Category Archives: Trauma Center

Radiographic Image Sharing Systems

There are generally three ways to share radiographic images with your upstream trauma center:

  • Hard copy. These days, that usually means a CD. Nearly all PACS systems (picture archiving and communications systems) can write CDs that can accompany your patient. Advantage: super cheap. Possible downsides: the CD may be corrupted and not openable, the software on the disk cannot be installed or will not run at the receiving hospital, and finally it can just be forgotten in the rush to get the patient out of the ED.
  • PACS system connections. These are software links that enable one hospital’s PACS software to communicate with another’s. They must be established in advance, and generally require some expertise from the hospitals’ IT departments. Images can be pushed from one system to another. Advantages: once set up, it is very inexpensive to maintain, and images can be viewed prior to patient arrival at the receiving hospital. Possible downside: Al-though the interchange format is standardized, every once in a while the systems just can’t communicate.
  • Web-based image sharing system. This consists of a web server-based software application available via the internet that allows subscribing hospitals to sign on and share images. Referring hospitals can upload images from their PACS systems for free, and the receiving hospital can view the images and/or download into their own system. Advantage: these products are simple to set up, and easy to use after just a little training. Compatibility is very high, and the services are continually working to ensure it. Downside: expensive. Depending on specifics, the annual subscription may be up to $100K per year, and is generally footed by the receiving trauma center.

Is a web-based solution worth it? MetroHealth in Cleveland looked at this over five years ago, and published their results in 2015. They looked at their experience pre- and post-implementation and found the following:

  • Three years of transfer data prior to the web system implementation was compared to one year of experience after
  • CT imaging decreased at both referring and receiving hospitals across the study period
  • Repeat scan rate decreased from 38% to 28%. Repeat head scans were the major driver at 21%.
  • Cost of reimaging dropped from about $1000 per patient to $600

Bottom line: As a referring hospital, it is your responsibility to ensure that the (hopefully) few images you obtain make it to the upstream trauma center. Although hard copy (CD) is the cheapest, it is also the least reliable. Work with your radiology and IT departments to determine which electronic solution is best for you. Some states and regional trauma systems help subsidize or provide a web-based solution for their member hospitals.

Reference: Implementation of an image sharing system significantly reduced repeat computed tomographic imaging in a regional trauma system. J Trauma 80(1):51-56, 2016.

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Impact Of Patient Imaging Prior To Transfer Out

The reality is that 90% of injuries are minor and can be treated at any hospital. A minority of patients actually have issues that require transfer to a higher-level trauma center. Physical examination can certainly help determine who some of those patients are. Think obvious open fracture or severe brain injury at a hospital without key specialists to care for them.

But not all injuries are that obvious. Imaging techniques are the next step to identifying injuries that would require transfer. The question is, how much imaging is appropriate?

A few hospitals are selective about it. But many proceed with a comprehensive battery of scans and x-rays. Some believe that their receiving trauma center expects it. And a few may be doing it for the money, unfortunately. So who is right?

There are three issues at play: time, accuracy, and radiation exposure. Let’s pick them apart.

Time. It takes time to get radiographic studies. Depending on the number obtained, it can take up to 90 minutes. A study looking at transfers from rural hospitals to a regional trauma center in Wisconsin found that the median time to transfer significantly in-creased from 67 to 140 minutes with the addition of even a single CT scan.

This issue appears to be even more of a problem in children. A group at Cincinnati Children’s Hospital studied the characteristics of children who experienced prolonged transfer times to a Level I pediatric trauma center. They reviewed 5 years of registry data, looking at time of injury to time of arrival at their center. The State of Ohio has a goal of a maximum 2-hour transfer time.

And here are the factoids:

  • 748 patients were included in the study, and the demographics were predictable (65%male, 97% blunt)
  • 25% were more severely injured (ISS > 15)
  • The majority of the patients (82%) arrived well after the 2-hour goal (7 hrs!!)
  • 79% of patients with high ISS and 47% of those with severe TBI arrived late (!!)
  • Transfer tardiness did not correlate with distance, and was only slightly improved when a helicopter was used
  • Significantly more CT scans were obtained in the late transfer group (49% vs 23%), and appeared to have no correlation with GCS or vital signs. There was, however, a significant correlation with private insurance.
  • Half of the children with scans arrived without results or had suboptimal imaging, resulting in repeat scans in about one third.

Accuracy and radiation exposure. These two factors are inextricably linked because inaccuracy begets additional imaging. As noted in the previous study, radiology results are frequently lacking, or the studies are not done well, as determined by the receiving center. This means that inaccurate results, or no results at all, are available after transfer. How much of a problem is this?

The Level I center at UC Davis looked at all incoming trauma transfers that had any CT imaging done prior. Of 370 patients, one quarter needed repeat scans. Most common were head scans (47%) and cervical spine (20%). The most common reasons for repetition were referring hospital scan not available (42%) (not sent, couldn’t open) and insufficient quality (20%). This resulted in significant additional radiation exposure, with 4% of patients receiving more than 10mSv!

Bottom line: Imaging prior to transfer definitely increases time to transfer and frequently results in repeat imaging and more radiation exposure. So why does it happen? Sometimes, it’s the mistaken belief that it will save time after transfer. Not the case. Or there is time left before the transport ambulance or helicopter arrives, so why not use it? Not a good reason, and it may delay the transfer team if they arrive early. Or the receiving trauma center “expects it.” Not if they’ve looked at any of these papers!

The best approach is to order only images that will guide your therapy. A chest x-ray on arrival or after intubation. A pelvic x-ray to determine if a binder should be applied. A CT of the abdomen to see if there are any injuries that can’t be taken care of at your hospital. As a general rule, once you have found an injury your hospital can’t treat, or have made the decision to transfer for any other reason, no additional imaging is indicated! 

