Category Archives: Guidelines

Best Practice: The MTP Coordinator

November 1, 2024 The Trauma Pro Leave a comment

Every trauma center has a massive transfusion protocol (MTP). But every trauma center also does it entirely differently. Ideally, an MTP is designed with the resources available at the hospital in mind. These may include whole blood, the use of O- vs. O+ blood, the number of units of each product per cooler, the different products in different coolers, and personnel available to move those coolers to the correct locations.

In my experience, one of the areas with the greatest variability is the person or persons who are actually directing the blood resuscitation, hanging the units, and doing the paperwork. Frequently, this is split across several people. In the ED, the surgeon is usually directing it. However, nurses typically hang the products and do the paperwork.

Often, though, the surgeon may be up to their elbows in a resuscitative thoracotomy and may be unable to direct their full attention to figuring out if more products are needed. In the OR, the anesthesiologist can frequently take over this task while the surgeon is busy in a body cavity. But sometimes, the resuscitation needs may overwhelm even their ability to concentrate on the MTP.

The Solution

The solution to this problem borrows from the team leader concept in trauma resuscitation. It is best if the team leader has minimal clinical responsibilities during the resuscitation. Once they move in and touch the patient, their area of attention collapses to that one spot, and they cannot fully concentrate on all of the big-picture issues going on in the room.

This is where the MTP coordinator comes in. This is a dedicated person who only has one job: to deal with the MTP. They have no other responsibilities in the room.

Here is a list of tasks that they can offload from the other nurses and physicians in the ED/OR:

Call for the next cooler to be sent from the blood bank, taking into account the transit time
Ensure required labs are being sent for crossmatch and TEG/ROTEM, if used
Order and hang TXA on appropriate patients
Transfuse products in the appropriate order
Fill out all required transfusion records
Ensure 1:1:1 transfusion ratios
Regularly inform the surgeon of the current product counts
Order calcium and cryoprecipitate when appropriate, according to your protocol
Inform the blood bank when the patient moves to a new area (e.g. ED to OR) and follow along with the patient
As the resuscitation winds down, interpret TEG/ROTEM and modify transfused products as indicated
Notify the blood bank when the MTP is terminated
Ensure all final paperwork is complete

This seems like a lot! But we are normally asking numerous people in the trauma bay to do it. Assigning it to one person and one person only creates a much more reliable and efficient system.

Who should it be assigned to? Generally, not one of the usual ED nurses. This is a specialized position that requires additional training and practice. Some trauma programs have dedicated trauma nurses for trauma resuscitation, and they may be a good choice. However, they are frequently the only nurses assigned to resuscitations, and making them the MTP coordinator takes them off all other duties. This may not be practical.

In my opinion, the best candidate is an ICU nurse who has received training for this duty. Ideally, it would be the ICU nurse who would be receiving and taking care of that patient in the ICU if they survive. They will be very familiar with their patient once they arrive there.

If you have an MTP coordinator at your center, please take a moment to leave comments or suggestions below! Let us know how you do it.

Guidelines

When To Call Your Urology Consultant

September 6, 2024 The Trauma Pro Leave a comment

Trauma professionals don’t always know everything. Sometimes we have to engage a specialist in the care of our patient. And unfortunately, we don’t always know which conditions demand immediate attention and which can wait.

This can lead to overuse of our consultant colleagues and calls at inappropriate times. So what if we diagnose an injury in their area of expertise at 2 am? Does it need attention or an operation before morning? If not, why call at that ungodly hour? Give them a break!

Let’s use our consultants wisely! I’ve listed most of the common urologic diagnoses that trauma professionals will encounter. There is also an indication of what you need to do, and exactly when to call your consultant.

Here’s a reference sheet formatted at a 3×5 index card that you can keep in your pocket. I’ve included a printable pdf file, as well as the original Microsoft Publisher file in case you want to make a few modifications to suit your own hospital.

Enjoy!

