All posts by The Trauma Pro

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Ready For Cold-Related Injuries?

It’s getting to be that time of year again. I don’t know about your place, but it gets pretty cold in Minnesota. We like to review what we know about cold injuries about this time of year so everyone can be on top of their game when the first one rolls through the door.

This is a video from one of our regular trauma conferences. It is being presented by David Ahrenholz MD, from the Regions Hospital Burn Unit. He is the president-elect of the American Burn Association, and always does a nice job reviewing state of the art thinking in this area. 

Enjoy!

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(Source: https://www.youtube.com/)
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Physician Assistants And Nurse Practitioners In US Trauma Centers

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The number of physician assistants (PAs) and nurse practioners (NPs) moving out of primary care to work in specialty areas in US healthcare is rising. Trauma programs in teaching hospitals have been affected by the work hour restrictions put into place 10 years ago. Non-teaching programs have been adding these midlevel providers to help balance workloads.

How common is the use of midlevel providers in trauma care? Nine-item surveys were sent to 464 designated or ACS verified trauma centers across the US. 

Here are the factoids:

  • The response rate was 53%, which is very good
  • It’s too bad that Level III and IV centers were excluded. There would have been some good data there.
  • About half were ACS verified trauma centers. Also, roughly half were Level I and half were Level II.
  • 35% used PAs, 33% used NPs, and 54% used residents. There was overlap in use.
  • ACS verified centers used midlevels more frequently than non-ACS centers (62% vs 41%)
  • Level I centers used them more than Level IIs (73% vs 53%)
  • Trauma centers with residents used midlevels more often than those without (66% vs 41%)
  • Midlevels were utilized for the traditional tasks of a surgical provider (H&P, discharge summary, rounds, trauma resuscitation, surgical assistant)
  • A third performed procedures like chest tubes, arterial and central lines
  • 19% of hospitals that did not use midlevels planned to start soon

Bottom line: Midlevel providers such as PAs and NPs are being used more and more frequently in trauma care. If you look at the graph, the inflection point happened just around the time of the new work hour rules. We use them at our trauma center, and they are very prevalent at the centers I have visited. These providers are valuable clinicians and their contributions to patient care should be embraced!

As a side note (opinion), the amount of trauma slowly grows with the population. And the number of “trauma hours” spent to take care of these patients is a zero sum game. This means that resident exposure to trauma must be decreasing as midlevel provider involvement increases. Physician training in trauma (and all other disciplines as well) is shrinking, but at least they’re not tired!

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Reference: Acceptance of physician assistants and nurse practitioners in trauma centers. JAAPA 23(1):35-41, 2010.

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Pagers vs Smartphones – Part 2

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Yesterday, I wrote about using smartphones in place of good, old-fashioned dumb pagers. Reader wang-kevin reblogged it and referenced another new article citing the pitfalls of the phones.

The article was a recital of 10 problems with smartphones in clinical care. These were derived from articles citing known shortcomings of these devices. Here’s a brief listing of them. In my opinion, only the bolded ones are significant for normal clinical use.

Disrupted clinical communication

  • Audio distortion – The audio quality of cell phones has never been a priority for the carriers. There may be an opportunity for misunderstanding spoken orders (e.g. the number “sixteen”) due to the usual poor audio quality.
  • Faulty monologue – Texts may be sent that contain significant misspellings or errors. Fortunately, entering orders via text message is not valid.
  • Fumbled messages – This refers to email that is not properly titled, or with ambiguous language or missing attachments.
  • Missive avalanches – (who thinks these up?) Caused by inadvertent “reply all” or large chains of messages.

Social disengagement

  • Mindless checking – Alas, this malady affects nearly everyone with a smartphone. And it’s probably not medical stuff being checked (think Facebook).
  • Surrounding neglect – This occurs when mindless checking meets walking. Less likely in a hospital.

Failures of technology

  • Unanticipated loss – Again, most trauma professionals are very mindful of their phones, so not very likely.
  • Myth of dependability – This one is very important. Sometimes texts are delayed, or calls go straight to voicemail without ringing the phone. Pagers are a bit less finicky.

