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Philosophy

Pet Peeve: “High Index of Suspicion”

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How often have you heard this phrase in a talk or seen it in a print article:

“Maintain a high index of suspicion”

What does this mean??? It’s been popping up in papers and textbooks for at least the last 20 years. And to me, it’s meaningless. You try to figure out that sentence!

An index is a number, usually mathematically derived in some way. Yet whenever I see or hear this phrase, it doesn’t really apply to anything that is quantifiable. What the author is really referring to is “a high level of suspicion”, not an index.

This term has become a catch-all to caution the reader or listener to think about a (usually) less common diagnostic possibility. As trauma professionals, we are advised to do this about so many things, it really has become sad and meaningless.

Bottom line: Don’t use this phrase in your presentations or your writing. It’s stupid. And feel free to chide any of your colleagues who do. Give us some concrete tips so we don’t miss the diagnosis!

Reference: High index of suspicion. Ann Thoracic Surg 64:291-292, 1997.

Trauma Systems

Are State Trauma Systems Cost-Effective?

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Every state in the US now has a formal trauma system. Several studies are available that document the advantages of these systems in terms of outcomes and survival. Trauma professionals get this. But the governmental agencies and legislators who help create, fund, and maintain them tend to focus on cost as well.

Arkansas was the last state in the union to implement a trauma system. A study in press from the University of Arkansas details their experience. They examined the impact of the new system on mortality, patient care, and attempted to calculate a return on investment from the taxpayers in an effort to show the added value.

The study was commissioned by the Arkansas Department of Health and carried out by the state Trauma Advisory Council. It was led by out of state investigators in an effort to maintain impartiality. A comprehensive review of records was performed by a panel of 5 surgeons, 1 emergency physician, 2 trauma program managers, 1 ground and 1 flight paramedic. Preventable and potentially preventable deaths were identified and analyzed in depth. Value of life lost was calculated by using a conservative $100,000 per year lost. A total of 290 charts were reviewed pre-system, and 382 post-trauma system implementation using proportional sampling of about 2500 trauma deaths in one year.

Here are the factoids:

  • A significantly higher percentage of patients were triaged to Level I trauma centers after the system was implemented
  • Preventable mortality was decreased from 30% to 14% (!!)
  • This means that 79 extra lives were saved due to implementation of the trauma system
  • Non-preventable deaths with opportunity for improvement remained constant at about 55%
  • Non-preventable deaths without opportunity for improvement increased from 16% to 38% (!)
  • Using the most conservative VLL calculation, this equates to $2.4M in savings per life saved
  • This adds up to $186M in savings to the taxpayers of Arkansas, a 9-fold return on their investment of $20M in the trauma system. 

Bottom line: Wow! This nicely done studies gives us excellent insight into the hows and whys of the value of an organized state trauma system. It is likely that the triage system directed more patients to the most appropriate level of care, leading to fewer preventable deaths. And it enticed hospitals to up their game and make the move toward formal trauma center designation. This improved education and training at those centers, leading to better patient care.

There is a wealth of information in this study, and I recommend that everyone with an interest in or are already participating in their state trauma system read it in its entirety. Hospitals that are reluctant to join or are lagging in meeting criteria need to recognize that they are not serving their communities as well as they think. And legislators must realize that the financial impact of even a small investment has real and significant consequences to their constituents.

Related posts:

Reference: Does the Institution of a Statewide Trauma
System Reduce Preventable Mortality and Yield
a Positive Return on Investment for Taxpayers? JACS in press, 2017.

Guidelines, Thorax

Retained Hemothorax Part 4: The Practice Guideline

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Over the last three days, I reviewed some data on lytics at the request of some of my readers. Then I looked at a paper describing one institution’s experience dealing with retained hemothorax, including the use of VATS. But there really isn’t much out there on how to roll all this together.

Until now. The trauma group at Vanderbilt has a paper in press describing their experience with a home-grown practice guideline for managing retained hemothorax.  Here’s what it looks like:

I know it’s small, so just click it to download a pdf copy. I’ve simplified the flow a little as well.

All stable patients with hemothorax admitted to the trauma service were included over a 2.5 year period. The practice guideline was implemented midway through this study period. Before implementation, patients were treated at the discretion of the surgeon. Afterwards, the practice guideline was followed.

Here are the factoids:

  • There were an equal number of patients pre- and post-guideline implementation (326 vs 316)
  • An equal proportion of each group required an initial intervention, generally a chest tube (69% vs 65%)
  • The number of patients requiring an additional intervention (chest tube, VATS, lytics, etc) decreased significantly from 15% to 9%
  • Empyema rate was unchanged at 2.5%
  • Use of VATS decreased significantly from 8% to 3%
  • Use of catheter guided drainage increased significantly from 0.6% to 3%
  • Hospital length of stay was the same, ranging from 4 to 11 days (much shorter than the lytics studies!)

Bottom line: This is how design of practice guidelines is supposed to work. Identify a problem, typically a clinical issue with a large amount of provider care variability. Look at the literature. In general, find it of little help. Design a practical guideline that covers the major issues. Implement, monitor, and analyze. Tweak as necessary based on lessons learned. If you wait for the definitive study to guide you, you’ll be waiting for a long time.

