title: Compartment syndrome performance improvement project is associated with increased combat casualty survival.
abstract: BACKGROUND
  In 2008, we showed that incomplete or delayed extremity fasciotomies were associated with mortality and muscle necrosis in war casualties with limb injury. Subsequently, we developed an education program focused on surgeon knowledge gaps regarding the diagnosis of compartment syndrome and prophylactic fasciotomy. The program included educational alerts, classroom training, video instruction, and a research publication. We compared casualty data before and after the program implementation to determine whether the education altered outcomes.
  
  
  METHODS
  Similar to the previous study, a case series was made from combat casualty medical records. Casualties were US military servicemen with fasciotomies performed in Iraq, Afghanistan, or Germany between two periods (periods 1 and 2).
  
  
  RESULTS
  In both periods, casualty demographics were similar. Most fasciotomies were performed to the lower leg and forearm. Period 1 had 336 casualties with 643 fasciotomies, whereas Period 2 had 268 casualties with 1,221 fasciotomies (1.9 vs. 4.6 fasciotomies per casualty, respectively; p < 0.0001). The mortality rate decreased in Period 2 (3%, 8 of 268 casualties) from Period 1 (8%, 26 of 336 casualties; p = 0.0125). Muscle excision and major amputation rates were similar in both periods (p > 0.05). Rates of casualties with revision fasciotomy decreased to 8% in Period 2, (22 of 268 casualties) versus 15% in Period 1 (51 of 336 casualties; p = 0.009).
  
  
  CONCLUSIONS
  Combat casualty care following implementation of a fasciotomy education program was associated with improved survival, higher fasciotomy rates, and fewer revisions. Because delayed fasciotomy rates were unchanged, further effort to educate providers may be indicated.
  
  
  METHODS
  Therapeutic study, level IV.
authors.affiliation: US Army Institute of Surgical Research, Fort Sam Houston, Houston, Texas 78234-6315, USA. john.kragh1@us.army.mil
authors.forename: John F
authors.initials: JF
authors.lastname: Kragh
authors.forename: James
authors.initials: J
authors.lastname: San Antonio
authors.forename: John W
authors.initials: JW
authors.lastname: Simmons
authors.forename: James E
authors.initials: JE
authors.lastname: Mace
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Stinner
authors.forename: Christopher E
authors.initials: CE
authors.lastname: White
authors.forename: Raymond
authors.initials: R
authors.lastname: Fang
authors.forename: James K
authors.initials: JK
authors.lastname: Aden
authors.forename: Joseph R
authors.initials: JR
authors.lastname: Hsu
authors.forename: Brian J
authors.initials: BJ
authors.lastname: Eastridge
authors.forename: Donald H
authors.initials: DH
authors.lastname: Jenkins
authors.forename: John D
authors.initials: JD
authors.lastname: Ritchie
authors.forename: Mark O
authors.initials: MO
authors.lastname: Hardin
authors.forename: Amber E
authors.initials: AE
authors.lastname: Ritenour
authors.forename: Charles E
authors.initials: CE
authors.lastname: Wade
authors.forename: Lorne H
authors.initials: LH
authors.lastname: Blackbourne
mesh_terms: D000293:Adolescent; D055826:Afghan Campaign 2001-; D003161:Compartment Syndromes / Q000209:etiology / Q000401:mortality / Q000517:prevention & control* / Q000601:surgery; D005121:Extremities / Q000293:injuries* / Q000601:surgery; D000071938:Fasciotomy; D006801:Humans; D054542:Iraq War, 2003-2011; D058996:Quality Improvement; D012086:Reoperation; D015996:Survival Rate; D014481:United States; D055815:Young Adult