Management of Non-Compressible Torso Hemorrhage of the Abdomen in Austere/Remote Environments by Non-Surgeon Using Truncal Hemorrhage Control

Background: Non-compressible torso hemorrhage (NCTH) of the abdomen is a potentially preventable cause of death due to injury. Over the last 26 years, the trauma community has not developed a temporizing or definitive intervention to preserve life in patients with non-compressible torso hemorrhage of the abdomen due to trauma. Individuals who sustain survivable injuries that are associated with non-compressible torso hemorrhage of the abdomen will, on average bleed out or hemorrhage within 30 minutes of sustaining injury. Truncal hemorrhage control is the intervention this research study would implement by non-surgeons managing patients with non-compressible torso hemorrhage of the abdomen in austere/remote environments. Truncal hemorrhage control by a non-surgeon is not a definitive hemorrhage control intervention; it is a temporizing intervention to sustain life until definitive surgical intervention by Trauma Surgeons can be obtained. Non-surgeons performing truncal hemorrhage control on patients with non-compressible torso hemorrhage of the abdomen may bridge the gap to decreasing mortality in the last of five preventable causes of death due to injury. Objective: This multi-phased research project aims (1) to gain consensus on an evidence-informed protocol, (2) assess barriers and facilitators to those items that did not gain consensus, assess barriers and facilitators to implementation, and (3) to develop strategies/Next Steps to overcome the barriers to those items that did not gain consensus, to develop a revised evidence-informed protocol and to develop Next Steps to overcome the barriers to implementation of an evidence-informed protocol toward non-surgeons performing truncal hemorrhage control on patients with non-compressible torso hemorrhage of the abdomen in the austere/remote environment. Method: This research project\u27s study design was conducted using three methodologies to answer the three written Aims and four research questions. The first Aim and the first and second research questions were investigated using a modified Delphi Study to gain expert and stakeholder consensus to assess the acceptability of an established evidence-informed protocol for non-surgeons to perform truncal hemorrhage control on patients’ non-compressible torso hemorrhage of the abdomen in austere/remote environments. The second Aim and third research question were investigated using a qualitative interview design to assess barriers to those items that did not establish consensus during the modified Delphi Study and assess barriers and facilitators to implementing an evidence-informed protocol. The third Aim and fourth research question were investigated using a qualitative focus group to identify strategies/Next Steps to overcome the barriers to gaining consensus and implementing an evidence-informed protocol for General Surgery Physician Assistants/Associates to perform truncal hemorrhage control on patients with non-compressible torso hemorrhage of the abdomen in austere/remote environments. Results: A modified Delphi survey was used to assess the consensus of 24 statements. There were two rounds of the modified Delphi survey each round was to gain consensus on the 24 statements to assess the acceptability of non-surgeons performing truncal hemorrhage control to manage non-compressible torso hemorrhage. The first modified Delphi Survey had a total of 29 participants (19 Trauma Surgeons and 10 General Surgery Physician Assistants/Associates) to assess consensus on 24 statements. Thirteen of the 24 statements gained consensus during the first modified Delphi Survey. The statements that did not gain consensus were restructured based on comments from the participants of the initial modified Delphi Survey. The second round of the modified Delphi survey had 27 of the original 29 participants (17 Trauma Surgeons and 10 General Surgery Physician Assistants/Associates) to assess the revised statements that did not gain consensus during the first modified Delphi survey. Six of the revised 13 questions gained consensus during the second round of the modified Delphi survey. Of the original 24 Statements presented to gain consensus, 19 of the statements gained consensus after the second round of the modified Delphi Survey. The second phase of this dissertation research study comprised qualitative interviews to assess barriers and facilitators to gaining consensus for those items that did not gain consensus and for implementation of the evidence-informed protocol. There was one round of qualitative interviews with a total of 19 participants (14 Trauma Surgeons and 5 General Surgery Physician Assistants/Associates). One participant had to be excluded because the participant did not meet the inclusion criteria that were discovered during the course of the interview. Thematic analysis with an inductive approach was used to yield three overarching themes based on eight established categories related to barriers and facilitators of gaining consensus and implementing an