Monthly Archives: March 2023

Abdomen, Complications

Colonic Pseudo-Obstruction In Trauma Patients – Part I

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A funny thing happened eight years ago. During one of our morbidity and mortality conferences at Regions Hospital, we got the first hint of an emerging pattern. We noted occasional trauma patients who developed colonic pseudo-obstruction (CPO), also known as Ogilvie’s syndrome.

In reviewing our experience, it seemed to occur mostly in men who had sustained pelvic or thoracolumbar spine injuries. Surgical instrumentation for these injuries also appeared to be a common factor, as was middle-aged or older, obesity, and metabolic diseases like type II diabetes.

We continued to see the pattern and treated it in a highly variable way depending on the attending surgeon. Abdominal x-rays were obtained semi-randomly, and if the cecum was considered as the ill-defined term “large,” the patient was sent to the ICU for an injection of neostigmine or endoscopic evacuation. If a perforation occurred, patients often got very sick.

As always, variable practice patterns are fodder for developing a practice guideline. This is the first part of a two-part series on CPO in trauma patients. First, I’ll review a new article describing this condition’s incidence in orthopedic patients. Then, in my next post, I will share a practice guideline we developed for use at Regions Hospital.

The paper was a retrospective cohort study performed by the surgical group at Copenhagen University Hospital in Denmark. They focused on patients who underwent pelvic or acetabular procedures for traumatic injury over twelve years. One cohort consisted of patients who developed CPO; the other did not.

The definition of CPO was based on standard procedures that this surgical group already used, although the specifics were not fully explained. It was based on a physical examination of the abdomen, laboratory tests, and radiographic images. Patients with a colonic diameter >10 cm were treated with neostigmine infusion. Colonoscopic decompression was used if neostigmine did not work or was contraindicated.

Here are the factoids:

  • Of 1060 patients who underwent pelvic or acetabular procedures for trauma, 25 developed CPO (2.4%)
  • The incidence was only 1.6% for pelvic fractures and about 2.6% for acetabular fractures or combined fracture patterns
  • Risk factors identified included motorcycle crash, preperitoneal packing, concomitant skull fracture or intracranial hemorrhage, paraplegia or tetraplegia, internal fixation, congestive heart failure, diabetes, and sepsis or nosocomial infection
  • CPO development increased ICU length of stay by 9 days and added a month to the hospital stay
  • Mortality was higher in the CPO group (8% vs. 6%), but this was not statistically significant

Bottom line: This is the first paper I’m aware of that quantifies what I have already seen regarding Ogilvie’s syndrome in trauma. It should be an eye-opener for everyone who sees seriously injured orthopedic patients. The increased lengths of stay are enormous, which adds to the cost and the potential for even more complications.

Obviously, this is a problem that needs to be taken very seriously. Use of the ICU for neostigmine infusion or procedural decompression should be common. But recognition and initial management should be standardized, so all appropriate patients are treated for the condition.

In my next post, I’ll share the practice guideline we developed at Regions hospital. It is designed to identify the condition early and provide decompressive therapy without moving the patient to the ICU.

Reference: Ogilvie Syndrome in Patients With Traumatic Pelvic and/or
Acetabular Fractures: A Retrospective Cohort Study. J Orthop Trauma 37(3):122-129, 2023.

Nursing, Trauma Center

Paying Respect After A Terminal Trauma Activation

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As all trauma professionals know, traumatic injuries are a major cause of death across all age groups. Well-trained trauma teams use all their skills to attempt to save critically injured patients. But, unfortunately, there are occasions in which they die despite all our efforts. In most of these cases, the time of death is called, and team members then peel off their protective clothing and melt away to pursue their usual duties.

These terminal trauma activations are mentally challenging as the proper interventions are ordered and carried out. They are also physically demanding, especially when heroic measures such as CPR are needed. But one often-neglected issue is the emotional challenge. Every team member is invested in saving that person. Frequently, they can visualize their own spouse, parent, or child in place of the patient, and go all out to try to save them.

When these trauma activations are over, team members frequently do not have an opportunity to resolve their own emotional turmoil or achieve closure for the turmoil of the previous 30 minutes.

A recent paper from the Gunderson Health System in La Crosse, Wisconsin, studied a practice that seeks to achieve this closure and recognize the life of the deceased patient. They call this the PAUSE, an acronym for Promoting Acknowledgment, Unity, and Sympathy at the End of life.

This process was implemented about five years ago, and a multidisciplinary team from a variety of religious backgrounds and beliefs carefully worded the script. It works like this:

  1. The team leader calls the time of death.
  2. Team leader then states, “At this time, we would like to take a moment to honor the patient and staff.”
  3. A chaplain takes over and does the following:
    • (Chaplain states) For those who would like to stay,
      we’ll take a moment of silence to acknowledge this
      person, their death, and our care for them …
    • (Moment of silence—10 s)
    • (Blessing)
      We give thanks for ___(Name), those they loved, and
      those who loved them.
      We give thanks for the privilege of caring for them.
      We give thanks for our caring team.
      We ask that all may be whole and find peace. Amen.
    • (Chaplain states) Thank you for your care—for those
      who would like to stay, please do, for those moving
      on to other duties, Thank You.
  4. The team disperses.

The research group circulated a pre-implementation questionnaire and then sent a post-implementation questionnaire two years later. The questionnaires were the same, except six additional questions regarding experience with PAUSE were added to the post-survey.

