All posts by The Trauma Pro

Impact Of Patient Imaging Prior To Transfer Out

The reality is that 90% of injuries are minor and can be treated at any hospital. A minority of patients actually have issues that require transfer to a higher-level trauma center. Physical examination can certainly help determine who some of those patients are. Think obvious open fracture or severe brain injury at a hospital without key specialists to care for them.

But not all injuries are that obvious. Imaging techniques are the next step to identifying injuries that would require transfer. The question is, how much imaging is appropriate?

A few hospitals are selective about it. But many proceed with a comprehensive battery of scans and x-rays. Some believe that their receiving trauma center expects it. And a few may be doing it for the money, unfortunately. So who is right?

There are three issues at play: time, accuracy, and radiation exposure. Let’s pick them apart.

Time. It takes time to get radiographic studies. Depending on the number obtained, it can take up to 90 minutes. A study looking at transfers from rural hospitals to a regional trauma center in Wisconsin found that the median time to transfer significantly in-creased from 67 to 140 minutes with the addition of even a single CT scan.

This issue appears to be even more of a problem in children. A group at Cincinnati Children’s Hospital studied the characteristics of children who experienced prolonged transfer times to a Level I pediatric trauma center. They reviewed 5 years of registry data, looking at time of injury to time of arrival at their center. The State of Ohio has a goal of a maximum 2-hour transfer time.

And here are the factoids:

  • 748 patients were included in the study, and the demographics were predictable (65%male, 97% blunt)
  • 25% were more severely injured (ISS > 15)
  • The majority of the patients (82%) arrived well after the 2-hour goal (7 hrs!!)
  • 79% of patients with high ISS and 47% of those with severe TBI arrived late (!!)
  • Transfer tardiness did not correlate with distance, and was only slightly improved when a helicopter was used
  • Significantly more CT scans were obtained in the late transfer group (49% vs 23%), and appeared to have no correlation with GCS or vital signs. There was, however, a significant correlation with private insurance.
  • Half of the children with scans arrived without results or had suboptimal imaging, resulting in repeat scans in about one third.

Accuracy and radiation exposure. These two factors are inextricably linked because inaccuracy begets additional imaging. As noted in the previous study, radiology results are frequently lacking, or the studies are not done well, as determined by the receiving center. This means that inaccurate results, or no results at all, are available after transfer. How much of a problem is this?

The Level I center at UC Davis looked at all incoming trauma transfers that had any CT imaging done prior. Of 370 patients, one quarter needed repeat scans. Most common were head scans (47%) and cervical spine (20%). The most common reasons for repetition were referring hospital scan not available (42%) (not sent, couldn’t open) and insufficient quality (20%). This resulted in significant additional radiation exposure, with 4% of patients receiving more than 10mSv!

Bottom line: Imaging prior to transfer definitely increases time to transfer and frequently results in repeat imaging and more radiation exposure. So why does it happen? Sometimes, it’s the mistaken belief that it will save time after transfer. Not the case. Or there is time left before the transport ambulance or helicopter arrives, so why not use it? Not a good reason, and it may delay the transfer team if they arrive early. Or the receiving trauma center “expects it.” Not if they’ve looked at any of these papers!

The best approach is to order only images that will guide your therapy. A chest x-ray on arrival or after intubation. A pelvic x-ray to determine if a binder should be applied. A CT of the abdomen to see if there are any injuries that can’t be taken care of at your hospital. As a general rule, once you have found an injury your hospital can’t treat, or have made the decision to transfer for any other reason, no additional imaging is indicated! 

References:

  • Consequences of increased use of computed tomography imaging for trauma patients in rural referring hospitals prior to transfer to a regional trauma centre. Injury 45:835-839, 2014.
  • Unnecessary imaging, not hospital distance, or transportation mode impacts delays in the transfer of injured children. Pediatric Emerg Care 26(7):481-486, 2010.
  • Rate and Reasons for Repeat CT Scanning in Transferred Trauma Patients. Am Surg 83(5):465-569, 2017.

