Tag Archives: EAST

Guidelines

EAST Practice Management Guideline: Handoffs And Transitions Of Care

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Medicine, in general, and trauma care, specifically, require frequent communication. These communications may be between two providers to maintain continuity of care or between providers and patients to explain it. Unfortunately, the Joint Commission has identified breakdowns in the process as a root cause of preventable events and a significant factor in preventable death.

To address this problem, many centers have sought to standardize this process, which may include some of the principles in my previous post. However, until now, there have been no evidence-based recommendations for this practice.

The Eastern Association for the Surgery of Trauma performed a systematic review and meta-analysis of the literature to develop a practice guideline. They focused specifically on handoffs for acute care surgery during perioperative interactions, patients arriving in the trauma bay, and patients transitioning to or from the ICU and floor. The goal was to reduce complications, handoff errors, medical errors, and preventable events.

The literature on this topic was searched from 1960 to 2021, and only observational and randomized studies were included. This yielded only ten papers that met all search criteria. The reviewers then used these papers to answer three questions. These and their answers are outlined below.

Question 1.  Should perioperative interactions in the care of ACS patients (P) include a standardized handoff versus current process without a standardized handoff to help reduce clinical complications, handoff errors, medical errors, and preventable adverse events?

Patients who received a standardized handoff were significantly less likely to experience a handoff error.  However, the impact on medical errors and adverse events could not be gauged because only one paper covered these problems.

Question 2. Should EMS utilize a standardized handoff at the arrival of trauma patients versus the current process without a standardized handoff to help reduce clinical complications, handoff errors, medical errors, and preventable adverse events?

We instituted a trauma team EMS timeout process in 2012, which persists to this day. Please take a look at my post here. The prehospital providers like it because they feel like they are more a part of the team. The receiving team can listen to their report without distraction. But what does the literature say? Unfortunately, we don’t know yet. Only one published paper covered this topic, and it included only 18 patients.  Thus, no conclusions can be drawn.

Question 3. Should intra/inter floor and ICU interactions in the care of ACS patients include a standardized handoff versus currently process without a standardized handoff to help reduce clinical complications, handoff errors, medical errors, and preventable adverse events?

Significantly fewer preventable adverse events occurred when a standardized handoff was used. There was no difference in clinical complications. The impact on medical errors could not be evaluated because only one study assessed this.

Bottom line: The general belief is that using a standardized handoff is a good thing. But I think you see the theme here. As in most EAST systematic reviews, there is painfully little high-quality data available for us to prove it. Most of the mundane, day-to-day things we do and decisions we make as trauma professionals are too dull to perform a study about. 

From the few papers available for this guideline, standardized handoffs are a good thing. They decrease handoff errors and reduce preventable adverse events as well. The EMS to trauma team handoff is well-received and is subjectively valuable. Unfortunately, there is little real data to prove this.

Overall, the real data on this topic is weak, and much more work needs to be done. I would encourage all trauma professionals to develop and refine their handoff processes. I strongly recommend coupling that with your own study so you can teach the rest of us how good it really can be.

Reference: Handoffs and Transitions of Care: A Systematic Review, Meta-Analysis, and Practice Management Guideline from the Eastern Association for the Surgery of Trauma. J Trauma, Publish Ahead of Print
DOI: 10.1097/TA.0000000000004285

Abdomen

Guidelines For Diagnosis Of Diaphragmatic Injury

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In today’s post, I will review the diaphragmatic injury practice guidelines published by the Eastern Association for the Surgery of Trauma (EAST).  I will follow this up on Friday with an interesting delayed diaphragm injury case.

Diaphragm injury is a troublesome one to diagnose. It is essentially an elliptical sheet of muscle that is doubly curved, so it does not lend itself well to diagnosis by axial imaging. The addition of sagittal and coronal reconstructions to a thoracoabdominal CT has been helpful but still has a far from perfect diagnostic record.

From an evaluation standpoint, there are several possibilities:

  • Observation – not generally recommended. It is usually combined with imaging such as a chest x-ray to see if interval changes occur that would indicate the injury.
  • Chest x-ray – this is not often diagnostic, but when herniation of abdominal contents is obvious, the patient most assuredly has an operative problem.
  • Thoracoabdominal CT scan – this technology keeps improving, especially with thinner cuts and different planes of reconstruction. Sometimes even subtle injuries can be detected. But this exam is still imperfect.
  • Laparoscopy or thoracoscopy – this technique yields excellent accuracy when the injury is in an area that can be viewed from the operative entry point chosen.
  • Laparotomy or thoracotomy – this is the ultimate choice and should be nearly 100% accurate. It is almost the most invasive and has more potential associated complications.

