Category Archives: Prehospital

EMS: Scoop and Run or Stay and Play for Trauma Care? Part 2

Yesterday, we looked at an older study that kind of examined the scoop and run vs stay and play debate.  Let’s move forward in time a little bit, and evaluate the two options in a penetrating trauma model.

This one is from the anesthesia and intensive care departments at the university hospital in Copenhagen. The authors prospectively captured information on 462 penetrating trauma victims, then looked up their 30 day survival status in a national administrative database.

Here are the factoids:

  • Only 95% of patient records (446) were available for 30 day review (better that in the US!)
  • Of those, 40 were dead (9%)
  • Using raw statistics, there seemed to be a significant increase in mortality if the prehospital crew was on scene more than 20 minutes
  • However, when corrected for age, sex, injury pattern, etc. there was no significant difference in survival for short vs longer scene stays
  • Multivariate analysis identified the number of procedures performed at the scene as a significant predictor of mortality, regardless of time

Bottom line: We still can’t seem to show a difference in patients who are tossed in the back of the squad and driven vs those who have IVs, immobilization, and other things done to begin resuscitation and increase safety prior to transport! However, the bit about number of procedures is intriguing. Is this just another surrogate for time? Are there unrecognized complications from them that affect survival?

Next time, I’ll look at a recent publication from the US that gives us yet another angle on this question.

Reference: On-scene time and outcome after penetrating trauma: an observational study. Emerg Med J 28(9):87-801, 2011.

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EMS: Scoop and Run or Stay and Play for Trauma Care? Part 1

Scoop and run vs stay and play are traditionally EMS concepts. Do I stay at the scene to perform invasive procedures and begin resuscitation, or do I perform the minimum I can and get to the nearest hospital ASAP?

Some newer papers have addressed this debate very recently with some intriguing results, but I wanted to start out with one that I’ve discussed before.

For trauma patients time is the enemy and there is a different flavor of scoop and run vs stay and play. Do I take the patient to a nearby hospital that is not a high level trauma center to stay and play, or do I scoop and run to the nearest Level I or II center?

Here are the factoids:

  • Admissions to a group of 8 trauma centers were analyzed over a 3 year period, and included a total of 1112 patients
  • A total of 76% were taken directly to a Level I trauma center (scoop and run, 76%); 24% were transferred to the trauma center from another hospital (stay and play?).
  • Patients who were taken to a non-trauma center first received 3 times more IV crystalloid, 12 times more blood, and were nearly 4 times more likely to die!

Obviously, the cause of this increased mortality cannot be determined from the data. The authors speculate that patients may undergo more aggressive resuscitation with crystalloid and blood at the outside hospital making them look better than they really are, and then they die. Alternatively, they may have been under-resuscitated at the outside hospital, making it more difficult to ensure survival at the trauma center.

Bottom line: This is an interesting paper, but it’s kind of a mutant. When I think about the stay and play concent, I’m really thinking about delays going to a trauma center, not a non-trauma hospital fierst! And the authors never really define a “nontrauma hospital.” Does a Level III or IV center count? How did patients who stayed at the outside hospital do?

Obviously, a lot of work needs to be done to add detail to this particular paper. Tomorrow, I’ll look at this concept as it applies to patients with penetrating injury.

Reference: Scoop and run to the trauma center or stay and play at the local hospital: hospital transfer’s effect on mortality. J Trauma 69(3):595-601, 2010.

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Making The Trauma Team Time Out Even Better!

Over the past two days, I’ve discussed a method for optimizing the hand-off process between prehospital providers and the trauma team. Besides improving the quality and completeness of information exchange, it also fosters a good relationship between the two. All too often, the medics feel that “the trauma team is not listening to me” if the procedure is to move the patient onto the ED bed as quickly as possible.

And they are right! As soon as the patient hits the table, the trauma team starts doing what they do so well. It’s impossible for humans to multi-task, even though they think they can (look at texting and driving). We switch contexts with our brain, from looking at the patient to listening to EMS, back and forth. And it takes a few extra seconds to switch from one to the other. Team members will not be able to concentrate on the potentially important details that are being relayed.

What should you do if the team doesn’t want to wait?

First, educate them. Except for those who are in extremis or arrest, the patient can wait on the EMS stretcher for 30 seconds. Nothing harmful is going to happen in that short period.

