Tag Archives: ED

ED Use of CT – Everyone Does It Differently

There is tremendous variability in ordering imaging in trauma patients. To some degree, this is due to the dearth of standards pertaining to radiographic imaging, at least in trauma. And when standards do exist, trauma professionals are not very good at adhering to them. We’d rather do it our way. Or the way we were trained to do it.

The group at Jamaica Hospital in Queens, NY quantified some of those differences, studying ordering patterns of trauma surgeons (TS), emergency physicians (EP), and surgery chief residents (CR). Unfortunately, they then tried to draw some interesting conclusions, which I’ll discuss at the end.

They reviewed all blunt trauma activations over a 6 month period at their urban trauma center. At the end of each trauma activation, each of the three physician groups wrote imaging orders, but only the trauma surgeons’ were submitted. Missed injuries were defined as any that would not have been found based on each provider group’s orders. Extremity injuries, and those found on physical exam or plain imaging were excluded.

Here are the factoids:

  • The authors do not state how many patients they saw in this period, but by extrapolation it appears to be about 250
  • Trauma surgeons ordered significantly more studies (1,012) than the EPs (882) or CRs (884)
  • This resulted in essentially a “pan-scan” in 78%, 64%, and 69%, respectively
  • Radiation exposure was said to be the same for all groups (18 vs 13 vs 15 mSv) [I’m having a hard time buying this]
  • But cost was higher in the trauma surgeon group ($344 vs $267 vs $292) [Huh? Is this only the electric bill for the CT scanner? Very low, IMHO]
  • And the trauma surgeons had a missed injury rate of only 1%, vs 11% for EPs and 7% for CRs [Wow!]

Bottom line: Sorry, I just can’t believe these results. There are a lot of things left unsaid in this poster. What were all these missed injuries? What magical CT scan that only the trauma surgeons ordered actually picked them up? And probably most importantly, were they clinically significant? A small hematoma somewhere doesn’t make a difference (see the “tree falls in a forest” post below).

It looks to me like the authors wanted to justify their use of pan-scan, and push their emergency physicians to follow suit. Unfortunately, this is a poster presentation, meaning that there will be limited opportunity to question the authors about the specifics.

The debate regarding pan-scan vs selective imaging is an active one. The evidence is definitely not in yet. While we sort it out, the best path is to develop a reasonable imaging practice guideline based on the literature, where available. Some areas such as head and cervical spine CT have been worked out fairly well. Then fill in the blanks and encourage all trauma professionals in your hospital to follow them. There is great value in adhering to good guidelines, even when there are blanks in our knowledge.

Related posts:

Reference: Variability in computed tomography imaging of trauma patients among emergency department physicians and trauma surgeons with respect to missed injuries, radiation exposure and cost. AAST 2016, Poster #75.

Extubating Trauma Patients In The ED

Many patients are intubated in the emergency department who need brief control of their airway or behavior. In some cases, the condition requiring intubation resolves while they are still in the department. Most of the time these patients are admitted, typically to an ICU bed, for extubation. This is expensive and uses valuable resources. Is it possible to safely extubate these patients and possibly send them home?

Maryland Shock Trauma and Mount Sinai Medical Center looked at their experience in extubating selected patients in the ED. They looked at a series of 50 patients who were intubated for combativeness, sedation, or seizures. A specific protocol was followed to gauge whether or not extubation should be attempted.

None of the patients who were extubated per protocol required unplanned reintubation. One patient underwent planned reintubation when taken to the OR for an orthopedic procedure. 16% of patients were able to be discharged home from the ED.

Bottom line: A subset of patients who are intubated in the emergency department can be extubated once the inciting factor has resolved. These factors include sedation for painful procedures and combativeness. Following this protocol can reduce admission rates and reduce the use of scarce intensive care unit resources.

Click here to download a copy of the ED extubation protocol.

Related post: Trauma 20 years ago: ED intubation for head injury

Reference: Trauma patients can be safely extubated in the emergency department. J Emerg Med 40(2):235-239, 2011.

NOTE: The EMCrit blog, written by Scott Weingart, covered this topic in November 2010. He is the first author on the paper and has created a nice podcast on the topic. You can find his blog here, and you can download the podcast here.

How To Decrease Medication Errors In The ED

The ED is a fast-paced environment where things must happen quickly at times. This makes it a ripe environment for errors. A recent study looked at one possible way of decreasing the number of medication errors in a Level I trauma center.

A prospective observational study was carried out in the ED, where pharmacists were on duty and attended all trauma activations for 10 hours each day. No pharmacist was present the rest of the time. The potential errors that were identified consisted of any of the following:

  • medication ordered but not given
  • medication given but not ordered
  • delay in administration

Nearly 700 patient encounters were evaluated, with about one third seen when the pharmacist was present, and two thirds when they were away (makes sense given their coverage hours). The demographics of the patient groups were the same. 

There was a huge difference in the number of medication errors! Only 6 errors (3%) occurred when pharmacists were present, but 137 occurred (30%) when they were not. An odds-ratio calculation showed that medication errors were 13.5 times more likely to occur on shifts when pharmacists were not present in the ED.

Bottom line: It’s helpful to have another set of eyes, not focused on the patient’s injuries, looking after critical medications. The error rate is so much lower with a pharmacist present that it must be cost effective to provide them 24/7. Time for another study!

Reference: On-site pharmacists in the ED improve medical errors. Am J Emerg Med Jun 10, 2011 (epub ahead of print).

Extubation in the Emergency Department

Many patients are intubated in the emergency department who need brief control of their airway or behavior. In some cases, the condition requiring intubation resolves while they are still in the department. Most of the time these patients are admitted, typically to an ICU bed, for extubation. This is expensive and uses valuable resources. Is it possible to safely extubate these patients and possibly send them home?

Maryland Shock Trauma and Mount Sinai Medical Center looked at their experience in extubating selected patients in the ED. They looked at a series of 50 patients who were intubated for combativeness, sedation, or seizures. A specific protocol was followed to gauge whether or not extubation should be attempted.

None of the patients who were extubated per protocol required unplanned reintubation. One patient underwent planned reintubation when taken to the OR for an orthopedic procedure. 16% of patients were able to be discharged home from the ED.

Bottom line: A subset of patients who are intubated in the emergency department can be extubated once the inciting factor has resolved. These factors include sedation for painful procedures and combativeness. Following this protocol can reduce admission rates and reduce the use of scarce intensive care unit resources.

Click here to download a copy of the ED extubation protocol.

Related post: Trauma 20 years ago: ED intubation for head injury

Reference: Trauma patients can be safely extubated in the emergency department. J Emerg Med 40(2):235-239, 2011.

NOTE: The EMCrit blog, written by Scott Weingart, covered this topic last November. He is the first author on the paper and has created a nice podcast on the topic. You can find his blog here, and you can download the podcast here.