EAST reviewed a large body of literature and selected 56 pertinent papers for their quality and design. Then, they critically reviewed them and applied a standard methodology to answer several questions.

Here are the questions with the recommendations from EAST, along with my comments:

  • Should laparoscopy or CT be used to evaluate left-sided thoracoabdominal stab wounds? First, these patients must be hemodynamically stable and not have peritonitis. If either is present, there is no further need for diagnosis; a therapeutic procedure must be performed.
    Left-sided diaphragm injuries from stabs are evil. The hole is small, and since the pressure within the abdomen is greater than the chest, things always try to wiggle their way through this small hole. It can remain asymptomatic if the wiggler is just a piece of fat, but it can be catastrophic if a bit of the stomach or colon pushes through and becomes strangulated. Furthermore, these holes enlarge over time, so more and more stuff can push up into the chest.
    EAST recommends using laparoscopy for evaluation to decrease the incidence of missed injury. However, if the injury is in a less accessible location (posterior), the patient has body habitus issues or adhesions from previous surgery may lead to incomplete evaluation, laparotomy should be strongly considered.
  • Should operative or nonoperative management be used to evaluate right-sided thoracoabdominal penetrating wounds? Note that this is different than the last question. All penetrating injuries (stabs and gunshots) are included, and this one is for management, not evaluation. And the same caveats regarding hemodynamic stability and peritonitis apply. Again, it applies to both stabs and gunshots.
    Unlike left-sided injuries, right-sided ones are much more benign. This is because the liver keeps anything from pushing up through small holes, and they do not tend to enlarge over time due to this protection. For that reason, EAST recommends nonoperative management to reduce operation-related mortality and morbidity.
  • Should stable patients with acute diaphragm injury undergo repair via an abdominal or thoracic approach? This question applies to any diaphragm injury that requires an operation, such as a right-sided penetrating injury or any blunt injury. EAST recommends an approach from the abdomen to reduce morbidity and mortality. However, since abdominal injury frequently occurs in these cases, an approach from the chest limits the ability to identify and repair abdominal injuries. Otherwise, you may find yourself doing a laparotomy in addition to the thoracotomy.
  • Should patients with delayed visceral herniation through a diaphragm injury undergo repair via an abdominal or thoracic approach?  For years, the preferred approach for delayed presentations has been through the chest because the injury is easier to appreciate and repair.  However, if ischemic or gangrenous viscera are present, it will be more challenging to manage and repair from the chest. EAST does not make a specific recommendation for this question and suggests the surgical approach be determined on a case-by-case basis.
  • Should patients with an acute diaphragm injury from penetrating injury without concern for other intra-abdominal injuries undergo open or laparoscopic repair? The quality and quantity of data addressing this question were very low, but EAST recommends laparoscopy to repair these injuries to reduce morbidity and mortality. This includes blunt injuries, which tend to be larger. There were some conversions to an open procedure, especially in the blunt cases. The usual caveats on exposure, injury location, body habitus, and previous surgery apply.

Reference: Evaluation and management of traumatic diaphragmatic injuries: A Practice Management Guideline from the Eastern Association for the Surgery of Trauma. J Trauma 85(1):198-207.

Guidelines

5 Guidelines For Diaphragmatic Injury

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Today’s post is another review of some of the practice guidelines published by the Eastern Association for the Surgery of Trauma (EAST).  This one covers the evaluation and management of diaphragmatic injury.

Diaphragm injury is a troublesome one to diagnose. It is essentially an elliptical sheet of muscle that is doubly-curved, so it does not lend itself well to diagnosis by axial imaging. Addition of sagittal and coronal reconstructions to a thoraco-abdominal CT has been helpful, but still has a far from perfect diagnostic record.

From an evaluation standpoint, there are several possibilities:

  • Observation – not generally recommended. It is usually combined with imaging such as chest x-ray to see if interval changes occur that would indicate the injury.
  • Chest x-ray – this is not often diagnostic, but when herniation of abdominal contents is obvious the patient most assuredly has an operative problem.
  • Thoraco-abdominal CT scan – this technology keeps getting better, especially with thinner cuts and different planes of reconstruction. Sometimes even subtle injuries can be detected. But this exam is still imperfect.
  • Laparoscopy or thoracoscopy – this technique yields excellent accuracy when the injury is in an area that can be viewed from the operative entry point chosen.
  • Laparotomy or thoracotomy – this is the ultimate choice and should be nearly 100% accurate. It is almost the most invasive and has more potential associated complications.

