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Trauma PI: The 7 Deadly Sins

Trauma performance improvement is the backbone of any trauma center. And it’s the most common reason that a center runs into problems or deficiencies during a site review. Today, I’ll review the seven most common problems encountered during site surveys and provide some possible solutions for them.

  1. No loop closure. Closing the loop is talked about all the time. One would think that this should never be a problem, but it is. It becomes evident to the reviewers in two ways: reviewing PI meeting minutes, and sin #2 below. This topic is complicated, so see my four part series on loop closure here.
  2. Repeat offenses. The same problem keeps coming up again and again. This usually happens because the problem was never really solved in the first place. See the link above on loop closure for the solution to this one.
  3. Superficial peer review discussions. This means that the minutes don’t reflect any in-depth discussion of PI issues. There are two possible reasons: there wasn’t any meaningful discussion, or the documentation just wasn’t that good (see point 4 below). The discussion must include a summary of the case, identification of the significant quality issues, and a description of what will be done to avoid the problem in the future and who is responsible for carrying it out. If issues are referred to other committees (trauma operations or hospital PI), then this should be stated and it should be possible to follow the PI trail in those minutes as well.
  4. Poor peer review meeting minutes. This is a carry-on from the last point. Sometimes there is robust discussion on an issue, but the minutes don’t reflect it. This occurs due to concern for discoverability by the public or outside legal counsel in some states, but most frequently happens because the person charged with documenting the minutes is not very good at it. Minutes need not mention specific names, but do need to detail the gist of any discussion, including specific points of concern and remedies. Most discussions will run several paragraphs long; a single brief one just won’t do.
  5. Poor record organization. All PI activity and documentation regarding a specific patient needs to be organized in a single location. A paper or electronic folder is recommended. A similar folder is recommended for each system issue that involves multiple patients. During a site review, be sure to include the appropriate folder of information with each of the patient charts that are inspected by reviewers. Don’t scatter your records across several file cabinets or notebooks. And make sure several people in the trauma program understand the organization system in case a key person gets sick or quits.
  6. No cooperation from other hospital services. Your trauma program sends a case to be reviewed out to another department. Two months pass and you finally notice you never received a reply. Repeat a couple of times with the same chart and at that point, no one remembers anything about the case. This is a sure-fire way to keep making the same patient care mistakes. Create the expectation of quick turnaround (2 weeks is reasonable) and start nagging when time is up. Escalate to your trauma medical director if it continues to be a problem. In more extreme cases, you may need to select another liaison to deal with, or enlist hospital administration or hospital PI to help put pressure on them from above.
  7. No cooperation between trauma program manager and trauma medical director. These two people must work very closely for the trauma PI program to function efficiently. Regular meetings (weekly) are essential so they can review and process the various items that must be addressed. The TMD must deal with any physician related items, such as counseling, verbal discussions, memos and letters. The TPM deals with items involving nursing and other personnel. Dysfunction at this level is somewhat common at Level II trauma centers and quickly drags the program down.
Please feel free to comment or ask questions below!

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Jehovah’s Witnesses And Blood Transfusion Demystified

Injury can be a bloody business, and trauma professionals take replacement of blood products for granted. Some patients object to this practice on religious grounds, and their health care providers often have a hard time understanding this. So why would someone refuse blood when the trauma team is convinced that it is the only thing that may save their life?

Jehovah’s Witnesses are the most common group encounted in the US that refuse transfusion. There are more than 20 million Witnesses worldwide, with over 7 million actively preaching. It is a Christian denomination that originated in Pennsylvania during the 1870s.

Witnesses beleive that the bible prohibits taking any blood products, including red cells, white cells, platelets or plasma. It also includes the use of any dialysis or pump equipment that must be primed with blood. This is based on the belief that life is a gift from God and that it should not be sustained by receiving blood products. The status of certain prepared fractions such as albumin, factor concentrates, blood substitutes derived from hemoglobin, and albumin is not clear, and the majority of Witnesses will accept these products. Cell saver techniques may be acceptable if the shed blood is not stored but is immediately reinfused.

Why are Witnesses so adamant about refusing blood products? If a transfusion is accepted, that person has abandoned the basic doctrines of the religion, and essentially separates themselves from it. They may then be shunned by other believers.

