All posts by TheTraumaPro

Admission To Nonsurgical Service = Longer LOS?

Previous studies have shown that higher hospital costs are associated with longer length of stay (LOS). This makes sense, because the longer a patient stays in the hospital, the more that is “done” for them, and more daily charges are incurred. Obvious savings can occur if we look globally at services, medications, etc while the patient is in the hospital.

But does the admission service make a difference in LOS or cost? It shouldn’t if care is fairly uniform. A group of orthopedic surgeons at Vanderbilt in Nashville looked at a large group of isolated hip fracture patients (n=614) to see if LOS (used as a surrogate for cost) was significantly different. They also tried to control for a host of factors that could affect time in the hospital between the two groups.

Here are the factoids:

  • About half of the patients were admitted to the orthopedics service, and half to medicine
  • Median length of stay was way different! 4.5 days on Ortho vs 7 days on Medicine
  • Readmission rates were also significantly higher on Medicine, 30% vs 23%
  • After controlling for factors such as medical comorbidities, age, smoking and alcohol, ASA score, obesity, and others, a regression model showed that patients were still likely to stay about 50% longer if admitted to a medicine service.

Bottom line: Obviously, this is the experience of a single institution. But the difference in length of stay, and hence costs, was striking. As the US moves toward a bundled payment system, this will become a major problem. The initial LOS is more costly on the medicine service, and readmission for the same problem will not be reimbursed. Why the difference? Coordination of care between two services? Lack of familiarity with surgical nuances? This study did not look at that.

But it does point out the need to more closely integrate the care of the elderly in particular, and patients with a broad range of needs in general. An integrated team with orthopedic surgeons and skilled geriatricians is in order. And a set of protocols for standard preop evaluation and postop management is mandatory.

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Reference: 

Does Admission to Medicine or Orthopaedics Impact a Geriatric Hip Patient’s Hospital Length of Stay? J Orthopedic Surg 30(2):95-99, 2016.

Metal Splints – Can You X-ray Through Them?

Splinting is an important part of the trauma resuscitation process. No patient should leave your trauma resuscitation room without splinting of all major fractures. It reduces pain, bleeding, and soft tissue injury, and can keep a closed fracture from becoming an open one.

But what about imaging? Can’t the splint degrade x-rays and hamper interpretation of the fracture images? Especially those pre-formed aluminum ones with the holes in them? It’s metal, after all.

Some of my orthopedic colleagues insist that the splint be removed in the x-ray department before obtaining images. And who ends up doing it? The poor radiographic tech, who has no training in fracture immobilization and can’t provide additional pain control on their own.

But does it really make a difference? Judge for yourself. Here are some knee images with one of these splints on:

Amazingly, this thin aluminum shows up only faintly. There is minimal impact on interpretation of the tibial plateau. And on the lateral view, the splint is well posterior to bones.

On the tib-fib above, the holes are a little distracting on the AP view, but still allow for good images to be obtained.

Bottom line: In general, splints should not be removed during the imaging process for acute trauma. For most fractures, the images obtained are more than adequate to define the injury and formulate a treatment plan. If the fracture pattern is complex, it may be helpful to temporarily remove it, but this should only be done by a physician who can ensure the fracture site is handled properly. In some cases, CT scan may be more helpful and does not require splint removal. And in all cases, the splint should also be replaced immediately at the end of the study.

 

How To Remember To Give The TXA!

The CRASH-2 study did a good job of demonstrating the value of giving tranexamic acid (TXA) in patients with major hemorrhage. The kicker is that the data seemed to show that the effect was best if given early, and might even be detrimental after 3 hours.

The reality is that most patients with major hemorrhage will present as a trauma activation. And if they really are bleeding badly, they will probably trigger your massive transfusion protocol (MTP). But at the same time, they will probably keep you very busy, and it’s easy to forget to order the TXA.

How can you make sure to start the TXA promptly on these patients? Easy! Check out this picture:

Yes, that’s a cheat sign right on top of the first cooler for the MTP! Have the blood bank include this sign in the cooler, so that everyone can see it when you crack the cooler open to give the first units of blood products.

In most hospitals, TXA is a pharmacy item. It should be stocked in the ED, and not in a far away pharmacy satellite. And don’t forget that TXA is given twice, 1 gram given over 10 minutes (or just IV push for speed), followed by another gram infused over 8 hours.

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Best Practice: Laundry Basket In The Resus Room?

How do you get patients out of their clothes during a trauma resuscitation? Most of the time, I bet your answer is “with a pair of scissors.” And once they are off, what do you do with them? Admit it. You just throw them on the floor. And sometime later, someone’s job is to find it all, put it in a bag, and store it or hand it over to the police.

There are more problems than you might think with this approach. First, and most importantly to the patient, their stuff can get lost. Swept up with all the other detritus from a trauma activation. And second, their belongings may become evidence and it’s just been contaminated.

So here’s an easy solution. Create a specific place to put the clothes. Make it small, with a tiny footprint in your trauma room. Make it movable so it can be kept out of the way. And make sure it is shaped so it can contain a large paper bag to preserve evidence without contamination.

And here’s the answer:

Yes, it’s a plain old laundry basket. The perfect solution. And best of all, these are dirt cheap when you are used to seeing what hospitals charge for stuff. So your ED can buy several ($14.29 ea on Amazon.com) in case they can’t be cleaned anymore or just disappear.