All posts by The Trauma Pro

Equipment

Why Use A Hybrid OR For Trauma?

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Trauma is a surgical disease, and specifically, a disease of bleeding. So many of the tools and processes we have developed for its management revolve around the control of hemorrhage.

When a major trauma patient arrives in the resuscitation room, the initial management involves rapid assessment and correction of life-threatening conditions. Recognition of bleeding is paramount. A rapid decision must be made about the source of hemorrhage and the best way to control it.

Traditionally, bleeding control has been relegated to the operating room. Body cavities are opened as appropriate, and exsanguination is controlled by clamping, repairing, and/or suturing.

However, some body regions are much more challenging. The most notable is the pelvis, and specifically, the unstable pelvis. In the old days, after wrapping or applying an external fixator, the best we could do was to ligate the internal iliac arteries bilaterally and hope the bleeding would slow down sufficiently (it never really stopped) so that internal packing might have a chance.

As the use of interventional radiography grew in trauma, it became possible to occlude the internal iliacs noninvasively. Then, the radiologists became skilled enough to selectively identify and embolize more distal bleeding vessels that would dramatically shut down pelvic bleeding.

But this introduced a conundrum. OR vs IR? Where to go after the trauma bay? I’ve long said that the only place an unstable trauma patient can go is to the OR. Not CT, and certainly not the radiology department.

Only the OR, because that’s the only place that something can actually be done about the bleeding. However, that’s not entirely true now.

Here’s the traditional algorithm for a patient with hemorrhage from pelvic fractures:

They go to the operating room or interventional radiology. If they start in the operating room and can be stabilized (think external fixation and/or preperitoneal packing), then they might be able to be packaged and taken to IR for embolization. Likewise, if they were initially stable enough to go to IR but crashed there, then they must immediately be taken to OR.

But what if you could do both in one room with interventional radiology capabilities and a full resuscitation team with surgical instruments?! That’s the beauty of the hybrid room! It is entirely possible to do two, three, and maybe more cases on the same patient in the same room. Hence, the hybrid OR.

Next post: Is the hybrid OR for trauma useful?

Equipment

The Hybrid OR For Trauma

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A hybrid operating room is a special OR suite that allows advanced imaging to be carried out simultaneously with one or more additional operative procedures. It’s that simple. It contains specialized imaging equipment, including fluoroscopy and infusion equipment for radiographic dye administration. Some also contain CT and/or MRI capabilities, but the shielding required for these makes them rare. It is generally stocked with a variety of endovascular

devices and supplies. The usual anesthesia circuits are available, as are selected surgical packs, typically related to vascular and CV surgery.

These suites are typically large and can easily accommodate multiple operating teams. However, they are costly in several ways.

First, they take up a great deal of space. Many have the square footage of two or more standard operating rooms. Initial construction costs are very high, as are remodeling and maintenance costs. They can also tax the hospital engineering infrastructure, from electrical to plumbing to ventilation.

However, if a hybrid room is available, it can deliver significant benefits to the hospital and patient care. Intraoperative imaging can provide immediate quality assurance, and patients can undergo more complex procedures and enjoy a shorter length of stay.

Next post: Why use a hybrid room for trauma?

Performance Improvement

NFTI: A Nifty Tool To Replace The Cribari Grid?

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In my last post, I reviewed using the Cribari grid to evaluate over- and under-triage at your trauma center.  This technique has been a mainstay for over a decade, but it has shortcomings. The most important one is that it relies only on the Injury Severity Score (ISS) to judge whether some type of mistriage occurred.  As you know, the ISS is usually calculated after discharge, so it can only be applied after the fact.

A few years ago, the Baylor University in Dallas group sought to develop an alternate method of determining who needed a full trauma team activation. They chose resource utilization as their surrogate to select these cases. They reviewed 2.5 years of their registry data (Level I center).  After several iterations, they settled on six “need for trauma intervention” (NFTI) criteria:

  • blood transfusion within 4 hours of arrival
  • discharge from ED to OR within 90 minutes of arrival
  • discharge from ED to interventional radiology (IR)
  • discharge from ED to ICU AND ICU length of stay at least 3 days
  • require mechanical ventilation during the first 3 days, excluding anesthesia
  • death within 60 hours of arrival

Patients who had at least one NFTI criterion were considered candidates for full trauma activation, and those who met none were not. Here are the factoids for this study:

  • There were a total of 2260 full trauma activations and 2348 partial activations during the study period (a little over 900 per year for each level)
  • Roughly 2/3 of full activations were NFTI +, and 1/3 were NFTI –
  • For partial activations, 1/4 were NFTI + and 3/4 were NFTI –
  • Only 13 of 561 deaths were NFTI – and all had DNR orders in place

The authors concluded that NFTI assesses anatomy and physiology using only measures of early resource utilization. They believe that it self-adjusts for age, frailty, and comorbidities, and that it is a simple and effective tool for identifying major trauma patients.

Bottom line: This is an elegant attempt to improve upon the simple (yet admittedly flawed) Cribari matrix method for assessment of major trauma patient triage. It was thoughtfully designed and evaluated at this one center. The authors recognize that it is based on retrospective data, but so is the Cribari technique. 

