Variation in Use of Damage Control Laparotomy for Trauma By Trauma Centers in the United States, Canada, and Australasia

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Roberts, Peter D. Faris, Chad G. Ball, Andrew W. Kirkpatrick, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-728617/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background: It is unknown how frequently damage control (DC) laparotomy is used across trauma centers in different countries. We conducted a cross-sectional survey of trauma centers in the United States, Canada, and Australasia to study variations in use of the procedure and predictors of more frequent use of DC laparotomy. Methods: A self-administered, electronic, cross-sectional survey of trauma centers in the United States, Canada, and Australasia was conducted. The survey collected information about trauma center and program characteristics. It also asked how often the trauma program director estimated DC laparotomy was performed on injured patients at that center on average over the last year. Multivariable logistic regression was used to identify predictors of a higher reported frequency of use of DC laparotomy. Results: Of the 366 potentially eligible trauma centers sent the survey, 199 (51.8%) trauma program directors or leaders responded [United States=156 (78.4%), Canada=26 (13.1%), and Australasia=17 (8.5%)]. The reported frequency of use of DC laparotomy was highly variable across trauma centers. DC laparotomy was used more frequently in level-1 than level-2 or -3 trauma centers. Further, high-volume level-1 centers used DC laparotomy significantly more often than lower volume level-1 centers (p=0.02). Nearly half (48.4%) of high-volume volume level-1 trauma centers reported using the procedure at least once weekly. Significant adjusted predictors of more frequent use of DC laparotomy included country of origin [odds ratio (OR) for the United States vs. Canada=7.49; 95% confidence interval (CI)=1.39-40.27], level-1 verification status (OR=6.02; 95% CI=2.01-18.06), and the assessment of a higher number of severely injured (Injury Severity Scale score >15) patients (OR per-100 patients=1.62; 95% CI=1.20-2.18) and patients with penetrating injuries (OR per-5% increase=1.27; 95% CI=1.01-1.58) in the last year. Conclusions: The reported frequency of use of DC laparotomy was highly variable across trauma centers. Those centers that most need to evaluate the benefit-to-risk ratio of using DC laparotomy in different scenarios may include high-volume, level-1 trauma centers, particularly those that often manage penetrating injuries. Critical Care & Emergency Medicine Surgery Cross-Sectional Study Damage Control Laparotomy Surgical Variation Wounds and Injuries Figures Figure 1 Figure 2 Figure 3 Background Damage control (DC) laparotomy was developed to quickly control exsanguinating hemorrhage and gross contamination in injured patients with severe physiologic derangements [ 1 ]. It was first adopted by American trauma centers in the 1990s and then increasingly used worldwide as it was felt to be associated with an increase in unexpected survival among the most critically injured patients [ 1 – 4 ]. However, systematic reviews of randomized and non-randomized studies have found insufficient evidence supporting that use of DC instead of definitive laparotomy improves mortality or other patient-important outcomes [ 5 , 6 ]. Further, use of the procedure is resource-intensive and associated with increased morbidity when compared to definitive laparotomy [ 7 – 13 ]. The above suggests that there is likely insufficient evidence to support the high DC laparotomy utilization rates reported by some trauma centers [ 5 ]. Limited data exist suggesting that there is substantial variation in the frequency of use of DC laparotomy across level-1 trauma centers [ 14 – 17 ]. In a post-hoc analysis of the Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial, DC was used among 33–83% of patients requiring urgent laparotomy across 12 participating American level-1 trauma centers between 2012 and 2013 [ 17 ]. While there was no significant mortality difference between the participating trauma centers, the risk of complications was higher among those treated with DC laparotomy [ 5 , 17 ]. This finding is supported by two other studies which reported that use of DC laparotomy among lower risk cohorts of injured patients is associated with increased risks of complications and longer hospital lengths of stay [ 5 , 16 , 18 ]. Reasons for variation in use of DC laparotomy between level-1 trauma centers in the United States are unknown. It is also unknown whether variation in use of DC laparotomy exists across trauma centers outside of the United States and how often the procedure is used across level-2 and − 3 trauma centers (e.g., to stabilize a critically injured patient before transport to a level-1 centers). To address these knowledge gaps, a cross-sectional survey of trauma centers located in the United States, Canada, and Australasia (Australia and New Zealand) was conducted [ 19 ]. This survey had two objectives. First, it sought to determine if variation in use of DC laparotomy across trauma centers may be partially driven by surgeon uncertainty as to when the procedure was appropriately indicated. Results of this part of the study have been reported [ 19 ]. Second, it sought to study variation in the frequency of use of DC laparotomy across level-1, -2, and − 3 trauma centers in these regions and predictors of more frequent use of the procedure (the subject of the current study). The study hypothesis was that the reported frequency of use of DC laparotomy would be highly variable across trauma centers, including level-1 trauma centers, and that this variation would be predicted by trauma center and program characteristics. Methods Design, Ethics, and Reporting: A self-administered, electronic, cross-sectional survey of trauma program medical directors or leaders located in 4 high-income countries with similar emergency medical services was conducted [ 19 , 20 ]. Study methods have previously been described in detail [ 19 ]. The University of Calgary Conjoint Health Research Ethics Board approved the study. It is reported according to the Strengthening of Observational Studies in Epidemiology (STROBE) statement [ 21 ]. Setting And Participants: The population of interest included level-1, -2, and − 3 trauma centers that treat adult or adult and pediatric trauma patients in the United States, Canada, and Australasia. The sampling frame of American, Canadian, and Australian trauma centers was identified using lists of those verified by the American College of Surgeons in 2013 [ 22 ], that contributed data to the Canadian National Trauma Registry Comprehensive Data Set in 2010 to 2011 (with the exception of Quebec) [ 23 ], and that were part of the Australian Trauma Quality Improvement Program as of August 31, 2014 [ 24 ], respectively. Questionnaire Development And Testing: The survey questionnaire was developed by modifying a previously developed questionnaire administered to trauma program directors or leaders in the above countries [ 25 ]. The modified questionnaire asked for information about respondents’ trauma center, including its geographic location, accreditation/verification, verification level, and academic status. It also asked for information about their trauma program, including the numbers and characteristics of injured patients assessed in the last calendar or fiscal year. Finally, it asked how often the trauma program director estimated DC laparotomy was performed on injured patients at that center on average over the last calendar or fiscal year. This last question had the following ordinal response options: 1) at least once daily, 2) more than once weekly but less than once daily, 3) once weekly, 4) once every 2-3-weeks, 5) once monthly, 6) once every 2-3-months, 7) less than once every 3-months, 8) never, 9) other frequency, or 10) unsure. DC laparotomy was defined in the question stem as “abbreviated laparotomy with planned reoperation (e.g., packing of the liver followed by temporary abdominal closure with plans for reoperation to remove packs at a later time).” The questionnaire’s clarity, length, and completeness were assessed during semi-structured interviews with 5 surgeons or physicians. It was then pilot tested on 5 surgeons or physicians and 2 trauma program directors. Questionnaire Administration: All trauma centers in the sampling frame were purposively sampled by sending an e-mail to their trauma program director or leader in September, 2014 [ 26 ]. E-mails explained the study purpose and invited potential respondents to participate by accessing a link to a Web-based survey. Consent for study participation was inferred with questionnaire completion. To increase response rate, personalized questionnaires were administered that provided assurance of respondent confidentiality [ 27 ]. Potential respondents were also sent pre-notification and follow-up e-mails at approximately 1 week, 2 to 3 weeks, 4 to 5 weeks, and 5 to 6 weeks followed by a closing soon e-mail at approximately 7–9 weeks [ 27 ]. Statistical Methods: Categorical survey responses were summarized using counts (percentages) and continuous survey responses using medians [with interquartile ranges (IQRs)]. Survey responses were summarized unstratified and stratified by country, reported frequency of use of DC laparotomy, and by volume and level of trauma center care. A high-volume trauma center was defined as per Nathens et al . as one that assessed > 650 major trauma [Injury Severity Scale (ISS) score > 15] patients in the last year [ 28 ]. Summary statistics were compared using Fisher’s exact and Kruskal-Wallis tests as appropriate. Multivariable logistic regression with robust standard errors was used to identify independent predictors of a higher reported frequency of use of DC laparotomy across trauma centers. As there have been no studies to guide selection of evidence-informed predictors for inclusion in the model, all variables felt to be potentially predictive that lacked evidence of multicollinearity were included in the model. We also tested whether the volume of severely injured patients modified the relationship between reported frequency of use of DC laparotomy and level-1 verification status. The degree of multicollinearity was estimated by calculating associations or correlations between variables and by using the Stata (Stata Corp. College Station, Texas, United States) command package “collin”. Model fit was tested using the Hosmer and Lemeshow’s goodness-of-fit test (non-significant p-values indicate that the model fits the data). Finally, overall classification performance of the logistic regression model was assessed by generating a receiver operating characteristic (ROC) curve that plotted sensitivity against false-positive rate (1-specificity) across a range of diagnostic thresholds. Statistical analyses were performed using Stata MP version 13.1. Results Response Rate: Of the 366 potentially eligible trauma program directors or leaders that were sent the survey, 199 (51.8%) responded and provided data on the frequency of use of DC laparotomy in their center. Characteristics Of Participating Trauma Centers: Of the 199 participating trauma centers, 156 (78.4%) were located in the United States, 26 (13.1%) in Canada, and 17 (8.5%) in Australasia. The 156 participating American trauma centers were located in 37 different states, with most in California (17.3%), Texas (9.6%), and Michigan (8.3%) (see the Figure in Supplementary Digital File 1 ). The 26 participating Canadian trauma centers were located in 7 different provinces, with most in Alberta (26.9%), Ontario (26.9%), and British Columbia or Nova Scotia (15.4% each). Finally, of the 17 Australasian trauma centers, 13 (76.5%) were located in Australia and 4 (23.5%) in New Zealand. Characteristics of the 199 participating trauma centers are outlined in Table 1 . Ninety (45.9%) were verified or accredited to provide level-1 trauma care, 72 (36.7%) to provide level-2 care, and 26 (13.3%) to provide level-3 care. Trauma centers in the United States and Australasia assessed more adult (p = 0.007) and pediatric (p = 0.008) trauma patients than those in