V. Morris1, M. K. McNutt1, L. S. Kao1, B. A. Cotton1 1McGovern Medical School at UTHealth,Acute Care Surgery,Houston, TEXAS, USA
Introduction: Venous thromboembolic events (VTE), which include deep vein thrombosis (DVT) and pulmonary embolism (PE), are used by many public and private agencies as a marker for quality of care. However, studies show rates may be affected by variability in screening practices; increased screening yields higher incidence. Reported incidence rates of VTE range from 4% to 16% in US trauma centers, suggesting a surveillance bias. The purpose of this study was to evaluate the incidence of both DVT and PE at our hospital, taking into account variability in aggressiveness in screening practices for the two distinct events.
Methods: Retrospective cohort study, examining VTE events, screening Duplex ultrasound, and screening chest CT-angiograms (CTA) in patients admitted to the trauma service. Inclusion: Highest level-trauma activations, >15 years old, and admitted 1/16-12/16. Exclusions: patients dying in the first 24 hours, those who were pregnant, and those with >20% TBSA burns. Statistical analysis was performed with continuous data presented as medians (25th-75th interquartile range, IQR) and categorical data as proportions.
Results: 1314 patients met inclusion; 60 patients deveoped a VTE, 27 (2.1%) were diagnosed with a DVT and 37 (2.8%) were diagnosed with a PE. A total of 141 patients had a Duplex scan and there was a total of 190 Duplex scans performed. 14.2% of Duplex scans were positive. Median Duplexes in DVT patients 1 (1, 2) vs 0 (0, 0) in those without DVT; p<0.05. 100% of DVT patients had at least one Duplex vs 9% of those without DVT, while 30% of DVT patients had at least two Duplexes vs 2% of those without DVT; both p<0.001. A total of 201 patients had a CTA and a total of 451 CTAs were performed. 8.2% of CTAs were positive. The median number of CTAs in PE patients 2 (1, 3) vs 0 (0, 0) in those without; p<0.001. 100% of PE patients had at least one CTA vs 13% of those without PE, while 80% of PE patients had at least two CTAs versus 11% of those without; both p<0.001. Of the PEs, 13% main pulmonary, 36% lobar, 24%segmental, and 27% were subsegmental. The rate of DVT per Duplex obtained was 1.8%, while the rate of PE per CTA was 2.6%. Controlling for age, gender, and injury severity, each Duplex obtained increased likelihood of DVT diagnosis 4-fold, while each CTA increased PE diagnosis almost 3-fold (TABLE).
Conclusion: The rate of VTE events in trauma centers is likely dependent on the intensity of screening for these events. An adjustment should be made for intensity of screening for these significant events when assigning scores for hospital performance and for reimbursement, least government, insurance, and quality organization discourage physicians and their hospitals from searching for these morbid and sometimes fatal events.
