How Often Are Protocols Followed at Level I Trauma Centers?


This study analyzes adherence to an evidence-based protocol established at two level I trauma centers to determine its effect on clinical decision making. The centers’ trauma databases were retrospectively studied and 51 patients with long bone fractures were identified who required revascularization and orthopaedic intervention and survived long enough to receive an index intervention. An arterial shunt was the protocol’s first step; the preprotocol rate of shunting was 9.5%, while the postprotocol rate of shunting was 3.3%. The protocol’s next step was external fixation; among the cases managed without a shunt, external fixation was the index intervention in 63.2% of the preprotocol cases and 31.0% of the postprotocol cases. Definitive vascular surgery was routinely performed before external fixation in 28.6% of the preprotocol cases and 56.7% of the postprotocol cases. This study demonstrates that this evidence-based protocol had no effect on the management of patients with combined orthopaedic and vascular injuries. Protocols should never supersede clinical judgment, but poor protocol adherence may represent a need for trauma centers to routinely review their protocols’ compliance and efficacy. (Journal of Surgical Orthopaedic Advances 27(2):109–112, 2018)
Key words: ACS, adherence, American College of Surgeons, arterial, clinical practice guideline, compliance, level I, long bone, open fracture, protocol, shunt, trauma center, type IIIC open fracture, vascular injury

Richard W. Nicolay, MD; Akhil A. Tawari, MD; Harish Kempegowda, MD; Michael Suk, MD; and Brian Mullis, MD