Utilization of pre-hospital pelvic circumferential compression devices for pelvic fractures: survey of U.S. level I trauma centers

Introduction There is a lack of data on the use and effectiveness of pre-hospital pelvic circumferential compression devices (PCCD) as a temporary intervention for pelvic fracture management; they are thought to decrease pelvic volume and hemorrhage but are not without risks. The purpose of this study is to examine pre-hospital PCCD practices at US Level I trauma centers. Methods This was a prospective cross-sectional survey of trauma medical directors at US Level I trauma centers. The aim of this study was to describe patterns of pre-hospital PCCD utilization for pelvic fractures. Responses were compared by region, length in time the center was designated Level I, trauma patient volume, pelvic management guideline followed and blood product guidelines. Data were compared using Fisher’s exact and chi-squared tests. Results Of the 158 Level I trauma centers invited, 25% responded. All Level I trauma centers use in-hospital PCCDs, whereas 71% of participant’s paramedic agencies trained on pre-hospital PCCD application. Of those, 44% trained to apply pre-hospital PCCDs to all suspected pelvic fractures. A higher proportion of high-volume centers (77%) than low-volume centers (25%) trained on pre-hospital PCCD placement, p = 0.06. PCCD practices were not dependent on the trauma center’s region, trauma volume, length in time as a Level I trauma center, or pelvic fracture guideline followed. Conclusions There is widespread application of in-hospital and pre-hospital PCCD at US Level I trauma centers, however pre-hospital PCCDs are not applied to all suspected pelvic fractures. Future studies should focus on efficacy, safety, and contraindications for pre-hospital PCCDs.


Introduction
The use of pelvic circumferential compression devices (PCCD) such as binders, sheets, or wraps, for pelvic fracture management are common. Their use is recommended by the Eastern Association for the Surgery of Trauma (EAST), Western Trauma Association (WTA), Advanced Trauma Life Support (ATLS), the World Society of Emergency Surgery (WSES), and Trauma Quality Improvement Project (TQIP) [1][2][3][4][5]. However, most studies consist of case reports or studies of human cadaveric specimens, with no Level I or II evidence on the effectiveness of PCCDs for pelvic fractures [6]. PCCDs are thought to decrease pelvic volume and limit hemorrhage but they are not without risk for skin damage, internal organ damage, increase in pelvic inlet area, internal rotation, ulceration, and additional fracturing for lateral compression fractures [1,3,4,[6][7][8][9]. It remains unresolved whether PCCD placement for certain fracture types is contraindicated [6].
Moreover, there is little data available on the use, effectiveness, and safety of PCCDs applied in a pre-hospital setting [6]. The only guideline that states that PCCD can be placed prehospital is the WTA guideline, but the WTA guideline also states that PCCDs are contraindicated for lateral compression fractures, which would likely be unknown during pre-hospital application [2,8]. Given the lack of data on the use and effectiveness of pre-hospital PCCDs, it is important to know current practices at Level I trauma centers. This study aimed to describe PCCD practices and to explore the relationship between Level I trauma center characteristics and practices via National survey.

