Monthly Archives: January 2019

Abstracts

EAST 2019 #11: Thawed Plasma And Rural Trauma Centers

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A massive transfusion protocol must be available at all trauma centers, large and small, urban and rural. In an ideal setting, attempts are made to keep the ratios of red blood cells to plasma transfused somewhere between a 1:1 and 2:1 ratio. Unfortunately, many hospitals do not keep any thawed plasma because of its 5-day shelf life, so they must resort to thawing it on demand. This process is slow and may take 20-40 minutes, so it is often difficult for these centers to keep within the optimal ratios.

The group at the Guthrie Clinic, a Level II trauma center in northern Pennsylvania, tried a novel approach to thawed plasma availability: keeping two units continuously available in the ED for trauma use only. After three days, these units were returned to the blood bank for general use and were replaced with new ones. They reviewed their one year experience with wasted plasma and compared it with the two years prior to implementation.

Here are the factoids:

  • The blood bank thawed 1127 units during the study period; 274 units were placed in the trauma bay
  • There was a significant increase in waste and cost of wasted products
  • Yet the authors did not find an increase in the relative cost of plasma waste
  • The average cost to maintain access to plasma in the trauma bay was $117 per month
  • The authors concluded that the increased waste and cost were insignificant compared to the cost of total blood bank waste (?)

Here are some questions for the authors and presenter to consider in advance to help them prepare for audience questions:

  • What do all the terms mean, like relative cost? I’m confused that the cost of waste is significantly higher, but not the relative cost. Please explain in your presentation.
  • Is the $117/month to maintain access just for the refrigerator itself and any other support hardware or software? It’s not clear if this includes any part of the blood product cost.
  • Why not keep the plasma in the blood bank? Even though it might still be wasted, couldn’t you save the $117 monthly and avoid the hassle of trying to find a cubby to put the ED blood refrigerator in?
  • Why is 3 days your magic number? Did you consider doing a simulation after you completed the study to see what would have happened if you picked 2 or 4 days in the ED instead?

This is a very creative approach to stocking perishable goods that are infrequently used. I look forward to hearing the presentation.

Reference: A novel protocol to maintain continuous access to thawed plasma at a rural trauma center. EAST 2019, Quick Shot Paper #14.

Abstracts, Imaging

EAST 2019 #10: Incidental Findings In Trauma Imaging

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Every major trauma patient undergoes some type of radiographic imaging during their initial evaluation. On occasion, some incidental finding unrelated to trauma shows up unexpectedly. These incidentalomas add several additional layers of complexity to the evaluation process.

What does the finding mean? Is it important? How do I tell the patient? Their primary care provider? When? Many times, these findings have little clinical significance. But on occasion, they can be life changing, such as the incidental renal cell carcinoma.

The group at University of Tennessee – Knoxville reviewed one year of incidental findings in trauma evaluations at their Level I trauma center. They specifically looked at diagnoses with malignant potential, and how findings were disclosed to the patient.

Here are the factoids:

  • Over 6000 patients were reviewed, and 22% had 1222 incidental findings (that’s 2 per patient!)
  • The findings were noted in males about 2/3 of the time
  • 59% of of incidentalomas were in the chest, and 16% in the abdomen
  • The most common findings were lung nodule (209), hernia (112), and renal cyst (103)
  • Only 60% of patients were informed prior to discharge (!)
  • Trauma registry abstraction resulted in an additional 20% of patients informed of the finding
  • 58 patients could not be located, and in 43 patients there was no documented attempt to contact them
  • An additional 100 registry charts that did not contain incidental findings were re-abstracted and searched for incidental findings. Nearly one third contained incidental findings!
  • If the incidental finding was noted in the radiology report summary, 78% of patients were informed. But when it was buried in the body of the report, only 22% were disclosed.

Here are some questions for the authors and presenter to consider in advance to help them prepare for audience questions:

  • The majority of the incidental findings were in the chest and abdomen. What and where were the rest?
  • What would you recommend for achieving optimal disclosure based on your results? It appears that 20% or so of patients never learned of the finding.
  • What should we do about our registry data? Should we force our registrars to comb all reports for possible incidental findings? Given that one fifth of patients have them (or more) that seems like a lot of work!
  • How has your work changed your practice at UT Knoxville?

This is a fascinating paper, and gives me some ideas for upcoming blog posts! I will definitely be in the audience for this presentation.

Reference:  A novel use of the trauma registry: incidental findings in the trauma patient. EAST 2019, Quick Shot Paper #13.

