Trauma centers generally design their trauma teams around the type and volume of injured patients they receive. There must be sufficient depth of coverage to handle multiple “hits” at once. But even the best planning can be overwhelmed by the occasional confluence of the planets where multiple, multiple patients arrive during a relatively short period of time (the “crunch”).
As the reserve of available trauma professionals to see new, incoming patients dwindles, it sometimes even becomes necessary to close the center to new patients. Once those who have already arrived have been processed, the trauma center can open again.
This scenario, while hopefully rare, unfortunately introduces a huge opportunity for errors and omissions in care. There is much more clinical activity, lots of patient information to be gathered and processed, and many decisions to be made. How can you reduce the opportunity for these potential problems?
Consider a “post-crunch” debriefing! Once things have quieted down, assemble all team members in one room. Systematically review each patient involved in the “crunch”, going through physical exam, imaging, lab results, and the final plan. It’s helpful to have access to the electronic medical record during this process so everything that is known can be reviewed. Make sure that all clinical questions are answered, and that solid plans are in place and specific people are assigned to implement them.
Once you’ve reviewed all of the incoming, don’t forget your patients already in the hospital. Significant issues may have occurred while you were busy, so quickly review their status as well. Chat with their nurses for updates. Make sure they are doing okay.
Then prepare yourself for the next “crunch”!
Injuries to pregnant women causes a lot of anxiety among trauma professionals. Not only is there one obvious seriously injured patient, but there’s a baby involved that is relatively invisible using the tools available in the trauma resuscitation room.
To help demystify and de-anxiefy (just made it up), the next newsletter will cover trauma in pregnancy in detail. Topics will include:
- Tips and tricks
- Predicting outcome
- Safe imaging
- Perimortem C-section
- And more!
If you haven’t already, subscribe to my Trauma MedEd newsletter so you can get this edition as soon as it’s released. Otherwise, it will be released here on the blog about 2 weeks later.
Click here to subscribe and download back issues!
Your patient is at their healthiest as they roll in through the emergency department door
Yes, major trauma patients are sick, but they are going to get sicker over the next few hours to days. No matter how bad they look now, they will tolerate more at the time you first see them than they will tomorrow.
Too often, we look at them and delay because “they are too sick to operate.” This is usually not the case.
Bottom line: Move quickly, get surgical clearances done promptly, and perform all interventions (especially major surgery) early before your trauma patient gets really sick!
Other Laws of Trauma:
I sat in on a committee meeting once where the management of a particular clinical problem was being vigorously discussed. One of the participants pulled out his smartphone, did a quick search, and said, “Aha! This article shows that my opinion is correct!”
This approach is wrong on so many levels, it’s almost laughable. But it illustrates a real weakness that all human beings have: susceptibility to cognitive bias.
Scientists have identified somewhere between 150 and 200 different types of cognitive bias, and trying to sort them out will literally make your head spin. For a quick and enlightening read, I recommend reading the article below. It sifts through the mess and lumps them into four understandable categories.
Bottom line: We are all capable of warping what we read, hear, and see to fit our own vortex of pre-existing beliefs. It’s very important to recognize the possibility of bias when you are seeking information so that you can do everything to minimize its impact. If you can’t or won’t do that, then you’ll end up being that know-it-all guy with the smartphone.
Hospital medicine in general, and inpatient trauma care specifically, is now characterized by a series of handoffs. These occur between physicians, trainees, nurses, and a host of other trauma professionals. Many trauma centers have implemented a “morning report” type of handoff, which formalizes part of the process and frequently adds a teaching component.
The group at the University of Arkansas studied the impact of implementing a morning report process on length of stay and care planning. Prior to the study, residents handed off care post-call to other residents without attending surgeon involvement. The morning report process added the presence of the post-call surgeon, and the trauma and emergency general surgery attendings coming on duty. Advanced practice nurses collected information on care plan changes.
Here are the factoids:
- Problem: There is mention of a survey with 79% response rate detailing 219 trauma admissions during the 90 day study period. This is not explained anywhere else in the abstract, so it is not clear if the data presented represents all admissions.
- 69% of patients were admitted to a ward bed, and 31% to ICU
- Change to the care plan occurred during morning report in 20% of patients
- The most common care plan changes were: addition of a procedure in 45%, medication change in 34% (typically pain management)
- Mean hospital length of stay decreased from 10 to 6 days (!)
Bottom line: This small, prospective study quantifies a few of the benefits of a formal “morning report” process. The fact that just a little bit of trauma attending oversight decreased length of stay by a whopping 4 days suggests that the residents really needed the increased supervision. Discharge planning is a multidisciplinary activity, and should be a major part of the rounding routine as well.
Formalizing the handoff process is always a good thing. Yes, it takes time and planning, but as this and other studies have shown, it is well worth the effort!
Reference: Morning report decreases length of stay in trauma patients by changing care plans in 20% of patients. AAST 2016, Poster 124.