Outcomes for trauma: is there an end (result) in sight?

In the following address I will discuss the role that EAST has had in developing an evidence-based approach to the practice of trauma, why it is important, who has made it important, and what the future of trauma outcomes will likely resemble. This talk is the third in a series, a series that started in the early 1990s, and hopefully will continue into the future. It also reinforces and extends the thoughts that Dr. Russell left us with yesterday in his address regarding the future of quality assessment in surgery. In 1994, in his presidential address to the Seventh Scientific Assembly of EAST, Dr. Michael Rhodes introduced us to the concepts of evidence-based medicine and practice management guidelines. Evidence-based medicine is defined as a method of patient care, decision making, and teaching that integrates high-quality research evidence with physiologic reasoning, experience, and patient preference. Patient management guidelines are systematically developed statements designed to assist practitioners in making decisions about appropriate healthcare for specific clinical circumstances. The five major purposes of practice management guidelines are to assist clinical decision making by patients and practitioners, educate individuals or groups of individuals, assess quality of care, guide the allocation of resources, and reduce the risk for legal liability. In his discussion, Dr. Rhodes stressed that the idea was to base clinical decisions on the best available evidence and understand the power or quality of that evidence. Evidencebased practice involves, at its core, a fundamental acknowledgment that our clinical convictions can be wrong as well as the fact that we invariably underestimate the power of the placebo effect and assume that because most patients we treat in a certain way feel better, the treatment must be effective. Obviously, these concepts were not universally embraced when they were first introduced, and a great deal of work has been put forth to arrive at where we are today with evidencebased practice. In addition to patients and practitioners, it was felt that guidelines could be useful to purchasers of healthcare, legislators, and regulators. Further, it was felt that guidelines must be used to decrease unnecessary practice variation, formulate necessary research proposals, and most importantly, evaluate outcomes of care. Only through such measures can patientspecific guidelines be developed and improvements in care be realized. Dr. Rhodes challenged the organization to move forward in developing such guidelines and EAST responded. Subsequent to his address, a jointly sponsored conference by EAST and HRSA (Health Resources and Services Administration) was held to define the methodology for practice management guideline development, leading to the creation of the first subcommittees addressing specific trauma related topics for guideline creation. This ultimately led to the 1998 Journal of Trauma article in which practice management guidelines for screening for blunt cardiac injury, cervical spine clearance, prophylaxis for venous thromboembolic disease, and antibiotic prophylaxis for penetrating abdominal trauma were presented. At around the same time, EAST established its Website and began placing the guidelines on the site thereby making them available to the membership and others interested in trauma care. Today, there are 27 guidelines, as well as a primer describing the evidence-based methodology for guideline development available for viewing. To date, there have been 283,056 downloads of the various guidelines, and on average, there are 775 hits per day on the guideline section of the EAST Website. Importantly, EAST, recognizing the evolution of acute care surgery, has charged the Guidelines Committee to begin to develop guidelines on emergency and acute care surgery subjects, and they have responded by preparing several relevant guidelines that will be presented later at this meeting during the plenary session on Friday. In 1999, Dr. Timothy Fabian addressed the 12th Scientific Assembly, reminding us that EAST had made an early and profound impact on evidence-based medicine through the management guidelines project. In a Star Wars analogy, he noted that we, like the crew of the Millennium Falcon, had begun a journey not quite sure whether our ship would make it to wherever we were going, but knowing that we could adapt and Submitted for publication October 11, 2007. Accepted for publication October 17, 2007. Copyright © 2008 by Lippincott Williams & Wilkins From the Department of Surgery, Lehigh Valley Hospital, Allentown, PA. Presented as the presidential address at the 20th Annual Meeting of the Eastern Association for the Surgery of Trauma, January 16–20, 2007, Fort Meyers, Florida. Address for reprints: Michael D. Pasquale, MD, FACS, FCCM, Div. Trauma/Surgical Critical Care, Lehigh Valley Hospital, P.O. Box 689, Cedar Crest & I-78, Allentown, PA 18105-1556; email: sally.lutz@lvh.com.