EAST 2016: Nursing Interruptions In The SICU

A few papers have been published in the nursing
literature about the detrimental effects of interruptions experienced during
patient care. Unfortunately, these papers have never taken the next step to
determine why they occur, and what steps can be taken to decrease the frequency
of this problem.

A group at Wright State in Dayton OH tried to
tease apart the various aspects of this issue. They observed registered nurses
in a 23 bed SICU at a Level I trauma center. A total of 25 sessions covering 75
hours and multiple nurses were analyzed for the cause and duration of any interruption,
and whether it caused a switch from their primary task.

Here are the factoids:

  • Nurses were interrupted every 18
    on average
  • The dominant location was in the patient room (58%), and the most
    common activity interrupted was documentation
  • Interruption by an attending or resident was less frequent (10%), but
    ended up being longer than interruptions by other nurses (3 mins vs 1 min)
  • Interruptions of longer duration more commonly
    caused the nurse to switch tasks

Frequency (left) and duration
(right) of interruptions from each source. CL = call light, ECD = electronic
communication device

line: This is a first look at the anatomy of nursing interruptions in the SICU.
They are much more common than you think. Task switching (either mentally or
physically) is something that humans do poorly. It always degrades performance,
and can ultimately lead to patient harm. Hopefully, operational protocols can
be developed to protect nurses from unnecessary or non-urgent interruptions to
improve quality of care.

The anatomy of nursing interruptions in a surgical intensive care unit at a
trauma center. EAST 2016 Poster abstract #18.

EAST 2016: Use Of Scribes To Increase Charge Capture

Ugh! What have we come to? And don’t get me
started regarding the electronic medical record. It is true, the burden of documenting what we do in
order to get paid continues to increase
. And, of course, this takes time.
And we don’t get paid for the time we spend doing this documentation.

The next
logical step? Hire cheap labor to do the documentation!
This is becoming a
fairly common practice, unfortunately. The next abstract is from MetroHealth in
Cleveland. They looked at the impact of hiring scribes from both time and money
standpoints. Two five-month periods were reviewed, with and then without
scribes. Hold on, the numbers here will make your head spin!

Here are the factoids:

  • A total of 9726 notes were written in the no-scribe period, and 10933
    were written with scribes
  • Despite the fact that there were 407 fewer patient-days during the
    scribe period, 882 more inpatient notes were written
  • More progress notes were written early in the day with scribes, and
    fewer were written during the evening hours
  • The number of notes written after patient discharge decreased from
    12.7% to 8.4% when using scribes
  • Charge capture increased by $32 per patient-day (?!)
  • The additional scribe notes resulted in an extra
    $316K in charges generated 

line: It’s just so annoying to think that we actually have to stoop to
something like this. The scribes cost this program about $33K. They generated
$316K. The paper estimates that they were actually paid about 20% of this, or
$63,000. So each of the eight trauma surgeons in this program collected an
extra $8,000 over the 5-month period.

So, is it
worth it? Maybe. The extra charges collected seem insignificant. But, if the
surgeon is actually able to dedicate less time to documenting, and this allows
them to spend more time operating (which is what really pays the bills), then
perhaps it is. I’m not easily convinced, though.

Trauma surgeons save lives – scribes save trauma surgeons! EAST 2016 Poster
abstract #16.

EAST 2016: (F)utility Of Antibiotic Use In Facial Fractures

The majority of
trauma patients presenting with facial fractures are managed without surgery.
Dogma in the facial fracture literature indicates that antibiotics should be
administered for some period of time, typically 7-10 days, for fractures that
involve one of the sinuses.

Although this idea
and practice have been around for a long time, there is no good literature out
there to support it
. Most medical professionals are now aware of the downside
to giving unnecessary antibiotics, including allergic reactions, C. Diff infections,
and promotion of antibiotic resistance.

A group at Geisinger
Medical Center in Danville, PA, performed a four-year retrospective review of
their registry data involving nonoperatively managed facial fractures. They
stratified their patients into three groups: no antibiotics, brief antibiotics
(1-5 days), and prolonged antibiotics (>5 days). A total of 289 patients
were studied.