Canada. Trauma centers in the United States also assessed a higher percentage of patients with penetrating injuries than those in Canada or Australasia (p = 0.008). However, the number of severely injured (defined as an ISS score > 15) patients assessed was similar across trauma centers in the three regions. Table 1 Characteristics of the Trauma Centers Participating in the Study. Characteristic (N = 199 Trauma Centers) No. (%) of Trauma Centers* p-value United States (n = 156 Trauma Centers) Canada (n = 26 Trauma Centers) Australasia (n = 17 Trauma Centers) Accredited/verified for treatment of† < 0.001 Adult patients 119 (76.3) 9 (34.6) 8 (47.1) Adult and pediatric patients 34 (21.8) 8 (30.8) 5 (29.4) Not accredited/verified – treat adult patients 0 (0) 3 (11.5) 4 (23.5) No accredited/verified – treat adult and pediatric patients 3 (1.9) 6 (23.1) 0 (0) ACS-designed level of adult care < 0.001 Level 1 68/154 (44.2) 10/196 (38.5) 12/16 (75.0) Level 2 64/154 (41.6) 6 (23.1) 2/16 (12.5) Level 3 21/154 (13.6) 4 (15.4) 1/16 (6.3) Not accredited/verified 0 (0) 5 (19.2) 1/16 (6.3) Other 1/154 (0.7) 1 (3.9) 0 (0) Geographic location 0.44 Urban (within a city) 87/150 (58.0) 17 (65.4) 10 (58.8) Suburban (residential area on outskirts of a city) 42/150 (28.0) 7 (26.9) 7 (41.2) Rural (outside a city) 21/150 (14.0) 2 (7.7) 0 (0) Teaching center (regularly has resident physicians on the trauma service) 83/147 (56.5) 17 (70.8) 11 (64.7) 0.39 Participates in research 113/154 (73.4) 22/24 (91.7) 17 (100) 0.006 Local investigator-initiated research 101/154 (65.6) 18/24 (75.0) 13 (76.5) Multicenter research 78/154 (50.7) 16/24 (66.7) 11 (64.7) Industry-sponsored research 44/154 (28.6) 5/24 (20.8) 5 (29.4) Designated trauma team 155/155 (100) 21/25 (84.0) 17 (100) < 0.001 Designated trauma service 150/154 (97.4) 15/25 (60.0) 14 (82.4) < 0.001 ICU that admits and cares for injured patients 153/153 (100) 24/24 (100) 17 (100) NA No. trauma patients assessed in last year, median (IQR) Adult, any ISS score 1,500 (953-2,524) 836 (650-1,349) 1,998.5 (1,300-3,500) 0.007 Adult, ISS score > 15 250 (142–452) 376.5 (129–520) 310 (220–500) 0.67 Pediatric, any ISS score 90 (38–200) 36 (0-100) 68 (20.5–400) 0.008 Pediatric, ISS score > 15 9 (2–27) 6 (0–37) 10 (5–30) 0.84 High volume trauma center‡ 18/135 (13.3) 3/22 (13.6) 1 (6.7) 0.84 Percentage of trauma patients assessed in last year with a penetrating injury, median (IQR) 8 (5–15) 5 (3-9.1) 5 (3–8) 0.008 *Denominator of responses is given if different than stated in the column heading. The number of responses in a category may be greater than the column or category total if responses are not mutually exclusive. †Trauma centers in the United States were accredited/verified by the American College of Surgeons; in Canada, the Trauma Association of Canada; and in Australasia, the Royal Australasian College of Surgeons. ‡Defined as a center that assessed > 650 major trauma (ISS > 15) patients in the last year [ 28 ]. Where ACS indicates American College of Surgeons; ICU, intensive care unit; IQR, interquartile range; and ISS, Injury Severity Scale. Reported Frequency of Use of DC Laparotomy By Trauma Centers : The reported frequency of use of DC laparotomy for trauma by the 199 participating trauma centers was highly variable (see the Figure in Supplementary Digital File 2 ). Forty-four (22.1%) trauma centers reported using DC laparotomy less than once every 3 months. Ten (5.0%) reported never using it. Sixty (30.2%) reported using it once monthly or once every 2–3 months and 73 (36.7%) using it greater than once a month. Twelve (6.0%) trauma centers were unsure how often they used DC laparotomy. DC laparotomy was reportedly used more frequently in level-1 than level-2 or -3 trauma centers (Fig. 1 ). High-volume level-1 trauma centers used DC laparotomy significantly more often than lower volume level-1 trauma centers (p = 0.02) (Fig. 2 ). In total, 24 (77.4%) high-volume and 34 (57.7%) lower volume level-1 trauma centers reported using DC laparotomy greater than once monthly. Further, 15 (48.4%) high-volume and 12 (20.3%) lower volume level-1 trauma centers reported using it at least once weekly. Two (6.4%) high-volume level-1 trauma centers reported never using DC laparotomy for trauma. Predictors of Increased Reported Frequency of Use of DC Laparotomy : Characteristics of the trauma centers that reported using DC laparotomy more instead of less frequently are compared in Table 2 . Those centers that reported using it more frequently were significantly more likely to be high-volume, level-1, teaching centers located in urban settings. They were also more likely to participate in research and have a designated trauma service. Finally, they were more likely to have assessed a higher number of injured adult and pediatric patients (including those with an ISS > 15) and a higher percentage of patients with penetrating injuries in the last year. Table 2 Characteristics of the Participating Trauma Centers That Reported Using Damage Control Laparotomy More Instead of Less Frequently. Characteristic (N = 199 Trauma Centers) No. (%) of Trauma Centers p-value Reported Using DC Laparotomy Greater Than Once Monthly (n = 73) Reported Using DC Laparotomy Once Monthly or Once Every 2–3 Months (n = 60) Reported Using DC Laparotomy Less Than Once Every 3 Months or Never Using It (n = 54) Accredited/verified for treatment of† 0.17 Adult patients 48 (65.8) 41 (68.3) 39 (72.2) Adult and pediatric patients 23 (31.5) 13 (21.7) 8 (14.8) Not accredited/verified – treat adult patients 1 (1.4) 3 (5.0) 2 (3.7) No accredited/verified – treat adult and pediatric patients 1 (1.4) 3 (5.0) 5 (9.3) ACS-designed level of adult care, n (%) < 0.001 Level 1 58 (79.5) 20/59 (33.9) 5/52 (9.6) Level 2 14 (19.2) 33/59 (55.9) 22/52 (43.1) Level 3 0 (0) 2/59 (3.4) 23/52 (44.2) Not accredited/verified or other 1 (1.4) 4/59 (6.8) 2/2 (3.9) Geographic location < 0.001 Urban (within a city) 55/72 (76.4) 28/57 (49.1) 23/52 (44.2) Suburban (residential area on outskirts of a city) 13/72 (18.1) 24/57 (42.1) 17/52 (32.7) Rural (outside a city) 4/72 (5.6) 5/57 (8.8) 12/52 (23.1) Teaching center (regularly has resident physicians on the trauma service) 55 (75.3) 30/55 (54.6) 17/49 (34.7) < 0.001 Participates in research 64 (87.7) 45/58 (77.6) 33/52 (63.5) 0.006 Local investigator-initiated research 60 (82.2) 39/58 (67.2) 25/51 (49.0) Multicenter research 53 (72.6) 24/58 (41.4) 20/51 (39.2) Industry-sponsored research 32 (43.8) 17/58 (29.3) 4/51 (7.8) Designated trauma team 73 (100) 58 (96.7) 51/52 (98.1) 0.28 Designated trauma service 71 (98.6) 54 (90.0) 46/52 (88.5) 0.04 ICU that admits and cares for injured patients 72/72 (100) 59/59 (100) 51/51 (100) NA No. trauma patients assessed in last year, median (IQR) Adult, any ISS score 2,326 (1,552-3,034.5) 1,300 (953-1,897) 733 (480-1,081) 15 449.5 (276–743) 257 (171–400) 97 (50.5–189) 15 21.5 (4–50) 10 (1–25) 3 (0.5-6) < 0.001 High volume trauma center‡ 18/66 (27.3) 4/55 (7.3) 0 (0) < 0.001 Percentage of trauma patients assessed in last year with a penetrating injury, median (IQR) 11.4 (6-17.3) 7.3 (5–10) 4 (2–8) < 0.001 *Denominator of responses is given if different than stated in the column heading. The number of responses in a category may be greater than the column or category total if responses are not mutually exclusive. †Trauma centers in the United States were accredited/verified by the American College of Surgeons; in Canada, the Trauma Association of Canada; and in Australasia, the Royal Australasian College of Surgeons. ‡Defined as a center that assessed > 650 major trauma (ISS > 15) patients in the last year [ 28 ]. Where ACS indicates American College of Surgeons; ICU, intensive care unit; IQR, interquartile range; and ISS, Injury Severity Scale. In a multivariable logistic regression model, there was no evidence that the volume of severely injured patients assessed in the last year modified the association between the reported frequency of use of DC laparotomy and level-1 verification status (p = 0.35). Variables describing teaching status and trauma center research activities were excluded from logistic regression models because there was evidence of multicollinearity between these variables and level-1 trauma center status. Significant adjusted predictors for more than once monthly reported use of DC laparotomy included country of origin (centers in the United States reported using DC laparotomy significantly more often than those in Canada), level-1 verification status, and the assessment of a higher number of severely injured patients and patients with penetrating injuries in the last year (Fig. 3 ). The Hosmer and Lemeshow test indicated that the model fit the data well (p = 0.62). The area under the ROC curve for the model was 0.88, indicating excellent performance for correctly classifying higher instead of lower reported use of DC laparotomy across trauma centers (see the Figure in Supplementary Digital File 3 ). Discussion In this large, international, cross-sectional survey of trauma program directors or leaders, the reported frequency of use of DC laparotomy was highly variable across trauma centers. DC laparotomy was used more often in level-1 than level-2 or -3 trauma centers in the United States, Canada, and Australasia. The frequency of use of DC laparotomy also varied significantly across level-1 trauma centers, especially between those that were high- versus lower volume (based on the number of severely injured patients assessed in the last year). Nearly half of high-volume, level-1 trauma centers reported using DC laparotomy at least once weekly. Trauma center and program characteristics that independently predicted higher reported use of DC laparotomy included country of origin (with centers in the United States reporting using DC laparotomy significantly more often than those in Canada), level-1 trauma verification status, and the assessment of a higher number of severely injured (ISS score > 15) patients and patients with penetrating injuries in the last year. Studying variation in use of DC laparotomy is important because surgeons are at risk of confirmation bias when only those with whom they work reflect their practice [ 29 ]. However, to date, only one other study has examined variation in use of DC surgery between trauma centers [ 17 ]. In a post-hoc analysis of the PROPPR trial, DC laparotomy was reportedly used among a highly variable 33–83% of patients requiring urgent laparotomy across 12 American level-1 trauma centers between 2012 and 2013 [ 17 ]. In the current study, the trauma program directors who were surveyed also reported that the frequency of use of DC laparotomy varied widely across trauma centers, including level-1 trauma centers. Most level-1 trauma centers reported using DC laparotomy at least once a month, and nearly half of high-volume, level-1 trauma centers reported using it at least once weekly. However, 6% of high-volume, level-1 trauma centers reporting never using DC laparotomy during the past year. Reasons for variation in use of DC laparotomy between level-1 trauma centers may include differences in patient injury mechanisms, injury severity, and/or physiology; trauma center experience; trauma surgeon capabilities; and trauma provider education. Trauma centers in the United States reported using DC laparotomy for trauma more often than those in Canada despite adjustment for level-1 verification status and the volume of severely injured patients and patients with penetrating injuries. This could be because of differences in institutional cultures regarding use of DC laparotomy between countries. It could also be because of unmeasured differences in patient mix between countries aside from injury mechanism or ISS scores (e.g., a higher percentage of patients with high-risk injury patterns, deranged physiology, or who receive significant volumes of resuscitation fluids) or beliefs regarding appropriate indications for use of the procedure [ 30 ]. Of the American, Canadian, and Australasian trauma centers included in this study, a nearly equal percentage reported using the procedure less than once every 3 months or never using it, using it once monthly or once every 2–3 months, or using it more than once monthly. Further, more than one-third of level-2 centers