evidence-informed protocol. The three overarching themes are: Theme-1: Providing General Surgery Physician Assistants/Associates with a validated roadmap to implementing management of noncompressible torso hemorrhage of the abdomen in austere/remote environments to increase trauma surgical capabilities, Theme-2: The diversity in education of fellowship-trained and on-the-job-trained General Surgery Physician Assistants/Associates in clinical and operative practice does not always lead to positive outcomes in their clinical and operative practice, Theme-3: Contextual determinants impede the implementation of Trauma Surgeons as change agents for General Surgery Physician Assistants/Associates in the management of non-compressible torso hemorrhage of the abdomen in austere/remote environments. The third phase of this dissertation research study comprised focus groups to assess strategies/Next Steps to overcome the barriers to gaining consensus and implementing an evidence-informed protocol. There were two separate focus groups to accommodate the participant’s work schedules. The two focus groups were on two separate days lasting for approximately one hour and 10 to 15 minutes each. There was a total of nine participants (6 Trauma Surgeons and 3 General Surgery Physician Assistants/Associates). The first focus group on day one had four participants (2 Trauma Surgeons and 2 General Surgery Physician Assistants/Associates), and the second focus group on day two had five participants (4 Trauma Surgeons and 1 General Surgery Physician Assistant/Associate). Inductive content analysis was used to yield five overarching Next Steps based on 17 codes related to overcoming the barriers to gaining consensus and implementing an evidence-informed protocol. The five overarching Next Steps are: Next Step-1: Embed General Surgery Physician Assistants/Associates on a surgical team and scaling up as a force multiplier to develop trust amongst change agents of the trauma surgery community will increase surgical capacity for the future; Next Step-2: Develop a plan for General Surgery Physician Assistants/Associates to acquire resuscitative and operative skills, sustain those skills, and develop a comprehensive understanding to make appropriate surgical decision-making in operative and non-operative trauma surgery; Next Step-3: Develop and implement a General Surgery Physician Assistants/Associates practice standardization capabilities proposal to increase surgical awareness within the surgical community of the General Surgery Physician Assistants/Associates capabilities; Next Step-4: Identify the non-surgical and or surgical team for implementation of General Surgery Physician Assistants/Associates to be a functional team member with direct supervision from a Trauma Surgeon until they acquire the comprehensive understanding to work with indirect supervision; Next Step-5: Identify Trauma Surgeons who are willing to be change agents for General Surgery Physician Assistants/Associates to increase surgical capacity within the Trauma Surgery community in austere/remote environments. Conclusion: Implementation of an evidence-informed protocol for the management of non-compressible torso hemorrhage of the abdomen by General Surgery Physician Assistants/Associates is a feasible option. General Surgery Physician Assistants/Associates will need to undergo formal training to acquire the appropriate skills to manage a patient with non-compressible torso trauma of the abdomen. Additionally, under the direct and or indirect supervision of a Trauma Surgeon, the General Surgery Physician Assistant/Associate will be required to sustain the newly acquired skills by repeated exposure to develop a comprehensive understanding which will allow the General Surgery Physician Assistant/Associate to make sound and just decisions when managing a patient with non-compressible torso hemorrhage of the abdomen. Understanding the barriers and facilitators to gaining consensus on those items that did not gain consensus during the modified Delphi Survey and implementing an evidence-informed protocol for General Surgery Physician Assistants/Associates to perform truncal hemorrhage control in austere/remote environments has supported the development of Next Steps. The five Next Steps that emerged will facilitate future consensus and implementation of an evidence-informed protocol for General Surgery Physician Assistant/Associate to perform truncal hemorrhage control of the abdomen in an austere/remote environment. However, as soon as possible, General Surgery Physician Assistant/Associate should be considered and inducted as members of an austere/remote Advanced Resuscitative Care Team or operative team with direct Trauma Surgeon supervision until a resuscitative and operative comprehensive understanding has been developed to allow for indirect supervision. General Surgery Physician Assistants/Associates working alongside Trauma Surgeons as surgical force multipliers will increase surgical capacity and potentially lead to a decrease in the mortality of patients with non-compressible torso hemorrhage of the abdomen in austere/remote environments