Category Archives: General

Trauma PI: Peer-related Loop Closure (Part II)

Yesterday I wrote about loop closure in general and what it is. Today I’ll cover the specifics of peer-related performance improvement issues and how loop closure works with them. 

A peer-related issue typically involves a single trauma professional. In most cases, this is a physician, but may be a nurse, PA or other provider as well. These issues are most often related to care delivered to a single patient. 

The trauma program can identify a peer-related issue in a number of ways, including (with examples):

  • PI filter – delay to laparotomy by a surgeon
  • Complication – intestinal anastomosis breakdown
  • Resuscitation video review – nonsterile insertion of urinary catheter by a nurse or tech
  • Word of mouth – “Geez, it took forever to get blood from the blood bank!”
  • and many more!

Once identified, a “paper trail” must be started that documents the specific issue and the details of how it was found. This can be on a paper PI form, or an entry in your PI or trauma registry software package. The key is that you need to be able to track the progress as long as the issue is “open.”

Next, a determination is needed as to how the particular issue needs to be resolved. For physician items, that may occur via a group meeting (e.g. M&M conference) or a one on one meeting with an appropriate department leader (e.g. trauma medical director). For nursing items, each hospital typically has its own procedure (e.g. meeting with nurse manager).

Once the specific provider has been “re-educated”, final documentation of the process must be prepared. This may include a portion of the M&M meeting minutes or a letter or email message detailing the specifics of the discussion or retraining. All of the documentation collected, from opening of the PI issue to closure, must be preserved in a “folder” associated with this patient (remember, paper or electronic). Furthermore, an entry should be made in the credentialing file for the provider so that these items can be discussed in their annual review.

Here’s a specific example: a surgeon admits a patient with a CT-proven Grade IV splenic laceration. Although hemodynamically stable at first, they have frequent drops in blood pressure in the ICU that respond to crystalloid and several units of blood. After 6 hours of pressures dipping into the 70s and 3 units of blood, the blood pressure finally drops to 50 and won’t come back up. The surgeon takes the patient to the OR and performs a splenectomy. The patient recoveries, but remains on the ventilator for 5 days because of the large volume resuscitation that was given.

The delay to laparotomy PI filters are triggered, and the TPM and TMD place the issue on the Trauma M&M conference agenda. After discussion with all the faculty, the determination is that the patient should have gone to the OR after the first pressure drop in the OR. It is believed that the number of ventilator days would have decreased significantly as well. The delay is deemed a preventable complication. The TMD dictates the meeting minutes, detailing the specifics of the discussion, and noting that the involved surgeon was present. 

The final folder for the patient will contain documentation of the filter violation, a copy of the minutes from the M&M conference, and a copy of the short memo dictated by the trauma medical director that was placed in the surgeon’s trauma credentialing file.

Related posts:

Please send questions you may have so I can discuss on Thursday and Friday!

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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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