Category Archives: Equipment

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.

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What’s The Best Pelvic Binder? Part 2

Yesterday, I detailed some pelvic binders commonly available in the US. Today, I’ll go through the (little) science there is regarding which are better than others.

There are a number of factors to consider when choosing one of these products. They are:

  • Does it work?
  • Does it hurt or cause skin damage?
  • Is it easy to use?
  • How much does it cost?

It’s difficult to determine how well binders work in the live, clinical setting. But biomechanical studies can serve as a surrogate to try to answer this question. One such cadaver study was carried out in the Netherlands a few years ago. They created one of three different fracture types in pelvis specimens. Special locator wires were placed initially so they could measure bone movement before and after binder placement. All three of the previously discussed commercial binders were used.

Here are the factoids:

  • In fracture patterns that were partially stable or unstable, all binders successfully closed the pelvic ring.
  • None of the binders caused adverse displacements of fracture fragments.
  • Pulling force to achieve complete reduction was lowest with the T-POD (40 Newtons) and highest with the SAM pelvic sling (120 Newtons). The SAM sling limits compression to 150 Newtons, which was more than adequate to close the pelvis.

So what about harm? A healthy volunteer study was used to test each binder for tissue pressure levels. The 80 volunteers were outfitted with a pressure sensing mat around their pelvis, and readings were taken with each binder in place.

Here are the additional factoids:

  • The tissue damage threshold was assumed to be 9.3 kPa sustained for more than 2-3 hours based on the 1994 paper cited below.
  • All binders exceeded the tissue damage threshold at the greater trochanters and sacrum while lying on a backboard. It was highest with the Pelvic Binder and lowest with the SAM sling.
  • Pressures over the trochanters decreased significantly after transfer to a hospital bed, but the Pelvic Binder pressures remained at the tissue damage level.
  • Pressures over the sacrum far exceeded the tissue damage pressure with all binders on a backboard and it remained at or above this level even after transfer to a bed. Once again, the Pelvic Binder pressures were higher. The other splints had similar pressures.

And finally, the price! Although your results may vary due to your buying power, the SAM sling is about $50-$70, the Pelvic Binder $140, and the T-POD $125.

Bottom line: The binder that performed the best (equivalent biomechanical testing, better tissue pressure profile) was the SAM sling. It also happens to be the least expensive, although it takes a little more elbow grease to apply. In my mind, that’s a winning combo. Plus, it’s narrow, which allows easy access to the abdomen and groins for procedures. But remember, whichever one you choose, get them off as soon as possible to avoid skin complications.

References:

  • Comparison of three different pelvic circumferential compression devices: a biomechanical cadaver study. JBJS 93:230-240, 2011.
  • Randomised clinical trial comparing pressure characteristics of pelvic circumferential compression devices in healthy volunteers. Injury 42:1020-1026, 2011.
  • Pressure sores. BMJ 309(6959):853-857, 1994.
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What’s The Best Pelvic Binder? Part 1

Several products for compressing the fractured pelvis are available. They range from free and simple (a sheet), to a bit more complicated and expensive. How to decide which product to use? Today, I’ll discuss the four commonly used products. Tomorrow, I’ll look at the science.

First, let’s dispense with the sheet. Yes, it’s very cheap. But it’s not easy to use correctly, and more difficult to secure. Click here to see my post on its use.

There are three commercial products that are commonly used. First is the Pelvic Binder from the company of the same name (www.pelvicbinder.com). It consists of a relatively wide belt with a tensioning mechanism that attaches to the belt using velcro. One size fits all, so you may have to cut down the belt for smaller patients. Proper tension is gauged by being able to insert two fingers under the binder.

Next is the SAM Pelvic Sling from SAM Medical Products (http://www.sammedical.com). This device is a bit fancier, is slimmer, and the inside is more padded. It uses a belt mechanism to tighten and secure the sling. This mechanism automatically limits the amount of force applied to avoid problems with excessive compression. It comes in three sizes, and the standard size fits 98% of the population, they say.

Finally, there is the T-POD from Pyng Medical (http://www.pyng.com/products/t-podresponder). This one looks similar to the Pelvic Binder in terms of width and tensioning. It is also a cut to fit, one size fits all device. It has a pull tab that uses a pulley system to apply tension. Again, two fingers must be inserted to gauge proper tension.

So those are the choices. Tomorrow, I’ll go over some of the data and pricing so you can make intelligent choices about selecting the right device for you.

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How To Design Your Trauma Bay

I spent the last two posts discussing the size of your trauma bay and how to measure it. This can obviously be helpful if you are updating or building new resuscitation rooms. But what about all the stuff that goes into it? Where is the best place to put it? If you are in the enviable position of being able to stock a brand new room, here are some tips.

Figure out what you really need in the trauma bay. You don’t have to put everything and the kitchen stove in there. It’s fine to have less commonly used equipment somewhere else, but it must be close! You don’t want someone to have to walk 50 yards to look for something you need right now.