reported using DC laparotomy once monthly or more than once monthly and even some level-3 trauma centers reported using the procedure. We assume that many of these level-3 (and likely some level-2) trauma centers may be using DC laparotomy to stabilize critically injured patients before transport to a higher level of trauma care [ 7 ]. In addition to country of origin, other independent predictors of an increased reported use of trauma DC laparotomy included level-1 trauma verification status and the assessment of a higher number of severely injured patients and patients with penetrating injuries in the last year. In the post-hoc analysis of the PROPPR study, the ISS score (OR per-1 point increase = 1.05; 95% CI = 1.02–1.07) of the patients assessed at level-1 trauma centers also predicted an increased odds of use of DC laparotomy [ 17 ]. This is likely because high-energy blunt torso trauma often results in high ISS scores and also may produce some of the high-risk injury patterns considered by many surgeons to be appropriate indications for DC laparotomy (e.g., massive pelvic fracture-related hemorrhage or multiple injuries spanning across more than one body cavity that each require surgery) [ 19 , 30 , 31 ]. Further, while patients with penetrating injuries may have a lower ISS score, those with gunshot wounds (and especially shotgun wounds) more often present with certain injury patterns that have been suggested to be appropriate indications for DC laparotomy [ 30 ]. These may include a major abdominal vascular injury and multiple associated hollow organ injuries or an injured pancreaticoduodenal complex [ 19 , 32 ]. The study findings should be considered in the context of its strengths and limitations. First, the opinions of trauma program directors could be argued to be only estimates of the frequency of use of DC laparotomy. We decided to use survey data from trauma program directors instead of registry or other data because there are limited sources of data available that allow for examination of DC laparotomy practice variation between trauma centers. Further, the ordinal responses provided by trauma program directors are likely accurate within a category of the ordinal response provided. Finally, as the results of this study support the variation in use of DC laparotomy practices identified using PROPPR trial data, we believe they are worth reporting. Second, although we used several techniques shown to increase response rates to surveys (and the response rate is above what has been reported by many surveys reported in the trauma or surgery literature), it is possible that respondents’ answers on the reported frequency of use of DC laparotomy differ systematically from those who did not respond to the survey [ 27 ]. Third, it could be argued that the data used in this study are somewhat outdated as they are now over 5-years old. However, surgical practice patterns often change slowly [ 29 , 33 ], and therefore our findings likely still reflect current practice. This study has important implications for future research, trauma surgery practice, and quality improvement efforts. First, a systematic review of 36 cohort studies found very little evidence to support that use of DC instead of definitive laparotomy in trauma patients was associated with an improvement in mortality or other patient-important outcomes [ 5 ]. However, use of the procedure is associated with an increased risk of morbidity, a longer length of intensive care unit and hospital stay, and possibly a reduced quality of life among survivors [ 7 , 11 – 13 , 34 – 36 ]. As equipoise now exists among some surgeons about the effectiveness of DC for improving mortality in many patients undergoing urgent laparotomy, there is a need for rigorously-designed randomized trials comparing it to definitive trauma laparotomy [ 37 ]. Second, although DC laparotomy is supported by insufficient evidence, nearly half of high-volume, level-1 trauma centers reported using it at least once weekly. One other study reported utilization rates exceeding 80% in some level-1 trauma centers (with most level-1 centers using it among 30% of those undergoing urgent laparotomy) [ 17 ]. Some authors have suggested that more comprehensive indications guiding patient selection for use of DC laparotomy may decrease its associated morbidity and costs [ 17 ]. However, our group previously compiled a comprehensive list of indications for the procedure that both experts and practicing trauma surgeons consistently agree appropriately indicate its use [ 7 , 31 , 32 ]. Further, a cohort study suggested that most of the indications that highly predicted use of DC laparotomy in practice had an incidence of 2% or less [ 30 ]. Collectively, the above may indicate that DC laparotomy is presently overused in trauma centers and that efforts to decrease its use may be necessary until further evidence becomes available. The group that may need to be targeted first include high-volume, level-1 trauma centers, particularly those that often manage penetrating injuries. Indeed, some data suggests that utilization rates of DC laparotomy can be safely reduced through quality improvement efforts such as audit-and-feedback without adversely influencing patient outcomes [ 14 , 38 , 39 ]. Conclusions In this large, international, cross-sectional survey of trauma program directors or leaders, the reported frequency of use of DC laparotomy was highly variable across level-1, -2, and − 3 trauma centers. The reported frequency of use of DC laparotomy also varied significantly across level-1 trauma centers, especially between those that were high- versus lower volume. The procedure was used most often in level-1 trauma centers in the United States that assessed a large percentage of patients with penetrating injuries. Nearly half of high-volume, level-1 trauma centers reported using DC laparotomy at least once a week. Those trauma centers that most need to evaluate the benefit-to-risk ratio of using DC laparotomy in different scenarios may include high-volume, level-1 trauma centers, particularly those that often manage patients with penetrating injuries. Abbreviations CI Confidence interval DC Damage control IQR Interquartile range ISS Injury Severity Scale OR Odds ratio PROPPR Pragmatic, Randomized Optimal Platelet and Plasma Ratios ROC Receiver operating characteristic STROBE Strengthening of Observational Studies in Epidemiology Declarations Ethics Approval and Consent to Participate The University of Calgary Conjoint Health Research Ethics Board approved the study. Consent to participate in the study was implied with survey completion. Consent for Publication Not applicable. Availability of Data and Materials Study data are available upon request from the principal author (D.J.R.). Competing Interests Dr. Kirkpatrickhas consulted for Zoll, Innovative Trauma Care, CSL Behring, and SAM Medical Corporations, and is the principal investigator for a randomized controlled trial partially supported by Acelity Corporation. Dr. Moore receives research support from Haemonetics, Instrumentation Laboratory, Hemosonics, Diapharma, Humacyte, and Genetech. He is also the cofounder of ThromboTherapeutics. The other authors have no conflicts of interest to declare. Funding This study was funded by an Alberta Innovates – Health Solutions Clinician Fellowship Award, a Knowledge Translation (KT) Canada Strategic Training in Health Research Fellowship, a KT Canada Student Research Stipend, and funding from the University of Calgary Clinician Investigator and Surgeon-Scientist Programs (all awarded to D.J.R.). Authors’ Contributions D.J.R. contributed to the study concept. All authors contributed to the study design. D.J.R. obtained funding for the study, created the protocol, designed the survey instrument, administered the survey instrument and sent reminders, and drafted the manuscript. D.J.R. also conducted the data analyses with input from P.D.F. and H.T.S. The manuscript was then critically revised after input from P.D.F., C.G.B., A.W.K., E.E.M., D.V.F., P.R., S.D., and H.T.S. H.T.S. contributed to study supervision. All authors approved the final version of the manuscript for submission for peer-review. Acknowledgments None References Roberts DJ, Ball CG, Feliciano DV, Moore EE, Ivatury RR, Lucas CE, et al. History of the Innovation of Damage Control for Management of Trauma Patients: 1902–2016. Ann Surg. 2017 May;265(5):1034–44. doi: 10.1097/sla.0000000000001803 . PMID: 27232248. Stone HH, Strom PR, Mullins RJ. Management of the major coagulopathy with onset during laparotomy. Ann Surg. 1983 May;197(5):532-5. PMID: 6847272. Rotondo MF, Schwab CW, McGonigal MD, Phillips GR 3rd, Fruchterman TM, Kauder DR, et al. 'Damage control': an approach for improved survival in exsanguinating penetrating abdominal injury. J Trauma. 1993 Sep;35(3):375–82. discussion 82 – 3. PMID: 8371295. Rotondo MF, Zonies DH. The damage control sequence and underlying logic. Surg Clin N Am. 1997 Aug;77(4):761–77. PMID: 9291979. Roberts DJ, Bobrovitz N, Zygun DA, Kirkpatrick AW, Ball CG, Faris PD, et al. Evidence for use of damage control surgery and damage control interventions in civilian trauma patients: a systematic review. World J Emerg Surg. 2021 Mar 11;16(1):10. PMID: 33706763. doi: 10.1186/s13017-021-00352-5 . Cirocchi R, Montedori A, Farinella E, Bonacini I, Tagliabue L, Abraha I. Damage control surgery for abdominal trauma. Cochrane Database Syst Rev. 2013;3:CD007438. doi: 10.1002/14651858.CD007438.pub3 . PMID: 23543551. Roberts DJ, Bobrovitz N, Zygun DA, Ball CG, Kirkpatrick AW, Faris PD, et al. Indications for use of damage control surgery and damage control interventions in civilian trauma patients: a scoping review. J Trauma Acute Care Surg. 2014. Shapiro MB, Jenkins DH, Schwab CW, Rotondo MF. Damage control: collective review. J Trauma. 2000 Nov;49(5):969–78. PMID: 11086798. Chovanes J, Cannon JW, Nunez TC. The evolution of damage control surgery. Surg Clin N Am. 2012 Aug;92(4):859 – 75, vii-viii. PMID: 22850151. doi: 10.1016/j.suc.2012.04.002 . Brenner M, Bochicchio G, Bochicchio K, Ilahi O, Rodriguez E, Henry S, et al. Long-term impact of damage control laparotomy: a prospective study. Arch Surg. 2011 Apr;146(4):395–9. doi: 10.1001/archsurg.2010.284 . PMID: 21173282. Miller RS, Morris JA Jr, Diaz JJ Jr, Herring MB, May AK. Complications after 344 damage-control open celiotomies. J Trauma. 2005 Dec;59(6):1365–71. discussion 71 – 4. PMID: 16394910. Dubose JJ, Scalea TM, Holcomb JB, Shrestha B, Okoye O, Inaba K, et al. Open abdominal management after damage-control laparotomy for trauma: a prospective observational American Association for the Surgery of Trauma multicenter study. J Trauma Acute Care Surg. 2013 Jan;74(1):113 – 20; discussion 1120-2. PMID: 23271085. doi: 10.1097/TA.0b013e31827891ce . Montalvo JA, Acosta JA, Rodriguez P, Alejandro K, Sarraga A. Surgical complications and causes of death in trauma patients that require temporary abdominal closure. Am Surg. 2005 Mar;71(3):219–24. PMID: 15869136. Higa G, Friese R, O'Keeffe T, Wynne J, Bowlby P, Ziemba M, et al. Damage control laparotomy: a vital tool once overused. J Trauma. 2010 Jul;69(1):53–9. doi: 10.1097/TA.0b013e3181e293b4 . PMID: 20622578. Hatch QM, Osterhout LM, Podbielski J, Kozar RA, Wade CE, Holcomb JB, et al. Impact of closure at the first take back: complication burden and potential overutilization of damage control laparotomy. J Trauma. 