Pelvic fractures, especially when unstable, may cause significant haemorrhage. The early application of a pelvic circumferential compression device (PCCD) in patients with suspected pelvic fracture has established itself as best practice. Ambulance services conduct corresponding performance measurement. Quality indicators (QIs) are ideally based on high-quality evidence clearly demonstrating that the desirable effects outweigh the undesirable effects. In the absence of high-quality evidence, best available evidence should be combined with expert consensus. The Effectiveness of Pelvic Circumferential Compression Devices Essay.

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Objectives

The aim of the present study was to identify, appraise and summarize the best available evidence regarding PCCDs for the purpose of informing an expert panel tasked to evaluate the validity of the following QI: A patient with suspected pelvic fracture has a PCCD applied.

Methods

A rapid review of four databases was conducted to identify relevant literature published up until 9 June 2020. Systematic reviews, experimental, quasi-experimental and observational analytic studies written in English were included. One author was responsible for study selection and quality appraisal. Data extraction using a priori extraction templates was verified by a second reviewer. Study details and key findings were summarized in tables.

Results

A total of 13 studies were assessed to be eligible for inclusion in this rapid review. Of these, three were systematic reviews, one was a randomized clinical trial (crossover design), two were before-after studies, and seven were retrospective cohort studies. The Effectiveness of Pelvic Circumferential Compression Devices Essay. The systematic reviews included mostly observational studies and could therefore not be considered as high-level evidence. Overall, the identified evidence is of low quality and suggests that PCCD may provide temporary pelvic ring stabilization and haemorrhage control, although a potential for adverse effects exists.

Conclusion

Given the low quality of the best available evidence, this evidence would need to be combined with expert consensus to evaluate the validity of a related quality indicator before its implementation.

Exsanguinating haemorrhage is one of the leading causes of death in patients suffering major trauma [1]. Besides catastrophic external haemorrhage, blood loss may occur from thoracic, abdominal, pelvic or limb injuries. Any of these alone or in combination can produce significant hypovolemia. Especially injury to the bony pelvis with disruption of the pelvic ring and damage to adjacent blood vessels may cause severe bleeding and can be associated with considerable morbidity and mortality [2,3,4]. As substantial force is required to cause fracture of the pelvic ring, some of the most frequent mechanisms of this injury involve road traffic accidents, falls from height and localized crush injuries [5, 6]. However, in the elderly with osteoporosis, disruption of the pelvic ring can also occur from low-energy mechanism [7]. Pelvic ring fractures may be classified in a number of ways.  The Effectiveness of Pelvic Circumferential Compression Devices Essay.Most commonly, the Tile [8] and Young-Burgess [9] classification systems are used. These divide pelvic ring injuries into various types based on stability/instability of the posterior sacroiliac complex (Tile type A: stable, Tile type B: rotationally unstable, Tile type C: vertically and rotationally unstable) and vector of injuring force (lateral compression types, anterior-posterior types, vertical shear types and combined mechanisms) respectively. Considering the potentially life-threatening haemorrhage associated with pelvic ring fractures, rapid identification and management are critical to optimize patient outcomes.

Historically, prehospital management in the form of pelvic binding was performed when inspection and palpation of the pelvis revealed deformity, instability and pain. However, the diagnostic reliability of identifying a pelvic fracture by physical examination is questionable, particularly in the patient with decreased level of consciousness [10,11,12]. Furthermore, manipulating and especially springing the pelvis carries significant risk of disrupting any clot that may have formed and thus interfering with any spontaneous haemostasis [11]. Therefore, the decision to apply a pelvic circumferential compression device (PCCD) in any blunt trauma patient with suspected pelvic ring fracture based predominantly on the mechanism of injury and any visual signs such as bruising around the pelvis is increasingly being advocated as best practice in the prehospital care [13,14,15]. As the name implies, the intended purpose of a PCCD is to wrap around and stabilize the pelvic ring thereby limiting haemorrhage from cancellous bone or venous sources. The placement of a PCCD on a patient with a mechanism of injury suggestive of pelvic ring disruption is now commonly regarded to be an indicator of high-quality prehospital trauma care [13,14,15]. As such, many ambulance services utilize this quality indicator (QI) in the measurement of their clinical performance [16]. The Effectiveness of Pelvic Circumferential Compression Devices Essay.

A QI is an explicitly defined and measurable aspect of health care services indicative of a desirable structure, process or outcome [17]. That is to say, there is evidence and/or consensus that the indicator can be used to quantify the quality of service provided, and thus monitor changes in quality over time [18]. This measurement provides a tool to identify unwarranted variation, facilitate data-driven improvement efforts and assess their impact. Systematically developed QIs are ideally based on scientific evidence. This may stem from rigorously developed guidelines [19, 20], but preferably is based directly upon high-quality scientific evidence such as thoroughly conducted (trial-based) empirical studies or robust systematic reviews and meta-analyses of randomized controlled trials (RCT) [17, 21]. In areas or disciplines where such evidence is scarce, it may be necessary to combine the best available evidence with expert consensus [17, 22]. Since the methodical review of underpinning evidence is fundamental to the systematic development of quality indicators, the expert consensus process should also be evidence-informed. The RAND/UCLA appropriateness method (RAM) is a formal group judgement process developed in the 1980s by the Research and Development (RAND) Corporation and the University of California, Los Angeles (UCLA) [23]. It combines expert opinion and scientific evidence in the form of systematic literature reviews by asking panellists to rate, discuss, and then re-rate statements.

