All posts by The Trauma Pro

Head

Is Decompressive Craniectomy Any Better Than Craniotomy?

July 25, 2017 The Trauma Pro Leave a comment

Severe TBI consists of a primary injury to the brain, followed by swelling, vascular, and ischemic problems which may cause a secondary injury. Much of the critical care management of this injury involves avoiding or ameliorating secondary injury. This is typically accomplished via medical means first, and through surgical procedures when medical management is insufficient.

Two types of surgical decompression are currently practiced: craniotomy and evacuation of blood/clot, and decompressive craniectomy with removal of a bone flap. The latter can be performed prophylactically before severe swelling occurs, or therapeutically as a damage control procedure when ICP is refractory to all other measures.

There has been a decades-old debate as to whether craniectomy, which is a major undertaking with months of skull/bone flap management, is actually worthwhile. Most studies have examined the utility of damage control craniectomy for refractory ICP. The results have not really been convincing one way or the other.

But what about prophylactic decompressive craniectomy (DC) to avoid future ICP problems while the patient is in the ICU? The surgical group at the University of Arizona at Tucson performed a five year retrospective review of their experience. Using propensity score matching, they identified 99 severe TBI patients who underwent DC (33) or craniotomy only (CO, 66). A power analysis showed that this sample size should be sufficient to demonstrate a significant difference.

Here are the factoids:

Both groups were similar with respect to age, GCS, ISS, AIS-head, and type of bleed
26% died and 63% were discharged to rehab or skilled nursing facility
When comparing DC to CO groups, there were no differences in mortality, discharge to skilled nursing facility, discharge GCS or Glasgow Outcome Scale
There were more complications in the DC group, including shunt insertion for hydrocephalus (9% vs 0%), and reoperation (12% vs 2%)
Rates of wound infection and ventriculitis were the same for both groups (0-3%)

Bottom line: Although the study is small, it supposedly had enough patients for identification of significant differences. And basically, it didn’t show a positive difference for prophylactic decompressive craniectomy. There is certainly some opportunity for selection bias by the neurosurgeons that cannot be controlled for by this retrospective design. But it is yet another piece of the decompressive craniectomy puzzle.

Overall, the literature support for either prophylactic or damage control craniectomy is not very strong. If it were, we would have identified some real benefits by now. What we don’t know is if there are specific subgroups of severe TBI patients who might benefit from it. So if your center is not involved in a project to study this, you should probably ask your neurosurgeons to base their practice only on what we know about this procedure to date.

Performance Improvement

When Is It Not An “Unplanned ICU Admission?”

July 24, 2017 The Trauma Pro Leave a comment

All US trauma centers verified by the American College of Surgeons (ACS) must now subscribe to the ACS Trauma Quality Improvement Program (TQIP). This program allows each center to benchmark themselves against other trauma centers that are just like them (level, volume, acuity, etc). Every quarter, TQIP members receive a report that details their performance in a number of key categories. The report slices and dices a large number of data points, and shows how they compare to those other trauma centers.

One of the more interesting portions of the TQIP report deals with risk-adjusted complications. The one I wrote about yesterday, the “ICU bounce back,” is officially called an “unplanned ICU admission.”

I’ve had several trauma centers ask me what constitutes an unplanned ICU admission. Is it any bounce back? What about patients who were never in the ICU?

This questions is particularly important to me because my own center’s TQIP report shows that we have a significant number of unplanned ICU admissions. But I know for a fact that they are not surprises. We have an inpatient trauma unit, with capabilities somewhere between the usual ward bed and an ICU bed. Patients can get telemetry, continuous oximetry, vital signs every 2 hours, and more. It functions as a kind of step-down unit, so we frequently admit patients who may require ICU admission at other hospitals.

Every once in a while, a patient who is receiving care in the trauma unit shows signs that they are going to need a true ICU level of care. In that case, we promptly move them to the ICU before they decompensate any further.

Is that situation an “unplanned ICU admission?” In my opinion, no. The patient received the highest level of care while outside the ICU, and ultimately a considered decision was made to move them. In my mind, this is a “planned ICU admission.”

Bottom line: There are two issues at play if your “unplanned ICU admissions” get flagged on your TQIP report. The first is determining if it was truly unplanned. If the Rapid Response Team (RRT) was called, then it was almost certainly unplanned. But if the patient was being monitored properly, showed signs that they would need an ICU level of care, and was preemptively transferred there, it was not. Similarly, if one of your surgical specialists wants the patient transferred (e.g. MAP goals), then that is also a planned admission.

The second factor is figuring out why the admissions are getting reported to TQIP as unplanned. This is usually a trauma registrar issue. They may be looking for any ward to ICU transfer, and classifying it as unplanned. Educate all your registrars on the nuances of what is planned and what isn’t.