Then, create a hard stop. The easiest way to do this is to place a laminated copy of the timeout procedure on the ED bed. And the rule is that the card doesn’t move until the timeout is done. This is very similar to what happens in the OR. The process should take only 30 seconds, then it’s over and the team can start.

Here’s a copy of a sample TTA Timeout card:

Download a TTA timeout card

Modify it to suit your hospital and process, and try it out!

Thanks to the trauma team at Ridgeview Hospital in Waconia MN for telling me about this cool trick!

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Prehospital To Trauma Team Handoff: A Solution

I wrote about handoffs between EMS and the trauma team yesterday. It’s a problem at many hospitals. So what to do?

Let’s learn from our experience in the OR. Best practice in the operating room mandates a specific time out process that involves everyone in the OR. Each participant in the operation has to stop, identify the patient, state what the proposed procedure and location is, verify that the site is marked properly, and that they have carried out their own specific responsibilities (e.g. infused the antibiotic).

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Some trauma centers have initiated a similar process for their trauma team as well. Here’s how it works:

  • The patient is rolled into the resuscitation room by EMS personnel, but remains on the stretcher.
  • Any urgent cares continue, such as ventilation.
  • The trauma team leader is identified and the EMS lead gives a brief report while everyone in the room listens. The report consists of only mechanism, all identified injuries, vital signs (including pupils and GCS), any treatments provided. This should take no more than 30 seconds.
  • An opportunity for questions to be asked and answered is presented
  • The patient is moved onto the hospital bed and evaluation and treatment proceed as usual.
  • EMS personnel provide any additional information to the scribe, and may be available to answer any additional questions for a brief period of time.

Bottom line: This is an excellent way to improve the relationship between prehospital and trauma team while improving patient care. It should help increase the amount of clinically relevant information exchanged between care providers. Obviously, there will be certain cases where such a clean process is not possible (e.g. CPR in progress). I recommend that all trauma programs consider implementing this “Trauma Activation Time Out For EMS” concept.

Tomorrow, I’ll share a best practice to make this process even better!

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The EMS Handoff: Opportunity for Improvement

Handoffs occur in trauma care all the time. EMS hands the patient off to the trauma team. ED physicians hand off to each other at end of shift. They also hand off patients to the inpatient trauma service. Residents on the trauma service hand off to other residents at the end of their call shift. Attending surgeons hand off to each other as they change service or a call night ends. The same process also occurs with many of the other disciplines involved in patient care as well.

Every one of these handoffs is a potential problem. Our business is incredibly complicated, and given that dozens of details on dozens of patients need to be passed on, the opportunity for error is always present. And the fact that resident work hours are becoming more and more limited increases the need for handoffs and the number of potential errors.

Today, I’ll look at information transfer at the first handoff point, EMS to trauma team. Some literature has suggested that there are 16 specific prehospital data points that affect patient outcome and must be included in the EMS report. How good are we at making sure this happens?

An observational study was carried out at a US Level I trauma center with video recording capabilities in the resuscitation room. Video was reviewed to document the “transmission” part of the EMS report. Trauma chart documentation was also reviewed to see if the “reception” half of the process by the trauma team occurred as well.

Here are the factoids:

  • A total of 96 handoffs were reviewed over a one year period
  • The maximum number of data elements in the study was 1536 (96 patients x 16 data elements)
  • The total number “transmitted” was 473, but only 329 of those were “received.”
  • This is not quite as bad as it seems, since 483 points were judged as not applicable by the reviewers. However, this left 580 that were applicable but were not mentioned by EMS.
  • Of the 16 key elements, the median number transmitted was 5, with a range of 1-9.

This sounds bad. However, the EMS professionals and the physicians have somewhat different objectives. EMS desperately wants to share what they know about the scene and the patient. The trauma team wants to start the evaluation process using their own eyes and hands. What to do?

Bottom line: EMS to trauma team handoffs are a problem for many hospitals. EMS has a lot of valuable information, and the trauma team wants to keep the patient alive. They are both immersed in their own world, working to do what they think is best for the patient. Unfortunately, they could do better if the just worked together a bit more.

Tomorrow I’ll share a solution to the EMS-trauma team handoff problem.

Reference: Information loss in emergency medical services handover of trauma patients. Prehosp Emerg Care 13:280-285, 2009.

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