Category Archives: General

EAST 2014: The Anticoagulated Patient Problem

Not only is the population getting older, many people end up on oral anticoagulants for one reason or another. This is supposed to be good, preventing stroke, pulmonary emobolism, etc. Until you fall down. Or crash your car. Or need emergency surgery.

All EDs are seeing more and more patients who are taking these drugs. But emergency departments are busy places, and if a patient looks okay, they may have to wait a bit for their evaluation. And for an unfortunate few, that wait time can be deadly. What we need is a way to promptly evaluate those patients while being mindful of resource utilization.

A Pennsylvania hospital addressed this problem by creating a special level of team activation called the AnitCoagulation and Trauma alert (ACT). The idea was to identify a subset of patients who were more likely to have problems from their anticoagulation after trauma. They selected the following critieria to trigger the ACT alert:

  • Age > 65 and
  • Taking an anticoagulant or anti-platelet agent and
  • GCS >= 13 and
  • Suspected loss of consciousness and
  • Fall in the last 24 hours

The ACT alert is called overhead and the patient is immediately ushered into a room. They must be seen by ED physician, nurse and phlebotomist within 15 minutes. A point-of-care INR must be performed within 20 minutes, and a head CT obtained within 30 minutes. Further management is then based on the CT result.

The hospital looked at their experience and reported these factoids:

  • A total of 426 patients had an ACT alert over a 10 month period and were compared to a similar control group from the previous year
  • Significantly fewer ACT alert patients who were admitted stayed more than 5 days compared to admitted control patients (38% vs 52%)
  • More ACT alert patients were discharged from the ED directly (56% vs 30%)
  • Patients discharged from the ED were out more quickly than controls (faster throughput)

Bottom line: The analyses in this abstract make me suspect that there is some slicing and dicing of data. Why not just report hospital length of stay rather than the percentage who were in hospital more than 5 days? And I think their criteria should be tightened up a bit. Nevertheless, their research illustrates an approach that addresses a real need in all trauma centers. Anticoagulated “minor” trauma patients (those that don’t meet trauma activation criteria) can quickly develop life-threatening problems. Every center should have a system for rapidly identifying and evaluating these patients. And not using the full trauma team is a good idea, because the amount of wear and tear on the team if they had to respond to every one of these patients would be counterproductive. 

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EAST 2014: TBI Evaluation In The ED

Concussion evaluation is a very common reason for presentation to the ED. Many centers discharge patients from the ED with a normal GCS and a normal head CT. But is this enough? How many of these patients would benefit from further outpatient evaluation and possible treatment?

Another study from Grant Hospital in Columbus looked at a subset of mild TBI patients from the ED who also underwent more robust neurocognitive evaluation within 48 hours of their discharge.

Here are the factoids:

  • of the 6000+ trauma patients seen over a 17 month period, only 396 met the inclusion criteria (age >13, GCS 15, normal head CT, blunt trauma, no psych issues) and had a neurocognitive eval within 48 hours
  • 41% were cleared for discharge without any followup or supervision. 88% of these had known or suspected loss of consciousness.
  • 25% required outpatient therapy or were not safe for discharge. 81% of these had possible LOC. 
  • Only 28% of patients who required ongoing therapy would have met traditional ED discharge guidelines

Bottom line: First, this abstract is very poorly written. The concept comes across (barely), but is presented badly. Obviously, loss of consciousness is not much of an indicator of anything. The question is, how can we more reliably determine if a patient will need further cognitive evaluation or therapy? Gross GCS and head CT results do not seem to be enough. One solution may be to have ED nurses administer a basic cognitive screen to identify more subtle problems. The Short Blessed Test is ideal for this, and takes only a few minutes of time. And the key is to have some type of TBI clinic available to refer these patients to if they fail the test!

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Reference: You can’t go home: routine concussion evaluation is not enough. EAST 2014, poster abstract #12.

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EAST 2014: Trochar vs Needle (vs Finger Thoracostomy) For Tension Pneumothorax?

I’ve been involved in a number of debates regarding the best way to decompress the chest if there is a suspected tension pneumothorax. Some are proponents of the needle (I used to be one). Some believe that finger thoracostomy is better because it does not necessarily create a simple pneumothorax if you were wrong (I’ve come around to this one).

Surgeons at Madigan Army Medical Center in Washington State tried something a little different. They experimented with placing a 5mm laparoscopy port for treatment of induced tension pneumo in a large animal model (swine) to see how safe it was.