2011 Dec;71(6):1503-11. PMID: 22182860. doi: 10.1097/TA.0b013e31823cd78d . Martin MJ, Hatch Q, Cotton B, Holcomb J. The use of temporary abdominal closure in low-risk trauma patients: helpful or harmful? J Trauma Acute Care Surg. 2012 Mar;72(3):601–6; discussion 6–8. PMID: 22491542. doi: 10.1097/TA.0b013e31824483b7 . Watson JJ, Nielsen J, Hart K, Srikanth P, Yonge JD, Connelly CR, et al. Damage control laparotomy utilization rates are highly variable among Level I trauma centers: Pragmatic, Randomized Optimal Platelet and Plasma Ratios findings. J Trauma Acute Care Surg. 2017 Mar;82(3):481–8. doi: 10.1097/ta.0000000000001357 . PMID: 28225739. Harvin JA, Wray CJ, Steward J, Lawless RA, McNutt MK, Love JD, et al. Control the damage: morbidity and mortality after emergent trauma laparotomy. Am J Surg. 2015 Dec 15. PMID: 26754456. doi: 10.1016/j.amjsurg.2015.10.014 . Roberts DJ, Zygun DA, Faris PD, Ball CG, Kirkpatrick AW, Stelfox HT. Opinions of Practicing Surgeons on the Appropriateness of Published Indications for Use of Damage Control Surgery in Trauma Patients: An International Cross-Sectional Survey. J Am Coll Surg. 2016 Sep;223(3):515–29. doi: 10.1016/j.jamcollsurg.2016.06.002 . PMID: 27321388. Arnold JL. International emergency medicine and the recent development of emergency medicine worldwide. Ann Emerg Med. 1999 Jan;33(1):97–103. PMID: 9867895. von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol. 2008 Apr;61(4):344–9. PMID: 18313558. doi: 10.1016/j.jclinepi.2007.11.008 . Surgeons ACo. Verified Trauma Centers. Chicago IL, U.S.A.: American College of Surgeons; 2013 [cited 2013 August 29, 2013]; Available from: https:/ /http://www.facs.org/search/trauma-centers?country=United States&distance = any. Information CIfH. National Trauma Registry Report 2013: Hospitalizations for Major Injury in Canada, 2010–2011 Data. Canadian Institutes for Health Information; 2013 [cited 2013 August 22, 2013]; Available from: https://secure.cihi.ca/free_products/NTR_Annual_Report_2013_EN.xls . Health A. Caring for the Severely Injured in Australia: Inaugural Report of the Australian Trauma Registry 2010 to 2012. Melbourne: Alfred Health; 2014. Stelfox HT, Straus SE, Nathens A, Gruen RL, Hameed SM, Kirkpatrick A. Trauma center quality improvement programs in the United States, Canada, and Australasia. Ann Surg. 2012 Jul;256(1):163–9. doi: 10.1097/SLA.0b013e318256c20b . PMID: 22580945. Burns KE, Duffett M, Kho ME, Meade MO, Adhikari NK, Sinuff T, et al. A guide for the design and conduct of self-administered surveys of clinicians. CMAJ. 2008 Jul 29;179(3):245–52. PMID: 18663204. doi: 10.1503/cmaj.080372 . Edwards PJ, Roberts I, Clarke MJ, Diguiseppi C, Wentz R, Kwan I, et al. Methods to increase response to postal and electronic questionnaires. Cochrane Database Syst Rev. 2009 (3):MR000008. PMID: 19588449. doi: 10.1002/14651858.MR000008.pub4 . Nathens AB, Jurkovich GJ, Maier RV, Grossman DC, MacKenzie EJ, Moore M, et al. Relationship between trauma center volume and outcomes. JAMA. 2001 Mar 7;285(9):1164–71. PMID: 11231745. Roberts DJ, Zygun DA, Ball CG, Kirkpatrick AW, Faris PD, James MT, et al. Challenges and potential solutions to the evaluation, monitoring, and regulation of surgical innovations. BMC Surg. 2019 Aug 27;19(1):119. PMID: 31455337. doi: 10.1186/s12893-019-0586-5 . Roberts DJ, Stelfox HT, Moore LJ, Cotton BA, Holcomb JB, Harvin JA. Accuracy of published indications for predicting use of damage control during laparotomy for trauma. J Surg Res. In press. Roberts DJ, Bobrovitz N, Zygun DA, Ball CG, Kirkpatrick AW, Faris PD, et al. Indications for Use of Damage Control Surgery in Civilian Trauma Patients: A Content Analysis and Expert Appropriateness Rating Study. Ann Surg. 2016 May;263(5):1018–27. doi: 10.1097/sla.0000000000001347 . PMID: 26445471. Roberts DJ, Bobrovitz N, Zygun DA, Ball CG, Kirkpatrick AW, Faris PD, et al. Indications for use of thoracic, abdominal, pelvic, and vascular damage control interventions in trauma patients: A content analysis and expert appropriateness rating study. J Trauma Acute Care Surg. 2015 Oct;79(4):568–79. doi: 10.1097/ta.0000000000000821 . PMID: 26402530. McCulloch P, Altman DG, Campbell WB, Flum DR, Glasziou P, Marshall JC, et al. No surgical innovation without evaluation: the IDEAL recommendations. Lancet. 2009 Sep 26;374(9695):1105-12. PMID: 19782876. doi: 10.1016/s0140-6736(09)61116-8 . Cheatham ML, Safcsak K, Llerena LE, Morrow CE Jr, Block EF. Long-term physical, mental, and functional consequences of abdominal decompression. J Trauma. 2004 Feb;56(2):237 – 41; discussion 41 – 2. PMID: 14960962. doi: 10.1097/01.ta.0000109858.55483.86 . Cheatham ML, Safcsak K. Longterm impact of abdominal decompression: a prospective comparative analysis. J Am Coll Surg. 2008 Oct;207(4):573–9. doi: 10.1016/j.jamcollsurg.2008.05.008 . PMID: 18926462. Sutton E, Bochicchio GV, Bochicchio K, Rodriguez ED, Henry S, Joshi M, et al. Long term impact of damage control surgery: a preliminary prospective study. J Trauma. 2006 Oct;61(4):831–4. doi: 10.1097/01.ta.0000239504.35149.c5 . discussion 5–6. PMID: 17033548. Harvin JA, Podbielski J, Vincent LE, Fox EE, Moore LJ, Cotton BA, et al. Damage control laparotomy trial: design, rationale and implementation of a randomized controlled trial. Trauma Surg Acute Care Open. 2017;2(1):e000083. PMID: 29766087. doi: 10.1136/tsaco-2017-000083 . Joseph B, Azim A, Zangbar B, Bauman Z, OʼKeeffe T, Ibraheem K, et al. Improving mortality in trauma laparotomy through the evolution of damage control resuscitation: Analysis of 1,030 consecutive trauma laparotomies. J Trauma Acute Care Surg. 2017 Feb;82(2):328–33. doi: 10.1097/ta.0000000000001273 . PMID: 27805990. Harvin JA, Kao LS, Liang MK, Adams SD, McNutt MK, Love JD, et al. Decreasing the Use of Damage Control Laparotomy in Trauma: A Quality Improvement Project. J Am Coll Surg. 2017 Aug;225(2):200–9. doi: 10.1016/j.jamcollsurg.2017.04.010 . PMID: 28445796. Supplementary Files SupplementalDigitalFile1.eps Supplementary Digital File 1. Location of the 156 Participating American Trauma Centers. SupplementalDigitalFile2.eps Supplementary Digital File 2. Reported Frequency of Use of Damage Control Laparotomy for Trauma By Trauma Centers in the United States, Canada, and Australasia (Australia and New Zealand). SupplementalDigitalFile3.eps Supplementary Digital File 3. Receiver Operating Characteristic Curve For the Multivariable Logistic Regression Prediction Model. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Major revision 25 Jul, 2021 Review # 1 received at journal 24 Jul, 2021 Review # 2 received at journal 24 Jul, 2021 Reviews received at journal 22 Jul, 2021 Reviewer # 2 agreed at journal 21 Jul, 2021 Editor assigned by journal 20 Jul, 2021 Reviewers invited by journal 19 Jul, 2021 Reviewer # 1 agreed at journal 19 Jul, 2021 Submission checks completed at journal 19 Jul, 2021 Editor invited by journal 19 Jul, 2021 First submitted to journal 17 Jul, 2021 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Location of the 156 Participating American Trauma Centers.","description":"","filename":"SupplementalDigitalFile1.eps","url":"https://assets-eu.researchsquare.com/files/rs-728617/v1/7dcb37d2a80d63a69c45dd89.eps"},{"id":11808722,"identity":"8a9147eb-63d9-47e3-806d-6b20c64a26b4","added_by":"auto","created_at":"2021-07-26 14:59:29","extension":"eps","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":16915,"visible":true,"origin":"","legend":"Supplementary Digital File 2. Reported Frequency of Use of Damage Control Laparotomy for Trauma By Trauma Centers in the United States, Canada, and Australasia (Australia and New Zealand).","description":"","filename":"SupplementalDigitalFile2.eps","url":"https://assets-eu.researchsquare.com/files/rs-728617/v1/609873138bc111fe8cd9f1df.eps"},{"id":11808721,"identity":"c1a3836b-cbef-4cf9-9208-e415964bc6a6","added_by":"auto","created_at":"2021-07-26 14:59:29","extension":"eps","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":481330,"visible":true,"origin":"","legend":"Supplementary Digital File 3. Receiver Operating Characteristic Curve For the Multivariable Logistic Regression Prediction Model.","description":"","filename":"SupplementalDigitalFile3.eps","url":"https://assets-eu.researchsquare.com/files/rs-728617/v1/72f2c434b551dea11b3e46a7.eps"}],"financialInterests":"","formattedTitle":"Variation in Use of Damage Control Laparotomy for Trauma By Trauma Centers in the United States, Canada, and Australasia","fulltext":[{"header":"Background","content":"\u003cp\u003eDamage control (DC) laparotomy was developed to quickly control exsanguinating hemorrhage and gross contamination in injured patients with severe physiologic derangements [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. It was first adopted by American trauma centers in the 1990s and then increasingly used worldwide as it was felt to be associated with an increase in unexpected survival among the most critically injured patients [\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. However, systematic reviews of randomized and non-randomized studies have found insufficient evidence supporting that use of DC instead of definitive laparotomy improves mortality or other patient-important outcomes [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Further, use of the procedure is resource-intensive and associated with increased morbidity when compared to definitive laparotomy [\u003cspan additionalcitationids=\"CR8 CR9 CR10 CR11 CR12\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe above suggests that there is likely insufficient evidence to support the high DC laparotomy utilization rates reported by some trauma centers [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Limited data exist suggesting that there is substantial variation in the frequency of use of DC laparotomy across level-1 trauma centers [\u003cspan additionalcitationids=\"CR15 CR16\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In a post-hoc analysis of the Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial, DC was used among 33\u0026ndash;83% of patients requiring urgent laparotomy across 12 participating American level-1 trauma centers between 2012 and 2013 [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. While there was no significant mortality difference between the participating trauma centers, the risk of complications was higher among those treated with DC laparotomy [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. This finding is supported by two other studies which reported that use of DC laparotomy among lower risk cohorts of injured patients is associated with increased risks of complications and longer hospital lengths of stay [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eReasons for variation in use of DC laparotomy between level-1 trauma centers in the United States are unknown. It is also unknown whether variation in use of DC laparotomy exists across trauma centers outside of the United States and how often the procedure is used across level-2 and \u0026minus;\u0026thinsp;3 trauma centers (e.g., to stabilize a critically injured patient before transport to a level-1 centers). To address these knowledge gaps, a cross-sectional survey of trauma centers located in the United States, Canada, and Australasia (Australia and New Zealand) was conducted [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. This survey had two objectives. First, it sought to determine if variation in use of DC laparotomy across trauma centers may be partially driven by surgeon uncertainty as to when the procedure was appropriately indicated. Results of this part of the study have been reported [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Second, it sought to study variation in the frequency of use of DC laparotomy across level-1, -2, and \u0026minus;\u0026thinsp;3 trauma centers in these regions and predictors of more frequent use of the procedure (the subject of the current study). The study hypothesis was that the reported frequency of use of DC laparotomy would be highly variable across trauma centers, including level-1 trauma centers, and that this variation would be predicted by trauma center and program characteristics.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDesign, Ethics, and Reporting:\u003c/h2\u003e \u003cp\u003eA self-administered, electronic, cross-sectional survey of trauma program medical directors or leaders located in 4 high-income countries with similar emergency medical services was conducted [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Study methods have previously been described in detail [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The University of Calgary Conjoint Health Research Ethics Board approved the study. It is reported according to the Strengthening of Observational Studies in Epidemiology (STROBE) statement [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\n\u003ch2\u003eSetting And Participants:\u003c/h2\u003e\n\u003cp\u003eThe population of interest included level-1, -2, and \u0026minus;\u0026thinsp;3 trauma centers that treat adult or adult and pediatric trauma patients in the United States, Canada, and Australasia. The sampling frame of American, Canadian, and Australian trauma centers was identified using lists of those verified by the American College of Surgeons in 2013 [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], that contributed data to the Canadian National Trauma Registry Comprehensive Data Set in 2010 to 2011 (with the exception of Quebec) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], and that were part of the Australian Trauma Quality Improvement Program as of August 31, 2014 [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], respectively.