Category Archives: Trauma Center

Trauma Center

Adolescent Experience At Pediatric vs Adult Trauma Centers

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A number of papers have addressed the clinical differences between adult trauma centers that provide care for children and pediatric trauma centers. For example, differences in TBI outcomes and solid organ injury management have been noted, to name a few. But I’ve seen very little written on the patient (and parent) experiences at these centers.

Adolescents exist between the adult and pediatric worlds. They frequently suffer injury from adult mechanisms like car crashes, interpersonal violence, and drugs/alcohol. But they are still developing from anatomic, physiologic, and psychosocial standpoints. So which trauma center is better for them? An adult center with more experience managing their injuries, or a pediatric center more attuned to their distinct psychosocial needs?

The surgery group at the University of Calgary in Alberta, Canada, performed a prospective, 1.5 year study of adolescents (aged 15-17) and their caregivers when admitted to the local adult or pediatric trauma center. Enrollees received a survey eight weeks after discharge to glean details of their experience. This survey was a validated tool called the QTTAC-PREM ( Quality of Teen Trauma Care Patient Reported Experience Measure).

This survey was very comprehensive and clocked in at 31 pages in length! It included questions on visits by friends, interactions with hospital staff, schoolwork, pain control, mental health, privacy, and follow-up visits.

Here are the factoids:

  •  A total of 90 patients were enrolled; 51 were admitted to pediatric trauma centers and 39 to adult centers
  • Survey completion rates were reasonable, with 77 returned in the pediatric center group and 41 in the adult center group (surveys could be completed by the patient, their caregiver, or both)
  • Patients taken to the adult center were more seriously injured (56% with ISS>9 vs. 10%)
  • Overall, there were few differences in experience, but parents gave lower ratings for communication, follow-up care, and the overall hospital score
  • The adult trauma centers had poorer family accommodations, as noted by both the patients and their parents

Bottom line: This is a (somewhat) interesting study looking beyond the purely clinical differences in adult vs. pediatric trauma centers. It has some significant problems, although it is still possible to derive some valuable information. 

First, it was a survey. And a 31-page survey at that! I throw most one-page surveys I receive away without a thought. So the enrollment and return rates are guaranteed to be low. Next, it was performed during the height of COVID, which changed everything. Fewer patients presented to the hospitals, and measures were in place, making them less friendly and accessible for patients and their caregivers. This could significantly alter any opinions of patient/parent experiences.

And finally, there are only two trauma centers in Calgary, one adult and one pediatric. So this study cannot be generalized easily to other centers in Canada or anywhere else in the world. In many ways, they are unique. So the actionable information contained in it is very limited. 

However, we can learn something. Communication is always an issue in hospitals. Pediatric centers are very familiar with dealing with parents, and adult centers would benefit by taking this page from their playbooks. Similarly, pediatric centers routinely provide housing for the parents, while adult centers have never had to prioritize this. 

A related question needs to be addressed: what about dual centers? That is, a combined Level I adult and Level I pediatric center. These hybrids are largely ignored, although they are more common in larger metropolitan areas. 

Regardless, ALL trauma centers can benefit from improved communication with their patients and accommodations for parents of pediatric patients.

Reference: Between Paradigms: Comparing experiences for adolescents treated at pediatric and adult trauma centres. Injury, published ahead of print, April 12, 2023.

If you are interested in the QTTAC-PREM questionnaire used in this study, you can find it in the supplemental data for this study:

Yeung M, Hagel BE, Bobrovitz N, Stelfox TH, Yanchar NL. Development of the quality of teen trauma acute care patient and parent-reported experience measure. BMC Res Notes. 2022 Sep 23;15(1):304. doi: 10.1186/s13104-022-06194-x. PMID: 36138467; PMCID: PMC9503226.

If you need help obtaining a copy, please feel free to email me.

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Trauma Center

Trauma Transfers Discharged From The ED

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Aren’t these embarrassing? A referring center sends you a patient with the idea that they will be evaluated and admitted to your hospital. But it doesn’t work out that way. The patient is seen, possibly by a surgical specialist, bandaged up, and then sent home. Probably to one that is quite a few miles away. Not only is this a nuisance for the patient and an embarrassment for the sending center, it may use resources at the trauma center that are already tight.