Here are the factoids:

  • Tension pneumo (TPTX) and/or pulseless electrical activity (PEA) was induced about 30 times each in 5 adult swine. TPTX was defined as a measured 50% decrease in cardiac output.
  • Placement of a 5mm laparoscopy trochar immediately relieved the abnormal physiology in 100% of TPTX cases
  • Trochar placement restored perfusion within 30 seconds in all PEA cases
  • No trochar induced injury to heart or lung was identified in any animal at necropsy
  • The authors compared these results to older needle decompression literature which showed only 40-70% success rates

Bottom line: Using a laparoscopy port to quickly relieve tension pneumo or PEA from TPTX looks like an option. It’s fast, reliable, and safe. Surgeons place these all the time in the OR, and they are designed to safely push skin and subq layers aside, not harming the viscera. However, it does suffer the same drawback as the needle: it will create a simple pneumothorax. And it will probably do so 100% of the time, guaranteeing the need for a chest tube. Furthermore, these are expensive toys to stock in an ED for only occasional use. Interesting, but I would not recommend.

Reference: 5mm trochars for the treatment of tension pneumothorax: a superior alternative to needle decompression. EAST 2014, poster abstract #1.

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EAST 2014: LEAN Process Improvement And Trauma Discharges

In many trauma hospitals, especially Level I and II centers, there tends to be a tendency toward complex, high volume care. As any trauma professional knows, this is a setup for system inefficiencies. Lean principles were derived from Japanese manufacturing practices in the 1980’s, and includes a toolset that helps companies eliminate waste. Any use of resources for anything but creating end value for the customer is considered waste and must be eliminated.

The discharge planning process for trauma inpatients is one of many parts of the care spectrum that contains waste, and researchers at Grant Medical Center in Columbus looked at the result of applying lean principles to it.

A lean mapping event was held, which is one of the tools promoted by the lean process. This identified areas for immediate evaluation and intervention. This, in turn, resulted in new workflows, which were then evaluated for their effect. 

The primary area of concern indentified was inter-service communication. This included getting reliable information from consult services and providing pertinent information to physical therapy. They also discovered that trauma patient admissions to units not designated for the trauma service resulted in lengths of stay 1.6 times the average.

Three areas for improvement were identified:

  1. Off-unit trauma admissions
  2. Patients with length of stay > 15 days
  3. Miscommunication regarding patient education at discharge

Bottom line: This abstract is heavy on theory and very light on practice. There is no statement or analysis of results. However, it does seem like there may be some use for Lean methodology in analyzing trauma care. The trick will be to develop interventions that actually remove some of the inefficiencies in our care processes. I will definitely sit in on this presentation!

Reference: Lean methodology for performance improvement in the trauma discharge process. EAST 2014, oral paper #31.

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EAST 2014: ICU Procedures – Residents vs ACPs

Involvement of advanced care practitioners (ACPs) like physician assistants and advanced clinical nurses has increased significantly due to the implementation of work hour restrictions for surgical residents. Prior to this, invasive procedures were performed almost exclusively by the residents. Now, more and more procedures are being performed by ACPs. The question is: is it safe?

Carolinas Medical Center retrospectively reviewed all ICU procedures performed in a year’s time in their SICU. They compared complication rates when the procedure was performed by a resident vs an ACP. 

The factoids:

  • Procedures reviewed included arterial lines, central venous lines, chest tubes, bronchoalveolar lavage, perc gastrostomy, and perc tracheostomy
  • Residents performed all procedures on trauma patients in the ICU, and ACPs performed procedures on all other SICU patients (note: this is not randomization!)
  • All procedures were supervised by an attending physician
  • A total of 1,575 procedures were performed, 1,020 by residents and 555 by ACPs
  • The complication rate for both groups was 2% (no difference)
  • Hospital and ICU length of stay were the same for both groups
  • In-hospital mortality was 11% for the resident group vs 9.7% for the ACP group, despite higher APACHE III for the latter.

Bottom line: ACPs can perform ICU level procedures as well as residents with proper supervision. As work hour restrictions continue to become more restrictive, expect to see further degradation of resident experience and expanded involvement of ACPs. For centers without residents, be confident in expanding the role of your ACPs in clinical care.

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Reference: Comparison of critical care procedural complication rates between residents and advanced clinical providers. EAST 2014, oral paper 21.

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