\u003c/p\u003e\n\u003ch2\u003eQuestionnaire Development And Testing:\u003c/h2\u003e\n\u003cp\u003eThe survey questionnaire was developed by modifying a previously developed questionnaire administered to trauma program directors or leaders in the above countries [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The modified questionnaire asked for information about respondents\u0026rsquo; trauma center, including its geographic location, accreditation/verification, verification level, and academic status. It also asked for information about their trauma program, including the numbers and characteristics of injured patients assessed in the last calendar or fiscal year. Finally, it asked how often the trauma program director estimated DC laparotomy was performed on injured patients at that center on average over the last calendar or fiscal year. This last question had the following ordinal response options: 1) at least once daily, 2) more than once weekly but less than once daily, 3) once weekly, 4) once every 2-3-weeks, 5) once monthly, 6) once every 2-3-months, 7) less than once every 3-months, 8) never, 9) other frequency, or 10) unsure. DC laparotomy was defined in the question stem as \u0026ldquo;abbreviated laparotomy with planned reoperation (e.g., packing of the liver followed by temporary abdominal closure with plans for reoperation to remove packs at a later time).\u0026rdquo; The questionnaire\u0026rsquo;s clarity, length, and completeness were assessed during semi-structured interviews with 5 surgeons or physicians. It was then pilot tested on 5 surgeons or physicians and 2 trauma program directors.\u003c/p\u003e\n\u003ch2\u003eQuestionnaire Administration:\u003c/h2\u003e\n\u003cp\u003eAll trauma centers in the sampling frame were purposively sampled by sending an e-mail to their trauma program director or leader in September, 2014 [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. E-mails explained the study purpose and invited potential respondents to participate by accessing a link to a Web-based survey. Consent for study participation was inferred with questionnaire completion. To increase response rate, personalized questionnaires were administered that provided assurance of respondent confidentiality [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Potential respondents were also sent pre-notification and follow-up e-mails at approximately 1 week, 2 to 3 weeks, 4 to 5 weeks, and 5 to 6 weeks followed by a closing soon e-mail at approximately 7\u0026ndash;9 weeks [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e\n\u003ch2\u003eStatistical Methods:\u003c/h2\u003e\n\u003cp\u003eCategorical survey responses were summarized using counts (percentages) and continuous survey responses using medians [with interquartile ranges (IQRs)]. Survey responses were summarized unstratified and stratified by country, reported frequency of use of DC laparotomy, and by volume and level of trauma center care. A high-volume trauma center was defined as per Nathens \u003cem\u003eet al\u003c/em\u003e. as one that assessed\u0026thinsp;\u0026gt;\u0026thinsp;650 major trauma [Injury Severity Scale (ISS) score\u0026thinsp;\u0026gt;\u0026thinsp;15] patients in the last year [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Summary statistics were compared using Fisher\u0026rsquo;s exact and Kruskal-Wallis tests as appropriate.\u003c/p\u003e \u003cp\u003eMultivariable logistic regression with robust standard errors was used to identify independent predictors of a higher reported frequency of use of DC laparotomy across trauma centers. As there have been no studies to guide selection of evidence-informed predictors for inclusion in the model, all variables felt to be potentially predictive that lacked evidence of multicollinearity were included in the model. We also tested whether the volume of severely injured patients modified the relationship between reported frequency of use of DC laparotomy and level-1 verification status.\u003c/p\u003e \u003cp\u003eThe degree of multicollinearity was estimated by calculating associations or correlations between variables and by using the Stata (Stata Corp. College Station, Texas, United States) command package \u0026ldquo;collin\u0026rdquo;. Model fit was tested using the Hosmer and Lemeshow\u0026rsquo;s goodness-of-fit test (non-significant p-values indicate that the model fits the data). Finally, overall classification performance of the logistic regression model was assessed by generating a receiver operating characteristic (ROC) curve that plotted sensitivity against false-positive rate (1-specificity) across a range of diagnostic thresholds.\u003c/p\u003e \u003cp\u003eStatistical analyses were performed using Stata MP version 13.1.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eResponse Rate:\u003c/h2\u003e \u003cp\u003eOf the 366 potentially eligible trauma program directors or leaders that were sent the survey, 199 (51.8%) responded and provided data on the frequency of use of DC laparotomy in their center.\u003c/p\u003e \u003c/div\u003e\n\u003ch2\u003eCharacteristics Of Participating Trauma Centers:\u003c/h2\u003e\n\u003cp\u003eOf the 199 participating trauma centers, 156 (78.4%) were located in the United States, 26 (13.1%) in Canada, and 17 (8.5%) in Australasia. The 156 participating American trauma centers were located in 37 different states, with most in California (17.3%), Texas (9.6%), and Michigan (8.3%) (see the Figure in \u003cb\u003eSupplementary Digital File 1\u003c/b\u003e). The 26 participating Canadian trauma centers were located in 7 different provinces, with most in Alberta (26.9%), Ontario (26.9%), and British Columbia or Nova Scotia (15.4% each). Finally, of the 17 Australasian trauma centers, 13 (76.5%) were located in Australia and 4 (23.5%) in New Zealand.\u003c/p\u003e \u003cp\u003eCharacteristics of the 199 participating trauma centers are outlined in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Ninety (45.9%) were verified or accredited to provide level-1 trauma care, 72 (36.7%) to provide level-2 care, and 26 (13.3%) to provide level-3 care. Trauma centers in the United States and Australasia assessed more adult (p\u0026thinsp;=\u0026thinsp;0.007) and pediatric (p\u0026thinsp;=\u0026thinsp;0.008) trauma patients than those in Canada. Trauma centers in the United States also assessed a higher percentage of patients with penetrating injuries than those in Canada or Australasia (p\u0026thinsp;=\u0026thinsp;0.008). However, the number of severely injured (defined as an ISS score\u0026thinsp;\u0026gt;\u0026thinsp;15) patients assessed was similar across trauma centers in the three regions.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of the Trauma Centers Participating in the Study.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCharacteristic (N\u0026thinsp;=\u0026thinsp;199 Trauma Centers)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eNo. (%) of Trauma Centers*\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eUnited States\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(n\u0026thinsp;=\u0026thinsp;156 Trauma Centers)\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eCanada\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(n\u0026thinsp;=\u0026thinsp;26 Trauma Centers)\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eAustralasia\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(n\u0026thinsp;=\u0026thinsp;17 Trauma Centers)\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAccredited/verified for treatment of\u0026dagger;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdult patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e119 (76.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (34.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (47.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdult and pediatric patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34 (21.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (30.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (29.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot accredited/verified \u0026ndash; treat adult patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (11.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (23.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo accredited/verified \u0026ndash; treat adult and pediatric patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (23.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eACS-designed level of adult care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLevel 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e68/154 (44.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10/196 (38.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12/16 (75.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLevel 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64/154 (41.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (23.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2/16 (12.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLevel 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21/154 (13.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (15.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1/16 (6.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot accredited/verified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (19.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1/16 (6.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1/154 (0.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (3.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeographic location\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.44\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrban (within a city)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e87/150 (58.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (65.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (58.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSuburban (residential area on outskirts of a city)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42/150 (28.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (26.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (41.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRural (outside a city)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21/150 (14.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (7.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTeaching center (regularly has resident physicians on the trauma service)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e83/147 (56.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (70.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (64.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.39\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParticipates in research\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e113/154 (73.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22/24 (91.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLocal investigator-initiated research\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e101/154 (65.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18/24 (75.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (76.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMulticenter research\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e78/154 (50.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16/24 (66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (64.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndustry-sponsored research\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44/154 (28.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5/24 (20.