Shahid Shafi M.D.

Dahdah, M. N., S. Barnes, A. Buros, R. Dubiel, C. Dunklin, L. Callender, C. Harper, A. Wilson, R. Diaz-Arrastia, T. Bergquist, M. Sherer, G. Whiteneck, C. Pretz, R. D. Vanderploeg and S. Shafi (2016). “Variations in inpatient rehabilitation functional outcomes across centers in the traumatic brain injury model systems study and the influence of demographics and injury severity on patient outcomes.” Arch Phys Med Rehabil 97(11): 1821-1831.

Full text of this article.

OBJECTIVE: To compare patient functional outcomes across Traumatic Brain Injury Model Systems (TBIMS) rehabilitation centers using an enhanced statistical model and to determine factors that influence those outcomes. DESIGN: Multicenter observational cohort study. SETTING: TBIMS centers. PARTICIPANTS: Patients with traumatic brain injury (TBI) admitted to 19 TBIMS rehabilitation centers from 2003-2012 (N=5505). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Functional outcomes of patients with TBI. RESULTS: Individuals with lower functional status at the time of admission, longer duration of posttraumatic amnesia, and higher burden of medical comorbidities continued to have worse functional outcomes at discharge from inpatient rehabilitation and at the 1-year follow-up, whereas those who were employed at the time of injury had better outcomes at both time periods. Risk-adjusted patient functional outcomes for patients in most TBIMS centers were consistent with previous research. However, there were wide performance differences for a few centers even after using more recently collected data, improving on the regression models by adding predictors known to influence functional outcomes, and using bootstrapping to eliminate confounds. CONCLUSIONS: Specific patient, injury, and clinical factors are associated with differences in functional outcomes within and across TBIMS rehabilitation centers. However, these factors did not explain all the variance in patient outcomes, suggesting a role of some other predictors that remain unknown.

Shafi, S., S. Barnes, C. Ahn, M. R. Hemilla, H. G. Cryer, A. Nathens, M. Neal and J. Fildes (2016). “Characteristics of acs-verified level i and level ii trauma centers: A study linking trauma center verification review data and the national trauma data bank of the american college of surgeons committee on trauma.” J Trauma Acute Care Surg 81(4): 735-742.

Full text of this article.

BACKGROUND: The Trauma Quality Improvement Project of the American College of Surgeons (ACS) has demonstrated variations in trauma center outcomes despite similar verification status. The purpose of this study was to identify structural characteristics of trauma centers that affect patient outcomes. METHODS: Trauma registry data on 361,187 patients treated at 222 ACS-verified Level I and Level II trauma centers were obtained from the National Trauma Data Bank of ACS. These data were used to estimate each center’s observed-to-expected (O-E) mortality ratio with 95% confidence intervals using multivariate logistic regression analysis. De-identified data on structural characteristics of these trauma centers were obtained from the ACS Verification Review Committee. Centers in the lowest quartile of mortality based on O-E ratio (n = 56) were compared to the rest (n = 166) using Classification and Regression Tree (CART) analysis to identify institutional characteristics independently associated with high-performing centers. RESULTS: Of the 72 structural characteristics explored, only 3 were independently associated with high-performing centers: annual patient visits to the emergency department of fewer than 61,000; proportion of patients on Medicare greater than 20%; and continuing medical education for emergency department physician liaison to the trauma program ranging from 55 and 113 hours annually. Each 5% increase in O-E mortality ratio was associated with an increase in total length of stay of one day (r = 0.25; p < 0.001). CONCLUSIONS: Very few structural characteristics of ACS-verified trauma centers are associated with risk-adjusted mortality. Thus, variations in patient outcomes across trauma centers are likely related to variations in clinical practices.

Shafi, S., A. W. Collinsworth, K. M. Richter, H. B. Alam, L. B. Becker, M. R. Bullock, J. M. Ecklund, J. Gallagher, R. Gandhi, E. R. Haut, Z. L. Hickman, H. Hotz, J. McCarthy, A. B. Valadka, J. Weigelt and J. B. Holcomb (2016). “Bundles of care for resuscitation from hemorrhagic shock and severe brain injury in trauma patients-translating knowledge into practice.” J Trauma Acute Care Surg 81(4): 780-794.

Full text of this article.