References:

  • Consequences of increased use of computed tomography imaging for trauma patients in rural referring hospitals prior to transfer to a regional trauma centre. Injury 45:835-839, 2014.
  • Unnecessary imaging, not hospital distance, or transportation mode impacts delays in the transfer of injured children. Pediatric Emerg Care 26(7):481-486, 2010.
  • Rate and Reasons for Repeat CT Scanning in Transferred Trauma Patients. Am Surg 83(5):465-569, 2017.
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The Electronic Trauma Flow Sheet – Final Answer

After more than 10 years of experience, moving to an electronic trauma flow sheet is still not ready for prime time. I’ve seen many, many hospitals struggling to make it work. And all but a very few have failed.

There are two major problems. First, existing computer input technology is underdeveloped. Trying to rapidly put information into small windows on a computer, and having to switch between mouse and keyboard and back is just too slow. And second, output reports are terrible. Humans cannot scan 26 pages of chronological data and reconstruct a trauma activation in their head. There is so much extra data in the typical computer-generated reports, the signal (potential PI issues) gets lost in the noise.

The technology exists to remedy both of the problems. However, the EHR vendors keep tight control over data exchange in and out of their products. Sure, there is CareAnywhere and it’s ilk, but the user is still forced to use the vendor’s flawed input and output systems.

Bottom line: You can’t make a complex system (trauma care) easier or safer by adding complexity (the EHR). Yet.

The electronic trauma flow sheet will never work as well as it could until all the vendors settle on a strong data interchange standard to put data into and get reports out of the EHR. Once that happens, scores of startup companies will start to design easy input systems and report outputs or displays that are actually meaningful. There’s not enough interest in this niche market to make it worthwhile for a company the size of Epic or McKesson, but there is definitely enough for a lot of young companies just chomping at the bit in Silicon Valley.

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The Electronic Trauma Flow Sheet – Part 1

I started voicing my concerns about trying to use an electronic trauma flow sheet (eTFS) way back in 2008. There are very few reports in the literature that specifically detail using the EHR as a trauma flow sheet. The first (see reference 1 below) described an early experience with the conversion process. It outlines lessons learned during one center’s experience, and I’ve not seen any published followup from that center.

Now, on to a report of a “positive” experience. A Level I pediatric trauma center made the same change to the eTFS. They designed a custom menu-driven electronic documentation system, once again using Epic. Specific nurses were trained to act as the

electronic scribe, and had to be present at every trauma resuscitation. The goal of the study was to compare completion rates between paper and electronic documentation. One year of experience with each was collected.

Here are the factoids:

  • There were about 200 trauma activations each year that were admitted, and only 50 or so were highest level activations (in a year!)
  • 11 data elements were compared, including treatments prior to arrival, vitals, fluids, primary survey, level and time of activation, patient and surgeon arrival, and disposition
  • The eTFS was better at capturing time of activation, primary survey components, attending arrival time, and fluid administration

Yes. That’s it. They looked at 11 data points. It says nothing about the wealth of other information that has to be recorded and needs to be abstracted or analyzed. And nothing about the reports generated and their utility. Or how much additional time must be spent by the trauma PI program to figure out what really happened. Or how good their paper documentation was in the first place (not so good, apparently). Or the bias of knowing that your documentation under Epic is being scrutinized for the study.

And to get to that level, this hospital had to maintain a complement of highly trained nurses who were facile with their customized Epic trauma narrator. And they had to maintain their skills despite seeing only one highest level trauma activation patient per week, or one activation at any level only every other day.

I’ve had a few discussions with the trauma program manager from this hospital, and I am convinced that they have managed to make it work well at their center. However, I’m not certain that their system can be generalized to hospitals with higher volumes and and degree of staffing restraints.

In my final post of this series, I’ll tell you what I really think about using the electronic trauma flow sheet in your trauma resuscitations, and why.

References:

  1. Using the electronic medical record for trauma resuscitations: is it possible? J Emerg Nursing 36(4):381-384, 2010.
  2. A comparison of paper documentation to electronic documentation for trauma resuscitations at a Level I pediatric trauma center. J Emerg Nursing 41(1):52-56, 2015.
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Trauma Patient Stay In The ED After Implementing an Electronic Health Record

So as we discovered, we may spend less time and see fewer patients if we use an EHR. One would think that ED length of stay (LOS) would then increase. But does it?

A 2 year observational study from Greece looked at ED throughput before and after implementation of an electronic trauma documentation system. A total of 101 trauma patients were processed under the paper charting system, and 99 were handled after implementation of the electronic system.

Here are the factoids:

  • Injury severity was high overall, with half going for emergent surgery and an overall mortality rate of about 12%
  • Total ED LOS decreased from 206 to 127 minutes with the EHR
  • This was accomplished by decreasing time between arrival and completion of care from 149 to 100 minutes, and from completion of care to leaving the ED from 47 to 26 minutes

Bottom line: Looks great! Badly hurt patients, moving through the ED at breakneck speed after implementation of an EHR. The problem is that it was not really an EHR, but an “electronic documentation system.” Upon close inspection, this is a homegrown system with very specific functionality for monitoring care, providing checklists, and offering case-specific guidance. This is not the type of complex documentation system one usually thinks of when visualizing an EHR. But it does go to show that well-designed and focused software can be beneficial.

Tomorrow, I’ll start to focus specifically on the electronic trauma flow sheet (eTFS).

Reference: The effect of an electronic documentation system on the trauma patient’s length of stay in an emergency department. J Emerg Nursing 40(5)469-475, 2014.

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