resolve in Iraq. Charts were reviewed for patient demographics, clinical care, and outcomes. Charts were also reviewed for compliance with JTS CPGs and Tactical Combat Casualty Care recommendations.
Results:
A total of 114 trauma patients were treated during the time period. The mean age was 26.9 ± 10.1 years, 90% were males, and 96% were host nation patients. The most common mechanisms of injury were blast (49%) and gunshot (42%). Records were compliant with documenting a complete set of vitals in 58% and a pain score in 50% of patients. Recommendations for treatment of hypothermia were followed for 97% of patients. Tranexamic acid was given outside guidelines for 6% of patients, and for 40%, it was not determined if the guidelines were followed. Recommendations for initial resuscitative fluid were followed for 41% of patients. Recommendations for antibiotic prophylaxis were followed for 40% of intra-abdominal and 73% of soft tissue injuries. Recommendations for tetanus prophylaxis were followed for 90% of patients. Deep vein thrombosis prophylaxis was given to 32% of patients and contraindicated in 27%. The recommended transfusion ratio was followed for 56% of massive transfusion patients. Recommendations for calcium administration were followed for 40% of patients. When composite scores were created for individual surgeons, there was significant variability between surgeons with regard to adherence to guidelines.
Conclusions:
There is significant deviation in the adherence to the CPGs.
Level Of Evidence:
Epidemiologic study, level IV.