All posts by The Trauma Pro

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But The Radiologist Made Me Do It!

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The radiologist made me order that (unnecessary) test! I’ve heard this excuse many, many times. Do these phrases look familiar?

  1. … recommend clinical correlation
  2. … correlation with CT may be of value
  3. … recommend delayed CT imaging through the area
  4. … may represent thymus vs thoracic aortic injury (in a 2 year old who fell down stairs)
Some trauma professionals will read the radiology report and then immediately order more xrays. Others will critically look at the report, the patient’s clinical status and mechanism of injury, and then decide they are not necessary. I am firmly in the latter camp.
But why do some just follow the rad’s suggestions? I believe there are two major camps:
  • Those that are afraid of being sued if they don’t do everything suggested, because they’ve done everything and shouldn’t miss the diagnosis
  • Those that don’t completely understand what is known about trauma mechanisms and injury and think the radiologist does
Bottom line: The radiologist is your consultant. While they are good at reading images, they do not know the nuances of trauma. Plus, they didn’t get to see the patient so they don’t have the full context for their read. First, talk to the rad so they know what happened to the patient and what you are looking for. Then critically look at their read. If the mechanism doesn’t support the diagnosis, or they are requesting unusual or unneeded studies, don’t get them! Just document your rationale clearly in the record. This provides best patient care, and minimizes the potential complications (and radiation exposure) from unnecessary tests.
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Reference: Pitfalls of the vague radiology report. AJR 174(6):1511-1518, 2000.

General

When You Order A Test, Check The Results!

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This is one of those rules that seems so obvious. But you would be surprised how many times it’s ignored. Here’s just one example that can go wrong in so many ways:

  • You order a chest xray during a trauma activation for blunt trauma, but don’t view it before the patient is transported to CT scan. 

How this can go wrong:

  1. A very large pneumothorax is present, bordering on a tension pneumothorax. Either the patient must be brought back to the ED or all the equipment needed to insert a chest tube must be taken to CT, which is not an ideal place for this procedure.
  2. The stomach is in the left chest. The patient should have been taken directly to OR. There is no need for CT.
  3. A massive hemothorax is noted. However, blood products have not been ordered and the patient suddenly becomes hypotensive in CT. This is not a good place for resuscitation. And the chest tube problem in #1 applies here, too.
  4. A bullet is plainly seen in the middle of the right chest. This unexpected finding shows that the physical exam (or the history of the event) was inaccurate.

And the list goes on. And this is just one of a zillion possible tests that are ordered every day. In this example, looking at the image is simple in this day and age of having PACS viewers everywhere. However, many tests are not available for hours (coags), or are actually done at a later time (morning hemoglobin). This means more opportunities to miss significant results, and although they may not be as life-threatening as my trauma example, failure to check them can still cause significant problems.

Bottom line: Always review the result of every test you order, on every patient. In this age of shift work and work hour restrictions, a good hand-off to other trauma professionals is very important. You must make sure that somebody sees that result in a timely manner soon after it is available. 

Corollary: If you really don’t need to see that result (i.e. it’s not going to change your care anyway), you shouldn’t have ordered the test!

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Trauma Care And HIPAA Demystified

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HIPAA

There is a lot of confusion and misinformation out there regarding HIPAA (Health Insurance Portability and Accountability Act). This law was enacted in 1996 with the intent of protecting the health insurance benefits of workers who lose or change their jobs, providing standards for electronic health care transactions, and protecting a patient’s sensitive health information. This last part has caused much grief among trauma professionals.

It is commonplace for a trauma patient to require the services of many providers, from the initial prehospital crew, doctors and nurses at the initial hospital, yet another ambulance or aeromedical crew, professionals at a receiving trauma center, rehab or transitional care providers, and the patient’s primary physician to name a few. Unfortunately, because there can be significant financial penalties for violating the HIPAA privacy guidelines, providers are more likely to err (incorrectly) on the side of denying information to others outside their own institution.

All of the people mentioned above are considered “covered entities” and must abide by the HIPAA Privacy Rule. This rule allows us to release protected information for treatment, payment and “health care operations” within certain limits. The first and last items are the key provisions for most trauma professionals.

Treatment includes provision, coordination and management of care, as well as consultations and referrals (such as transferring to a trauma center). Think of this as the forward flow of information about your patient that accompanies them during their travels.

Health care operations include administrative, financial, legal and quality improvement activities. These quality improvement activities depend on the reverse flow of information to professionals who have already taken care of the patient. They need this feedback to ensure they continue to provide the best care possible to everyone they touch.

