Category Archives: General

EAST 2014: LEAN Process Improvement And Trauma Discharges

In many trauma hospitals, especially Level I and II centers, there tends to be a tendency toward complex, high volume care. As any trauma professional knows, this is a setup for system inefficiencies. Lean principles were derived from Japanese manufacturing practices in the 1980’s, and includes a toolset that helps companies eliminate waste. Any use of resources for anything but creating end value for the customer is considered waste and must be eliminated.

The discharge planning process for trauma inpatients is one of many parts of the care spectrum that contains waste, and researchers at Grant Medical Center in Columbus looked at the result of applying lean principles to it.

A lean mapping event was held, which is one of the tools promoted by the lean process. This identified areas for immediate evaluation and intervention. This, in turn, resulted in new workflows, which were then evaluated for their effect. 

The primary area of concern indentified was inter-service communication. This included getting reliable information from consult services and providing pertinent information to physical therapy. They also discovered that trauma patient admissions to units not designated for the trauma service resulted in lengths of stay 1.6 times the average.

Three areas for improvement were identified:

  1. Off-unit trauma admissions
  2. Patients with length of stay > 15 days
  3. Miscommunication regarding patient education at discharge

Bottom line: This abstract is heavy on theory and very light on practice. There is no statement or analysis of results. However, it does seem like there may be some use for Lean methodology in analyzing trauma care. The trick will be to develop interventions that actually remove some of the inefficiencies in our care processes. I will definitely sit in on this presentation!

Reference: Lean methodology for performance improvement in the trauma discharge process. EAST 2014, oral paper #31.

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EAST 2014: ICU Procedures – Residents vs ACPs

Involvement of advanced care practitioners (ACPs) like physician assistants and advanced clinical nurses has increased significantly due to the implementation of work hour restrictions for surgical residents. Prior to this, invasive procedures were performed almost exclusively by the residents. Now, more and more procedures are being performed by ACPs. The question is: is it safe?

Carolinas Medical Center retrospectively reviewed all ICU procedures performed in a year’s time in their SICU. They compared complication rates when the procedure was performed by a resident vs an ACP. 

The factoids:

  • Procedures reviewed included arterial lines, central venous lines, chest tubes, bronchoalveolar lavage, perc gastrostomy, and perc tracheostomy
  • Residents performed all procedures on trauma patients in the ICU, and ACPs performed procedures on all other SICU patients (note: this is not randomization!)
  • All procedures were supervised by an attending physician
  • A total of 1,575 procedures were performed, 1,020 by residents and 555 by ACPs
  • The complication rate for both groups was 2% (no difference)
  • Hospital and ICU length of stay were the same for both groups
  • In-hospital mortality was 11% for the resident group vs 9.7% for the ACP group, despite higher APACHE III for the latter.

Bottom line: ACPs can perform ICU level procedures as well as residents with proper supervision. As work hour restrictions continue to become more restrictive, expect to see further degradation of resident experience and expanded involvement of ACPs. For centers without residents, be confident in expanding the role of your ACPs in clinical care.

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Reference: Comparison of critical care procedural complication rates between residents and advanced clinical providers. EAST 2014, oral paper 21.

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EAST 2014: The Dogma Of Putting Chest Tubes To Suction?

Chest trauma is a very common occurrence. One of the more common procedures for managing it is insertion of a chest tube. In the majority of cases, the drain is connected to a system to collect blood and vent air. And they are nearly always automatically hooked up to 20cm of suction.

A study was constructed to randomize the use of suction vs water seal in patients with pneumothorax, hemothorax, or a combination of both. Patients who had early positive pressure ventilation (ventilated, emergency OR), chronic lung disease, or severe TBI (?) were excluded.

Here are the factoids:

  • 110 patients were randomized to either water seal (54) or 20cm of suction (56)
  • There was no difference in the length of time the tube was in place between the groups (3 days)
  • Incidence of retained hemothorax and empyema was no different (and hopefully rare!)
  • Hospital length of stay was the same
  • There was a significantly increased incidence of persistent air leak in the suction group

Bottom line: First, this is a small study so it doesn’t have enough power to make definitive statements. However, it is definitely provocative. We blithely put every patient on suction, not thinking about the negative implications such as decreased mobility, increased atelectasis, and DVT. Patients on suction are much less likely to move around at all! A mobile patient is just as likely to push any air and blood out of the tube as an immobile one is to have it sucked out. Let’s do a larger study to confirm this! And hey, use a protocol to manage the tube! Three days is too long to have a tube in place.

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Reference: Negative pleural suction in thoracic trauma patients: a randomized controlled trial. EAST 2014 oral paper 14.

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EAST 2014: Spine Imaging In Elderly Falls

Many people don’t realize, but falls are more common than motor vehicle crashes. The elderly are most commonly involved, and injuries frequently have a major impact on quality of life. Dogma tells us that we should image the full spine if any part of it is fractured. 

A group at Thomas Jefferson University questioned this practice (good!) and designed a study to look at its efficacy. They hypothesized that the low energy involved would not cause enough non-contiguous spine injuries to be of concern.

They designed a retrospective study using a large pool of data from the Pennsylvania Trauma Systems Foundation trauma registry. Here are the factoids:

  • Only patients older than 65 who fell from standing and sustained a cervical spine fracture were included
  • Of over 14,500 elderly patients who fell, 1102 sustained a cervical fracture
  • 1083 of these patients were neurologically intact (99%) and the status of the remainder of their spine was evaluated
  • 7% of neuro intact patients with a cervical fracture also had a thoracolumbar spine fracture
  • Three of these 74 patients required a surgical spine procedure
  • The presence of a rib fracture was associated with triple the incidence of a thoracolumbar fracture

Bottom line: Although this study looks convincing, there are a few issues. First, it’s a registry study and data quality is always a concern. This may explain the lower than usual incidence of thoracolumbar fractures after fall from standing compared to other reports. And based on their work, the authors recommend CT screening of the T and L spines if a cervical fracture is present. This may be overkill, and an initial screen with conventional spine xrays may help decrease the number of spine CTs performed, even though sensitivity and specificity for these studies is low.

Reference: Is full spine imaging necessary in the elderly, fall from standing trauma patient with a cervical fracture? EAST 2014, oral paper 13.

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