Rural Trauma Team Development Course Impact On Trauma Transfers

The Rural Trauma Team Development Course (RTTDC) is yet another quality program developed by the American College of Surgeons (ACS). It is designed for all trauma professionals in rural areas including doctors, nurses, advanced practice providers, prehospital providers, and administrative support. The course is presented over the course of one day and covers a number of topics including:

  • Organizing a rural trauma team
  • Preparing rural hospitals to manage trauma patients
  • Identifying local resources and limitations
  • Resuscitation of trauma patients
  • Initiating early transfer
  • Developing a performance improvement process
  • Building relationships between rural hospitals and regional or state trauma systems

The trauma group at Vanderbilt compared a group of six non-trauma hospital in rural Tennessee who had participated in the RTTDC with six other rural hospitals matched for size, volume, and distance from the Level I center.

Here are the factoids:

  • A total of 130 RTTDC patients were compared with 123 from hospitals that had not participated
  • Overall demographics and number of imaging studies were the same
  • The call to transfer occurred 41 minutes sooner in the RTTDC hospitals
  • Length of stay in the referring ED was 61 minutes shorter in the RTTDC hospitals
  • Number of images obtained pre-transfer and mortality were unchanged

Bottom line: The numbers were small and the review was retrospective, but the results are nonetheless impressive. Granted, there was no decrease in mortality, but this is a relatively crude indicator, especially when small numbers are involved. But time to phone call and time spent in the referring ED were significantly shorter. Does anyone think that longer times to transfer are somehow good for patients?

Rural hospitals should consider attending RTTDC in order to improve the care of patients from their communities.

Reference: Rural trauma team development course de-creases time to transfer for trauma patients. J Trauma 81(4):632-637, 2016.

Are You Still Using MRI To Clear The Cervical Spine?

There is a fairly robust  amount of data that shows that, properly performed, the cervical spine can be cleared using a high quality CT read by a highly skilled radiologist. This is true even for obtunded patients. Pooled data suggest that the miss rate in this group is only 0.017%. And MRI is not perfect either, missing significant ligamentous injury in a small number of patients.

But it seems that some trauma professionals are still using MRI in some cases despite this data. The latest study on MRI focuses on the cost-effectiveness of the technique. The authors selected patients with GCS < 13 to be their obtunded group, which is probably a bit high. Nevertheless, they used a fairly sophisticated (meaning hard to understand) modeling-based decision analysis using a computerized simulation. This allowed them to compare different clearance strategies without performing large randomized clinical trials.

The authors considered MRI vs no MRI, false results, collar use and complications, MRI use with cost and complications, and the worst-case scenario of tetraplegia. Here is a flow chart of the scenarios considered. (Courtesy JAMA Surgery)

Here are the factoids:

  • The mean cost for followup vs no followup was $14K vs $1K, with no increase in quality adjusted life years (QALY)
  • No followup was the better strategy when the negative predictive value of CT was high (>98%), when the risk of an unstable injury treated with a collar turning into a permanent deficit was >25%, or if the chance of a missed injury becoming a permanent deficit was >58%
  • No followup MRI was the better strategy in all 10,000 iterations of the simulation

Bottom line: Yes, this is a fairly heavy computer simulation. But the reality is that we will never be able to design a large enough study to critically evaluate this issue and have it pass any IRB review. So it’s probably as good as it will ever get. It’s time to stop wasting money and putting obtunded patients in harm’s way by locking them into a relatively inaccessible MRI scanner for 30 minutes just to confirm the CT. Or keeping a collar until until the skin breaks down.

Here is a copy of the practice guideline we use for clearing all cervical spines, obtunded or not. Yes, there is some weirdness with soft collars, which mainly serve as a reminder to re-examine the patient at some point. But note the scan technique and requirement that it be read by a neuroradiologist for final clearance.

