Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
Department of Orthopedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
Injury. 2024 Nov;55(11):111878. doi: 10.1016/j.injury.2024.111878. Epub 2024 Sep 12.
The American College of Surgeons recommends operative debridement of open tibial fractures within 24 h of presentation. It is unknown what the compliance rates are with this recommendation and what factors contribute to delays to operation.
To determine the characteristics associated with delays to operation for open tibial fractures, we conducted a retrospective cohort study utilizing American College of Surgeons Trauma Quality Improvement Program data from 2017 to 2021. Individuals aged 18 and older presenting to a trauma center with an open tibial fracture were included. Associations were determined with a hierarchal regression model nesting patients within facilities.
Of the 24,102 patients presenting to 491 trauma centers, 66.3 % identified as White, 21.7 % as Black, 1.5 % as Asian, 1.1 % as American Indian, and 10.6 % as Other race. In total, 15.8 % identified as Hispanic. Patients were most often men (75.9 %) and privately insured (47.6 %). The median time to OR was 10.2 h (IQR 4.4-17.7) with 84.6 % receiving surgery within 24 h. In adjusted analyses, Black and American Indian patients had 5.5 % (CI 1.3 %-9.9 %) and 17.8 % (CI 2.2 %-35.8 %) longer wait times, respectively, and a decreased odds of receiving surgery within 24 h (AOR 0.85, CI 0.8-0.9; AOR 0.69, CI 0.5-0.9) when compared to White patients. Female patients had 6.5 % (CI 3.0 %-10.2 %) longer wait times than men. Patients with Medicaid had 5.5 % (CI 1.2 %-9.9 %) longer wait times than those with private insurance. Greater time to OR was associated with increasing age (p < 0.001), increasing injury severity (p < 0.001), and the presence of altered mentation (p < 0.001).
We identified longer wait times to operative irrigation and debridement of open tibial fractures for Black and American Indian patients, women, and those with Medicaid. The implementation of health equity focused quality metrics may be necessary to achieve equity in trauma care.
美国外科医师学院建议在开放性胫骨骨折出现后 24 小时内进行手术清创。目前尚不清楚遵守这一建议的比率是多少，以及哪些因素导致手术延迟。
为了确定与开放性胫骨骨折手术延迟相关的特征，我们利用美国外科医师学院创伤质量改进计划 2017 年至 2021 年的数据进行了回顾性队列研究。纳入在创伤中心就诊的年龄在 18 岁及以上的开放性胫骨骨折患者。采用嵌套于医疗机构内的层次回归模型确定关联。
在 491 家创伤中心就诊的 24102 名患者中，66.3%为白人，21.7%为黑人，1.5%为亚洲人，1.1%为美洲印第安人，10.6%为其他种族。总计 15.8%为西班牙裔。患者多为男性（75.9%）和私人保险（47.6%）。手术间中位数时间为 10.2 小时（IQR 4.4-17.7），84.6%的患者在 24 小时内接受手术。在调整后的分析中，黑人患者和美洲印第安人患者的等待时间分别延长了 5.5%（CI 1.3%-9.9%）和 17.8%（CI 2.2%-35.8%），接受 24 小时内手术的可能性降低（AOR 0.85，CI 0.8-0.9；AOR 0.69，CI 0.5-0.9），与白人患者相比。女性患者的等待时间比男性长 6.5%（CI 3.0%-10.2%）。与私人保险相比，拥有医疗补助的患者等待时间延长了 5.5%（CI 1.2%-9.9%）。手术间中位数时间与年龄增加（p<0.001）、损伤严重程度增加（p<0.001）和意识改变的存在（p<0.001）有关。
我们发现黑人患者和美洲印第安人患者、女性患者以及医疗补助患者接受开放性胫骨骨折手术清创的等待时间更长。可能需要实施注重公平的质量指标，以实现创伤护理的公平。