Transfer patients who are seen and discharged are another form of “ultimate overtriage.” In this case, the incorrect triage takes place at the outside hospital.  The trauma group in Oklahoma City reviewed their experience with these patients over a two year period. They looked exclusively at patients who were transferred in to a Level I center and then discharged.

Here are the factoids:

  • A total of 2,350 patients were transferred in, and 27% were transferred home directly from the trauma bay (!)
  • The three most common culprits by injury pattern were face (51%), hand (31%), isolated ortho injury (9%)
  • A third of these patients required a bedside procedure, including laceration repair (53%), eye exam (24%), splinting (18%), and joint reduction (5%)
  • Ten facilities accounted for 40% of the transfers

The authors concluded that the typical injuries prompting transfer are predictable. It may be possible to reduce the number of transfers by deploying telemedicine systems to push evaluations out to the referring hospitals.

Bottom line: This is quite interesting. Anyone who works in a Level I or II center is aware of this phenomenon. This abstract went a step further and quantified the specific issues involved. This center ended up discharging over 300 patients per year after transfer in. This is a tremendous drain on resources by patients who did not truly have the need for them.

The authors speculate that telemedicine evaluation may help reduce some of those transfers. This seems like an easy solution. However, it also poses a lot of issues in terms of who will actually staff the calls and how will they be compensated for their time.

There are a number of important take-aways from this abstract:

  1. Know your referring hospitals. In this study, there were 10 hospitals that generated an oversize number of referrals. Those are the targets / low hanging fruit. Identify them!
  2. Understand what their needs are. Are they frequently having issues with simple ortho injuries? Eye exams? This is what they need!
  3. Provide education and training to make them more comfortable. This allows you to target those hospitals with exactly the material they need and hopefully make them more self-sufficient.

This allows the higher level centers to reserve phone and/or telemedicine consultation for only the most ambiguous cases. It’s a better use of telehealth resources that may be needed, typically at night and on weekends.

Reference: Trauma transfers discharged from the emergency department-Is there a role for telemedicine? J Trauma Acute Care Surg. 2022 Apr 1;92(4):656-663. 

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Nursing, Trauma Center

Paying Respect After A Terminal Trauma Activation

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As all trauma professionals know, traumatic injuries are a major cause of death across all age groups. Well-trained trauma teams use all their skills to attempt to save critically injured patients. But, unfortunately, there are occasions in which they die despite all our efforts. In most of these cases, the time of death is called, and team members then peel off their protective clothing and melt away to pursue their usual duties.

These terminal trauma activations are mentally challenging as the proper interventions are ordered and carried out. They are also physically demanding, especially when heroic measures such as CPR are needed. But one often-neglected issue is the emotional challenge. Every team member is invested in saving that person. Frequently, they can visualize their own spouse, parent, or child in place of the patient, and go all out to try to save them.

When these trauma activations are over, team members frequently do not have an opportunity to resolve their own emotional turmoil or achieve closure for the turmoil of the previous 30 minutes.

A recent paper from the Gunderson Health System in La Crosse, Wisconsin, studied a practice that seeks to achieve this closure and recognize the life of the deceased patient. They call this the PAUSE, an acronym for Promoting Acknowledgment, Unity, and Sympathy at the End of life.

This process was implemented about five years ago, and a multidisciplinary team from a variety of religious backgrounds and beliefs carefully worded the script. It works like this:

  1. The team leader calls the time of death.
  2. Team leader then states, “At this time, we would like to take a moment to honor the patient and staff.”
  3. A chaplain takes over and does the following:
    • (Chaplain states) For those who would like to stay,
      we’ll take a moment of silence to acknowledge this
      person, their death, and our care for them …
    • (Moment of silence—10 s)
    • (Blessing)
      We give thanks for ___(Name), those they loved, and
      those who loved them.
      We give thanks for the privilege of caring for them.
      We give thanks for our caring team.
      We ask that all may be whole and find peace. Amen.
    • (Chaplain states) Thank you for your care—for those
      who would like to stay, please do, for those moving
      on to other duties, Thank You.
  4. The team disperses.

