Category Archives: General

EAST 2015: Keeping An ICU Bed Open For Trauma

January 8, 2015 The Trauma Pro Leave a comment

Many busy trauma hospitals have equally busy trauma ICUs. Frequently, trauma patients who need critical care are backed up in the emergency department (ED) while awaiting a bed in such cases. This slows ED throughput for other patients, and increases the possibility of an adverse event while waiting for the ICU bed.

The group at the University of Kentucky in Lexington will present an abstract examining the impact of keeping an open bed in the ICU, as well as having a charge nurse in that unit without a patient assignment to help manage bed availability and staffing.

Here are the factoids:

The study examined highest level trauma activations in the ED requiring ICU admission before implementation of the open bed policy
303 patients pre-implementation were compared to 261 patients post-implementation
The usual demographics were similar for both groups
Time in the ED decreased from 4:17 to 2:34 after the open bed policy was instituted, which was highly significant
ICU length of stay (LOS) for patients who were admitted after the policy was in place decreased despite an increase in ISS, but not significantly so
There was no change in mortality
There was a cost savings of about $1000 per patient due to increased nursing productivity and the decreased LOS

Bottom line: Making the effort to reserve a bed for an incoming trauma patient at all times seems to be well worth it. I have visited many hospitals with incredible logjams of these patients in the ED. Frequently, this has a disproportionate and negative impact on the throughput of other ED patients. Creating such a policy should serve to improve patient flow (and satisfaction: what family wants to spend hours sitting in the ED?) as well save money.

Related posts:

Reference: Maintaining an open ICU be for rapid access to the trauma intensive care unit is cost effective. Presented at EAST 2015, paper 28.

General

EAST 2015: The “Impact” Of Graduated Driver License Laws

January 7, 2015 The Trauma Pro Leave a comment

Most states have implemented graduated driver license laws for teen drivers over the past 10+ years. Typically, these laws place age limits, approved times of day for driving, and passenger restrictions on young drivers. There is a growing body evidence that these laws have decreased the number of crashes and injuries/fatalities involving new drivers.

A group at the University of Rochester looked at changes in injuries and deaths in new driver related crashes over an extended period in New York state. During this time, the state first implemented graduated licenses, then added further restrictions on passengers under age 21 six years later. Some interesting patterns emerged.

Here are the factoids:

Before graduated licenses were implemented in New York, young drivers made up 4.2% of all fatal crashes and 3.3% of all personal injury crashes
After implementation of graduated licenses (time of day restrictions), the numbers dropped to 2.9% of fatal crashes and 2.7% of personal injury crashes
When the number of youthful passengers was further limited, the fatality rate for those young riders decreased from 43% to 37%. Injury rate also decreased from 41 to 37%.
Driver fatalities and injuries also decreased further after the number of young passengers was limited (numbers not listed in abstract). [Fewer distractions?]

Bottom line: Graduated driver license laws have been passed in nearly every state (with the exception of Vermont [no night-time driving restrictions], and Florida, South Dakota, Virginia [no young passenger restrictions]). It appears that these laws have reduced the number of deaths and injuries in young drivers. But the unintended consequence is that it has also reduced those numbers in the few young passengers they are allowed to carry as well.

Related posts:

Reference: Impact of graduated driver’s license law on crashes involving young passengers in New York State. Presented at EAST 2015, paper 17.

General

EAST 2015: Effect Of An In-Hospital Falls Prevention Program

January 6, 2015 The Trauma Pro Leave a comment

The Centers for Disease Control (CDC) has developed a neatly packaged falls prevention program that clinicians can apply to their elderly patients. Of course, there’s a cute acronym (STEADI = Stopping Elderly Accidents, Deaths, and Injuries), and a lot of slickly packaged reference material. The trauma group at Parkland wondered if the application of this outpatient program on an inpatient population would be helpful.

They looked at elderly patients (age>65) who were admitted for falls. The patients went through STEADI evaluation and interventions, and were compared with a group of historical controls from the prior year.