EAST reviewed a large body of literature and selected 56 pertinent papers for their quality and design. They critically reviewed them and applied a standard methodology to answer several questions.

Here are the questions with the recommendations from EAST, along with my comments:

  • Should laparoscopy or CT be used to evaluate left-sided thoraco-abdominal stab wounds? First, these patients must be hemodynamically stable and not have peritonitis. If either is present, there is no further need for diagnosis; a therapeutic procedure must be performed.
    Left sided diaphragm injuries from stabs are evil. The hole is small, and since the pressure within the abdomen is greater that the chest, things always try to wiggle their way through this small hole. It can remain asymptomatic if the wiggler is just a piece of fat, but can be catastrophic if a bit of the stomach or colon pushes through and becomes strangulated. Furthermore, these holes enlarge over time, so more and more stuff can push up into the chest.
    EAST recommends the use of laparoscopy for evaluation to decrease the incidence of missed injury. However, if the injury is in a less accessible location (posterior), the patient has body habitus issues, or adhesions from previous surgery may lead to incomplete evaluation, laparotomy should be strongly considered.
  • Should operative or nonoperative management be used to evaluate right-sided thoraco-abdominal penetrating wounds? Note that this is different than the last question. All penetrating injuries are included (stabs and gunshots), and this one is for management, not evaluation. And the same caveats regarding hemodynamic stability and peritonitis apply. It applies to both stabs and gunshots.
    Unlike left-sided injuries, right-sided ones are much more benign. The liver keeps anything from pushing up through small holes, and they do not tend to enlarge over time due to this protection. For that reason, EAST recommends nonoperative management to reduce mortality and morbidity related to operation.
  • Should stable patients with acute diaphragm injury undergo repair via an abdominal or thoracic approach? This question applies to any diaphragm injury that requires operation, such as right-sided penetrating injury or any blunt injury. EAST recommends an approach from the abdomen to reduce morbidity and mortality. Since abdominal injury frequently occurs in these cases, an approach from the chest limits the ability to identify and repair abdominal injuries. Otherwise, you may find yourself doing a laparotomy in addition to the thoracotomy.
  • Should patients with delayed visceral herniation through a diaphragm injury undergo repair via an abdominal or thoracic approach?  For years, the preferred approach for delayed presentations has been through the chest because the injury is easier to appreciate and repair.  However, if ischemic or gangrenous viscera are present, it will be more difficult to manage and repair from the chest. EAST does not make a specific recommendation for this question and suggests the surgical approach be determined on a case by case basis.
  • Should patients with an acute diaphragm injury from penetrating injury without concern for other intra-abdominal injuries undergo open or laparoscopic repair? The quality and quantity of data addressing this question were very low, but EAST recommends laparoscopy for repair of these injuries to reduce morbidity and mortality. This includes blunt injuries, which tend to be larger. There were some conversions to an open procedure, especially in the blunt cases. The usual caveats on exposure, injury location, body habitus and previous surgery apply.

Reference: Evaluation and management of traumatic diaphragmatic injuries: A Practice Management Guideline from the Eastern Association for the Surgery of Trauma. J Trauma 85(1):198-207.

General

EAST 2017 Page on The Trauma Pro Blog

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Hello all! I’ve created a separate page for posts regarding the upcoming meeting of the Eastern Association for the Surgery of Trauma.

I will be reviewing a baker’s dozen abstracts over the next 2 weeks, giving my own analysis and commentary. I’ll also provide some suggestions and questions to anticipate for the authors to refer to.

Click here to visit the EAST 2017 page!

And if you are a presenter and would like me to look at your paper, just email, tweet, or connect via your method of choice.

General

The Best of EAST! Starts tomorrow!

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Starting tomorrow, and continuing through the annual meeting of the Eastern Association for the Surgery of Trauma, I will be analyzing one of the upcoming presentations each day. That’s 13 papers, and I’ll be picking some of the notable ones.

Remember, abstracts are teasers to get you to read/listen to the full paper. I’ll be reviewing them in detail, putting them into context, and this year I’ll be providing a list of questions that the presenters should be prepared to field from the audience. And I’ll be in that audience, so I will probably ask a few of them!

Enjoy the commentary, and I’ll see many of you at EAST in sunny Hollywood, Florida!