If you are on the receiving end of a TQIP variance on unplanned ICU admissions, use the drill-down tool to identify the exact patient records involved. Review the involved medical records, paying close attention to vital signs, monitoring, and all decision making leading up to the time of the ICU transfer. If it isn’t truly unplanned, educate your registrars. But if it is, make sure that it was properly dealt with by your trauma performance improvement program.

Complications

The ICU Bounce Back

July 19, 2017 The Trauma Pro Leave a comment

We’ve all experienced it. A seriously injured trauma patient is admitted to the ICU and begins the process of recovery. Everything looks well, and after a few days they’re transferred to a ward bed. But then they languish, never really doing what we expect. Finally (and usually in the middle of the night), they begin to look bad enough where we have to transfer them back to the ICU. Before or after the call to the Rapid Response Team. Yes, it’s the feared “unexpected readmission to ICU.”

What’s the problem here? A failure of the ICU team? Did they send the patient out too soon? Did we all miss something about the patient? And is there any way we can avoid this problem? The major issue is that these “bounce backs” tend to do poorly compared to patients who successfully stay in their ward bed. Estimates are that mortality for patients successfully and finally discharged from the ICU range from 4-8%, whereas the mortality in bounce back patients is 20-40%!

Researchers at the Medical University of South Carolina in Charleston looked at the characteristics that defined the bounce back patient. They reviewed nearly 2000 patients discharged from their trauma ICU and analyzed the variables that predicted an unplanned bounce back. They noted the following interesting factoids:

More than two thirds of bounce backs occurred within 3 days
Males, patients with an initial GCS < 9, transfer during the day shift were the major risk factors
More comorbidities was associated with a higher chance of bounce back
Mortality in the bounce back group was 20%
The most common immediate factors causing bounce back were respiratory failure or bleeding

Bottom line: This is an intriguing single-institution study that supports my own personal observations. Fewer bounce backs occur at night because staffing tends to be lower and there is more resistance to transfers out of the ICU then. Both the ICU team and the ward team need to scrutinize every transfer carefully. Significant head injury or the presence of medical comorbidities should trigger a careful assessment to make sure that the transfer is appropriate. Otherwise, your patient may be placed in unnecessary jeopardy.

Next, I’ll discuss when an unexpected return to ICU is not an unexpected return!

Reference: Intensive care unit bounce back in trauma patients: An analysis of unplanned returns to the intensive care unit. J Trauma 74(6):1528-1533, 2013.

Education

Surgical Residents And The Danger Of Social Media

July 18, 2017 The Trauma Pro Leave a comment

Social media usage is ubiquitous, and has a higher prevalence of usage in younger age groups. When the paper I am reviewing was written, 71% of adults with internet access reported using Facebook, and two thirds checked it daily. And now, three years later, I’m sure it’s used even more.

Unfortunately, many people don’t have a good sense of what is appropriate or not. And coupled with confusion about privacy settings, some post things that they probably shouldn’t. And unfortunately, everyone else on the internet can view them.

As a resident, it is more common to be “fired” from residency for unprofessional conduct, not cognitive failure or malpractice. When one is under investigation, the professional organization conducting it may look at prior behavior. And these days, that behavior may be years old and posted for all to see.

Is this a problem? Surgeons at the University of Nebraska were interested in how Facebook was used by surgical residents. They identified surgical residencies at 12 states in the Midwest region. They found all surgical residencies within the region and searched their program websites for the names of active residents. Facebook accounts were then created by the authors and were used to determine which of these residents had their own accounts.

The researchers then viewed those pages and classified the content into three categories: professional, potentially unprofessional, and clearly unprofessional. Definitions were based on criteria from the ACGME and the AMA. Accounts that were not accessible to the public were judged professional.

A total of 57 surgical residencies were identified, and 40 provided an institutional website with a current roster of their residents. Of 996 surgical residents, the accounts of 319 residents could be evaluated.

Here are the factoids:

One third of residents had identifiable Facebook accounts
About 74% had only professional content on their site
This means that a quarter had potentially or clearly unprofessional content on their sites
Clearly unprofessional content included:
- binge drinking (5 pints of beer in front of a dinner plate, keg stands, comments about being drunk or hung over)
- sexually suggestive photos (simulated oral sex, female residents in bikinis pointing to their breasts, simulating intercourse on a large cannon)
- HIPAA violations

Bottom line: Be careful! The use of social media is pervasive. Inappropriate or unprofessional can end a career, or can come back to haunt you years later. And this phenomenon is not limited to surgical residents. All professionals, even attending physicians, may succumb to its charms.

Know the social media policy for your hospital or residency program. Be very careful, and think very carefully about everything you post. Take advantage of built-in privacy settings for the platform you are using. But don’t assume that using them will keep inappropriate material from getting out. If in doubt, show your potential post to a trusted and reliable friend for a “second opinion.” Otherwise you may find your (not so) friendly “compliance police” knocking on your door. And possibly ending your career.

Reference: An assessment of unprofessional behavior among surgical residents on Facebook: a warning of the dangers of social media. J Surg Educ 71(6):e28-e32, 2014.

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