Methods
This anonymous cross-sectional survey conducted via SurveyMonkey Inc. (San Mateo, California; www.surveymonkey.com) was approved by the Western Institutional Review Board. Level I trauma centers were identified from the American College of Surgeons (ACS) website and the trauma medical director was identified via telephone or the center's website. Six email invitations were sent to 158 trauma medical directors at all ACS-verified Level I trauma centers, to view invitees, see Appendix 1. SurveyMonkey kept responses anonymous while tracking participation so that only those who did not participate, or those who did not reject the invitation to participate, were sent reminder email invitations. Responses to survey questions were not linked to those who participated. The trauma medical director was called before sending the final two invitations to confirm they received the invitation.
Forty-six questions were asked; questions pertaining to this manuscript can be found in Table 1 in Appendix 2. SurveyMonkey's 'skip logic' skipped irrelevant questions; for example, if the paramedic agency did not train on pre-hospital PCCD placement, then the participant was not asked if the paramedic agency trained to apply prehospital PCCDs to all pelvic fractures. Participants were also able to skip questions for any reason; therefore, the denominator reported for each question varies based on the number of participants who responded. Level I trauma center characteristics have been previously reported and included the US census bureau region, volume of trauma admissions in 2017, and length in time the center has been an ACS-verified Level I trauma center [10,11]. The volume of trauma admissions was dichotomized as high-volume (≥1501 admissions) and low-volume (≤1500 admissions).
Responses to survey questions were summarized as proportions (counts). The relationship between survey responses on the application of pre-hospital PCCDs with the Level I trauma center's characteristics and guidelines were compared using Fisher's exact or chi-squared tests when appropriate, alpha = 0.05. Level I trauma center's characteristics included: the region of the participating trauma center, the volume of trauma admissions in 2017, and the length of time in years that the participating center has been an ACS-verified Level I trauma center. Guideline characteristics of interest included: the guideline followed, the year that the guideline followed was published, and the inclusion of blood products in the guideline followed.

Results
Of the 158 invited to participate in the survey, 25% (40/ 158) responded and 90% (36/40) completed the survey. Seventy-one percent (25/35) of participants reported that their paramedic agency required training on PCCD application ( Table 1 in Appendix 2). Of those, 44% (11/ 25) of paramedic agencies trained to apply pre-hospital PCCDs to all suspected pelvic fractures. Although not everyone used pre-hospital PCCD, all participants [100% (27/27)] utilized in-hospital PCCD. The priority treatment sequence for hemodynamically unstable pelvic fractures was previously reported; almost all of the participants, [89% (24/27)], applied PCCD first [10]. There were two participants who applied PCCD following angioembolization and external fixation and one participant who applied PCCD following angioembolization, external fixation, and exploratory laparotomy.
Most participants [43% (9/21)] followed the EAST guideline for pelvic fracture management ( Table 1 in Appendix 2). Guidelines followed were published between from 1995 to 2018, although most followed a guideline published in 2016 [21% (3/14)]. A majority of Level I trauma centers [78% (28/36)] followed a guideline that included the administration of blood products; 69% (25/36) using the massive transfusion protocol (MTP). Thirty-three percent (12/36) of Level I trauma centers guidelines included other blood products or fluids, outside of the MTP in their pelvic fracture management guideline.
All participants following TQIP and ATLS had paramedic agencies who required training on pre-hospital PCCD placement; whereas 67% (4/6) of those following the WTA guideline had paramedic agencies who required training on pre-hospital PCCD placement ( Table  2 in Appendix 2). There was a higher proportion of highvolume centers [77% (24/31)] than low-volume centers [25% (1/4)] that had paramedic agencies who trained on PCCD placement; however, this was not statistically significant, p = 0.06. Paramedic agency training on PCCD placement was not dependent on the length of time the trauma center was an ACS-verified Level I trauma center, p = 0.71 or the region, p = 0.73. Both the Level I trauma centers' characteristics and the guideline characteristics did not significantly affect the paramedic agency on the training of PCCDs application to all patients with a suspected pelvic fracture ( Table 3 in Appendix 2).