Here are the factoids:

  •  There were 466 participants in this study; the number of patients treated was not stated
  • Participation rates were typical of questionnaire studies (40% pre-surveys and 23% post-surveys)
  • While not statistically significant, many team members reported improvements in internal conflict, feelings of emptiness, resilience, and ability to move on to the next task

Note the higher slightly and significantly improved feelings in the post-study. This chart was based on 57 respondents.

The authors concluded that the PAUSE process was a meaningful way to help trauma team members emotionally.

Bottom line: Studies like this are difficult to conduct and even more challenging to apply rigorous statistical methods. They frequently do not have statistically significant results. But one can see specific improvements despite the soft numbers. 

Many hospitals have some processes for terminal trauma activations. Most are not as well-scripted as this. But having been involved in them myself, I find it very helpful and comforting. I recommend all centers consider implementing something similar. Like most practice guidelines, this one is only suitable for adoption with adaptation. When adopting this, it is essential to work with your chaplains and recognize the specific ethnic and religious representation in your trauma center.

Reference: Trauma and Death in the Emergency Department: A Time to PAUSE (Promoting Acknowledgment, Unity, and Sympathy at the End of Life). J Trauma Nursing 29(6):291-297, 2022.

Nursing, Trauma Center

Impact Of A Trauma Nurse Practitioner Model On Nonsurgical Admissions

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Nonsurgical admissions are a concern for most verified/designated trauma centers. Under the current 2014 Resources for Optimal Care of the Injured Patient, all trauma patient admissions to a nonsurgical service must be concurrently reviewed by the trauma program. This process guards against trauma patients sneaking into the hospital on medicine services where the quality of the care for their injuries may not be monitored.

Typically, this requirement is met by having the trauma program manager (TPM), trauma PI coordinator (TPIC), or registrar run a daily admission report and mark patients with a potential trauma diagnosis for further review. Some clinician then reviews the patient in person or via a chart check. No further attention is needed if the patient has low acuity injuries or has been seen by the trauma or other surgical service. If not, additional scrutiny is recommended to identify patients who might be better off with a trauma service consult or even a transfer of service.

The trauma group at the Charleston Area Medical Center in West Virginia postulated that adopting a trauma nurse practitioner (TNP) model to provide care for patients otherwise admitted to a hospitalist service would improve care and decrease nonsurgical admissions. The nurses were supervised directly by the trauma attending surgeons.

They analyzed retrospective registry data during a 22-month period and compared nonsurgical admission rates with the same data for the preceding three years. Several performance metrics were evaluated, including length of stay and those statistics hospitals love to watch, discharge orders placed by noon, discharge location, and time to operating room.

Here are the factoids:

  • A total of 749 patients were admitted to the TNP service and 651 to hospitalist services
  • Patients in the TNP group were significantly younger (59 vs. 76) and more likely to be male
  • ISS was the same, but the TNP service patients had slightly more injuries (1.6 vs. 1.2) overall, and their patients were more likely to require an operation
  • The number of comorbidities was higher on the hospitalist service (2 vs. 1.6)
  • Hospital length of stay was one day shorter in the TNP group, which  was significant
  • TNP service patients were more likely to discharge home rather than to a skilled nursing facility
  • Time to OR for the TNP patients was significantly shorter by 11 hours
  • 30-day readmission rates were the same
  • The percentage of patients admitted to a nonsurgical service decreased from 20% to 14% after implementation

The authors concluded that the nonsurgical admission rate declined significantly, and several performance metrics also improved. In addition, the decreased length of stay was projected to result in a decrease of over $876,000 in hospital charges throughout the study.

Bottom line: This study illustrates some potential differences that surface when patients are admitted and managed by a trauma service rather than a hospitalist service. I say potential because there are a lot of confounders here.

The patients on the two services were very different. Although the TNP service patients had slightly more injuries (1.6 vs. 1.2), their ISS was identical. They also had fewer comorbidities. There appears to be some selection process in play here, but it was not explicitly stated in the paper. It also appears that older and more complicated patients, in terms of their comorbidities, were admitted to the hospitalists. Those with injuries more likely to require surgery were admitted to the TNP service.

Nonsurgical admission rates definitely decreased, but without knowing the selection criteria, this could have been due to just the presence of the TNP service and the desire to admit patients to it. The decreased hospital LOS and higher discharge rate to home are impressive, but could this also be due to these patients’ younger age?

The final issue is that the rules have changed! Starting later this year with the implementation of the 2022 Resource Document, the 10% nonsurgical admission rate threshold will disappear. Now, all nonsurgical trauma admissions must undergo primary review via the PI process. If any issues are identified, the ISS is greater than 9, or there was no trauma or surgical consultation, they must be escalated to a timely secondary review by the trauma medical director. Gone are the days of retrospective reviews of these cases!

What to do? It’s a balancing act in terms of trauma service capacity and staffing. Ideally, most injured patients are best served on the trauma or surgical specialty service. Several papers have outlined improved outcome metrics with this arrangement. Utilizing TNPs or physician assistants to capture and manage appropriate patients can definitely be helpful. 

An alternative is to integrate a hospitalist, preferably with geriatric expertise, into the trauma service so injured patients with more complex medical issues can be comfortably managed on the trauma service.

Reference: Rate of Nonsurgical Admissions at a Level 1 Trauma Center: Impact of a Trauma Nurse Practitioner Model. J Trauma Nurs 27(3):163-169, 2020.