The research group circulated a pre-implementation questionnaire and then sent a post-implementation questionnaire two years later. The questionnaires were the same, except six additional questions regarding experience with PAUSE were added to the post-survey.

Here are the factoids:

  •  There were 466 participants in this study; the number of patients treated was not stated
  • Participation rates were typical of questionnaire studies (40% pre-surveys and 23% post-surveys)
  • While not statistically significant, many team members reported improvements in internal conflict, feelings of emptiness, resilience, and ability to move on to the next task

Note the higher slightly and significantly improved feelings in the post-study. This chart was based on 57 respondents.

The authors concluded that the PAUSE process was a meaningful way to help trauma team members emotionally.

Bottom line: Studies like this are difficult to conduct and even more challenging to apply rigorous statistical methods. They frequently do not have statistically significant results. But one can see specific improvements despite the soft numbers. 

Many hospitals have some processes for terminal trauma activations. Most are not as well-scripted as this. But having been involved in them myself, I find it very helpful and comforting. I recommend all centers consider implementing something similar. Like most practice guidelines, this one is only suitable for adoption with adaptation. When adopting this, it is essential to work with your chaplains and recognize the specific ethnic and religious representation in your trauma center.

Reference: Trauma and Death in the Emergency Department: A Time to PAUSE (Promoting Acknowledgment, Unity, and Sympathy at the End of Life). J Trauma Nursing 29(6):291-297, 2022.

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Nursing, Trauma Center

Impact Of A Trauma Nurse Practitioner Model On Nonsurgical Admissions

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Nonsurgical admissions are a concern for most verified/designated trauma centers. Under the current 2014 Resources for Optimal Care of the Injured Patient, all trauma patient admissions to a nonsurgical service must be concurrently reviewed by the trauma program. This process guards against trauma patients sneaking into the hospital on medicine services where the quality of the care for their injuries may not be monitored.

Typically, this requirement is met by having the trauma program manager (TPM), trauma PI coordinator (TPIC), or registrar run a daily admission report and mark patients with a potential trauma diagnosis for further review. Some clinician then reviews the patient in person or via a chart check. No further attention is needed if the patient has low acuity injuries or has been seen by the trauma or other surgical service. If not, additional scrutiny is recommended to identify patients who might be better off with a trauma service consult or even a transfer of service.

The trauma group at the Charleston Area Medical Center in West Virginia postulated that adopting a trauma nurse practitioner (TNP) model to provide care for patients otherwise admitted to a hospitalist service would improve care and decrease nonsurgical admissions. The nurses were supervised directly by the trauma attending surgeons.

They analyzed retrospective registry data during a 22-month period and compared nonsurgical admission rates with the same data for the preceding three years. Several performance metrics were evaluated, including length of stay and those statistics hospitals love to watch, discharge orders placed by noon, discharge location, and time to operating room.

Here are the factoids:

  • A total of 749 patients were admitted to the TNP service and 651 to hospitalist services
  • Patients in the TNP group were significantly younger (59 vs. 76) and more likely to be male
  • ISS was the same, but the TNP service patients had slightly more injuries (1.6 vs. 1.2) overall, and their patients were more likely to require an operation
  • The number of comorbidities was higher on the hospitalist service (2 vs. 1.6)
  • Hospital length of stay was one day shorter in the TNP group, which  was significant
  • TNP service patients were more likely to discharge home rather than to a skilled nursing facility
  • Time to OR for the TNP patients was significantly shorter by 11 hours
  • 30-day readmission rates were the same
  • The percentage of patients admitted to a nonsurgical service decreased from 20% to 14% after implementation

The authors concluded that the nonsurgical admission rate declined significantly, and several performance metrics also improved. In addition, the decreased length of stay was projected to result in a decrease of over $876,000 in hospital charges throughout the study.

Bottom line: This study illustrates some potential differences that surface when patients are admitted and managed by a trauma service rather than a hospitalist service. I say potential because there are a lot of confounders here.

The patients on the two services were very different. Although the TNP service patients had slightly more injuries (1.6 vs. 1.2), their ISS was identical. They also had fewer comorbidities. There appears to be some selection process in play here, but it was not explicitly stated in the paper. It also appears that older and more complicated patients, in terms of their comorbidities, were admitted to the hospitalists. Those with injuries more likely to require surgery were admitted to the TNP service.