Abstracts

EAST 2019 #9: BENEFITS OF LEVEL IV TRAUMA CENTERS

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Level I and II trauma centers are considered resource centers in that they have very robust capabilities in terms of surgical specialties and other services. But no trauma system is complete unless there are a sufficient number of potential feeder centers to ensure that quality trauma care is available outside the usual catchment area of the resource centers.

Level III trauma centers have physician staffed emergency departments, solid orthopedic coverage, and varying degrees of neurosurgical expertise (from none to equivalent to a Level I). Designated Level III centers can frequently keep a variety of patients that would otherwise require transfer.

But what about Level IV centers? They are not required to have any trauma-related surgical specialties or even physicians staffing the ED for designation purposes. The expectation is that nearly all patients will be transferred upstream to a resource trauma center. What is the advantage to pursuing designation if you are still not going to be able to keep patients?

One obvious reason is that injured patients will still be brought to your hospital, especially if it is located in a rural area. But surely there must be other reasons, right? The Penn Medicine group in Lancaster PA examined registry data from the Pennsylvania Trauma Systems Foundation over a six year period, focusing on hospitals that became new Level IV centers during that time interval. They looked at demographics, injury severity, mortality, and incidence of surgical intervention.

Here are the factoids:

  • Five hospitals underwent their initial accreditation as a Level IV center during the study period, and about 5000 total patient cases were reviewed during their pre- and post-designation periods
  • There were no differences in patient demographics or injury severity before or after designation
  • The transfer rate remained steady at 63% before and after
  • There was a trend toward decreased mortality (p = 0.09)
  • There was also a trend toward fewer surgical interventions before patient transfer, after designation

Here are some questions for the authors and presenter to consider in advance to help them prepare for audience questions:

  • I presume that the observation of trends and the failure to achieve statistical significance are due to the small sample of centers, correct? Unfortunately, this is not avoidable due to the number of hospitals entering into the system.
  • During your presentation, be sure to show the audience absolute numbers and basic statistics for your findings. Adjusted odds ratios are not as well understood by the average brain.
  • Do you have any suggestions for additional research that would help show a significant mortality advantage, since additional registry data will not be of help?
  • How do you expect that Level IV wannabes or existing Level IV centers will interpret this study?

I’m looking forward to hearing this presentation in person next week!

Reference: Early analysis of Level IV trauma centers within an organized trauma system. EAST 2019, Quick Shot paper #10.

Abstracts

EAST 2019 #8: How To Keep Neurotrauma Patients At Level III Trauma Centers

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Hospitals that do not have neurosurgical coverage are faced with a dilemma when they receive a head-injured patient. Do they automatically transfer to a higher level trauma center, or do they keep the patient? This is especially poignant in rural areas, where transfer times may be lengthy. If a patient doesn’t really have any significant pathology, they are likely to be evaluated at the receiving Level I or II center, then discharged all the way back home. But if they are kept at the initial hospital, there may be a nagging doubt about what happens if…

Five years ago, the group at University of Arizona – Tucson published a simple brain injury classification system that was designed to predict which injuries were likely to progress and need neurosurgical intervention. They called this system BIG for Brain Injury Guidelines. It was created and validated on a group of nearly 4,000 patients over four years, and the results have been promising. Since then, BIG has been validated using small study groups (<405) in pediatric head injury, and at Level I and III trauma centers.

Here’s the guideline:

One of the Quick Shot presentations at next week’s EAST Annual Scientific Assembly is another validation study at a Level III center in Lake Havasu City, Arizona that introduces one small modification to the guidelines. Normally, BIG is calculated after CT of the head is complete. This modification entailed BIG calculation after anticoagulation was reversed. Patients with BIG scores of 1 or two after reversal was complete were kept at the Level III, and were managed by the trauma surgeons. All BIG 3 patients were transferred to a higher level center.

Four years of trauma registry data were analyzed. During the first two years, patients with any positive BIG score were transferred. During the final two years, only patients who scored BIG 3 after reversal were moved.

Here are the factoids:

  • During the pre-BIG period, there were 72 transfers: 36 BIG-1, 23 BIG-2, and 13 BIG-3
  • Once the protocol was in place, there were 119 patients identified, 52 patients with BIG-1 or 2 who were kept and 67 BIG-3 patients who were transferred
  • 13 patients in the post-BIG time frame were excluded
  • None of the BIG-1 or 2 patients required transfer later
  • 39 of the 52 BIG-1 or 2 patients had repeat scans, and none worsened clinically, with an average hospital length of stay of 1.4 days
  • Estimated helicopter transport savings was $1.9M based on an average charge of nearly $50K per flight

The authors concluded that modified BIG could be used to triage neurotrauma patients for transfer, but cautioned that good clinical judgment should also be applied.

