Category Archives: Trauma Center

Trauma Center

Virtual Site Visit Walkthrough Best Practice

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The American College of Surgeons Committee on Trauma and many state systems have adopted a virtual site review process since the pandemic. There are pros and cons to this choice, but one of the most significant issues that is difficult to surmount is the physical plan walkthrough. It is typically done using one or more cameras connected to teleconferencing software, which tours various trauma-related areas in the hospital.

Unfortunately, this approach leaves the reviewers with an incomplete appreciation of the hospital layout. When it comes to moving trauma patients from the ambulance unloading area to various treatment areas, the mental picture the reviewers draw from the separate cameras doesn’t do justice to your hospital’s physical plant. It’s like trying to interpret a CT scan made of only six slices.

What can be done to remedy this? The easiest solution is to provide a map that the reviewers can refer to in advance. It should show the locations of the key areas that trauma patients visit (ED, CT, OR, ICU, blood bank) with the approximate distances listed. This simple tool will make the reviewers’ lives (and yours) much easier if you provide it in advance. They can then visualize the logistics at your center more easily.

Here is a sample map to give you an idea of how it might look. Just click the image to see a larger view.

Bottom line: To assist in the review process, provide a map of key areas of the virtual walkthrough. It should display those areas, and if not readily apparent, spell out the approximate distance from one to the other. There is usually no place to add this to the application, so you may need to send it to your reviewers separately.

Click here for my virtual video walkthrough best practices document

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Trauma Center

Optimizing Feedback To Referring Hospitals

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The American College of Surgeons requires that referring hospitals provide feedback to prehospital providers and referring hospitals regarding the transfer process.

Failure to do so can actually result in an opportunity for improvement or deficiency during a site visit. (Psst! Pay attention, referring hospitals if you want to start getting feedback. Read that first sentence again. See standard 7.10.) Sometimes the feedback is verbal, either in person or by phone. Many receiving centers send written letters outlining care and care issues. But unfortunately, some don’t do it at all, or only very inconsistently.

Harborview Hospital in Seattle is a very busy Level I center, with nearly 6,000 trauma admissions per year. More than half of their patients come from a vast catchment area that includes Washington state, Wyoming, Alaska, Idaho, and Montana. Providing proper feedback on over 3,000 patients annually can be overwhelming, given the amount of work required.

They implemented a “U-link” program that provided access to patient chart info for the hospital sending each patient. It was HIPAA compliant, and login information was sent within 72 hours of patient arrival.

Here are the factoids:

  • 90 referring hospitals set up the U-link system
  • Care transcripts, radiology reports, and discharge summaries were the most frequently viewed items
  • The most desired feedback was on over- or under-resuscitation (89%), injuries (84%), appropriateness of transfer (78%), and deviation from ATLS protocols (76%)
  • Information was used for education (100%), systems analysis (99%), and performance improvement (PI, 92%)

Bottom line: Your referral partners crave feedback on the patients they send! Develop a system that guarantees it for each patient at a reasonable time after admission. You may or may not be able to link them into your specific electronic medical record, but you can certainly send out informational letters and emails!

Reference: Optimizing feedback from a designated Level I trauma/burn center to referring hospitals. JACS 220(1):99-104, 2015.

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Trauma Center

How Soon Does The Backup Surgeon Need to Arrive?

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Expected response times are common in the verification and designation standards for all trauma centers. Some examples are:

  • Trauma surgeon at Level I or Level II ACS centers for highest-level trauma activation – 15 minutes
  • Trauma surgeon at Level III ACS centers for highest-level trauma activation – 30 minutes
  • OR and PACU personnel and backups – 30 minutes
  • Neurosurgeon and orthopedic surgeon response to certain high-risk patient conditions – 30 minutes
  • Interventional radiologist and team for hemorrhage control – 60 minutes to needle stick

However, the majority of standards say nothing about how soon the backup trauma surgeon must arrive when called. Each trauma center is left to decide this on its own.

What is a reasonable time frame? Here’s how I think about it:

  • With the exception of interventional radiology and the trauma surgeon at higher-level trauma centers, everyone else has a 30-minute expectation.
  • And if you look at the interventional response, it’s a whole team, and most people have to be there within about 30 minutes to have the patient prepped and ready for the needle stick.
  • If you are the trauma surgeon on duty when the s#!t hits the fan, how long do you want to wait for your partner to arrive to help out? Probably not long!

My recommendation is to have an expected response time of no more than 30 minutes. This should be reasonable for most trauma centers. However, each one will need to examine their own particular factors. How often is the backup surgeon needed? Do you really want to have them stay in-house or exclude them from the backup schedule if they are slightly outside the 30-minute window?

If your center does have backup surgeons living on the fringe, so to speak, you could consider a system where the on-call surgeon calls the backup to put them on notice once they become seriously encumbered. This would help the backup improve their readiness, allowing them to arrive more quickly if needed.

I think the most important thing is to think about this process well in advance to make sure that your backup is readily available to maintain patient safety during any potential crush of activity.

If you have developed a different way of dealing with the backup surgeon issue, please describe it in the comments!

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Mechanism, Trauma Center

Trauma Activation For Hanging: Yes or No?

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In my last post, I discussed a little-reviewed topic, that of strangulation. I recommended activating your trauma team only for patients who met the physiologic criteria for it.