Related link:

Reference: Cost-effectiveness of Magnetic Resonance Imaging in Cervical
Clearance of Obtunded Blunt Trauma After a Normal
Computed Tomographic Finding

Electronic Trauma Flow Sheet – The Video!

I’ve written a lot about the downside of the electronic trauma flow sheet. Well, a picture (or video in this case) is worth a thousand words!

I found a nice video on YouTube in which a nurse demonstrates some of the basic features of the Epic Trauma Narrator. As you watch, pay particular attention about the need for significant back and forth between mouse and keyboard, and the amount of scrolling necessary to get to all the various fields that need to be completed.

And keep an eye on the time. Now granted, the speaker has to slow down a bit to explain things. But if you look at how little gets entered in 8 minutes, you’ll get my point!

For those of you out there who have already adopted an electronic product, or are thinking about it, please leave comments here or Tweet your comments/questions!

YouTube player

REBOA At An Academic Trauma Center

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is the big thing these days. I’ve written about this topic in the past, and a number of centers continue to refine our understanding of this new(er) tool.  A recent paper from the University of Florida – Gainesville outlines their experience in implementing this procedure at an academic Level I trauma center.

This trauma program is staffed by a group of surgeons who have considerable experience in guidewire-based skills, fellowship or military exposure, and/or completion of a vascular fellowship. One surgeon attended a trauma endovascular skills course (6 hrs).  An internal education program with a 1.5 hour slide presentation and some hands-on simulation training was developed. All surgeons and residents completed this program.

A retrospective review of their experience from June 2015 to March 2017 was carried out on unstable trauma patients due to hemorrhage. All cases were performed in a hybrid OR with imaging capabilities. A 12Fr REBOA catheter was initially used, but was changed to 7Fr once that catheter became commercially available.

Here are the factoids:

  • 16 patients underwent REBOA in this 22 month period; mean SBP was 97 torr and mean ISS was 39
  • Hemodynamic status improved in 10 of 16 patients to a mean SBP 132
  • 14 survived the initial operative procedure, but only 6 survived to hospital day 30. It appears that all of these patients were neurologically normal (GCS 15+0).
  • 1 survivor developed a common femoral artery pseudoaneurysm
  • The authors made the interesting comment that they also performed 8 ED thoracotomies (EDT) during this period and that there were no survivors
  • The authors concluded that the procedure was beneficial, that extensive training was not needed, and that it should be available trauma centers

Bottom line: But not so fast! This was a very select academic Level I center. The surgeons had extensive wire skills and vascular experience. All procedures were performed in a hybrid room, which is a very controlled OR setting. And they only performed REBOA every 6 weeks or so. 

REBOA is still an advanced procedure, and the average trauma surgeon would probably benefit from some more intensive training to ensure adequate initial skills. But if the surgeon can’t then maintain their skills via somewhat regular practice, errors may creep in. In a group of 6-8 surgeons, each may only get to perform the procedure once a year! Add in some interested emergency physicians, and no one can keep in practice.

The bit about ED thoracotomy is a bit of a red herring. Typically, this procedure is performed once the patient has lost their vital signs. Comparing mortality from REBOA with EDT here is not valid, because it appears that most of the REBOA patients in this study still had vital signs when it was inserted. It would be interesting if the authors shared the outcomes in the REBOA patients who had the device inserted after arrest to level the playing field with EDT.

So what to do? Be cautious and thorough if you are planning to try out REBOA at your center. Do the math. On how many patients per year can I expect to perform this? How many physicians want credentialing to do it? How many procedures can the typical physician expect per year? What is the baseline level of physician training and what additional training is needed? Will I report my experience to a national registry or write it up for sharing?

These are important questions! Everyone wants to play with the newest shiny toy in the toybox. But make sure that when you do play with it, you are able to provide the maximum benefit to your patients with the least amount of harm!