So what can trauma professionals do to provide best care while abiding by our patient’s religious belief? In trauma care it gets tricky, because time is not on our side and non-blood products are not necessarily effective or available. Here are some tips:

  • Your first duty is to your patient. Provide the best, state of the art care you can until it is absolutely confirmed that they do not wish to receive blood products. In they are comatose, you must use blood if indicated until the patient has been definitively identified by a relative who can confirm their wishes with regard to blood. Mistaken identity does occur on occasion when there are multiple casualties, and withholding blood by mistake is a catastrophe.
  • Talk with the patient or their family. Find out exactly what they believe and what they will allow. And stick to it.
  • Aggressively reduce blood loss in the ED. We are not always as fastidious as we should be because of the universal availabilty of blood products. Use direct pressure or direct suture ligation for external bleeding. Splint to reduce fracture bleeding.
  • Aggressively use damage control surgery. Don’t go for a definitive laparotomy which may take hours. Pack well, close and re-establish normal physiology before doing all the final repairs.
  • Always watch the temperature. Pull out all the stops in terms of warming equipment. Keep the OR hot. Cover every bit of the patient possible with warming blankets. All fluids should be hot. Even the ventilator gases can be heated.
  • Think about inorganic and recombinant products such as Factor VIIa, tranexamic acid and Vitamin K. These are generally acceptable.
  • Consider angiography if appropriate, and call them early so their are no delays between ED and angio suite or OR and angio suite.

Bottom line: Do what is right for your patient. Once you are aware of their beliefs, avoid the use of any prohibited products. Speak with them and their family to clarify exactly what you can and cannot do. This is essentially an informed consent discussion, so make sure they understand the consequences. Follow their wishes to the letter, and don’t let your own beliefs interfere with what they want.

Retained Hemothorax And Empyema

Patients with chest trauma sustain hemothorax on occasion. The trauma professional usually picks this diagnosis up in the initial evaluation and makes a decision whether or not to drain it. The parameters for this decision are not very clear, even today. But what happens when there is residual hemothorax? Should we be more aggressive in getting it out?

All this boils down to an understanding of the natural history of retained hemothorax. This kind of information can help us decide whether to be more aggressive in our efforts to remove it. The results of a multicenter study looking at this issue was published recently. They focused on patients who had a chest tube placed for management of either hemo- or pneumothorax within 24 hours of admission. Patients who had suspected retained hemothorax after tube removal received a CT scan within 14 days. The usual outcomes were studied (length of stay, complications) as well as development of empyema (purulence, acidic pleural fluid, positive Gram stain or culture).

Some interesting results:

  • 328 patients were enrolled across 20 centers. Not a lot, but one of the bigger studies to date.
  • Empyema was diagnosed in 27% of patients
  • Risk factors identified included rib fractures, ISS > 25, and performance of additional interventions for drainage
  • Patients who developed empyema stayed in the ICU and the hospital longer

Bottom line: Retained hemothorax turns into a very serious problem in a quarter of trauma patients who have a chest tube inserted. The presence of residual blood after the chest tube is removed should prompt us to figure out if it’s solid clot or liquid blood (remember the old decubitus view chest xray? They still work!). If it’s liquid, consider drainage via thoracentesis or a smaller catheter. If it’s clot, it may require more invasive techniques to drain it (VATS). If you decide to send the patient home, have them watch out for fevers, chest pain, dyspnea and other symptoms and signs of a developing complication, and make sure they report it to you promptly.

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Reference: Development of posttraumatic empyema in patients with retained hemothorax: Results of a prospective, observational AAST study. J Trauma 73(3):752-757, 2012.

When to Give Spleen Vaccines After Splenectomy for Trauma

I’ve written previously on the (f)utility of giving vaccines after splenectomy for trauma (click here to read). However, it is more or less a medicolegal standard, so pretty much everyone gives them. The big question is, when? 

Some centers give them immediately postop, some before hospital discharge, and some during their postop visit. Who is right? The argument is that major surgery produces some degree of immunocompromise. So if the vaccines are given too early, perhaps the anitbodies will not be processed as effectively, and the response to an actual bacterial challenge might not be as good.

One prospective study randomized patients to receive their pneumococcal vaccine either 1, 7, or 14 days after surgery. IgG levels were measured before vaccination and again after 4 weeks. This study found that antibody concentrations were the same in all groups. However, functional activity of the antibodies was low in the 1 and 7 day groups, and nearly normal in the 14 day group.

Following this, a rat study looked at vaccination timing followed by exposure to pneumococcus. These animals were splenectomized, then given a real or sham vaccination at 1, 7, or 42 days. They then had pneumococcus injected into their peritoneal cavity. About 70% of all rats with sham vaccination died. Only 1.5% of the vaccinated rats died, and there were no differences based on vaccination timing.

Bottom line: Neither antibody titer studies nor rat studies easily translate into recommendations for treating overwhelming post-splenectomy sepsis (OPSS) in humans. And such a study can never be done because of the rarity of this condition (less than 70 cases since the beginning of time). It really boils down to your specific population, balancing your assurance that your patient will get it against the possibility that their immune system may not react to it as much as it could. 

At our center, we give the vaccines as soon as possible postoperatively. This ensures that it is given, and erases any doubt of what might happen if the patient does not show up for their postop check.

References:

  • Immune responses of splenectomized trauma patietns to the 23-valent pneumococcal polysaccharide vaccine at 1 versus 7 versus 14 days after splenectomy. J Trauma 44(5):760-766, 1998.
  • Timing of vaccination does not affect antibody response or survival after pneumococcal challenge in splenectomized rats. J Trauma 45(4):682-697, 1998.

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