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (29.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDesignated trauma team\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e155/155 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21/25 (84.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDesignated trauma service\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e150/154 (97.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15/25 (60.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (82.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eICU that admits and cares for injured patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e153/153 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24/24 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo. trauma patients assessed in last year, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdult, any ISS score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,500 (953-2,524)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e836 (650-1,349)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1,998.5 (1,300-3,500)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.007\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdult, ISS score\u0026thinsp;\u0026gt;\u0026thinsp;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e250 (142\u0026ndash;452)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e376.5 (129\u0026ndash;520)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e310 (220\u0026ndash;500)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.67\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePediatric, any ISS score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e90 (38\u0026ndash;200)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36 (0-100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e68 (20.5\u0026ndash;400)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.008\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePediatric, ISS score\u0026thinsp;\u0026gt;\u0026thinsp;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (2\u0026ndash;27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (0\u0026ndash;37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (5\u0026ndash;30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.84\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh volume trauma center\u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18/135 (13.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3/22 (13.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (6.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.84\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePercentage of trauma patients assessed in last year with a penetrating injury, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (5\u0026ndash;15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (3-9.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (3\u0026ndash;8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.008\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e*Denominator of responses is given if different than stated in the column heading. The number of responses in a category may be greater than the column or category total if responses are not mutually exclusive.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u0026dagger;Trauma centers in the United States were accredited/verified by the American College of Surgeons; in Canada, the Trauma Association of Canada; and in Australasia, the Royal Australasian College of Surgeons.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u0026Dagger;Defined as a center that assessed\u0026thinsp;\u0026gt;\u0026thinsp;650 major trauma (ISS\u0026thinsp;\u0026gt;\u0026thinsp;15) patients in the last year [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eWhere ACS indicates American College of Surgeons; ICU, intensive care unit; IQR, interquartile range; and ISS, Injury Severity Scale.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eReported Frequency of Use of DC Laparotomy By Trauma Centers\u003c/b\u003e:\u003c/p\u003e \u003cp\u003eThe reported frequency of use of DC laparotomy for trauma by the 199 participating trauma centers was highly variable (see the Figure in \u003cb\u003eSupplementary Digital File 2\u003c/b\u003e). Forty-four (22.1%) trauma centers reported using DC laparotomy less than once every 3 months. Ten (5.0%) reported never using it. Sixty (30.2%) reported using it once monthly or once every 2\u0026ndash;3 months and 73 (36.7%) using it greater than once a month. Twelve (6.0%) trauma centers were unsure how often they used DC laparotomy.\u003c/p\u003e \u003cp\u003eDC laparotomy was reportedly used more frequently in level-1 than level-2 or -3 trauma centers (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). High-volume level-1 trauma centers used DC laparotomy significantly more often than lower volume level-1 trauma centers (p\u0026thinsp;=\u0026thinsp;0.02) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). In total, 24 (77.4%) high-volume and 34 (57.7%) lower volume level-1 trauma centers reported using DC laparotomy greater than once monthly. Further, 15 (48.4%) high-volume and 12 (20.3%) lower volume level-1 trauma centers reported using it at least once weekly. Two (6.4%) high-volume level-1 trauma centers reported never using DC laparotomy for trauma.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003ePredictors of Increased Reported Frequency of Use of DC Laparotomy\u003c/b\u003e:\u003c/p\u003e \u003cp\u003eCharacteristics of the trauma centers that reported using DC laparotomy more instead of less frequently are compared in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Those centers that reported using it more frequently were significantly more likely to be high-volume, level-1, teaching centers located in urban settings. They were also more likely to participate in research and have a designated trauma service. Finally, they were more likely to have assessed a higher number of injured adult and pediatric patients (including those with an ISS\u0026thinsp;\u0026gt;\u0026thinsp;15) and a higher percentage of patients with penetrating injuries in the last year.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of the Participating Trauma Centers That Reported Using Damage Control Laparotomy More Instead of Less Frequently.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCharacteristic (N\u0026thinsp;=\u0026thinsp;199 Trauma Centers)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eNo. (%) of Trauma Centers\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eReported Using DC Laparotomy Greater Than Once Monthly (n\u0026thinsp;=\u0026thinsp;73)\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eReported Using DC Laparotomy Once Monthly or Once Every 2\u0026ndash;3 Months (n\u0026thinsp;=\u0026thinsp;60)\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eReported Using DC Laparotomy Less Than Once Every 3 Months or Never Using It (n\u0026thinsp;=\u0026thinsp;54)\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAccredited/verified for treatment of\u0026dagger;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdult patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48 (65.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41 (68.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39 (72.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdult and pediatric patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (31.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (21.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (14.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot accredited/verified \u0026ndash; treat adult patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (5.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (3.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo accredited/verified \u0026ndash; treat adult and pediatric patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (5.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (9.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eACS-designed level of adult care, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLevel 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58 (79.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20/59 (33.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5/52 (9.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLevel 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (19.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33/59 (55.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22/52 (43.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLevel 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2/59 (3.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23/52 (44.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot accredited/verified or other\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4/59 (6.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2/2 (3.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeographic location\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrban (within a city)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55/72 (76.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28/57 (49.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23/52 (44.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSuburban (residential area on outskirts of a city)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13/72 (18.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24/57 (42.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17/52 (32.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRural (outside a city)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4/72 (5.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5/57 (8.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12/52 (23.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTeaching center (regularly has resident physicians on the trauma service)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55 (75.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30/55 (54.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17/49 (34.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParticipates in research\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64 (87.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45/58 (77.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33/52 (63.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLocal investigator-initiated research\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60 (82.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39/58 (67.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25/51 (49.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMulticenter research\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53 (72.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24/58 (41.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20/51 (39.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndustry-sponsored research\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (43.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17/58 (29.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4/51 (7.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDesignated trauma team\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e73 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58 (96.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e51/52 (98.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDesignated trauma service\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71 (98.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54 (90.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e46/52 (88.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eICU that admits and cares for injured patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72/72 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59/59 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e51/51 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo. trauma patients assessed in last year, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdult, any ISS score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2,326 (1,552-3,034.