Category Archives: Guidelines

Best Practice: Use of CT Scan In Trauma Activations – Part 1

May 23, 2019 The Trauma Pro Leave a comment

Computed tomography is an essential part of the diagnostic workup for many trauma patients. However, it’s a limited resource in most hospitals. Only so many scanners are affordable and available. Typically, trauma centers have a scanner located in or very near the trauma bay, which makes physical access easy. Others may be located farther away, which can pose logistical and safety issues for critically injured patients.

Even if the CT is close to the ED, availability can be an issue. This availability applies not only to trauma scans, but to others as well. There is an expectation that CT be immediately available when needed for trauma activation patients. However, chances are that the same scanner is also used for high priority scans for services other than trauma, such as stroke evaluation.

Who gets the scanner first? Obviously, many trauma patients need rapid diagnosis for treatment of their serious injuries. But a fresh stroke patient also has a neurologic recovery countdown clock running if they might be eligible for lytic administration.

And don’t forget that trauma and stroke aren’t the only services vying for that scanner. The hospital undoubtedly has a stream of elective scans queued up for other in-house patients. Every urgent or emergent scan needed for trauma sets the elective schedule back another 30 minutes or more.

How does your trauma center manage CT scan usage for trauma? The vast majority essentially lock it down at some fixed point. This is typically either upon trauma activation, or at patient arrival. The former is very common, but also very wasteful because there can be a significant wait for the patient to actually arrive. Then add on the time it takes to complete the trauma bay evaluation. Up to an hour may pass, with no throughput in the CT scanner. This can be a major work flow headache for your radiology department.

Is there another way? My center was one of those that stopped the scanner after the current patient was finished at the time the trauma activation was called. We have two scanners just 30 feet from the trauma bays, so one could continue working while the other was held. However, this cut their throughput by 50% for roughly half an hour. We recognized that this was a creating a problem for the whole hospital, so we worked with the radiology department to come up with a better way.

Tomorrow I’ll detail the new system we implemented, and provide data showing the real impact of this new system on CT scan productivity.

Guidelines

Solid Organ Injury Practice Guideline Updated

April 16, 2019 The Trauma Pro Leave a comment

Regions Hospital developed a clinical practice guideline for solid organ management in 2002-2003. It has been revised a few times over the years, as any good guideline should with the availability of new data.

I’ve just put the finishing touches on the latest revision as a result of the updated organ scaling rules published by the American Association for the Surgery of Trauma. I reviewed the new scales for both liver and spleen earlier this year (links below). In the previous iteration of the scaling system, the importance of contrast pooling (pseudoaneurysm) or extravasation beyond the organ was not well defined.

The new guideline explicitly includes these injuries in the high grade group, which for us is grade IV or V. Technically, pseudoaneurysm of the liver is only grade III, but in my opinion demands angiographic investigation and embolism. Thus the inclusion in the high grade / angiography arm of our guideline.

For those of you who have not seen this guideline before, there are several important directives that are listed on the left side of the page:

Patients are NOT made NPO
They do NOT have activity restrictions (such as bed rest)
Serial hemoglins are NOT drawn
An abdominal CT scan is NOT repeated

These changes were made in 2015 based on our clinical experience that properly selected patients almost never fail. And they still don’t, so why starve, restrain, poke, and re-irradiate them?

Additionally, we included explicit impact activity restrictions for post-discharge so that patients would get the same message from all members of our team.

Click the image below to download the guideline and have a look. I’m interested in your comments!

Related posts:

Guidelines

Guidelines for Consultants to the Trauma Service

February 19, 2019 The Trauma Pro Leave a comment

This post is a favorite, and I’m publishing it again since I just finished my “When To Call” series.

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 a variety of other surgical and medical specialists may be needed. I have found that providing a set of guidelines to consultants helps to ensure quality care and provide good communication between caregivers and patients / families.

We have disseminated a set of 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.

In order to deliver the highest quality and most cost-effective care, we request that 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) in a timely manner.
If additional tests, imaging or medications are recommended, discuss with the trauma service first. We will write the orders or clear you to do so if appropriate, and will discuss the plan with the patient.
We round at specific times every day and welcome your attendance and input.
Please communicate any post-discharge instructions to us or enter in the medical record so we can expedite the discharge process and ensure all followup visits are scheduled.

Bottom line: A uniform “code of behavior” is important! 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 they will not be familiar with how their recommendations may impact other injuries.

Click here to download the full copy of the Regions Hospital Trauma Services consultant guidelines.

Guidelines

When To Call: Orthopedic Surgery

February 18, 2019 The Trauma Pro Leave a comment

And here’s the last in my short “When To Call” series. This one’s a little different, and quite a bit longer. That’s due to the complexity and sheer number of potential orthopedic problems.

When consulting a specialty service, always keep the patient paramount in your decision making. Then think about how soon and under what context they really need to see the patient. Can it wait until morning? Do they even really need to be seen in the ED, or can this be an outpatient visit?

Tomorrow: Expectations on how your consultants should go about their business when seeing your patients.

Guidelines

When To Call: Ophthalmology

February 14, 2019 The Trauma Pro Leave a comment

Here’s another in my series of “When To Call” pieces. We sometimes overuse our consultants and call then 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?

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

Unfortunately, this one won’t fit on 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 Word file in case you want to make a few modifications to suit your own hospital.

In my next post, I’ll provide a comprehensive reference for when to call your orthopedic surgeon.

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