How often have you seen this in an admitting history and physical exam note? “Admit for observation; serial abdominal exams.” We say it so often it almost doesn’t mean anything. And during your training, did anyone really teach you how to do it? For most trauma professionals, I believe the answer is no.
Yet the serial abdominal exam is a key part of the management of many clinical issues, for both trauma patients as well as those with acute care surgical problems.
Here are the key points:
- Establish a baseline. As an examiner, you need to be able to determine if your patient is getting worse. So you need to do an initial exam as a basis for comparisons.
- Pay attention to analgesics. Make sure you know what was given last, and when. You do not need to withhold pain medications. They will reduce pain, but not eliminate it. You just need enough information to determine if the exam is getting worse with the same amount of medication on board.
- Perform regular exams. It’s one thing to write down that serial exams will be done, but someone actually has to do them. How often? Consider how quickly your patient’s status could change, given the clinical possibilities you have in mind. In general, every 4 hours should be sufficient. Every shift is not. And be thorough!
- Document, document, document. A new progress note should be written, dated and timed, every time you see your patient. Leave a detailed description of how the patient looks, vital signs, pertinent labs, and of course, exact details of the physical exam.
- Practice good handoffs. Yes, we understand that you won’t be able to see the patient shift after shift. So when it’s time to handoff, bring the person relieving you and do the exam with them. You can describe the pertinent history, the exam to date, the analgesic history, and allow them to establish a baseline that matches yours. And of course, make sure they can contact you if there are any questions.
Injury can be a bloody business, and trauma professionals take replacement of blood products for granted. Some patients object to this practice on religious grounds, and their health care providers often have a hard time understanding this. So why would someone refuse blood when the trauma team is convinced that it is the only thing that may save their life?
Jehovah’s Witnesses are the most common group encountered in the US that refuse transfusion. There are more than 20 million Witnesses worldwide, with over 7 million actively preaching. It is a Christian denomination that originated in Pennsylvania during the 1870s.
Witnesses believe that the bible prohibits taking any blood products, including red cells, white cells, platelets or plasma. It also includes the use of any dialysis or pump equipment that must be primed with blood. This is based on the belief that life is a gift from God and that it should not be sustained by receiving blood products. The status of certain prepared fractions such as albumin, factor concentrates, blood substitutes derived from hemoglobin, and albumin is not clear, and the majority of Witnesses will accept these products. Cell saver techniques may be acceptable if the shed blood is not stored but is immediately reinfused.
Why are Witnesses so adamant about refusing blood products? If a transfusion is accepted, that person has abandoned the basic doctrines of the religion, and essentially separates themselves from it. They may then be shunned by other believers.
So what can trauma professionals do to provide best care while abiding by our patient’s religious belief? In trauma care it gets tricky, because time is not on our side and non-blood products are not necessarily effective or available. Here are some tips:
- Your first duty is to your patient. Provide the best, state of the art care you can until it is absolutely confirmed that they do not wish to receive blood products. In they are comatose, you must use blood if indicated until the patient has been definitively identified by a relative who can confirm their wishes with regard to blood. Mistaken identity does occur on occasion when there are multiple casualties, and withholding blood by mistake is a catastrophe.
- Talk with the patient or their family. Find out exactly what they believe and what they will allow. And stick to it.
- Aggressively reduce blood loss in the ED. We are not always as fastidious as we should be because of the universal availability of blood products. Use direct pressure or direct suture ligation for external bleeding. Splint to reduce fracture bleeding.
- Aggressively use damage control surgery. Don’t go for a definitive laparotomy which may take hours. Pack well, close and re-establish normal physiology before doing all the final repairs.
- Always watch the temperature. Pull out all the stops in terms of warming equipment. Keep the OR hot. Cover every bit of the patient possible with warming blankets. All fluids should be hot. Even the ventilator gases can be heated.
- Think about inorganic and recombinant products such as Factor VIIa, tranexamic acid and Vitamin K. These are generally acceptable.
- Consider angiography if appropriate, and call them early so their are no delays between ED and angio suite or OR and angio suite.
Bottom line: Do what is right for your patient. Once you are aware of their beliefs, avoid the use of any prohibited products. Speak with them and their family to clarify exactly what you can and cannot do. This is essentially an informed consent discussion, so make sure they understand the consequences. Follow their wishes to the letter, and don’t let your own beliefs interfere with what they want.
Yesterday, I discussed what to do if your hospital is thinking about switching to an electronic trauma flow sheet (eTFS). Today I’ll give you some tips on what to do if the cat’s already out of the bag and it’s already been implemented.
The number one priority is to show the impact of the eTFS on the trauma program. There are two components:
- Accuracy. The trauma program must measure the impact of the “garbage in” phenomenon on the performance improvement (PI) process. This is critically important, because bad data will decrease the quality of your PI analysis. For example, if the PI program is not able to determine that hypotensive patients are being taken to CT scan, patient harms could occur that are not detected. This could result in two bad things for your trauma program (and patients): unanticipated mortality and deficiencies during a verification visit.
