All posts by TheTraumaPro

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.

The IVC Filter In Trauma: Why?

The inferior vena cava (IVC) filter has been around in one form or another for over 40 years. One would think that we would have figured everything about it out by now. But no!  The filter has evolved through a number of iterations and form factors over the years. The existing studies, in general, give us piecemeal information on the utility and safety of the device.

One of the major innovations with this technology came with the development of a removable filter. Take a look at the product below. Note the hook at the top and the (relatively) blunt tips of the feet. This allows a metal sheath to be slipped over the filter while in place in the IVC. The legs collapse, and the entire thing can be removed via the internal jugular vein.

ivc-filter-complications1

The availability of the removable filter led the American College of Chest Physicians to recommend their placement in patients with known pulmonary embolism (PE) or proximal deep venous thrombosis (DVT) in patients with contraindications to anticoagulation. Unfortunately, this has been generalized by some trauma professionals over the years to include any trauma patients at high risk for DVT or PE, but who don’t actually have them yet.

One would think that, given the appearance of one of these filters, they would be protective and clots would get caught up in the legs and be unable to travel to the lungs as a PE. Previous studies have taught us that this is not necessarily the case. Plus, the filter can’t stop clots that originate in the upper extremities from becoming an embolism. And there are quite a few papers that have demonstrated the short- and long-term complications, including clot at and below the filter as well as post-phlebitic syndrome in the lower extremities.

A study from Boston University reviewed their own experience retrospectively over a 9 year period. This cohort study looked at patients with and without filters, matching them for age, sex, race, and injury severity. The authors specifically looked at mortality, and used four study periods during the 9 year interval.

Here are the factoids:

  • Over 18,000 patients were admitted during the study period, resulting in 451 with an IVC filter inserted and 1343 matched controls
  • The patients were followed for an average of 4 years after hospitalization
  • Mortality was identical between patients with filters vs the matched controls

dvt-study

  • There was still no difference in mortality, even if the patients with the filter had DVT or PE present when it was inserted
  • Only 8% ever had their “removable” filter removed (!)

Bottom line: Hopefully, it’s becoming obvious to all that the era of the IVC filter has come and gone. There are many studies that show the downside of placement. And there are several (including this one) that show how forgetful we are about taking them out when no longer needed. And, of course, they are expensive. But the final straw is that they do not seem to protect our patients like we thought (hoped?) they would. It’s time to reconsider those DVT/PE protocols and think really hard about whether we should be inserting IVC filters in trauma patients at all.

Tomorrow: a look at trends in filter insertion and retrieval.

Related post:

Reference: Association Between Inferior Vena Cava Filter Insertion
in Trauma Patients and In-Hospital and Overall Mortality. JAMA Surg, online ahead of print, September 28, 2016.

When Should You Activate Your Backup Trauma Surgeon?

The American College of Surgeons requires all US Trauma Centers to publish a call schedule that includes a backup trauma surgeon. This is important for several reasons:

  • It maintains a high level of care when the on-call surgeon is encumbered with multiple critical patients, or has other on-call responsibilities such as acute care surgery
  • It reduces the need to place the entire trauma center on divert due to surgeon issues

However, the ACS does not provide any guidance regarding the criteria for and logistics of mobilizing the backup surgeon. In my mind, the guiding principle is a simple one:

The backup should be called any time a patient is occupying the on-call surgeon’s time to the extent that they cannot manage the care of a newly arrived (or expected to arrive) patient with critical needs that only the surgeon can provide.

There’s a lot of meat in that sentence, so let’s go over it in detail. 

First, the on-call surgeon must already be busy. This means that they are actively managing one or more patients. Depending on the structure of the call system, they may be involved with trauma patients, general/acute care surgery patients, ICU patients, or a combination thereof. Busy means tied up to the point that they cannot meaningfully manage another patient.

Note that I did not say “evaluate another patient.” Frequently, it is possible to have a resident (at an appropriate training level) or advanced practice provider (APP) see the new patient while the surgeon is tied up, say in the operating room. They can report back, and the surgeon can then weigh his or her choices regarding the level of management that will be needed. Or if operating with a chief resident, it may be possible for the surgeon to briefly leave the OR to see the second patient or quickly check in on the trauma resuscitation. Remember, our emergency medicine colleagues can easily run a trauma activation and provide initial care for major trauma patients. They just can’t operate on them.

What if the surgeon is in the OR? Should they call the backup every time they are doing a case at night? Or every time a trauma activation is called while they are doing one? In my opinion, no. The chance of having a highest level trauma activation called is not that high, and as above, the surgeon, resident, or APP may be able to assess how much attention the new patient is likely to need. But recognize that the surgeon may not meet the 15 minute trauma activation attendance requirement set forth by the ACS.

However, once such a patient does arrive (or there is notification that one of these patients is on the way), call in the backup surgeon. These would include patients that are known to, or are highly suspected of needing immediate operative management. Good examples are penetrating injuries to the torso with hemodynamic problems, or those with known uncontrolled bleeding (e.g. mangled extremity).

If two or more patients are being managed by the surgeon, and they believe that they would not be able to manage another, it’s a good idea to notify the backup that they may be needed. This lets them plan their evening better to ensure rapid availability.

Finally, what is the expected time for the backup to respond and arrive at the hospital to help? There is no firm guideline, but remember, your partner and the patient are asking for your assistance! In my opinion, total time should be no more than 30 minutes. If it takes longer, then the trauma program should look at its backup structure and come up with a way to meet this time frame.