Tag Archives: PI

An Audit Tool For Your Massive Transfusion Protocol

Every trauma center is required to have a massive transfusion protocol (MTP). This protocol lays out in precise detail how large quantities of blood products get to and into your patient when needed. It’s important to have all of these processes worked out in advance so that the products are safely and rapidly available.

But what happens after the MTP winds down is equally important. Without a detailed analysis of the entire process, it’s impossible to know if all of its components worked as planned. While a few centers activate the MTP frequently enough to be smooth and well-practiced, many do not. For those, it’s even more critical to pick each activation apart, looking for ways to improve.

Here are some of the important things to review:

  • Demographics
  • Components used for ratio analysis
  • Lab values (INR, TEG, Hgb)
  • Logistics
  • Waste

Bottom line: I’ve included links to two audit tools below. The Broxton tool is more rudimentary, but is a good start. The Australian tool is excellent, in my opinion. It covers all the bases, and allows the center to get meaningful information and/or research material from the data.

Do you have a great MTP audit tool? Please send me a copy so I can share.

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When Does The PI Clock Start Ticking? The Answer, Part 2!

I analyzed the first of two PI clock scenarios in my last post. They are not always as obvious as they seem. Now let’s look at the second case:

A young male is involved in a motor vehicle crash and strikes his head. He enters your trauma center at exactly midnight as a trauma activation. Head CT shows a 7mm epidural hematoma with no shift and no effacement. GCS is 15, and the neurologic exam is completely normal. He is admitted to the SICU for neuro monitoring and is scheduled to have a repeat CT scan at 06:00. The scan shows significant expansion of the hematoma, with midline shift and ventricular effacement. He is taken to the OR for craniotomy by neurosurgery at 6:55.

This one is very similar to the first, except there is no indication to go to the OR at initial presentation. But about 7 hours later, he is in the operating room. So the PI trigger occurs, right? That’s more than 4 hours!

Not so fast! Let’s analyze this a bit more. Everything seems to be going well until the 6 AM CT scan. If the patient’s condition is unchanged, the earliest possible time the change in his head could have been recognized was shortly after 6:00. So the patient was actually in the OR less than an hour after the problem was recognized, right?

Not quite so fast again. The trauma PI program still has to examine the entire process from arrival until operation. Here are the questions that need to be answered:

  • Was neurosurgery involved in the initial evaluation in a timely manner?
  • Was the patient admitted to an appropriate inpatient unit?
  • Did appropriate monitoring occur?
  • Did any change in exam occur that could have suggested the hematoma was changing?
  • If so, did nursing and physician staff act appropriately with that information?

Bottom line: If everything went according to plan, and there was no change in exam or vital signs through the repeat CT scan, then this is an exemplary catch, and instead of sending the usual trauma PI nasty-gram to neurosurgery, they should receive a congratulatory note for providing such excellent service!

All too often, the trauma program just routinely sends out these “nasty-grams” without doing any further analysis of the data. And in cases like this one, the work involved in responding is just a waste of time. 

General rule: If the actual time noted for one of these time-sensitive filters is very, very long (e.g. delay to laparotomy of 62 hours), then look at it very closely. Did someone actually sit on a bleeding spleen for nearly three days, of was the patient doing well and suddenly failed nonoperative management? I think you know the answer.

And don’t forget to send out a few love letters to the other services for work well done from time to time! They probably cringe when they see trauma PI notes, since they always seem to imply something bad has happened.

When Does The PI Clock Start Ticking? The Answer, Part 1!

In my last post, I presented two potential performance improvement (PI) cases. I asked for your input as to when the clock should actually start for the 4-hour craniotomy/craniectomy rule. Today, I’ll give you my answer to the first case.

Lets look at it again:

A young male is involved in a motor vehicle crash and strikes his head. He enters your trauma center at exactly midnight as a trauma activation. Head CT shows a 12mm epidural hematoma with 8mm midline shift and ventricular effacement. GCS was 14 on arrival, but has declined to 12 by the time you leave the CT scanner. He is taken to the OR for craniotomy by neurosurgery at 4:15.