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,300 (953-1,897)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e733 (480-1,081)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdult, ISS score\u0026thinsp;\u0026gt;\u0026thinsp;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e449.5 (276\u0026ndash;743)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e257 (171\u0026ndash;400)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e97 (50.5\u0026ndash;189)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePediatric, any ISS score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e110 (47\u0026ndash;360)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e86 (39\u0026ndash;197)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e48 (22\u0026ndash;99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.009\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePediatric, ISS score\u0026thinsp;\u0026gt;\u0026thinsp;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21.5 (4\u0026ndash;50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (1\u0026ndash;25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (0.5-6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh volume trauma center\u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18/66 (27.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4/55 (7.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePercentage of trauma patients assessed in last year with a penetrating injury, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.4 (6-17.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.3 (5\u0026ndash;10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (2\u0026ndash;8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e*Denominator of responses is given if different than stated in the column heading. The number of responses in a category may be greater than the column or category total if responses are not mutually exclusive.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u0026dagger;Trauma centers in the United States were accredited/verified by the American College of Surgeons; in Canada, the Trauma Association of Canada; and in Australasia, the Royal Australasian College of Surgeons.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u0026Dagger;Defined as a center that assessed\u0026thinsp;\u0026gt;\u0026thinsp;650 major trauma (ISS\u0026thinsp;\u0026gt;\u0026thinsp;15) patients in the last year [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eWhere ACS indicates American College of Surgeons; ICU, intensive care unit; IQR, interquartile range; and ISS, Injury Severity Scale.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn a multivariable logistic regression model, there was no evidence that the volume of severely injured patients assessed in the last year modified the association between the reported frequency of use of DC laparotomy and level-1 verification status (p\u0026thinsp;=\u0026thinsp;0.35). Variables describing teaching status and trauma center research activities were excluded from logistic regression models because there was evidence of multicollinearity between these variables and level-1 trauma center status. Significant adjusted predictors for more than once monthly reported use of DC laparotomy included country of origin (centers in the United States reported using DC laparotomy significantly more often than those in Canada), level-1 verification status, and the assessment of a higher number of severely injured patients and patients with penetrating injuries in the last year (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The Hosmer and Lemeshow test indicated that the model fit the data well (p\u0026thinsp;=\u0026thinsp;0.62). The area under the ROC curve for the model was 0.88, indicating excellent performance for correctly classifying higher instead of lower reported use of DC laparotomy across trauma centers (see the Figure in \u003cb\u003eSupplementary Digital File 3\u003c/b\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this large, international, cross-sectional survey of trauma program directors or leaders, the reported frequency of use of DC laparotomy was highly variable across trauma centers. DC laparotomy was used more often in level-1 than level-2 or -3 trauma centers in the United States, Canada, and Australasia. The frequency of use of DC laparotomy also varied significantly across level-1 trauma centers, especially between those that were high- versus lower volume (based on the number of severely injured patients assessed in the last year). Nearly half of high-volume, level-1 trauma centers reported using DC laparotomy at least once weekly. Trauma center and program characteristics that independently predicted higher reported use of DC laparotomy included country of origin (with centers in the United States reporting using DC laparotomy significantly more often than those in Canada), level-1 trauma verification status, and the assessment of a higher number of severely injured (ISS score\u0026thinsp;\u0026gt;\u0026thinsp;15) patients and patients with penetrating injuries in the last year.\u003c/p\u003e \u003cp\u003eStudying variation in use of DC laparotomy is important because surgeons are at risk of confirmation bias when only those with whom they work reflect their practice [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. However, to date, only one other study has examined variation in use of DC surgery between trauma centers [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In a post-hoc analysis of the PROPPR trial, DC laparotomy was reportedly used among a highly variable 33\u0026ndash;83% of patients requiring urgent laparotomy across 12 American level-1 trauma centers between 2012 and 2013 [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In the current study, the trauma program directors who were surveyed also reported that the frequency of use of DC laparotomy varied widely across trauma centers, including level-1 trauma centers. Most level-1 trauma centers reported using DC laparotomy at least once a month, and nearly half of high-volume, level-1 trauma centers reported using it at least once weekly. However, 6% of high-volume, level-1 trauma centers reporting never using DC laparotomy during the past year. Reasons for variation in use of DC laparotomy between level-1 trauma centers may include differences in patient injury mechanisms, injury severity, and/or physiology; trauma center experience; trauma surgeon capabilities; and trauma provider education.\u003c/p\u003e \u003cp\u003eTrauma centers in the United States reported using DC laparotomy for trauma more often than those in Canada despite adjustment for level-1 verification status and the volume of severely injured patients and patients with penetrating injuries. This could be because of differences in institutional cultures regarding use of DC laparotomy between countries. It could also be because of unmeasured differences in patient mix between countries aside from injury mechanism or ISS scores (e.g., a higher percentage of patients with high-risk injury patterns, deranged physiology, or who receive significant volumes of resuscitation fluids) or beliefs regarding appropriate indications for use of the procedure [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Of the American, Canadian, and Australasian trauma centers included in this study, a nearly equal percentage reported using the procedure less than once every 3 months or never using it, using it once monthly or once every 2\u0026ndash;3 months, or using it more than once monthly. Further, more than one-third of level-2 centers reported using DC laparotomy once monthly or more than once monthly and even some level-3 trauma centers reported using the procedure. We assume that many of these level-3 (and likely some level-2) trauma centers may be using DC laparotomy to stabilize critically injured patients before transport to a higher level of trauma care [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn addition to country of origin, other independent predictors of an increased reported use of trauma DC laparotomy included level-1 trauma verification status and the assessment of a higher number of severely injured patients and patients with penetrating injuries in the last year. In the post-hoc analysis of the PROPPR study, the ISS score (OR per-1 point increase\u0026thinsp;=\u0026thinsp;1.05; 95% CI\u0026thinsp;=\u0026thinsp;1.02\u0026ndash;1.07) of the patients assessed at level-1 trauma centers also predicted an increased odds of use of DC laparotomy [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. This is likely because high-energy blunt torso trauma often results in high ISS scores and also may produce some of the high-risk injury patterns considered by many surgeons to be appropriate indications for DC laparotomy (e.g., massive pelvic fracture-related hemorrhage or multiple injuries spanning across more than one body cavity that each require surgery) [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Further, while patients with penetrating injuries may have a lower ISS score, those with gunshot wounds (and especially shotgun wounds) more often present with certain injury patterns that have been suggested to be appropriate indications for DC laparotomy [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. These may include a major abdominal vascular injury and multiple associated hollow organ injuries or an injured pancreaticoduodenal complex [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe study findings should be considered in the context of its strengths and limitations. First, the opinions of trauma program directors could be argued to be only estimates of the frequency of use of DC laparotomy. We decided to use survey data from trauma program directors instead of registry or other data because there are limited sources of data available that allow for examination of DC laparotomy practice variation between trauma centers. Further, the ordinal responses provided by trauma program directors are likely accurate within a category of the ordinal response provided. Finally, as the results of this study support the variation in use of DC laparotomy practices identified using PROPPR trial data, we believe they are worth reporting. Second, although we used several techniques shown to increase response rates to surveys (and the response rate is above what has been reported by many surveys reported in the trauma or surgery literature), it is possible that respondents\u0026rsquo; answers on the reported frequency of use of DC laparotomy differ systematically from those who did not respond to the survey [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Third, it could be argued that the data used in this study are somewhat outdated as they are now over 5-years old. However, surgical practice patterns often change slowly [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], and therefore our findings likely still reflect current practice.