Bottom line: Trauma professionals do not have to deny patient information to others if they follow the rules. Obviously, full information must be provided to EMS personnel and receiving physicians when a patient is transferred to a trauma center. But sending information the other way is also okay when used for performance improvement purposes. This includes providing feedback to prehospital providers, physicians, and nurses who were involved in the patient’s care at every point before the transfer. The key is that the information must be limited and relevant to that specific encounter.

Feedback letters and forms, phone conversations and other types of communications for PI are fine! But stay away from email, which is not secure and is usually a violation of your institutional privacy policies.

Always consult your hospital compliance personnel if you have specific questions about HIPAA compliance.

Reference: HIPAA Privacy Rule

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The Value of Protocols in Trauma

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Most trauma centers have a massive trauma protocol. Many have pain management or alcohol withdrawal or a number of other protocols. The question sometimes comes up: why do we need another protocol? Can we show some benefit to using a protocol?

I’ve looked at the literature, and unfortunately there’s not a lot to go on. Here are my thoughts on the value of protocols.

In my view, there are a number of reasons why protocols need to be developed for commonly encountered issues. 

  • They allow us to build in adherence to any known practice guidelines or literature.
  • They help conserve resources by standardizing care orders and resource use.
  • They reduce confusion. Nurses do not have to guess what cares are necessary based on the specific admitting surgeon.
  • They reduce errors for the same reason. All patients receive a similar regimen, so potential errors are more easily recognized.
  • They promote team building, particularly when the protocol components involve several different services within the hospital.
  • They teach a consistent, workable approach to our trainees. When they graduate, they are familiar with a single, evidence based approach that will work for them in their practice.

A number of years ago, we implemented a solid organ injury protocol here at Regions Hospital. I noted that there were large variations in simple things like time at bedrest, frequency of blood draws, how long the patient was kept without food and whether angiography should be considered. Once we implemented the protocol, patients were treated much more consistently and we found that costs were reduced by over $1000 per patient. Since we treat about 200 of these patients per year, the hospital saved quite a bit of money! And our blunt trauma radiographic imaging protocol has significantly reduced patient exposure to radiation.

Bottom line: Although the proof is not necessarily apparent in the literature, protocol development is important for trauma programs for the reasons outlined above. But don’t develop them for their own sake. Identify common problems that can benefit from consistency. It will turn out to be a very positive exercise and reap the benefits listed above.

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Unnecessary Triage To High Level Trauma Centers

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Trauma centers and trauma systems are dedicated to getting the right patient to the right hospital at the right time. In the US, The American College of Surgeons (ACS) has set forth criteria for identifying injured patients that should be taken to trauma centers (right patient). The ACS and a number of state authorities have also developed rules for becoming a trauma center (right hospital). Many state authorities have developed additional rules for setting maximum transfer times to the trauma centers (right time).

However, it is possible to short circuit these carefully crafted rules. It has been said (a phrase that indicates some dogma is on the way) that 85% of injured patients can be treated in the local hospital, and that only 15% need transfer to a trauma center. But most Level I and II trauma centers receive transfers from outside hospitals that are less injured than the criteria that would mandate their transfer. 

This is called “secondary overtriage.” A recent study from Dartmouth, which is a rural Level I trauma center, looked at how common this really is. They did a retrospective review of 4796 transfers in to their hospital over a 5 year period. Secondary overtriage was defined as a transferred patient with an ISS<15 and hospital stay <48 hours and no operation. The results are interesting:

  • The hospital treated 7793 patients during the study period, so transfers represented 62% of their activity
  • 24% of adult transfers (1006 patients) and 49% of pediatrics (258 patients) were considered overtriage
  • 216 patients were sent home from the ED (very irritating for families)
  • Half of overtriaged patients arrived on weekends, and 62% arrived between 6PM to 6AM
  • 8% were transferred by air(!)
  • Although Dartmouth received transfers from 72 hospitals (capacities ranged from 6 to 330 beds), 36% of overtriage patients originated from only 5 hospitals

Bottom line: Secondary overtriage is a common occurrence, found in 26% of transfers in this rural trauma center. It is reportedly closer to 40% in urban centers. Whether due to legitimate lack of resources or convenience, they increase the cost of healthcare and inconvenience families. High level trauma centers should monitor for this phenomenon, identify outlier referring facilities, and step up outreach and education to those hospitals to increase their experience and comfort with treating (and keeping) appropriate trauma patients.

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Reference: Secondary overtriage: the burden of unnecessary interfacility transfers in a rural trauma system. JAMA Surg Online First June 19, 2013.