Be on the lookout for extraneous or impossible data points. Keep a list of information that is consistently missing. Use all of this information work with your hospital administration to find ways to make it better.
- Efficiency. Your program must also find a way to measure the efficiency of abstraction by the trauma program manager, PI coordinator, registrars, or whoever is tasked with doing it. Keep track of the time needed to abstract a trauma activation chart vs a non-activation. This will give you an idea of the extra time needed to process the eTFS data. Or just clock in when starting eTFS abstraction, and clock out when finished. The amount of time will probably astonish you.
Monitor average days to completion of registry entries, and look at the number of cases not fully abstracted by 60 days to see if there is a noticeable impact on your registry concurrency. Delays here are common in centers with high volumes of trauma activations, because the abstractors must spend an inordinate amount of time trying to pull information from the eTFS.
Once your hospital has taken the plunge and adopted the eTFS, it is very difficult to go back. Many centers are convinced that “this next update is going to make it so much better.” It never does! I have visited programs that have been tweaking their processes and reports for almost 8 years! None have been able to improve it significantly.
Your hospital administration will ultimately need to decide how to proceed, depending on how damaging the eTFS is to the trauma PI program and how much it will cost to continue to tweak it vs returning to a paper flow sheet. Good luck!
I’ve spent the last few days showing you the major problems inherent in using an electronic trauma flow sheet (eTFS). It boils down to Garbage In / Garbage Out and time. It costs a lot of money, and weakens the otherwise strong trauma performance improvement process.
Here’s the real bottom line:
” A hospital using an electronic trauma flow sheet is paying a lot of money for a product that forces them to pay even more money for people to essentially transcribe inaccurate data back onto a paper trauma flow sheet.”
So what can be done about it? That depends on whether the eTFS has already been implemented. Today, I’ll discuss what to do if it’s still in the planning stages.
You’ve just heard that your hospital is considering switching to an eTFS. Here’s what you should do:
- Warn everyone you can, loudly! Use all of the ammunition you’ve read about here. Talk to your administrative contacts. Ultimately, your CEO needs to hear the concerns.
- Visit another hospital with similar trauma volumes using the same eTFS. Don’t just call them up and ask how it’s going. Actually go and visit, and watch during an actual trauma activation. How is the scribe doing? Can they keep up? Is there a “cheat sheet?” Then talk to the people who abstract the eTFS data. Ask how long it takes compared to the old days of paper.
- Consider a test implementation, and have two scribes, one using the eTFS and one using a paper sheet. After each trauma activation, objectively compare scribe performance, accuracy, and completeness. The eTFS cannot be allowed until they are equivalent (which I have never seen).
- During the test implementation, have two abstractors analyze the data, one using the eTFS and one using the paper sheet. How long does it take to find all pertinent demographics, sign-in times, primary survey, secondary survey/exam, procedures, vital signs flow, fluids & IVs, I&O? Was the patient hypotensive? What activities occurred during those times: procedures, drugs, CT scan? The eTFS cannot be allowed until they are equivalent (which I have also never seen).
- Continue to work with your hospital administration, showing them this data. Hopefully they will see the light and abandon this “great idea.”
But what if they don’t? Or what if you’ve walked into a program that is already using it? I’ll discuss that tomorrow.
Yesterday, I wrote about how the electronic trauma flow sheet (eTFS) practically assures a garbage in situation. Today, I’ll dig into what happens on the back end, and how it creates a garbage out situation.
There are two ways to view the eTFS on the back end (abstraction phase): read a paper report or view it live in the electronic health record (EHR). Let’s look at each:
- Paper report. Anyone who has actually generated one of these can tell you that it’s a disaster! Reams of paper, typically 20-30 pages. Hundreds of “chronological” entries. Inclusion of extraneous information from later in the hospital stay. Difficult to understand. Hard to pick out the true “signal” due to all the “noise!” And it doesn’t matter how customized the report is, it will always fail on these issues.
- Live EHR. Your abstractor (registrar, PI coordinator, trauma program manager) logs in and pulls up the screen(s) containing the eTFS. Once again, they need to mouse and keyboard around, looking for the specific things they are interested in. Piece by piece, they try to assemble a human-understandable picture of what happened. But since it’s not chronological across all activities in this view, it can be very challenging.
- Both. And then there’s the issue of Garbage In I discussed yesterday. Conflicting patient arrival times. Lack of accurate team arrival documentation. Vital signs and IV infusions recorded after patient expiration or discharge. No massive transfusion start time. Inaccurate data from the scribe’s “cheat sheet.”
The final result of all of the shortcomings listed above is this: it increases trauma flow sheet abstraction time by three-fold or more! If you are a trauma center with a two tier trauma activation system, you probably have a lot of TTAs. Therefore, it takes a lot of time to abstract all those flow sheets. Which ultimately means that you (this really means your hospital) will have to pay for more registrars / PI coordinators / nurses!
Hopefully, I’ve convinced you that the eTFS is not a great way to go. Tomorrow, I’ll discuss strategies to use if your hospital is “considering” moving to an eTFS. And Friday, I’ll wrap up with what to do if you’ve already been burdened with it.