Here’s a list of the critical stuff:

  • Temperature and light controls.  These must be inside the room for easy and rapid access. And the doors should close to contain the heat. Resus rooms that are used frequently should be kept warm, doors closed, at all times.
  • Personal protective equipment. This should be located just inside the room (if space is available) or just outside. It absolutely must be near the entrance and easily accessible or no one will wear it.
  • Airway cart and video laryngoscope. These items must always be located near the head of the bed for immediate availability.
  • Difficult airway cart. These are not used frequently, so need not be placed inside the room. But make sure it is close by.
  • Travel ventilator. This can be stored outside unless you have lots of space available.
  • IV start/blood draw carts. One of these should be stationed on either side of the patient.
  • Rapid infuser. This may be located inside or outside of your trauma room based on the number of times it is typically needed.
  • Procedure packs. These should be located inside the trauma bay, and clearly organized inside cabinets.
  • Medication dispenser. This must be inside the room. Period.
  • Other commonly used equipment/supplies.  These should be placed intuitively in the bay and/or cabinets depending on frequency of usage of each item. Clear marking is essential.
  • Scribe stand. Don’t forget the scribe. They obviously have to be in the room, and need some space for the (preferably) paper trauma flow sheet.
  • Pediatric cart. This can be stored inside or outside the resus room, but should be nearby. Make sure that the measuring card that translates child size into equipment size is easily located.
  • Blood refrigerator. This item is optional, but is becoming more common. It can be located inside or close outside the trauma bay depending on space available.
  • Blanket and sheet warmer. These are nice to have, wherever you have room to put one. The patients will appreciate it.
  • Procedure lights. Ceiling mounted are best because they don’t take up floor space. However, these are notorious for developing a mind of their own as they age. After a while, they never seem to stay focused on your field.
  • Forced air warming blanket unit. This is important here in Minnesota, but also anywhere your patients can get cold. Which is pretty much everywhere. The airflow unit itself is relatively small and can usually be tucked under a counter somewhere. Otherwise, keep it nearby.
  • Linens hamper. You need to get rid of that gown / those sheets and blankets / or whatever. There’s no reason to take up space in the room for this. Park it outside.
  • Laundry basket. This is a valuable item that is generally overlooked. What do you usually do with all that stuff you cut off the patient? Drop it on the floor, right? This is setting you up to lose your patient’s stuff. Get a cheap plastic laundry basket from Target and put it under one of the counters. Toss clothing, shoes, etc in it as they are removed.
  • Cast cart. These are typically huge. They can be anywhere else but inside the trauma bay. Roll it outside the door when needed.

Now where do you put all this stuff? Most trauma centers already have an established layout and flow in their existing trauma bays. When you are moving to a new one, plan ahead! Hopefully you will have more room, so you’ll have some additional flexibility as to where to place everything.

But designing the placement and flow on paper alone is of limited use. You must try it out in advance! How do you do this? Have your contractor mock up a space exactly the size of your new resuscitation room. Move actual carts, cabinets, and equipment into it. If it’s not possible to cart the exact stuff into it, have the contractor build mock-ups of them and place them in the bay.

Now have actual trauma team members practice simulations of common types of resuscitation: basic no frills, basic with intubation, basic with splinting/casting, advanced with all of the above plus multiple procedures. Take careful notes of flow and any glitches that arise. Then move your stuff around to fix any problems, and try again!

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How To Measure Your Trauma Bay

Yesterday I detailed some standard info on trauma bay size. Today, I’ll describe what I found when I brought in my trusty tape measure today to check out my trauma bays at Regions Hospital. I came up with several helpful measurements to help gauge the relative utility of the rooms.

Here are the indices that I came up with:

  • TBTA: Trauma Bay Total Area. This is the total square footage (meterage?) measured wall to wall.
  • TBWA: Trauma Bay Working Area. This is the area that excludes equipment carts next to a wall, and areas under countertops that extend away from the wall.
  • TBAA: Trauma Bay Available Area. This is the TBWA less any other unusable areas in the room. We have an equipment post near one corner that eats up 16.5  sq ft of space. Also remember to subtract the area taken up by the patient bed, as this area is not available to the trauma team, either.
  • TBSI: Trauma Bay Space Index. This value is derived by dividing the TBAA by the number of team members in the room. It gives an indication of how much space is available for each trauma team member to work in.

Values in my trauma center:

  • TBTA: 291 sq ft
  • TBWA: 220.5 sq ft
  • TBAA: 186.5 sq ft
  • TBSI: 15.5

What does it all mean? Hard to say without more info from you for comparison. For my team, it means we each have a 4×4 foot square to move around in, on average. This is fairly tight, I would say.

Why don’t you generate some comparison data? Tomorrow is “take a tape measure to work” day! Calculate these constants in your own resuscitation room. Then post them by leaving comments below, or tweet/email me the values for the metrics listed above. If I get enough, I’ll post the data here!

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