Concussion evaluation is a very common reason for presentation to the ED. Many centers discharge patients from the ED with a normal GCS and a normal head CT. But is this enough? How many of these patients would benefit from further outpatient evaluation and possible treatment?
Another study from Grant Hospital in Columbus looked at a subset of mild TBI patients from the ED who also underwent more robust neurocognitive evaluation within 48 hours of their discharge.
Here are the factoids:
- of the 6000+ trauma patients seen over a 17 month period, only 396 met the inclusion criteria (age >13, GCS 15, normal head CT, blunt trauma, no psych issues) and had a neurocognitive eval within 48 hours
- 41% were cleared for discharge without any followup or supervision. 88% of these had known or suspected loss of consciousness.
- 25% required outpatient therapy or were not safe for discharge. 81% of these had possible LOC.
- Only 28% of patients who required ongoing therapy would have met traditional ED discharge guidelines
Bottom line: First, this abstract is very poorly written. The concept comes across (barely), but is presented badly. Obviously, loss of consciousness is not much of an indicator of anything. The question is, how can we more reliably determine if a patient will need further cognitive evaluation or therapy? Gross GCS and head CT results do not seem to be enough. One solution may be to have ED nurses administer a basic cognitive screen to identify more subtle problems. The Short Blessed Test is ideal for this, and takes only a few minutes of time. And the key is to have some type of TBI clinic available to refer these patients to if they fail the test!
Reference: You can’t go home: routine concussion evaluation is not enough. EAST 2014, poster abstract #12.
I’ve been involved in a number of debates regarding the best way to decompress the chest if there is a suspected tension pneumothorax. Some are proponents of the needle (I used to be one). Some believe that finger thoracostomy is better because it does not necessarily create a simple pneumothorax if you were wrong (I’ve come around to this one).
Surgeons at Madigan Army Medical Center in Washington State tried something a little different. They experimented with placing a 5mm laparoscopy port for treatment of induced tension pneumo in a large animal model (swine) to see how safe it was.
Here are the factoids:
- Tension pneumo (TPTX) and/or pulseless electrical activity (PEA) was induced about 30 times each in 5 adult swine. TPTX was defined as a measured 50% decrease in cardiac output.
- Placement of a 5mm laparoscopy trochar immediately relieved the abnormal physiology in 100% of TPTX cases
- Trochar placement restored perfusion within 30 seconds in all PEA cases
- No trochar induced injury to heart or lung was identified in any animal at necropsy
- The authors compared these results to older needle decompression literature which showed only 40-70% success rates
Bottom line: Using a laparoscopy port to quickly relieve tension pneumo or PEA from TPTX looks like an option. It’s fast, reliable, and safe. Surgeons place these all the time in the OR, and they are designed to safely push skin and subq layers aside, not harming the viscera. However, it does suffer the same drawback as the needle: it will create a simple pneumothorax. And it will probably do so 100% of the time, guaranteeing the need for a chest tube. Furthermore, these are expensive toys to stock in an ED for only occasional use. Interesting, but I would not recommend.
Reference: 5mm trochars for the treatment of tension pneumothorax: a superior alternative to needle decompression. EAST 2014, poster abstract #1.
In many trauma hospitals, especially Level I and II centers, there tends to be a tendency toward complex, high volume care. As any trauma professional knows, this is a setup for system inefficiencies. Lean principles were derived from Japanese manufacturing practices in the 1980’s, and includes a toolset that helps companies eliminate waste. Any use of resources for anything but creating end value for the customer is considered waste and must be eliminated.
The discharge planning process for trauma inpatients is one of many parts of the care spectrum that contains waste, and researchers at Grant Medical Center in Columbus looked at the result of applying lean principles to it.
A lean mapping event was held, which is one of the tools promoted by the lean process. This identified areas for immediate evaluation and intervention. This, in turn, resulted in new workflows, which were then evaluated for their effect.
The primary area of concern indentified was inter-service communication. This included getting reliable information from consult services and providing pertinent information to physical therapy. They also discovered that trauma patient admissions to units not designated for the trauma service resulted in lengths of stay 1.6 times the average.
Three areas for improvement were identified:
- Off-unit trauma admissions
- Patients with length of stay > 15 days
- Miscommunication regarding patient education at discharge
Bottom line: This abstract is heavy on theory and very light on practice. There is no statement or analysis of results. However, it does seem like there may be some use for Lean methodology in analyzing trauma care. The trick will be to develop interventions that actually remove some of the inefficiencies in our care processes. I will definitely sit in on this presentation!
Reference: Lean methodology for performance improvement in the trauma discharge process. EAST 2014, oral paper #31.
Involvement of advanced care practitioners (ACPs) like physician assistants and advanced clinical nurses has increased significantly due to the implementation of work hour restrictions for surgical residents. Prior to this, invasive procedures were performed almost exclusively by the residents. Now, more and more procedures are being performed by ACPs. The question is: is it safe?
Carolinas Medical Center retrospectively reviewed all ICU procedures performed in a year’s time in their SICU. They compared complication rates when the procedure was performed by a resident vs an ACP.
- Procedures reviewed included arterial lines, central venous lines, chest tubes, bronchoalveolar lavage, perc gastrostomy, and perc tracheostomy
- Residents performed all procedures on trauma patients in the ICU, and ACPs performed procedures on all other SICU patients (note: this is not randomization!)
- All procedures were supervised by an attending physician
- A total of 1,575 procedures were performed, 1,020 by residents and 555 by ACPs
- The complication rate for both groups was 2% (no difference)
- Hospital and ICU length of stay were the same for both groups
- In-hospital mortality was 11% for the resident group vs 9.7% for the ACP group, despite higher APACHE III for the latter.
Bottom line: ACPs can perform ICU level procedures as well as residents with proper supervision. As work hour restrictions continue to become more restrictive, expect to see further degradation of resident experience and expanded involvement of ACPs. For centers without residents, be confident in expanding the role of your ACPs in clinical care.
Reference: Comparison of critical care procedural complication rates between residents and advanced clinical providers. EAST 2014, oral paper 21.
Chest trauma is a very common occurrence. One of the more common procedures for managing it is insertion of a chest tube. In the majority of cases, the drain is connected to a system to collect blood and vent air. And they are nearly always automatically hooked up to 20cm of suction.
A study was constructed to randomize the use of suction vs water seal in patients with pneumothorax, hemothorax, or a combination of both. Patients who had early positive pressure ventilation (ventilated, emergency OR), chronic lung disease, or severe TBI (?) were excluded.
Here are the factoids:
- 110 patients were randomized to either water seal (54) or 20cm of suction (56)
- There was no difference in the length of time the tube was in place between the groups (3 days)
- Incidence of retained hemothorax and empyema was no different (and hopefully rare!)
- Hospital length of stay was the same
- There was a significantly increased incidence of persistent air leak in the suction group
Bottom line: First, this is a small study so it doesn’t have enough power to make definitive statements. However, it is definitely provocative. We blithely put every patient on suction, not thinking about the negative implications such as decreased mobility, increased atelectasis, and DVT. Patients on suction are much less likely to move around at all! A mobile patient is just as likely to push any air and blood out of the tube as an immobile one is to have it sucked out. Let’s do a larger study to confirm this! And hey, use a protocol to manage the tube! Three days is too long to have a tube in place.
Reference: Negative pleural suction in thoracic trauma patients: a randomized controlled trial. EAST 2014 oral paper 14.