However, this prominent advantage that RAM has over other consensus processes may also be a deterring factor. A systematic review is conducted to provide the expert panel with all pertinent information that will guide evidence-based decision-making [23]. Due to the rigorous methods applied when conducing full systematic reviews, they can take an extensive period of time to complete [24, 25]. This may be particularly problematic when multiple areas are being covered, there is high complexity in the topic, or both. Rapid reviews are a form of knowledge synthesis in which components of the systematic review process are simplified or omitted to produce information in a more timely manner [26]. As such, rapid reviews may offer a time- and resource-efficient alternative to modify RAM and prevent a potentially protracted and misaligned decision timeline. Although the rapid review approach has several inherent limitations, it may be a suitable compromise to facilitate swift synthesis of available evidence and adequately inform decisions in a RAM expert consensus process.

The aim of the present study was to apply rapid review methods to identify, appraise and summarize the best available evidence regarding PCCDs and in doing so provide an evidence summary to inform an expert panel tasked to validate the QI used for the measurement of prehospital trauma care quality.  The Effectiveness of Pelvic Circumferential Compression Devices Essay.More specifically, this rapid review aimed to investigate current evidence for the effectiveness and safety of non-invasive PCCDs. This study forms part of a larger research project aimed at developing and testing prehospital care quality indicators for the Australian setting (https://www.aspireproject.net).

Preliminary work

As the initial part of the larger research project, a scoping review was conducted in accordance with Joanna Briggs Institute (JBI) methodology [16]. The scoping review’s purpose was to map the attributes of ‘quality’ in the context of prehospital care, to chart existing international prehospital care QIs and explore their development processes. Identified QIs were categorized as either system/organizational/non-clinical (domain A) or clinical (domain B). Within these two domains, several sub-domains were formed, including ‘trauma care’ (sub-domain B.6). QIs describing in one way or another the application of a PCCD in a patient with suspected pelvic fracture were identified in several included articles and aggregated into one single QI concisely describing the specific clinical intervention (Table 1). Furthermore, the QI was labelled as a process indicator according to Donabedian’s model, and as a QI primarily addressing ‘effectiveness’, one of the attributes of ‘quality’ mapped in the review. The Effectiveness of Pelvic Circumferential Compression Devices Essay.

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Rapid review

Literature search strategy

Guided by the approaches to rapid reviews and evidence summaries by JBI and the World Health Organization (WHO) [27], a rapid systematic literature review was conducted to develop a summary of the best available evidence concerning the placement of a PCCD in the prehospital environment. Systematic searches of four electronic databases (the Cochrane Library, the JBI Database of Systematic Reviews, PubMed and CINAHL) were conducted on 9 June 2020. No date range filters were set but the search was limited to studies involving human participants and written in English. Due to the small number of systematic reviews identified, the search was expanded to include lower levels of evidence [28]. Nevertheless, observational descriptive studies, case series and case reports were excluded, as were non-systematic literature reviews. The full search strategy is available in Appendix S1.

Study selection

One author (RP) carried out the literature search, screened the results by title and abstracts using Covidence (Covidence, Melbourne VIC, Australia), and performed full-text review of shortlisted articles based on pre-defined inclusion criteria. The Effectiveness of Pelvic Circumferential Compression Devices Essay.T he pre-defined inclusion criteria were based on the following population, intervention, comparison, outcome, context, study design (PICOCS) criteria:

• Population: Trauma patients with suspected or confirmed pelvic fracture(s)
• Intervention: Application of a PCCD
• Comparison: No intervention (or wrapping sheet)
• Outcomes: Clinical endpoints and/or adverse effects
• Context: Emergency trauma care
• Study designs: Systematic review, experimental and quasi-experimental studies, and observational analytical studies.

Quality appraisal

Following the search, studies selected for retrieval were assessed for internal validity using applicable JBI critical appraisal checklists [27]. This risk-of-bias assessment was performed by one author (RP). The quality threshold scores on respective checklists was 7 out of 11 for systematic reviews, 8 out of 13 for randomized control trials, 6 out of 9 for quasi-experimental studies and 7 out of 11 for cohort studies. These scores equated to a minimum quality threshold of 60% which was deemed to indicate sufficient quality for the research to be included in the review.

Data extraction and synthesis

Data were extracted by one author (RP) and verified by another (RM) using a standardized extraction template created a priori in Microsoft Excel for Mac 2019 (Microsoft Corp., Richmond, WA, USA). For systematic reviews, the following data were extracted: author(s), year of publication, number of studies included their designs, whether meta-analysis was performed and key findings. For primary research studies, following data were extracted: author(s), year of publication, study objectives and design, number of participants, participant characteristics, device(s), and key findings. Each systematic review and primary study was assigned a level of evidence in accordance with JBI [28].The Effectiveness of Pelvic Circumferential Compression Devices Essay.