Here are the factoids:

  • 17% received no antibiotics, 22% received a short course, and 61% got them
    for more than 5 days (!)
  • There were no soft tissue infections in any of the groups
  • There was 1 C. Diff infection, which occurred in the prolonged
    antibiotic group. This was not statistically significant.

line: Granted, this was a small, retrospective study. But absolutely no difference
in soft tissue infections was seen, and fear of infection is the usual
justification for the use of antibiotics in these patients. A single case of C.
Diff colitis was noted, and it just happened to occur in the prolonged
antibiotic group. It’s time that we consider abandoning the blanket use of
antibiotics for facial fractures involving the sinuses.

Reference: Utility of
prophylactic antibiotics for non-operative facial fractures. EAST 2016 Poster
abstract #11.

EAST 2016: Measuring Volume Status Using Jugular Ultrasound

We’re getting pretty handy using ultrasound at
the bedside to tell us some interesting things. It started with FAST exams in
the ED. Then we added a few views and came up with the Extended FAST, which was
helpful in showing potential chest pathology.

Ultrasound made its way into other areas of the
hospital, and is now used routinely to place IV lines, arterial lines, and
central venous catheters. I’ve previously written about using ultrasound to
evaluate volume status by imaging the IVC in the abdomen. And now, the group at
Shock Trauma in Baltimore is trying to reach even further.

They are now using IVC variations and cardiac
stroke volume variations to assist in volume assessment in critically ill
patients. These studies have a learning curve, especially the stroke volume
calculations. They performed a study that evaluated another possible window
into the patient’s volume status, the positional internal jugular change.

The diameter of the IJ was evaluated while the patient
was flat, and again when the head was elevated to 90 degrees. A fluid bolus was
given, and the positional change in diameter was measured again. The results
were then correlated with changes in measured stroke volume of at least 10%.

Here are the factoids:

  • This prospective, observational study involved 159 patients over 1.5
  • Positional IJ diameter change was much better than IVC diameter changes
    (receiver operating characteristic areas of 0.93 vs 0.67)
  • The authors tried to use the stroke volume variation during passive leg
    raise (odd, but doesn’t involve sitting the patient up), and concluded they
    could not accurately assess it. This arm of the study was abandoned.

line: Leave it to the folks at Shock Trauma to come up with more weird yet interesting
stuff. This is very preliminary data, and their analysis is ongoing. Any
application of this study will be somewhat limited, since many patients are not
allowed to sit up due to their injuries or baseline hemodynamic status. We will
see where this technique
ends up: in our armamentarium, or in the trash heap.

Go for the
jugular: assessing volume responsiveness in critically ill surgical patients.
EAST 2016 Oral abstract #32.

EAST 2016: How Long Does VTE Risk Last In TBI?

Most trauma patients
are considered to be at some risk for deep venous thrombosis (DVT) and/or
venous thromboembolism (VTE) during their hospital stay. Trauma professionals
go to great lengths to screen for, prophylax against, and treat these problems.
One of the tougher questions is, how long do we need to worry about it? For
fractures, we know that the risk can persist for months. But what about head

A group at Brigham
and Women’s Hospital did a large database study looking at the VTE risk in adults
who sustained significant head injury, with only minor injuries to other body
regions. They tried to tease out the risk factors using multivariate regression

Here are the

  • Patients were only included if their AIS Head
    was >3, and all other AIS were <3
  • Of the over 50,000 patients in the study,
    overall incidence of VTE was 1.3% during the hospital stay, and 2.8% overall
    within 1 year
    of injury
  • Risk factors for VTE after discharge included
    age > 64 (3x), discharge to a skilled nursing facility (3x), and prolonged
    hospital length of stay

Incidence of VTE over time

Bottom line: View this paper as a glimpse of a potential unexpected
issue. The risk of VTE persists for quite some time after head injury (and
probably in most other risky injuries like spine and pelvic fractures. The
three risk factors identified seem to identify a group of more seriously
injured patients who do not return to their baseline soon after injury. We may
need to consider a longer period of screening in select patients, but I believe
further work needs to be done to help figure out exactly who they are.

Reference: How long should we fear? Long-term risk of
venous thromboembolism in patients with traumatic brain injury. EAST 2016 Oral
abstract #28.