Here are some questions for the authors and presenter to consider in advance to help them prepare for audience questions:

  • Are you satisfied that BIG is sufficiently validated? To date, there are only a handful of validation studies and they have relatively small numbers.
  • Why did you choose to modify the score to wait until anticoagulation? Couldn’t this nullify the validation studies?
  • Do you have any practice guidelines in place to ensure consistent care of the patients you now keep at your center? Do they allow you to manage common problems like subarachnoid hemorrhage or intraparenchymal hemorrhage?
  • How did you ensure that your surgeons, hospitalists, and nurses were comfortable managing these neurotrauma patients? Did you have any educational sessions or other training for things like GCS monitoring and neuro exam?
  • How do you reverse anticoagulation, and how long does that usually take? Plasma and prothrombin complex concentrate are commonly used, but with vastly different reversal times. And what do you do about aspirin, clopidogrel, and the novel oral anticoagulants?
  • Why did you exclude 13 patients once you started using BIG?
  • Has your hospital administration provided any numbers regarding increased revenue from this practice? Your hospital is larger (171 beds), but this type of information will be vital for small, critical access hospitals.

This is very interesting work, and highly applicable to rural trauma centers!

References:

  • Successful management of select radiographic intracranial injuries in a rural trauma center without neurosurgeon coverage using a modified brain injury guideline. EAST 2019, Quick Shot Paper #6.
  • The BIG (brain injury guidelines) project: Defining the management of traumatic brain injury by acute care surgeons. J Trauma 76(4):965-969, 2014.
Abstracts

EAST 2019 #7: Falls Screening In The Elderly

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Falls in our elderly population are one of the largest issues facing trauma centers in the US, if not world-wide. The sheer numbers, along with the significant morbidity and mortality experienced by this group is mind boggling. ACS verified trauma centers are encouraged to have geriatric specific practice guidelines to assist in optimal care of these patients, and falls prevention programs are common among them.

The Centers for Disease Control is promoting a program called the Stopping Elderly Accidents, Deaths, and Injuries (STEADI) initiative. They provide a suite of tools and resources, and screening begins with a 12 point questionnaire (see links). This tool obviously takes a bit of time to administer, and time is precious. The research group at
Baystate Medical Center in Massachusetts postulated that giving the full screen may be a bit cumbersome.

They explored a possible simplification to the 12-point STEADI screen, reducing it to only 3 of the questions. They sought to determine whether this easier and more convenient screen might be as accurate as the full STEADI screen. They evaluated a group of 60 elderly patients use the abbreviated tool, and those who scored high were referred to a physical therapy for further assessment and intervention. The primary outcome was performance improvement on the Timed Up and Go test (TUG), a measure of the patient’s ability to get up from a chair, walk a fixed distance and back, then sit down again. Normal performance is < 12 seconds.

Here are the factoids:

  • The median age of the 60 study patients who were considered high risk was 77
  • Median TUG before interventions was 16 seconds
  • After physical therapy intervention, the time decreased significantly to 12.3 seconds

The authors concluded that the abbreviated screen could be used to effectively identify elderly patients at risk for falls.

Here are some questions for the authors and presenter to consider in advance to help them prepare for audience questions:

  • Show the audience the full STEADI questionnaire, and highlight the three questions used in your study. This was not specified in the abstract. Did the patients have to score positive on all three questions to qualify for intervention?
  • How much time difference is there in answering the full 12-question survey vs the abbreviated 3 question one? The full survey looks pretty simple to me.
  • Did you also administer the full screen to see the correlation with your subset of three questions? This could provide interesting information that could validate the brief screen. How many more receiving the full screen would have qualified for the intervention?
  • What exactly were the interventions that the therapists provided in PT? Were they the same for each patient? How do you think they improved the TUG score?
  • Did all 60 patients complete the program? Or were more enrolled and only 60 qualified for intervention?
  • Is the TUG score difference clinically significant? You showed statistical significance, but are these patients really less likely to fall? Did you collect any data of falls after completion of the intervention?

This is a timely and pertinent study. I look forward to hearing the nitty gritty at the conference.

Links:

  • The STEADI algorithm
  • The 12 point STEADI screen

Reference: Fall prevention initiative: A fall screening pilot study in the ambulatory setting. EAST 2019 Paper #21.