But now, what about hangings? There are basically two types. The judicial hanging is something most of you will never see. This is a precisely carried out technique for execution and involves falling a certain height while a professionally fashioned noose arrests the fall. This results in a fairly predictable set of cervical spine/cord, airway, and vascular injuries. Death is rapid.

Suicidal hangings are far different. They involve some type of ligature around the neck, but rarely and fall. This causes slow asphyxiation and death, sometimes. The literature dealing with near hangings is a potpourri of case reports, speculation, and very few actual studies. So once again, we are left with little guidance.

What type of workup should occur? Does the trauma team need to be called? A very busy Level I trauma center reviewed their registry for adult near-hangings over a 19 year period. Hanging was strictly defined as a ligature around the neck with only the body weight for suspension. A total of 125 patients were analyzed, and were grouped into patients presenting with a normal GCS (15), and those who were abnormal (<15).

Here are the factoids:

  • Two thirds of patients presented with normal GCS, and one third were impaired
  • Most occurred at home (64%), and jail hangings occurred in 6%
  • Only 13% actually fell some distance before the ligature tightened
  • If there was no fall, 32% had full weight on the ligature, 28% had no weight on it,  and 40% had partial weight
  • Patients with decreased GCS tended to have full weight on suspension (76%), were much more likely to be intubated prior to arrival (83% vs 0% for GCS 15), had loss of consciousness (77% vs 35%) and had dysphonia and/or dysphagia (30% vs 8%)
  • Other than a ligature mark, physical findings were rare, especially in the normal GCS group. Subq air was found in only 12% and stridor in 18%.
  • No patients had physical findings associated with vascular injury (thrill, bruit)
  • Injuries were only found in 4 patients: 1 cervical spine fracture, 2 vascular injuries, and 1 pneumothorax
  • 10 patients died and 8 suffered permanent disability, all in the low GCS group

Bottom line: It is obvious that patients with normal GCS after attempted hanging are very different from those who are impaired. The authors developed an algorithm based on the initial GCS, which I agree with. Here is what I recommend:

  • Do not activate the trauma team, even for low GCS. This mechanism seldom produces injuries that require any surgical specialist. This is an exception to the usual GCS criterion.
  • The emergency physician should direct the initial diagnosis and management. This includes airway, selection of imaging, and directing disposition. A good physical exam, including auscultation (remember that?) is essential.
  • Patients with normal GCS and minimal neck tenderness or other symptoms do not need imaging of any kind.
  • Patients with abnormal GCS should undergo CT scanning, consisting of a CT angiogram of the neck and brain with soft tissue images of the neck and cervical spine recons.
  • Based on final diagnoses, the patient can be admitted to an appropriate medical service or mental health. In the very rare case of a spine, airway, or vascular injury, the appropriate service can be consulted.

Reference: A case for less workup in near hanging. J Trauma 81(5):925-930, 2016.

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Mechanism, Trauma Center

Trauma Activation For Strangulation: Yes or No?

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Trauma activation criteria generally fall into four broad categories: physiology, anatomy, mechanism of injury, and co-factors. Of these, the first two are the best predictors of patients who actually need to be assessed by the full trauma team. Many trauma centers include a number of mechanistic criteria, usually much to their chagrin. They typically end up with frequent team activations and the patient usually ends up have trivial injuries.

However, there are some mechanisms that just seem like they demand additional attention. Death of another occupant in the vehicle. Fall from a significant height. But what about a patient who has been strangled?

Unfortunately, the published literature gives us little guidance. This usually means that trauma centers will then just do what seems to “make sense.” And unfortunately, this frequently results in significant overtriage, with many patients going home from the emergency department.

Since there is little to know research to show us the way, I’d like to share my thoughts:

  • As a guiding principle, the trauma  team should be activated when the patient will derive significant benefit from it. And the benefit that the team really provides is speed. The team approach results in quicker diagnosis from physical exam and FAST. It gets patients to diagnostic imaging quicker, if appropriate. And gets them to the OR faster when it’s not appropriate to go to CT.
  • Activating for a strangulation mechanism alone is probably a waste of time.
  • Look at the patient’s physiology first. Are the vital signs normal? What is the GCS? If either are abnormal, activate.
  • Then check out the anatomy. If the patient has any voice changes, or has obvious discoloration from bruising, crepitus, or subcutaneous emphysema, call the team. They may suffer a deteriorating airway at any moment.

If physiologic and anatomic findings don’t trigger an activation, then standard evaluation is in order. Here are some things to think about:

  • A complete physical exam is mandatory. This not only includes the neck, but the rest of the body. Strangulation is a common injury from domestic violence, and other injuries are frequently present.
  • If there are any marks on the neck, CT evaluation is required. This includes soft tissue, CT angiography, and cervical spine evaluation. All three can be done with a single contrast-enhanced scan. The incidence of spine injury is extremely low with strangulation, but the spine images are part of the set anyway.
  • CT of the chest is never indicated. There is no possibility of aortic injury with this mechanism, and all the other stuff will show up on the chest x-ray, if significant enough for treatment.
  • Even if there are no abnormalities, your patient may need admission while social services arranges a safe place for their discharge. Don’t forget the social and forensic aspects of this injury. Law enforcement may need photographic evidence or statements from the patient so this event can’t happen again.

Next post: Trauma Activation for Hanging: Yes or No?

Reference: Strangulation forensic examination: best practice for health care providers. Adv Emerg Nurs J 35(4):314-327, 2013.

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