All posts by TheTraumaPro

When Is It Not An “Unplanned ICU Admission?”

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.

The ICU Bounce Back

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.

Surgical Residents And The Danger Of Social Media

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.

The July 2017 Trauma MedEd Newsletter Is Here!

Welcome to the current newsletter. This one is dedicated to all of you out there who receive incoming trauma patient transfers from other hospitals. Here’s the scoop on what’s inside:

  • Can Transfer Patients Actually Pay Their Bills?
  • EMS Documentation In Transfer Patients
  • Technology To Reduce Radiation Exposure
  • The Value Of Reinterpreting Outside CT Scans
  • Optimizing Feedback to Referring Hospitals

To download the current issue, just click here! Or copy this link into your browser: http://bit.ly/TME201707

I’ve also included a sample transfer feedback form so you don’t forget anything when you send the patient. There is also a link to a Word version so you can customize it for your center. The link is:
http://bit.ly/trauma-fb

To view and download back issues, just click here.

Newsletter

What Happens To Your Average Subarachnoid Hemorrhage?

Management of traumatic brain injury (TBI) is a common issue faced by trauma professionals. And isolated subarachnoid hemorrhage (SAH) is one of the more common presentations. In many centers, this diagnosis frequently results in admission to the hospital, neurosurgical consultation, and repeat imaging.

Is this too much care? We adopted a practice guideline nearly two years ago based on our own clinical experience that eliminated the last two. Patients were still admitted for neurologic monitoring for 16 hours. But is even this too much?

What we really need is a better understanding of the natural history of uncomplicated traumatic SAH. Well, a study from Sunnybrook and the University of Toronto does just that. They performed a 17 year meta-analysis of the literature on isolated SAH with mild TBI (GCS 13-15). They pared their initial literature search of nearly 2900 studies down to the usual few, 13 in this case. All but one were retrospective, of course, and they had the usual design flaws.

Here are the factoids:

  • How many patients eventually needed neurosurgical intervention?  0 (Well, almost zero. It was 0.0017%, to be exact.)
  • How many had progression of the SAH? About 6%
  • How many had neurologic deterioration? 0.75%, which included two  patients with increased headache and one with some confusion. Two developed intraparenchymal hemorrhage (one was on anticoagulants)
  • How many died? Only 1 died from neurologic causes, and that patient was anticoagulated at the time of injury.

Bottom line: It looks like we may be overdoing it for patients with isolated SAH and mild TBI. The natural history seems to be fairly benign, unless the patient is taking anticoagulants. The type of drug was not specified, so warfarin, aspirin, clopidogrel, and the newer anticoagulants should all be included.

Perhaps it’s time to update the our practice guidelines further. It looks like most of these simple, isolated SAH can be evaluated and released. However, if the GCS is 13 or 14, they should still be admitted for monitoring for a short period. And if on anticoagulants, admission with a repeat CT is in order.

Related posts:

Reference: The clinical significance of isolated traumatic subarachnoid hemorrhage in mild traumatic brain injury: A meta-analysis. J Trauma , published ahead of print, July 8 2017.