I believe that NFTI can be used as an adjunct to Cribari. The matrix identifies gross under- and over-triage using ISS as a surrogate for trauma activation criteria. Normally, the trauma program then needs to review the outliers to see if mistriage actually occurred. It is basically a “first pass” that seeks to over-identify potential problem patients.

NFTI uses the need for resource utilization as a surrogate. I recommend that it be applied to the Cribari outliers, and then the remaining few charts can be analyzed to see if your trauma activation criteria were met. Combining both techniques can dramatically reduce the workload for reviewing undertriage cases.

Reference: Asking a Better Question: Development and Evaluation of the Need For Trauma Intervention (NFTI) Metric as a Novel Indicator of Major Trauma. J Trauma Nursing 24(3):150-157, 2017.

Performance Improvement

The Cribari Grid And Over/Undertriage

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Any trauma performance improvement professional understands the importance of undertriage and overtriage.  Overtriage occurs when a patient who does not meet trauma activation criteria gets one anyway. And undertriage is the converse, where no activation is called despite criteria being met. As you may expect, the latter is much more dangerous for the patient than the former.

I frequently get questions on the “Cribari grid” or “Cribari method” for calculating these numbers. Dr. Chris Cribari is a former chair of the Verification Review Subcommittee of the ACS Committee on Trauma. He developed a table-format grid that provides a simplified method for calculating these numbers.

But remember, the gold standard for calculating over- and undertriage is examining each admission to see if it met any of your trauma activation triage criteria. The Cribari method is designed for those programs that do not check these on every admission. It is a surrogate that allows you to identify patients with higher ISS who might have benefited from a trauma activation.

So, if you use the Cribari method, use it as a first pass to identify potential undertriage. Then, examine every patient’s chart in the undertriage list to see if they meet your activation criteria. If not, they were probably not undertriaged. However, you must then look at their injuries and overall condition to see if they might have been better cared for by your trauma team. If so, you may need to add a new activation criterion. Then, count that patient as undertriage, of course.

I’ve simplified the calculation process even more and provided a Microsoft Word document that automates the task for you. Just download the file, fill in four values in the table, update the formulas, and you’ve got your numbers! Instructions for manual calculations are also included. Download it by clicking the image below or the link at the end of this post.

cribarigrid

Download the calculator by clicking here

In my next post, I’ll examine how the NFTI score (need for trauma intervention) fits into the undertriage/overtriage calculations.

Performance Improvement, Philosophy

Don’t Write This In Your PI Committee Minutes!

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One of the more poorly understood concepts in trauma performance improvement is the focus of the process. Are we really discussing the patient who had a quality issue?

I occasionally see something like the following in the published multidisciplinary trauma PI committee minutes:

“Although an opportunity for improvement was found, it was non-contributory and had no impact on patient outcome.”

Unfortunately, the true purpose of the committee discussion has been lost. The simple truth is that we are trying to learn from a patient we have cared for. None of the events or opportunities for improvement identified can impact them. Time has passed, and if there were any irregularities in their care, it is too late to fix them. For this patient.

However, the proper focus of the performance improvement program is to make things better for the next, similar patient. Here’s an example:

Scenario 1: An elderly patient presents after a fall with a mild head strike. They are awake and alert and present to a trauma center where this is recognized as a high-risk mechanism. A limited activation occurs, the patient is rapidly assessed, and she is whisked off to CT scan 20 minutes after arrival. The report is back in 10 minutes and shows a 1.5cm subdural hematoma with mild ventricular effacement.

Neurosurgery is rapidly consulted and sees the patient within 15 minutes. He plans an emergent operation. The patient is taken to the OR two hours later for a successful craniectomy and drainage. She does well and is discharged home neurologically intact four days later.

Everything looks great, right? Unfortunately, no.

This case could very easily be called a great save. But the patient’s identical twin sister comes in two weeks later with exactly the same presentation. What if the patient vomits, becomes unresponsive, and blows her pupils just one hour after the neurosurgeon sees her? They get a stat repeat CT, and the neurosurgeon now pronounces the larger lesion a non-survivable injury.

The second case will definitely end up being discussed by your multidisciplinary trauma PI committee as a death. Perhaps the one-hour delay is deemed acceptable because “that’s how we do it here” (shudder, a big red flag).

But what if the PI process picks up that two-hour delay in the first case and deems it suboptimal despite the rosy outcome? Processes are implemented to get an OR ready quicker and ensure the neurosurgeon’s availability. Now, a patient can theoretically be in the OR within 30 minutes of this “emergency” designation. When the second patient arrives two weeks later, this new process works flawlessly, and she, too, has a great outcome.

Bottom line: Your PI program is designed to protect the next similar trauma patient arriving at your center. Don’t forget that. Scrutinize care closely, even if the outcome was great and it’s exactly how you “normally” do it. Ask yourself if you would be satisfied if it were your spouse, parent, or child receiving that care. If not, fix everything that isn’t right. For all you know, that next patient could very well be your family member!