Here are the factoids:

218 patients went through the STEADI process, and were compared with 194 controls
The usual demographics appeared to be the same in both groups
The fall rate in-hospital was 4.1% for both groups (!)
The fall recidivism rate (fell after discharge) was also the same (2.8% STEADI vs 2.1% controls)

STEADI consists of a number of assessments, including looking for medical conditions and medications that may impair mobility, visual problems, gait and balance testing, footwear evaluation, cognitive screening, and home evaluation. This program was modified by the authors for inpatient use, although the exact modifications were not listed in the abstract.

Bottom line: The application of the CDC STEADI program did not appear to affect falls in-hospital or those after discharge. The authors question whether maintaining the resources ($) to implement this program is justified. The paper does raise that question, but it is not clear what modifications were made to the full program to tailor it to an inpatient population. The fact that nearly 1 in 20 elderly patients are falling in the hospital is concerning, with or without STEADI. What the abstract does confirm is that elderly falls are a huge problem. The CDC notes that 1 in every 3 patients age 65 and older will fall each year! Further evaluation of STEADI and other similar programs is essential to decrease the morbidity and mortality of falls in this age group.

Related posts:

Reference: UnSTEADI: Implementation of the CDC fall prevention program does not prevent in-hospital falls or reduce fall recidivism rates. Presented at EAST 2015, Paper 16.

General

Bowel Sounds, Or Just Plain BS?

January 5, 2015 The Trauma Pro Leave a comment

“Bowel sounds are normal”

How often do you see this on an H&P? Probably a lot more often than they are actually listened for, I would wager. But what do they really mean? Are they important to trauma professionals?

(Un)fortunately, there’s not a whole lot of research that’s looked at this mundane item. And pretty much all of it deals with surgical pathology (e.g. SBO) or the state of the postop abdomen. Over the years, papers have been published about the basics, and I will summarize them below:

Where to listen? Traditionally, auscultation is carried out in all four abdominal quadrants. However, sound transmission is such that listening centrally is usually sufficient.
Listen before palpation? Some papers suggest that palpation may stimulate peristalsis, so you should listen first.
How long should you listen? Reports vary from 30 seconds to 7 minutes (!).
Significance? This is the big question. We’re not expecting to find hyperactive or high pitched sounds suggestive of surgical pathology here. Really, we’re just looking for sounds or no sounds.

But does it make a difference whether we hear anything or not?

Bottom line: In trauma, we don’t care about BS! We’ve all had patients with minimal injury and no bowel sounds, as well as patients with severe abdominal injury and normal ones. We certainly don’t have time to spend several minutes listening for something that has no bearing on our clinical assessment of the patient. Skip this unnecessary part of the physical exam, and continue on with your real evaluation!

Reference: A critical review of auscultating bowel sounds. Br J Nursing 18(18):1125-1129, 2009.

General

Is This A Good Chest Tube? The Answer!

January 2, 2015 The Trauma Pro Leave a comment

I showed you this x-ray the other day, and asked what the problem was.

If you look carefully, you can see the lung outline in the middle of the right side of the chest. Big-time pneumothorax despite what looks like a perfectly placed tube. There are several possible explanations, and many of you sent me your guesses:

The tube is in the lung. This rarely happens to normal lungs. Sure, you can probably do it to an ARDS lung, but otherwise it’s not likely.
The tube is in the fissure. This does happen on occasion, but not often. And many times it works anyway.
The tube is occluded or kinked. A PA or AP chest x-ray will show the kink, although bent tubes frequently work anyway. If a hemothorax is present, it is possible that a clot is plugging the tube. Clearing a plugged tube will be the subject of another post.
It’s not really a chest tube. Hopefully, this would have been detected when it was placed, but it’s not always. The chest x-ray above looks great, right? Unfortunately, it’s a 2 dimensional representation of a 3-D object. Where is that tube in the z-axis?

In this case the correct answer is the last one. This is one time when I would actually recommend a lateral chest x-ray. Have a look at the result. You can clearly see the tube snaking around into the soft tissues of the back.

Bottom line: Remember that a perfect x-ray doesn’t necessarily mean a perfect tube. Go through the various possibilities quickly, and make it work.

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