Category Archives: General

Trauma PI: Loop Closure Part I

Trauma performance improvement (PI) is a rigorous system that ensures high quality care of trauma patients. For the next three days I’ll be digging into the final goal of the process, loop closure. Today I’ll talk about what loop closure really is. And remember, this process applies to all phases of care from prehospital to post-discharge.

Your trauma PI program basically identifies problems of any type, requires someone to come up with potential solutions, applies these solutions, then monitors the result. This process is a cycle, since the first solution may only partially solve the problem. The initial solution may need to be tweaked or totally changed. This loop continues until a reasonable result has been achieved.

Loop closure is really two things: achievement of the best possible resolution of the initial problem, and documentation of the process. One is not possible without the other. A common trauma PI problem I encounter is documentation of “loop closure” when the original problem is still recurring.

When most people talk about loop closure, they are usually referring to the documentation part. Each PI problem must have a discrete “folder” of documentation that details every step of the process, from recognition to closure. This folder may reside securely on a computer (remember to back up regularly), or it can be a good old-fashioned manila folder.

The documents that are saved vary depending on the specific problem that was addressed. However, typical materials may include meeting minutes, registry reports, personnel letters, email messages, and protocols. I will give specific examples of the documents that should be included tomorrow and Wednesday.

All related documents should be included in the folder for that specific issue. All PI issue folders should then be kept in a single location, not spread across several binders or locations. Multiple people in your trauma program should be familiar with the PI folder organization. Otherwise, what happens if your Trauma Program Manager, who has been with you for years and is the only one that really understands how PI is organized, decides to retire or move to another trauma program? Your entire program may be in jeopardy.

Related posts:

Please email any specific questions you have, and I’ll answer those on Thursday and Friday.

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Carotid and Vertebral Artery Injury From Blunt Trauma

Blunt injury to the carotid or vertebral arteries (BCVI) is relatively uncommon, but potentially very deadly. Up to 2% of patients with high energy blunt trauma suffer this injury. Many are not diagnosed until the patient has ischemic symptoms or a stroke. However, more aggressive screening has shown a higher incidence that previously thought and may allow intervention before neurologic injury occurs.

Recently, a series of 222 patients with 263 BCVI was retrospectively reviewed, with an eye toward effectiveness of interventions. A total of 29 strokes occurred in the hospital in these patients, but only 7 of these occurred after diagnosis of the BCVI. Mortality was much higher in the stroke group (34% vs 7%). The authors looked at both medical and interventional therapies.

This paper identified the following items:

  • Car crash was the most common mechanism of injury (81%)
  • Vertebral arterial injury was slightly more common than carotid artery BUT
  • Women were much more likely to sustain a carotid injury
  • Older patients were more likely to have a vertebral injury

These authors found that CT angio was not sufficiently sensitive to identify all BCVI. They recommend a formal 4-vessel arteriogram in patients with a negative CT angio who have significant risk factors (unexplained neurologic deficit, Horner’s syndrome, LeFort II or III injury, cervical spine injury, soft tissue injury of the neck).

If a BCVI is identified, the patient should be heparinized until all other injuries are definitively managed. At that point, they should be preloaded with clopidogrel and aspirin and a repeat arteriogram should be performed. Endovascular stenting using a bare metal stent should be performed when possible because it results in the lowest stroke rate and requires the shortest duration of anti-platelet therapies. Patients then continue on aspirin and clopidogrel for an appropriate period of time.

To download the algorithm used by the authors, click here.

Reference: Optimal outcomes for patients with blunt cerebrovascular injury (BCVI): tailoring treatment to the lesion. J Am Coll Surg 212(4):549-559, 2011.

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Predicting Bleeding In Patients With Stable Pelvic Fractures

Bleeding is a well-recognized complication of severe pelvic fracture. Certain fracture patterns, usually with significant involvement of the posterior portions of the ring, are associated with significant bleeding. Most of these fractures are unstable to some degree.

Stable pelvic fractures (those that do not require internal or external fixation) are not generally prone to a large amount of bleeding. However, it can occur on occasion, and surgeons at the Massachusetts General Hospital have devised a simple prediction system so patients more likely to bleed can be identified and monitored more closely.

They retrospectively looked at their stable pelvic fracture population over 5+ years. A total of 391 patients with stable pelvic injury were identified. Of those, 280 never required transfusion and 111 did. Of the latter, only 15 bled from their stable pelvic fractures. 

The authors found the following three significant indicators of bleeding from stable pelvic fractures:

  • Admission hematocrit < 30%
  • Pelvic hematoma on CT
  • Any systolic blood pressure < 90 mm Hg

Bottom line: This is a simple, retrospective study with low numbers. However, the three indicators commonly indicate significant early bleeding in any trauma patient, so it makes sense to apply it here, too. If a patient meets one or two criteria, consider monitoring in the ICU and consider angiography. If all three or met, strongly consider appropriate intervention (angiography if good blood pressures can be maintained, or fixation and/or preperitoneal packing if not).

Reference: Predictors of bleeding from stable pelvic fractures. Arch Surg 146(4):407-411, 2010.

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Technology: A New Teaching Tool For Orthopedic Injury

Here’s a look at some new technology (made from five pieces of old technology) to help injured patients follow their activity and exercise regimens better after injury. It allows patients to “look beneath the surface” of their injured extremity to get a better idea of what is wrong and why they need to be compliant to heal.

Microsoft Research Labs cobbled together a projection unit from a handheld projector, a digital camera and an infrared camera. The control unit consists of a wireless controller and a laser pointer. Put them together and you can superimpose stock injury images over a patient’s extremity, or review images on a wall.

Two physical therapists did an uncontrolled test on several patients and indicated that overall compliance with the therapy regimen seemed to be better. Obviously, this is not sound science. But it does have some potential in allow physicians and therapists to give a better explanation about what is injured and what needs to be done about it. In my opinion, this could be generalized to just about any internal injury, and can provide an easy to understand teaching tool for trauma professionals.

Anatomic injury projector

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