Discussion
The results of this survey show that all participating Level I trauma centers are using in-hospital PCCDs for pelvic fracture management, the majority of trauma center's paramedic agencies have required training on pre-hospital PCCD placement, but less than half taught to apply pre-hospital PCCDs to all suspected pelvic fractures. PCCD practices were not dependent on the guideline followed, the trauma center's region, volume of trauma admissions, or length of time as an ACS-verified Level I trauma center.
Although data on the effectiveness of pre-hospital PCCDs is limited, the majority of Level I trauma centers in this study indicated that their paramedic agency required training on pre-hospital PCCD application [1,9,12]. The limited data on pre-hospital PCCD application is reflected in the lack of guideline recommendations on pre-hospital placement [1][2][3][4][5]. The WTA guideline is the only guideline that recommends pre-hospital application, however only 67% of those who reported following the WTA guideline also reported their paramedic agency taught paramedics on pre-hospital PCCD application [2]. These results came as a surprise as the hospitals following the WTA guideline had the lowest rates of use of pre-hospital PCCDs.
The WSES guideline states that commercial pelvic binders are more effective in controlling hemorrhage than sheets or wraps, which are frequently used in pre-hospital settings where resources are low and sheets are available [4,13,14]. This could be in part due to the ease of application for commercial binders compared to pelvic wraps and sheets [8,15]. In fact, one study found that commercial binders were secured correctly 100% of the time and typically in under a minute [15]. Alternatively, another study found a low adherence (50%) to PCCD guidelines for both sheets and commercial devices, but did not report the adherence rate among PCCDs applied in a pre-hospital setting [8,13]. A common application error is that PCCDs are not placed over the great trochanter, however sheets are sometimes wrapped too loose, too tight, or tied in a knot, when it is recommended to secure PCCDs using clamps [16].
Although it has been suggested not to use PCCD on lateral compression fractures, inclusion of fracture type in treatment guidelines could create confusion as first providers have limited diagnostic tools [8]. One case report described hemodynamic instability and extremity shortening after prehospital PCCD placement and hypothesized additional fracturing was the cause [7]. Interestingly this case presented with an absence of a lateral compression fracture, a fracture type thought to be worsened by PCCDs [2,8]. Another study found 11% of cases experienced increased displacement or deformities after PCCD placement [8]. Even though early PCCD application is thought to decrease the number of transfusions required, this may only occur for specific fracture types, which may not be known in the pre-hospital setting [1,4,13,17]. Matched data comparing blood transfusions for patients who had a pre-hospital PCCD placed and who did not have a pre-hospital PCCD placed is needed to determine if pre-hospital PCCD placement is associated with a risk for blood transfusions.

Limitations
The response rate of 25% (40/158) was a limitation. Some may have responded based on memory despite survey instructions to have their guideline available. We did not collect data on what qualifies a patient for pre-hospital PCCD placement at paramedic divisions that do not train to apply pre-hospital PCCDs to all suspected pelvic fractures. Additionally, we did not ask if the individual trauma center has a paramedic division specific to their hospital or are at all involved with training of paramedic staff in any capacity. Therefore, some of the participants who responded that their paramedic agency does not train on PCCD application may not have a paramedic agency or may not have knowledge of the paramedic training practices.

Conclusions
There was no specific guideline followed by all US Level I trauma centers responding to this survey. PCCD practices did not vary based on pelvic fracture guideline followed, region, volume of trauma admissions, or length of time as an ACS-verified Level I trauma center. There is widespread use of pre-hospital PCCD application at US Level I trauma centers and all participating centers utilized in-hospital PCCDs, primarily as the first management approach for hemodynamically unstable pelvic fractures. However, the results of this survey show that pre-hospital PCCDs are not uniformly applied to all suspected pelvic fractures and that a majority of hospitals utilizing pre-hospital PCCDs are selecting specific patients for placement.   (14) EAST eastern association for the surgery of trauma, WTA western trauma association, TQIP trauma quality improvement project, ATLS advanced trauma life support, PCCD pelvic circumferential compression device EAST eastern association for the surgery of trauma, WTA western trauma association, TQIP trauma quality improvement project, ATLS advanced trauma life support, PCCD pelvic circumferential compression device, MTP massive transfusion protocol, ACS american college of surgeons  EAST eastern association for the surgery of trauma, WTA western trauma association, TQIP trauma quality improvement project, ATLS advanced trauma life support, PCCD pelvic circumferential compression device, MTP massive transfusion protocol, ACS american college of surgeons