All posts by TheTraumaPro

The 30-Minute Rules: Response Times

In my last post, I reviewed the first component of the 30-minute rules, the actual criteria themselves. It’s not called a 30-minute response rule for no reason. There is an absolutely required time to respond that has been set at 30 minutes.  Today, I’ll look at an equally important component: the response time itself. Why do we have it, and when does the event start and stop?

So why does a rule like this exist? Is it to punish the providers who are being monitored, torturing them to get to the hospital as quickly as possible? No! As with so many of our performance improvement (PI) filters, they are designed to test many, many things. Some examples for this one are:

  • Recognition of a life or limb threatening condition by the in-hospital providers
  • Communications systems (ED clerk, pagers, phones, etc.)
  • The call schedule system
  • Clinician responsiveness and commitment (orthopedics, neurosurgery)
  • Nursing documentation
  • And more!

What is the actual time interval that must be measured? First, it does not start when the clinical condition in the criterion is recognized. If a patient has a large subdural hematoma with shift on CT scan, a radiologist must bring it to the attention of the advanced practice provider, emergency physician, or surgeon, who must then take the next step. The timer actually starts when the clinician causes the specialist to be notified. This may occur when the clerk pages or calls them, or when the clinicians do it directly.

One point of confusion: the clock does not start when the clinician responds to the page or call. What if they don’t call back for 45 minutes? Do they then have another 30 minutes to get to the hospital? No!! It starts when the first notification goes out.

So when does the clock stop? This one is easy. It occurs when the specialist who has been called gets to the patient’s bedside and begins the assessment.

One final thing about the clock? Does the clinician have to respond within the 30-minute time frame on every patient? Ideally, this would be great but it’s not realistic. There is no guidance in the Orange Book about a threshold. But if past experience is any indication, it is most likely a timely response somewhere around 80% of the time. But strive for perfection!

Tomorrow, I’ll list some ways to address the most challenging part of the 30-minute rules: actually recording the response times. And I’ll provide a best practice to help meet it.

 

The 30-Minute Rules: What Are They Exactly?

Yesterday, I talked about the new 30-minute rules for orthopedics and neurosurgery in general terms. Today, I’ll write about the who and what.

The rules state that a service representative “must be present and respond within 30 minutes based on institutional-specific criteria.” The response needs to be in person and not by phone. But who can it be? The Clarification Document states that the response can be met by an orthopedic surgery resident, mid-level provider, or the orthopedic surgeonHowever, if a resident or midlevel respond, they must document their communication with the orthopedic surgeon in their note.

The neurosurgery service representative is not as clearly spelled out. However, it is presumed that this person meets the same requirements as for orthopedics: resident, midlevel, or neurosurgeon.

The most important issue the trauma program must address is the selection of the actual criteria.  Here are some tips to guide you:

  • Select only a few. Three is a good number. Any more than this will tax your specialists.
  • Choose good criteria that your orthopedic surgeon or neurosurgeon would absolutely want to be there  in 30 minutes for. See my examples below.
  • Make sure they are very specific. Vague terms like “TBI” or “open fracture” would result in your specialist being called in way too often.
  • Ensure that the criteria do not rely on the judgement of the specialist. For example, language such as “a subdural requiring operative intervention” requires the neurosurgeon to pass judgment from home and should be avoided.
  • One exception to the previous point: futile neurotrauma care. Your neurosurgeon may review the images from outside the trauma bay and pronounce the care futile. Howeverthey should document this clearly in a note in the chart as soon as possible. And they had better not change their mind later.
  • Avoid vague language like “when requested by the trauma team.”

So what are some good criteria? Here are a few:

  • Ortho
    • Mangled extremity
    • Dysvascular limb
    • Compartment syndrome
    • Unstable pelvic fracture
    • Open pelvic fracture with external hemorrhage
  • Neurosurgery (you/they pick the exact numbers)
    • Subdural/epidural > x mm
    • Subdural/epidural with midline shift > x mm
    • Subdural/epidural with impending herniation
    • Open skull fracture with brain extrusion
    • Brain extrusion from nose/ear
    • Decrease in GCS of > x points
    • Unilateral dilated pupil with GCS < x points
    • Spinal cord injury with unstable spine

This is not a comprehensive, list, but hopefully you get the idea. Each center needs to develop their own list, with input from their specialists. Once agreed upon, these should be put into policy and approved at the trauma program operations committee.

Tomorrow: call and response.

 

Trauma Centers: The 30-Minute Rules for Orthopedic Surgery and Neurosurgery

I’m kicking of a week-long series for trauma program leaders that explains the details of a trauma center requirement that creates confusion for many. With the adoption of the 2014 Resources for Optimal Care of the Injured Patient (i.e. The Orange Book), a number of new requirements were introduced to obtain and maintain status as an American College of Surgeons verified trauma center. One (or actually two) of the requirements for Level I and II centers are known collectively as the 30-minute rules.