This study did not significantly change outcomes like hospital stay or complications. But it did decrease the number of more invasive procedures and decreased variability of care, with the attendant benefits from both of these. It also dictates more selective (and intelligent) use of additional tubes, catheters, and lytics. 

I like this so much that I plan to adopt it at my center!

Download the practice guideline here.

Related posts:

Posts in this series:

Reference: Use of an evidence-based algorithm for patients with traumatic hemothorax reduces need for additional interventions. J Trauma, in press, December 14, 2016.

Complications, Thorax

Retained Hemothorax Part 3: VATS

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I’ve written about the use of lytics to treat retained hemothorax over the past few days. Although it sounds like a good idea, we just don’t know that it works very well. And they certainly don’t work fast. Lengths of stay were on the order of two weeks in both studies reviewed.

The alternative is video assisted thoracoscopic surgery (VATS). So let’s take a look at what we know about it. This procedure is basically laparoscopy of the chest. A camera is inserted, and other ports are added to allow insertion of instruments to suck, peel, and scrape out the hemothorax.

A prospective, multi-center study was performed over a 2 year period starting in 2009. Twenty centers participated, contributing data on 328 patients with retained hemothorax. This was defined as CT confirmation of retained blood and clot after chest tube placement, with evidence of pleural thickening.

Here are the factoids:

  • 41% of patients had antibiotics given for chest tube placement (this is interesting given the lack of consensus regarding their effectiveness!)
  • A third of patients were initially managed with observation, and most of them (82%) did not need any further procedures (83 of 101 patients)
  • Observation was more successful in patients who were older, had smaller hemothoraces (<300cc), smaller chest tubes (!!, <34 Fr), blunt trauma, and peri-procedure antibiotics (?)
  • An additional chest tube was inserted in 19% of patients, image guided drain placement in 5%, and lytics in 5%. Half to two-thirds of these patients required additional management.
  • VATS was used in 34% of patients. One third of them required additional management including another chest tube, another VATS, or even thoracotomy.
  • Thoracotomy was most likely required if there was a diaphragm injury or large hemothorax (<900cc)
  • Empyema and pneumonia were common (27% and 20%, respectively)

Bottom line: There’s a lot of data in this paper. Most notably, many patients resolve their hemothorax without any additional management. But if they don’t, additional tubes, guided drain placement, and lytics work only a third of the time and contribute to additional time in the hospital. Even VATS and thoracotomy require additional maneuvers 20-30% of the time. And infectious complications are common. This is a tough problem!

Tomorrow, I’ll try to roll it all together and suggest an algorithm to try to optimize both outcomes and cost.

Posts in this series:

Reference: Management of post-traumatic retained hemothorax: A prospective, observational, multicenter AAST study. 72(1):11-24, 2012.

Complications, Thorax

Retained Hemothorax Part 2: Lytics (again)

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Yesterday, I reviewed a small case report that was published a couple of years ago on lytics for treatment of retained hemothorax. But surely, there must be something better, right?

After digging around, I did find a paper from 2007 that prospectively looked at protocolized management of retained hemothorax, and its aftermath. It was carried out at a busy Level I trauma center over a 16 month period.

All patients with a hemothorax treated with chest tube received daily chest x-rays. Those with significant opacification on day 3 underwent CT scan of the chest. If more than 300 cc of retained blood was present, the patient received streptokinase or urokinase (surgeon preference and drug availability) daily, and rolled around in bed for 4 hours to attempt to distribute it. The chest tube was then unclamped and allowed to drain. This was repeated for 3 days, and if there was still opacification, a repeat CT was obtained. If the volume was still greater than 300 cc, the cycle was repeated for the next 3 days. If the opacification cleared at any point, or the repeat CT showed less than 300 cc, the protocol was stopped and the chest tube removed. If the chest was still opacified after 6 days, VATS was offered.

Here are the factoids:

  • A total of 203 patients with hemothorax were admitted during the study period and 25 (12%) developed a retained hemothorax
  • While a few had treatment start within 4 days, the majority did not receive lytics until day 9 (range 3  –30 days!)
  • The average length of time in hospital after start of lytics was 7 days, leading to a total length of stay of 18 days
  • 92% of patients had “effective” evacuation of their retained hemothorax, although 1 had VATS anyway which found only 100 cc of fluid
  • 16 patients had “complete” evacuation, and 5 had “partial” evacuation
  • There were no hemorrhagic complications, but one third of patients reported significant pain with drug administration

Bottom line: Sounds good, right? The drug seems reasonably effective, although lengths of stay are relatively long. However, streptokinase and urokinase are no longer available in the US, having been replaced with tissue plasminogen activator (tPA). This paper does a cost analysis of lytics vs VATS and found that the former treatment cost about $15000 (drug + hospital stay) vs $34000 for VATS. However, a big part of this was that the drug only cost about $75 per dose. tPA is much more expensive.

So once again, small series, longer lengths of stay, but at least nicely done. Unfortunately, the drug choice is no longer available so use of tPA tilts the balance away from lytics. Tomorrow, I’ll explore the results of using VATS for this condition.

Posts in this series:

Reference: Intrapleural Thrombolysis for the Management of Undrained Traumatic Hemothorax: A Prospective Observational Study. J Trauma 62(5):1175-1179, 2007.