This one looks straightforward, right? But not so fast. The crani occurred more than 4 hours after arrival. Isn’t that a violation of the 4 hour filter? But did you know he needed an operation when he arrived in the ED? No! GCS and exam were reasonable, so the clock starts once the CT scan finishes, even if the surgeon doesn’t see them at that time. Why then? because the 4 hour rule is testing all of the following:

  • Whether a physician was present in CT and recognized what was on the images (not required, but reviewed if there was one there)
  • How long it takes for the radiologist to get the images
  • How long it takes for the report to be done
  • How quickly the surgeon or emergency physician review the report
  • How long it takes to contact the neurosurgeon
  • How long it takes them to see the patient and decide they need an operation
  • How easy it is to get this emergency case to the OR suite
  • How long it takes for anesthesia to do their assessment and get the patient into the room
  • How long it takes the OR team to be ready to cut

Lots of stuff! So if the scan finished any later than 12:15 am, this filter gets triggered. But hold on! In my opinion, 4 hours is a long time to wait for an emergent problem like this large epidural. Even if the scan finished at 12:30, the 4 hour rule is met, but why did it take so long to get the operation started? I’ve seen cases like this where the incision was started less than an hour after the patient arrived in the trauma bay!  Some of these cases need review even if they appear to meet the time limits.

Bottom line: Case #1 – the clock officially starts when the proof of clinical injury has been provided. This could be an abnormal physical exam, a CT scan, a critical lab test draw, a phone call from a concerned nurse, etc. The clock doesn’t necessarily start when the patient rolls in the door, unless you have some kind of weird superpowers!

I’ll review and analyze the second case tomorrow.

When Does The PI Clock Start Ticking?

This is a question that comes up frequently in trauma performance improvement (PI) programs. Several of the PI audit filters typically used at trauma centers include a time parameter. Some of these include:

  • Craniotomy > 4 hrs
  • Laparotomy > 4 hrs
  • OR for open fracture > 8 hrs (although this is now outdated)
  • OR for compartment syndrome > 2 hrs

The question that needs to be asked is: 2 or 4 or 8 hours after what?

Let’s consider the following scenario:

A young male is involved in a motor vehicle crash and strikes his head. He enters your trauma center at exactly midnight as a trauma activation. Head CT shows a 12mm epidural hematoma with 8mm midline shift and ventricular effacement. GCS was 14 on arrival, but has declined to 12 by the time you leave the CT scanner. He is taken to the OR for craniotomy by neurosurgery at 4:15.

And this one:

A young male is involved in a motor vehicle crash and strikes his head. He enters your trauma center at exactly midnight as a trauma activation. Head CT shows a 7mm epidural hematoma with no shift and no effacement. GCS is 15, and the neurologic exam is completely normal. He is admitted to the SICU for neuro monitoring and is scheduled to have a repeat CT scan at 06:00. The scan shows significant expansion of the hematoma, with midline shift and ventricular effacement. He is taken to the OR for craniotomy by neurosurgery at 6:55.

My questions for you:

  • When does the PI clock start ticking in each case?
  • What information do you need to review to make this decision?
  • Do you send a PI “love note” to the neurosurgeons in either case?

Share your thoughts on Twitter or by commenting below. I give you my answers in the next post.

Value Of The “Delay To Operating Room” Trauma PI Filter: Part 2

Yesterday, I discussed a paper that tried to show that the “delay to OR” trauma performance improvement (PI) filter was not cost effective. As I mentioned, I’m dubious that the outcomes and information reviewed could realistically demonstrate this.

Today, I’m going to list the parts of the system that this PI filter helps to monitor:

  • Was the patient appropriately triaged as a trauma activation?
  • Was the trauma surgeon called / involved in a timely manner?
  • Was an appropriate physical exam carried out?
  • If needed, was the CT scanner accessible?
  • Did the surgeon make an appropriate clinical decision?
  • If needed, did the backup trauma surgeon arrive in a timely manner?
  • Were there any transport delays to the OR?
  • Was an OR room promptly available?
  • Did the OR backup team arrive within the required time, if needed?
  • Were anesthesia services promptly available?
  • If a failure of nonoperative management occurred:
    • Was the practice guideline followed?
    • Were repeat vitals and physical exam performed and documented?
    • Did any of the other issues listed above occur?

And you may be able to think of even more!

Bottom line: As you can see, this seemingly innocuous filter tests many components within the trauma center. And even if one particular patient who triggers the “delay to OR” filter is lucky enough to escape unharmed, many of the areas listed above can harm other patients who may not trigger it. Actively looking for these issues and fixing them makes your entire trauma program better!

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