Although clinical practice guidelines for the management of hemorrhagic shock and TBI have been developed and disseminated by multiple organizations, adoption of evidence-based practices at trauma centers remains suboptimal.7,8 In a study of 5 Level I trauma centers, compliance with 22 commonly recommended clinical practices for TBI, hemorrhagic shock, pelvic fractures, and long-bone extremity fractures ranged from 13% to 94%.7 After adjustment for patient demographics and injury severity, each 10% increase in compliance with recommended care was associated with a 14% reduction in risk of death. These findings indicate a gap in knowledge translation.8–10

Tominaga, G. T., K. L. Staudenmayer, S. Shafi, K. M. Schuster, S. A. Savage, S. Ross, P. Muskat, N. T. Mowery, P. Miller, K. Inaba, M. J. Cohen, D. Ciesla, C. V. Brown, S. Agarwal, M. B. Aboutanos, G. H. Utter and M. Crandall (2016). “The american association for the surgery of trauma grading scale for 16 emergency general surgery conditions: Disease-specific criteria characterizing anatomic severity grading.” J Trauma Acute Care Surg 81(3): 593-602.

Full text of this article.

The concepts for the EGS grading scales were modeled loosely from cancer staging criteria and trauma organ injury scales. For each of EGS diseases, the descriptions and grade were specifically defined using findings derived from four distinct categories: (1) clinical, (2) imaging, (3) operative, and (4) pathologic. These categories were selected to create the most holistic picture of the disease process. Furthermore, it was recognized that not all EGS conditions would require operative intervention, so the grading system could not rely solely on operative or pathologic findings. In cases where the grade differed between the four categories, the highest grade of EGS disease would apply. For example, if the computed tomography (CT) scan shows evidence of acute gangrenous appendicitis without perforation (Grade 2) but the pathologic findings are transmural necrosis with perforation (Grade 3), then the patient would be classified as Grade 3. Definitions were derived after examination of existing grading systems, review of the literature, and expert opinion. Previously reported scoring systems for these 16 EGS diseases were reviewed. No anatomic disease grading scales were found for breast abscess, intestinal obstruction, infectious colitis, pelvic inflammatory disease, and pleural space infections. Diagnostic imaging (CT, magnetic resonance imaging [MRI], ultrasound, endoscopic, nuclear medicine scan) descriptions based on disease severity have been published for acute cholecystitis,18–20 acute diverticulitis,9,10,21,22 esophageal perforation,23 acute pancreatitis,24–26 pelvic inflammatory disease,27 perforated peptic ulcer,28 and perirectal abscess.29 These were reviewed and incorporated into our data dictionary for these disease processes where applicable. Proposed EGS disease data dictionaries for each grade of disease were then carefully reviewed and revised until a consensus was achieved.

Shafi, S., A. W. Collinsworth, K. M. Richter, H. B. Alam, L. B. Becker, M. R. Bullock, J. M. Ecklund, J. Gallagher, R. Gandhi, E. R. Haut, Z. L. Hickman, H. Hotz, J. McCarthy, A. B. Valadka, J. Weigelt and J. B. Holcomb (2016). “Bundles of care for resuscitation from hemorrhagic shock and severe brain injury in trauma patients – translating knowledge into practice.” J Trauma Acute Care Surg: 2016 Jul [Epub ahead of print].

Full text of this article.

BACKGROUND: Hemorrhagic shock and traumatic brain injury (TBI) are the 2 leading causes of death after injuries. Evidence-based practice guidelines for managing patients with these conditions have been developed, but their adoption remains suboptimal. Bundles of care for other conditions have been shown to improve compliance with evidence-based practices and patient outcomes. We sought to develop evidence-based bundles of care for early management of hemorrhagic shock and severe TBI. METHODS: We conducted a literature review to identify current treatment recommendations and supporting evidence for hemorrhagic shock and severe TBI. A multispecialty panel of 14 experienced surgeons, physicians, nurses and a former trauma patient reviewed the recommendations. The Delphi method was used to reach consensus. RESULTS: After an extensive literature review and three rounds of the Delphi process, the panel recommended 5 interventions for managing each condition. The bundle for resuscitation from hemorrhagic shock include: 1) Activate massive transfusion protocol; 2) Measure lactate or base deficit upon arrival; 3) Transfuse packed red blood cells, plasma, and platelets in a 1:1:1 ratio; 4) Measure coagulopathy using viscoelastic methods upon arrival; and 5) Do not use large volume crystalloid resuscitation. The bundle for early management of severe TBI included: 1) Avoid and treat hypoxia; 2) Avoid and treat hypotension; 3) Avoid excessive hyperventilation; 4) Evaluate and treat intracranial hypertension; and 5) Do not use steroids. CONCLUSIONS: We have proposed 2 evidence-based bundles of care for the early management of injured patients presenting with hemorrhagic shock and severe TBI. Further studies are needed to assess implementation of these bundles and their impact on patient outcomes.