Direct patient harm

  • Nosocomial infections – Yes, really. There have been a host of articles showing that white coats, stethoscopes, ties, magazines, even sanitizing foam dispensers are colonized with bad bacteria. Your phone can be as well, and it’s a bit harder to sterilize.
  • Breached confidentiality – Lose an unlocked phone, and there could be confidential information on it. But it’s not very likely, since there are no good electronic medical record systems for phones yet.

Bottom line: There’s really no new information in this article that people don’t already know. And only a minority of the “issues” are pertinent to real clinical care. The rest may be significant if the phone is used for general daily use at work. Given the sheer number of brands and models of smartphones out there, they are here to stay. This has given rise to the bring your own device (BYOD) concept, meaning that it won’t be possible for a hospital to mandate that only one specific smartphone is acceptable. Not unless they want to buy that model for every clinical employee.

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Reference: Pitfalls with smartphones in medicine. J General Internal Medicine 28(10):1260-1263, 2013.

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Pagers vs Smartphones. Duh!

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I wrote about good, old-fashioned pagers yesterday. They are very old, yet reliable technology. But these days, smartphones are all the rage. People walk around everywhere, staring at them. Are they useful in a hospital setting?

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These days, 90% or so of healthcare providers carry a smartphone. They can transmit and receive much more information than a pager ever could. Would trauma team members at a Level I US trauma center find them valuable? The University of Arizona, Tucson sent a questionnaire to surgeons, residents, and midlevel providers rotating through their trauma service asking them a series of 31 questions about use of these devices.

Here are the factoids:

  • 50 people completed the survey, most of whom (40) were residents. It appears that everyone was forced to return it.
  • 94% were in favor of using it for communications
  • 78% found it easy to use and user friendly
  • 98% believed that it improved speed and quality of communication
  • 98% believed it improved the accessibility of team members
  • 90% felt that it improved physician response time
  • 4% believed that it could not be used due to HIPAA regulations

Bottom line: This is a good example of an unscientific study dressed up to look a little scientific. And it essentially confirms the bias of the researchers. Nonetheless, it is an indicator of where we’re heading with in-hospital and out-of-hospital communications. The days of good, old-fashioned pagers and walkie-talkies are rapidly waning. Smartphones, and whatever follows (Google Glass?), are rapidly replacing them. The only obstacles now are ensuring good signal strength deep inside hospital buildings, and being ever mindful of HIPAA requirements.

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Reference: Improving communication in Level I trauma centers: replacing pagers with smartphones. Telemedicine and e-Health, 19(3):150-153, 2013.

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Paging And The Trauma Pro

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People who work in hospitals, particularly physicians, physician assistants, nurse practitioners and residents are throwbacks who still use old-fashioned paging technology. My colleague, the Skeptical Scalpel, recently lamented this fact in one of his blog posts. But they do seem to be a necessary evil, since cellular coverage is often limited deep inside of buildings.

But how much to trauma professionals get paged? An oral presentation at the recent Congress of Neurological Surgeons described a study that monitored paging practices between nurses and neurosurgical residents.

Medical students were paid to follow neurosurgical residents during 8 12-hour call shifts. They recorded the paging number and location, priority, and what the resident was doing when paged. The results were enlightening but not surprising:

  • 55 pages were received per shift, on average, ranging from 33 to 75
  • An average of 5 pages per hour were received, with a range of 2 to 7
  • A substantial number of pages were received during sleep times (4 per hour)
  • It took an average of 1.4 minutes to return the page
  • 68% of pages were non-urgent
  • 65% interrupted a patient care activity
  • An average of 1.1 hours was spent returning pages per shift

Bottom line: Yes, we are throwbacks using an old technology. But it does serve us well. Unfortunately, it’s an old technology being used in an inefficient manner. I recommend that nursing units make it a practice to maintain a “page list” of nonurgent items. The trauma professional can then stop by or call each unit periodically (every 2 hours or some other appropriate time interval) and deal with all of them at once. Obviously, urgent and emergent problems should still be called immediately. This will ensure that routine issues are taken care of in a timely manner and the trauma pro can attend to their other duties as efficiently as possible.

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Reference: Oral Paper 113: An Observational Study of Hospital Paging Practices and Workflow Interruption Among On-call Junior Neurosurgery Residents. Presented at the Congress of Neurological Surgeons 2012.