\u003c/p\u003e \u003cp\u003eThis study has important implications for future research, trauma surgery practice, and quality improvement efforts. First, a systematic review of 36 cohort studies found very little evidence to support that use of DC instead of definitive laparotomy in trauma patients was associated with an improvement in mortality or other patient-important outcomes [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. However, use of the procedure is associated with an increased risk of morbidity, a longer length of intensive care unit and hospital stay, and possibly a reduced quality of life among survivors [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan additionalcitationids=\"CR35\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. As equipoise now exists among some surgeons about the effectiveness of DC for improving mortality in many patients undergoing urgent laparotomy, there is a need for rigorously-designed randomized trials comparing it to definitive trauma laparotomy [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Second, although DC laparotomy is supported by insufficient evidence, nearly half of high-volume, level-1 trauma centers reported using it at least once weekly. One other study reported utilization rates exceeding 80% in some level-1 trauma centers (with most level-1 centers using it among 30% of those undergoing urgent laparotomy) [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Some authors have suggested that more comprehensive indications guiding patient selection for use of DC laparotomy may decrease its associated morbidity and costs [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. However, our group previously compiled a comprehensive list of indications for the procedure that both experts and practicing trauma surgeons consistently agree appropriately indicate its use [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Further, a cohort study suggested that most of the indications that highly predicted use of DC laparotomy in practice had an incidence of 2% or less [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Collectively, the above may indicate that DC laparotomy is presently overused in trauma centers and that efforts to decrease its use may be necessary until further evidence becomes available. The group that may need to be targeted first include high-volume, level-1 trauma centers, particularly those that often manage penetrating injuries. Indeed, some data suggests that utilization rates of DC laparotomy can be safely reduced through quality improvement efforts such as audit-and-feedback without adversely influencing patient outcomes [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e].\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn this large, international, cross-sectional survey of trauma program directors or leaders, the reported frequency of use of DC laparotomy was highly variable across level-1, -2, and \u0026minus;\u0026thinsp;3 trauma centers. The reported frequency of use of DC laparotomy also varied significantly across level-1 trauma centers, especially between those that were high- versus lower volume. The procedure was used most often in level-1 trauma centers in the United States that assessed a large percentage of patients with penetrating injuries. Nearly half of high-volume, level-1 trauma centers reported using DC laparotomy at least once a week. Those trauma centers that most need to evaluate the benefit-to-risk ratio of using DC laparotomy in different scenarios may include high-volume, level-1 trauma centers, particularly those that often manage patients with penetrating injuries.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eConfidence interval\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDamage control\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIQR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInterquartile range\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eISS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInjury Severity Scale\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eOR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eOdds ratio\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePROPPR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePragmatic, Randomized Optimal Platelet and Plasma Ratios\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eROC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eReceiver operating characteristic\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSTROBE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStrengthening of Observational Studies in Epidemiology\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe University of Calgary Conjoint Health Research Ethics Board approved the study. Consent to participate in the study was implied with survey completion.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudy data are available upon request from the principal author (D.J.R.).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDr. Kirkpatrickhas consulted for Zoll, Innovative Trauma Care, CSL Behring, and SAM Medical Corporations, and is the principal investigator for a randomized controlled trial partially supported by Acelity Corporation. Dr. Moore receives research support from Haemonetics, Instrumentation Laboratory, Hemosonics, Diapharma, Humacyte, and Genetech. He is also the cofounder of ThromboTherapeutics. The other authors have no conflicts of interest to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was funded by an Alberta Innovates \u0026ndash; Health Solutions Clinician Fellowship Award, a Knowledge Translation (KT) Canada Strategic Training in Health Research Fellowship, a KT Canada Student Research Stipend, and funding from the University of Calgary Clinician Investigator and Surgeon-Scientist Programs (all awarded to D.J.R.).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eD.J.R. contributed to the study concept. All authors contributed to the study design. D.J.R. obtained funding for the study, created the protocol, designed the survey instrument, administered the survey instrument and sent reminders, and drafted the manuscript. D.J.R. also conducted the data analyses with input from P.D.F. and H.T.S. The manuscript was then critically revised after input from P.D.F., C.G.B., A.W.K., E.E.M., D.V.F., P.R., S.D., and H.T.S. H.T.S. contributed to study supervision. All authors approved the final version of the manuscript for submission for peer-review.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRoberts DJ, Ball CG, Feliciano DV, Moore EE, Ivatury RR, Lucas CE, et al. History of the Innovation of Damage Control for Management of Trauma Patients: 1902\u0026ndash;2016. Ann Surg. 2017 May;265(5):1034\u0026ndash;44. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/sla.0000000000001803\u003c/span\u003e\u003c/span\u003e. PMID: 27232248.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStone HH, Strom PR, Mullins RJ. 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PMID: 17033548.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarvin JA, Podbielski J, Vincent LE, Fox EE, Moore LJ, Cotton BA, et al. Damage control laparotomy trial: design, rationale and implementation of a randomized controlled trial. Trauma Surg Acute Care Open. 2017;2(1):e000083. PMID: 29766087. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/tsaco-2017-000083\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJoseph B, Azim A, Zangbar B, Bauman Z, OʼKeeffe T, Ibraheem K, et al. Improving mortality in trauma laparotomy through the evolution of damage control resuscitation: Analysis of 1,030 consecutive trauma laparotomies. J Trauma Acute Care Surg. 2017 Feb;82(2):328\u0026ndash;33. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/ta.0000000000001273\u003c/span\u003e\u003c/span\u003e. PMID: 27805990.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarvin JA, Kao LS, Liang MK, Adams SD, McNutt MK, Love JD, et al. Decreasing the Use of Damage Control Laparotomy in Trauma: A Quality Improvement Project. J Am Coll Surg. 2017 Aug;225(2):200\u0026ndash;9. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jamcollsurg.2017.04.010\u003c/span\u003e\u003c/span\u003e. PMID: 28445796.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"world-journal-of-emergency-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"wjes","sideBox":"Learn more about [World Journal of Emergency Surgery](http://wjes.biomedcentral.com)","snPcode":"13017","submissionUrl":"https://submission.nature.com/new-submission/13017/3","title":"World Journal of Emergency Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Cross-Sectional Study, Damage Control Laparotomy, Surgical Variation, Wounds and Injuries","lastPublishedDoi":"10.21203/rs.3.rs-728617/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-728617/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e It is unknown how frequently damage control (DC) laparotomy is used across trauma centers in different countries. We conducted a cross-sectional survey of trauma centers in the United States, Canada, and Australasia to study variations in use of the procedure and predictors of more frequent use of DC laparotomy.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A self-administered, electronic, cross-sectional survey of trauma centers in the United States, Canada, and Australasia was conducted. The survey collected information about trauma center and program characteristics. It also asked how often the trauma program director estimated DC laparotomy was performed on injured patients at that center on average over the last year. Multivariable logistic regression was used to identify predictors of a higher reported frequency of use of DC laparotomy.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eOf the 366 potentially eligible trauma centers sent the survey, 199 (51.8%) trauma program directors or leaders responded [United States=156 (78.4%), Canada=26 (13.1%), and Australasia=17 (8.5%)]. The reported frequency of use of DC laparotomy was highly variable across trauma centers. DC laparotomy was used more frequently in level-1 than level-2 or -3 trauma centers. Further, high-volume level-1 centers used DC laparotomy significantly more often than lower volume level-1 centers (p=0.02). Nearly half (48.4%) of high-volume volume level-1 trauma centers reported using the procedure at least once weekly. Significant adjusted predictors of more frequent use of DC laparotomy included country of origin [odds ratio (OR) for the United States vs. Canada=7.49; 95% confidence interval (CI)=1.39-40.27], level-1 verification status (OR=6.02; 95% CI=2.01-18.06), and the assessment of a higher number of severely injured (Injury Severity Scale score \u0026gt;15) patients (OR per-100 patients=1.62; 95% CI=1.20-2.18) and patients with penetrating injuries (OR per-5% increase=1.27; 95% CI=1.01-1.58) in the last year.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e The reported frequency of use of DC laparotomy was highly variable across trauma centers. Those centers that most need to evaluate the benefit-to-risk ratio of using DC laparotomy in different scenarios may include high-volume, level-1 trauma centers, particularly those that often manage penetrating injuries.\u003c/p\u003e","manuscriptTitle":"Variation in Use of Damage Control Laparotomy for Trauma By Trauma Centers in the United States, Canada, and Australasia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-07-26 14:59:27","doi":"10.21203/rs.3.rs-728617/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2021-07-26T00:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2021-07-25T00:00:00+00:00","index":1,"fulltext":"Recommendation: Reviewer's comments unavailable due to the journal's policy.\n"},{"type":"editorInvitedReview","content":"","date":"2021-07-25T00:00:00+00:00","index":2,"fulltext":"Recommendation: Reviewer's comments unavailable due to the journal's policy.\n"},{"type":"editorInvitedReview","content":"","date":"2021-07-22T15:28:04+00:00","index":0,"fulltext":""},{"type":"reviewerAgreed","content":"","date":"2021-07-22T00:00:00+00:00","index":2,"fulltext":""},{"type":"editorAssigned","content":"","date":"2021-07-20T08:19:51+00:00","index":"","fulltext":""},{"type":"reviewersInvited","content":"","date":"2021-07-20T00:00:00+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2021-07-20T00:00:00+00:00","index":1,"fulltext":""},{"type":"checksComplete","content":"","date":"2021-07-19T23:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2021-07-19T23:00:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"World Journal of Emergency Surgery","date":"2021-07-17T13:46:47+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"world-journal-of-emergency-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"wjes","sideBox":"Learn more about [World Journal of Emergency Surgery](http://wjes.biomedcentral.com)","snPcode":"13017","submissionUrl":"https://submission.nature.com/new-submission/13017/3","title":"World Journal of Emergency Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8ad2f15d-b6d0-4a25-936e-b137d339525a","owner":[],"postedDate":"July 26th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":5968893,"name":"Critical Care \u0026 Emergency Medicine"},{"id":5968894,"name":"Surgery"}],"tags":[],"updatedAt":"2021-09-19T18:08:22+00:00","versionOfRecord":[],"versionCreatedAt":"2021-07-26 14:59:27","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-728617","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-728617","identity":"rs-728617","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}