Although posterior hip dislocation is an uncommon injury, the consequences of delayed recognition or treatment can be dire. The majority are caused by head-on car crashes, and 90% of these are posterior dislocations. The femoral head is forced across the back wall of the acetabulum, either by the knee striking the dash, or by forces moving up the leg when the knee is locked. This occurs most commonly on the right side when the driver is standing on the brake pedal, desperately trying to stop.
On exam, the patient presents with the hip flexed, internally rotated and somewhat adducted. Range of motion is limited, and increasing resistance is felt when you try to move it out of position. An AP pelvic X-ray will show the femoral head out of the socket, but it may take a lateral or Judet view to tell if it is posterior vs anterior.
These injuries need to be reduced as soon as possible to decrease the chance of avascular necrosis of the femoral head. Procedural sedation is required for all reductions, since it makes the patient much more comfortable and reduces muscle tone. The ED cart needs to be able to handle both the patient’s weight and your own. I also recommend a spotter on each side of the cart.
Standing on the cart near the patient’s feet, begin to apply traction to the femur and slowly flex the hip to about 90 degrees. Then gently adduct the thigh to help jump the femoral head over the acetabular rim. You will feel a satisfying clunk as the head drops into place. Straighten the leg and keep it adducted. If you are unsuccessful after two tries, there is probably a bony fragment keeping the head out of the socket. See an instructional video on this in my next post.
Regardless of success, consult your orthopedic surgeon for further instructions. And be sure to thoroughly evaluate the rest of the patient. It takes a lot of energy to cause this injury, and it is flowing through the rest of the patient, breaking other things as well.
In the last post, 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. This involves the same two components I’ve already written about:
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 to 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 several posts 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 an otherwise robust 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. 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 scans? 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.” At least until the technology improves, which it hasn’t for the last ten years!
But what if they don’t? Or what if you’ve walked into a program already using it? I’ll talk about that in the next post on Friday.
In my last post, 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 also creates a garbage out situation.
There are two ways to view the eTFS on the back end (abstraction phase): read a paper report (timeline), 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. Ebola screens. Sepsis score. Many things that have nothing to do with trauam. They are difficult to understand, and it is very difficult to pick out the true “signal” due to all the “noise!” And it doesn’t matter how customized the report is, it will nearly 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 are 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. In the next post, I’ll discuss strategies to use if your hospital is “considering” moving to an eTFS. And next week, I’ll wrap up with what to do if you’ve already been burdened with it.
Home of the Trauma Professional's Blog
Do you want to get a daily email every time there’s a new post? See what I’m up to.