Nonsurgical admission rates definitely decreased, but without knowing the selection criteria, this could have been due to just the presence of the TNP service and the desire to admit patients to it. The decreased hospital LOS and higher discharge rate to home are impressive, but could this also be due to these patients’ younger age?

The final issue is that the rules have changed! Starting later this year with the implementation of the 2022 Resource Document, the 10% nonsurgical admission rate threshold will disappear. Now, all nonsurgical trauma admissions must undergo primary review via the PI process. If any issues are identified, the ISS is greater than 9, or there was no trauma or surgical consultation, they must be escalated to a timely secondary review by the trauma medical director. Gone are the days of retrospective reviews of these cases!

What to do? It’s a balancing act in terms of trauma service capacity and staffing. Ideally, most injured patients are best served on the trauma or surgical specialty service. Several papers have outlined improved outcome metrics with this arrangement. Utilizing TNPs or physician assistants to capture and manage appropriate patients can definitely be helpful. 

An alternative is to integrate a hospitalist, preferably with geriatric expertise, into the trauma service so injured patients with more complex medical issues can be comfortably managed on the trauma service.

Reference: Rate of Nonsurgical Admissions at a Level 1 Trauma Center: Impact of a Trauma Nurse Practitioner Model. J Trauma Nurs 27(3):163-169, 2020.

 

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Trauma Center

Nonsurgical Admissions And The Nelson Score

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All trauma centers admit some of their patients to nonsurgical services. This usually occurs when patients have medical comorbidities that overshadow their injuries. Unfortunately, the decision-making that goes into balancing the medical versus trauma issues is not always straightforward. The fear is that if trauma patients are inappropriately placed on a nonsurgical service, mortality and morbidity may be higher because their injuries may not receive adequate attention.

To take some of the variability out of the decision-making process for admitting service, two surgical groups on Long Island created a scoring system that incorporated several parameters described in the ACS Optimal Resource Document (Orange book). Some additional parameters were also included that the authors believed were relevant to the choice of admitting service. Here’s the final list:

The first author on the paper was a nurse, Laura Nelson, and hence this has come to be known as the Nelson Score. Patients with a score score of 7 were considered definitely appropriate for nonsurgical admission. Scores of 4 or 5 were subject to more in-depth review, and those with a score of 3 or less were considered definitely appropriate for trauma service admission. There is no mention of what to do with a score of 6 in the original paper, but I presume it should be almost a slam dunk for considering nonsurgical admission.

The authors evaluated this system’s utility over a two year period. They found that using it placed more patients on the trauma service (nonsurgical admissions decreased from a peak of 28% to somewhere around 10%). They also examined morbidity and mortality statistics between the two types of admissions, and found no significant differences.

The concept was further tested by the trauma group at UCHealth in Colorado Springs. They performed a retrospective review of four years of data that included over 2,000 patients. Patients were older (mean 79 years) and nearly all had blunt mechanism. Mean ISS was 9 and the nonsurgical admission rate was 19%. Patients with a Nelson score of 6 or 7 were even older and had more comorbidities.

Regression analysis did not identify admitting service as a predictor of mortality. The authors concluded that using this score is a safe way to objectively identify patients who would benefit from nonsurgical admission.

Bottom line: I have visited a number of hospitals that successfully use the Nelson score to assist with admission service decision-making while the patient is still in the emergency department. The only gray zone is the score of 4 or 5. Each program will need to determine their own cut point so they can make the service decision more objectively.

Trauma programs can also use this tool to expedite PI review of patients who have already been admitted to a nonsurgical service to check appropriateness. If the score is less than 6 further scrutiny is needed to determine if a consult from or transfer to trauma should be recommended.

References:

  1. Nonsurgical Admissions With Traumatic Injury: Medical Patients Are Trauma Patients Too. Journal of Trauma Nursing, 25 (3), 192-195, 2018.
  2. Evaluation of the Nelson criteria as an indicator for nonsurgical admission in trauma patients. Am Surg, 88(7), 1537-1540, 2022.
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