Transfers In: Direct Admit vs Send To The ED

Level I and II trauma centers are frequently asked to accept patients who need a higher level of care. This necessitates an inter-hospital transfer that is subject to scrutiny by the trauma performance improvement program of both trauma centers. The practice at many centers is to bring all transfer patients in through the emergency department. But is this really necessary?

Bringing Patients To Your Emergency Department

  • Patients can be reassessed to see if they meet any of your trauma activation criteria.
  • The work-up from the referring hospital can be re-evaluated. If some testing or imaging has been omitted, it can be obtained after arrival.
  • Specialist assessment may be more timely or may involve interventions that are more difficult after leaving the ED. Here’s an example. In some hospitals, orthopedics may choose to place a traction pin to provide initial fracture management. They may choose to use sedation, which may not be as readily available on a surgery ward.
  • Access to certain critical services may be more rapid from the emergency department. A patient may be more rapidly taken to the operating room or interventional radiology if the patient is in the emergency department.
  • It is easier to determine the correct admitting service in the ED prior to the actual admission. Sometimes patients are suitable for admission to a surgical subspecialist service, or to a medical service if they have complex comorbidities. Initial admission to the correct service from the ED is easier than later transfer.

But there are a few downsides to ED arrival:

  • The emergency department may be swamped. Taking a patient who could just as easily have been admitted directly increases congestion in the ED and slows throughput even further.
  • There is a built-in time delay going through any emergency department. You can count on patients spending eight hours, if not much, much more if they come to the ED first.
  • It’s a big dissatisfier for patients. They’ve already gone through this time-intensive process once and are usually not happy to have to do it again.

Direct Admissions

Direct admissions essentially reverse the pros and cons listed for emergency department evaluation.

There is a mistaken belief that the ACS Verification Review Committee looks askance direct admissions. This is not the case, and there are no criterion deficiencies that refer to them. Direct admits may be reported on the site visit pre-review questionnaire, and the reviewers may have questions about your numbers and how you identify them. Otherwise, each center is free to choose how they handle them.

Here are some guidelines for directing incoming patients to the most appropriate place.

  • Are you familiar with the referring physician or APP? If you have worked with them before and are confident of their evaluation skills, then a direct admission could be appropriate.
  • Is the referring hospital a trauma center, and are you familiar with how they work up patients? What has your previous experience with them been? Again, if they are part of your hospital system and/or you have had successful direct admissions from them in the past, consider it again.
  • Will the patient need rapid access to specialized services after arrival? Do they need to go to the operating room quickly? Or might they need advanced imaging that can be arranged more expeditiously from the ED?
  • Will they need any procedures after arrival that are more easily done in your ED? Do they need a complicated laceration repair best done with equipment in the ED? Will they require conscious sedation for a procedure?
  • Are you unsure of the most appropriate admitting service? Does the patient have significant comorbidities? Do you have two or more potential admitting services but just need to lay eyes on the patient to help you decide?
  • How busy is your ED? The longer the wait time, the more desirable it is to just skip it altogether, especially if none of the items above apply.

But make sure that you are able to accurately identify and track each and every direct admission coming into the hospital. Although high numbers of direct admission patients is not a violation of ACS standards, allowing trauma patients to get into the hospital on non-trauma services without being identified by the PIPS program is. I recommend that you review each and every one of them shortly after they arrive. Then make sure the decision-making was correct and the patient is on the service that best meets their needs.

What You Need To Know About Blunt Cardiac Injury

Blunt cardiac injury can be an enigma. Significant injuries are uncommon, and the literature on it consists of case reports and small series. The group at Scripps La Jolla has an excellent review article on the topic that is currently in press. This post will relate some of the key points in this nicely prepared article.

  • Use the correct nomenclature. For years, many have called this condition “cardiac contusion” or “myocardial contusion.” Unfortunately, these descriptors are too specific. The proper term is “blunt cardiac injury (BCI),” which encompasses the entire gamut of injury from asymptomatic contusion to pericardial injury to cardiac rupture.
  • BCI occurs more commonly than you think. If one defines BCI as any arrhythmia or cardiac enzyme elevation, it is fairly common. However, if the definition is limited to clinically significant sequelae such as potentially malignant arrhythmia or cardiac failure, the incidence is easily less than 1% in blunt trauma patients.
  • Be aware of the usual mechanisms of injury. This is a condition caused by blunt trauma, with motor vehicle crashes causing half and pedestrians struck by them another one-third. Motorcycle crashes and falls caused the remaining 12%.
  • Diagnosis can be challenging.
    • Physical examination is usually of little help. New onset of a heart murmur may indicate a serious cardiac injury but is exceedingly rare.
    • EKG evidence of a new onset arrhythmia is important, particularly bundle branch blocks, PVCs, and ST segment / T wave changes, which require further investigation.
    • CPK-MB enzyme measurements are useless. Please don’t get them.
    • Troponin T and Troponin I are frequently used but do not reliably predict BCI. Testing in asymptomatic patients is not helpful and may result in additional asymptomatic testing.
    • Echocardiography is not indicated in asymptomatic patients with isolated enzyme elevations.
    • Cardiac CT may be used to differentiate acute MI from BCI. Frequently, patients at risk are having a chest CT with contrast performed anyway.

Here is the recommended treatment algorithm:

  1. If BCI is possible based on mechanism of injury, follow the ATLS protocols and perform a physical exam, E-FAST, and place on EKG monitoring.
  2. If the patient is hemodynamically unstable, quickly identify and treat tamponade or tension pneumothorax if present. If significant arrhythmias are present, treat with appropriate medications. If heart failure is present, treat medically and evaluate for surgical problems such as valve, septum, or coronary artery injury.
  3. If the patient is hemodynamically stable, obtain a 12 lead EKG. If significant arrythmias are present, treat with appropriate medications. If there is organ hypoperfusion, obtain an echocardiogram. If this study reveals an effusion, a pericardial window is indicated. If the echo shows hypokinesis or structural injury, appropriate medical or surgical management should be carried out.
  4. Patients who have only significant arrhythmias should be admitted to a monitored bed for 24 hours. Once arrhythmias have resolved, the patent can be discharged.
  5. Patients with nonspecific EKG changes should have troponin levels drawn after 8 hours of observation in the ED. If elevated, admit to a monitored bed for 24 hours. Once EKG and troponin have normalized, the patent can be discharged.
  6. If EKG and labs are normal, may discharge home from the ED if there are no other indications for admission.

Reference: Diagnosis and Management of Blunt Cardiac Injury: What You Need to Know. J Trauma, accepted for publication. DOI: 10.1097/TA.0000000000004216