The 30-minute rules apply to both orthopedic surgeons and neurosurgeons. They state that care must be continuously available and that a service representative “must be present and respond within 30 minutes based on institutional-specific criteria.” And most who peruse the Orange Book have already realized, any phrase that contains the word must denotes that failure to meet the requirement will result in a deficiency during a site review, whereas the word shall means that it will likely result in a weakness.

For the rest of the week, I’ll work through these requirements. I will describe what they mean and what some typical institutional-specific criteria are. I will explain who is actually required to respond. I’ll work through the logistics of being able to accurately record their response time, and offer best practices for how to capture it. And finally, I’ll look at the consequences of not meeting these criteria.

Tomorrow: Typical criteria for orthopedic surgery and orthopedics.

 

Mistaken Identity In Trauma Care

There was a well-publicized and tragic case of mistaken identity after a motor vehicle crash in Indiana a number of years ago. A van carrying several college students and staff crashed, resulting in multiple fatalities at the scene. Survivors were transported to a Michigan trauma center, and it wasn’t until five weeks later that the identity mixup was discovered.

One of the fatally injured students and one of the survivors were both female, blonde, and about the same height and size. Their identities were not confirmed because the next of kin of the deceased was advised not to look at the body. And the face of the surviving woman was significantly contused and she had sustained multiple facial fractures. She remained comatose and intubated for over month after the other was buried (by the wrong family, it turns out). After extubation, she began correcting people who called her by the deceased woman’s name, and the correct identification was finally made.

How can this happen?! It’s not as difficult as it might seem, for a number of reasons:

  • Faces and identifying marks may be mutilated
  • Position in the vehicle may be mistaken
  • Bystander descriptions are notoriously inaccurate in these situations

It is neither practical nor safe to delay transport from the scene in the interest of obtaining positive identification. And hospitals have even less information than prehospital providers, whom they rely on almost exclusively for accurate data.

What can be done to avoid a case of mistaken identity? EMS and hospitals must develop protocols to follow in any case where multiple patients are treated at once. The baseline assumption must be that the identities are unclear or unknown until definitively made, and preferably from multiple sources. What are these definitive items?

  • An official ID that is still on the victim’s person (not cut off in the clothes)
  • Self identification
  • Visual identification from someone who personally knows the victim and views or talks to them
  • Written description, where the patients have very different identifying characteristics

However, remember that every one of these can be made in error. This is why multiple sources are so important. If in doubt, the patients should remain a “Doe” and not be given a real name.

If you have specific protocols or policies, please share them with me by email so I can post them!

Trends In IVC Filter Placement And Retrieval

Yesterday, I reviewed a paper that highlighted a single-institution experience for IVC filter usage. Today, let’s look at a much larger pool of data.

Placement of a filter in the inferior vena cava (IVC) is one of the many tools for managing pulmonary embolism. There was a significant increase in filter placement during the 1990s and 2000s due to a broadening of the indications for its use.  There has been continuing debate over the complications and efficacy of use of this device.

A paper from NYU Langone Health in New York City, the Harvey L. Neiman Health Policy Institute, and Georgia Institute of Technology School of Economics looked a long-term trends in IVC filter use in the Medicare population. They scanned a Centers for Medicare and Medicaid Services (CMS) database over the 22 year period from 1994 to 2015. They specifically analyzed trends in insertion, removal, placement setting, and specialty of the inserting physician.

Here are the factoids:

  • 2008 seemed to be the heyday of IVC filter insertion. Rates nearly tripled by 2008, but have declined about 40% since then (see below). Pay attention to the retrieval rates.

  • Overall, filters were most commonly placed by radiologists, followed by surgeons and cardiologists. Here’s the diagram above broken down by specialty.

  • This chart shows the market share of each specialists inserting IVC filters during the study period. Of note, radiologists continue to increase and surgeons are decreasing.

Bottom line: This study shows some interesting data, but can’t be completely applied to trauma patients because it focuses on Medicare recipients. But the trends are valid. IVC filter use peaked in 2008 and has been declining ever since. Radiologists place more filters than other specialties, and their market share continues to increase.

Most disturbing is the low filter retrieval rate, similar to what was seen in yesterday’s post. Device manufacturers recommend removal of most filters, but timeframes are not specified. The real bottom line is that we have an indwelling device which works well in very limited situations only, can cause long term complications, and that we frequently forget to remove. It behooves all trauma professionals to develop strict guidelines for both use and removal.

Reference: National Trends in Inferior Vena Cava Filter Placement and Retrieval Procedures in the Medicare Population Over Two Decades. J Am Coll Radiol 15:1080-1086, 2018.