When to call Urology reference card (pdf)

Guidelines

EAST Practice Management Guideline: Handoffs And Transitions Of Care

March 8, 2024 The Trauma Pro Leave a comment

Medicine, in general, and trauma care, specifically, require frequent communication. These communications may be between two providers to maintain continuity of care or between providers and patients to explain it. Unfortunately, the Joint Commission has identified breakdowns in the process as a root cause of preventable events and a significant factor in preventable death.

To address this problem, many centers have sought to standardize this process, which may include some of the principles in my previous post. However, until now, there have been no evidence-based recommendations for this practice.

The Eastern Association for the Surgery of Trauma performed a systematic review and meta-analysis of the literature to develop a practice guideline. They focused specifically on handoffs for acute care surgery during perioperative interactions, patients arriving in the trauma bay, and patients transitioning to or from the ICU and floor. The goal was to reduce complications, handoff errors, medical errors, and preventable events.

The literature on this topic was searched from 1960 to 2021, and only observational and randomized studies were included. This yielded only ten papers that met all search criteria. The reviewers then used these papers to answer three questions. These and their answers are outlined below.

Question 1. Should perioperative interactions in the care of ACS patients (P) include a standardized handoff versus current process without a standardized handoff to help reduce clinical complications, handoff errors, medical errors, and preventable adverse events?

Patients who received a standardized handoff were significantly less likely to experience a handoff error. However, the impact on medical errors and adverse events could not be gauged because only one paper covered these problems.

Question 2. Should EMS utilize a standardized handoff at the arrival of trauma patients versus the current process without a standardized handoff to help reduce clinical complications, handoff errors, medical errors, and preventable adverse events?

We instituted a trauma team EMS timeout process in 2012, which persists to this day. Please take a look at my post here. The prehospital providers like it because they feel like they are more a part of the team. The receiving team can listen to their report without distraction. But what does the literature say? Unfortunately, we don’t know yet. Only one published paper covered this topic, and it included only 18 patients. Thus, no conclusions can be drawn.

Question 3. Should intra/inter floor and ICU interactions in the care of ACS patients include a standardized handoff versus currently process without a standardized handoff to help reduce clinical complications, handoff errors, medical errors, and preventable adverse events?

Significantly fewer preventable adverse events occurred when a standardized handoff was used. There was no difference in clinical complications. The impact on medical errors could not be evaluated because only one study assessed this.

Bottom line: The general belief is that using a standardized handoff is a good thing. But I think you see the theme here. As in most EAST systematic reviews, there is painfully little high-quality data available for us to prove it. Most of the mundane, day-to-day things we do and decisions we make as trauma professionals are too dull to perform a study about.

From the few papers available for this guideline, standardized handoffs are a good thing. They decrease handoff errors and reduce preventable adverse events as well. The EMS to trauma team handoff is well-received and is subjectively valuable. Unfortunately, there is little real data to prove this.

Overall, the real data on this topic is weak, and much more work needs to be done. I would encourage all trauma professionals to develop and refine their handoff processes. I strongly recommend coupling that with your own study so you can teach the rest of us how good it really can be.

Reference: Handoffs and Transitions of Care: A Systematic Review, Meta-Analysis, and Practice Management Guideline from the Eastern Association for the Surgery of Trauma. J Trauma, Publish Ahead of Print
DOI: 10.1097/TA.0000000000004285

Guidelines

Guidelines for Consultants to the Trauma Service

November 10, 2023 The Trauma Pro Leave a comment

My last two posts were dedicated to the use of consultants for your trauma patients. Here are my thoughts on best practices in using their services.

Trauma surgeons often rely on consultants to assist in the care of their patients. Orthopedic surgeons and neurosurgeons are some of the more frequent consultants, but various other surgical and medical specialists may be needed. I have found that providing guidelines to consultants helps ensure quality care and good communication between caregivers and patients/families.

We have disseminated guidelines to our colleagues, and I wanted to touch on some of the main points. You can download the full document using the link at the bottom of this post.

To deliver the highest quality and most cost-effective care, we request that the services we consult do the following:

Please introduce yourself to our patient and their family, and explain why you are seeing them.
Although you may discuss your findings with the patient, please discuss all recommendations with a member of the trauma service first. This avoids patient confusion if the trauma team chooses not to implement any recommendations due to other patient factors you may not be aware of.
Document your consultation results in writing (paper or EMR) promptly.
If additional tests, imaging, or medications are recommended, discuss with the trauma service first. If appropriate, we will write the orders or clear you to do so and discuss the plan with the patient.
We round at specific daily times and welcome your attendance and input.
Please communicate any post-discharge instructions to us or enter into the medical record so we can expedite the discharge process and ensure all follow-up visits are scheduled.

Bottom line: A uniform “code of behavior” is essential! Ensuring good patient communication is paramount. They need to hear the same plans from all of their caregivers, or else they will lose faith in us. One of the most important lessons I have learned over the years is that you do not need to implement every recommendation that a consultant makes. They may not be aware of the most current trauma literature and will not be familiar with how their recommendations may impact other injuries.

Click here to download a sample Trauma Services consultant guidelines document.

Abstracts, Guidelines, Imaging

Best Of EAST 2023 #5: Imaging The Elderly

January 9, 2023 The Trauma Pro Leave a comment

Several papers have been published over the years regarding underdiagnosis when applying the usual imaging guidelines to elderly trauma patients. Unfortunately, our elders are more fragile than the younger patients those guidelines were based on, leading to injury from lesser mechanisms. They also do not experience pain the same way and may sustain serious injuries that produce no discomfort on physical exam. Yet many trauma professionals continue to apply standard imaging guidelines that may not apply to older patients.

EAST sponsored a multicenter trial on the use of CT scans to minimize missed injuries. Eighteen Level I and Level II trauma centers prospectively enrolled elderly (age 65+) trauma patients in the study over one year. Besides the usual demographic information, data on physical exams, imaging studies, and injuries identified were also collected. The study sought to determine the incidence of delayed injury diagnosis, defined as any identified injury that was not initially imaged with a CT scan.

Here are the factoids:

Over 5,000 patients were enrolled, with a median age of 79
Falls were common, with 65% of patients presenting after one
Nearly 80% of patients actually sustained an injury (!)
Head and cervical spine were imaged in about 90% of patients, making them the most common initial studies
The most commonly missed injuries involved BCVI (blunt carotid and vertebral injury) or thoracic/lumbar spine fractures
38% of BCVI injuries and 60% of T/L spine fractures were not identified during initial imaging
Patients who were transferred in, did not speak English, or suffered from dementia were significantly more likely to experience delayed diagnosis

The authors concluded that about one in ten elderly blunt trauma patients sustained injuries in body regions not imaged initially. They recommended the use of imaging guidelines to minimize this risk.

Bottom line: Finally! It has taken this long to perform a study that promotes standardizing how we perform initial patient imaging after blunt trauma. Granted, this study only applies to older patients, but the concept can also be used for younger ones. The elderly version must mandate certain studies, such as head and the entire spine. Physical exams can still be incorporated in the guidelines for younger patients but not the elderly.

The overall incidence of BCVI was low, only 0.7%. But its presence was missed in 38% of patients, setting them up for a potential stroke. Some way to incorporate CT angiography of the neck will need to be developed. The risk / benefit ratio of the contrast load vs. stroke risk will also have to be determined.

Here are my questions and comments for the presenter/authors:

Did you capture all of the geriatric patients presenting to the study hospitals? By my calculation, 5468 patients divided by 18 trauma centers divided by 14 months of study equals 22 patients enrolled per center per month. Hmm, my center sees more than that number of elderly injured patients in the ED per day! Why are there so few patients in your study? Were there some selection criteria not mentioned in the abstract?
Why should we believe these study numbers if you only included a subset of the total patients that were imaged?

My own reading of the literature leads me to believe that your conclusions are correct. I believe that all centers should develop or revise their elderly imaging guidelines to include certain mandatory scans regardless of how benign the physical exam appears. Our elders don’t manifest symptoms as reliably as the young. But the audience needs a little more information to help them understand some of the study numbers.

Reference: SCANNING THE AGED TO MINIMIZE MISSED INJURY, AN EAST MULTICENTER TRIAL. EAST 2023 podium abstract #12.

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