Tag Archives: evidence based review

The Value of Protocols in Trauma

Most trauma centers have a massive trauma protocol. Many have pain management or alcohol withdrawal or a number of other protocols. The question arose: why do we need another protocol? Can we show some benefit to using a protocol?

I’ve looked at the literature, and unfortunately there’s not a lot to go on. Here are my thoughts on the value of protocols.

In my view, there are a number of reasons why protocols need to be developed for commonly encountered issues.

  • They allow us to build in adherence to any known practice guidelines or literature.
  • They help conserve resources by standardizing care orders and resource use.
  • They reduce confusion. Nurses do not have to guess what cares are necessary based on the specific admitting surgeon.
  • They reduce errors for the same reason. All patients receive a similar regimen, so potential errors are more easily recognized.
  • They promote team building, particularly when the protocol components involve several different services within the hospital.
  • They teach a consistent, workable approach to our trainees. When they graduate, they are familiar with a single, evidence based approach that will work for them in their practice.

A number of years ago, we implemented a solid organ injury protocol here at Regions Hospital. I noted that there were large variations in simple things like time at bedrest, frequency of blood draws, how long the patient was kept without food and whether angiography should be considered. Once we implemented the protocol, patients were treated much more consistently and we found that costs were reduced by over $1000 per patient. Since we treat about 200 of these patients per year, the hospital saved quite a bit of money! And our blunt trauma radiographic imaging protocol has significantly reduced patient exposure to radiation.

Bottom line: Although the proof is not necessarily apparent in the literature, protocol development is important for trauma programs for the reasons outlined above. But don’t develop them for their own sake. Identify common problems that can benefit from consistency. It will turn out to be a very positive exercise and reap the benefits listed above.

The Value of Protocols in Trauma

Earlier this week, I wrote about several protocols that can be used in patients with rib fractures. Most trauma centers have a massive trauma protocol. Many have pain management or alcohol withdrawal or a number of other protocols. The question arose: why do we need another protocol? Can we show some benefit to using a protocol?

I’ve looked at the literature, and unfortunately there’s not a lot to go on. Here are my thoughts on the value of protocols.

In my view, there are a number of reasons why protocols need to be developed for commonly encountered issues.

  • They allow us to build in adherence to any known practice guidelines or literature.
  • They help conserve resources by standardizing care orders and resource use.
  • They reduce confusion. Nurses do not have to guess what cares are necessary based on the specific admitting surgeon.
  • They reduce errors for the same reason. All patients receive a similar regimen, so potential errors are more easily recognized.
  • They promote team building, particularly when the protocol components involve several different services within the hospital.
  • They teach a consistent, workable approach to our trainees. When they graduate, they are familiar with a single, evidence based approach that will work for them in their practice.

A number of years ago, we implemented a solid organ injury protocol here at Regions Hospital. I noted that there were large variations in simple things like time at bedrest, frequency of blood draws, how long the patient was kept without food and whether angiography should be considered. Once we implemented the protocol, patients were treated much more consistently and we found that costs were reduced by over $1000 per patient. Since we treat about 200 of these patients per year, the hospital saved quite a bit of money! And our blunt trauma radiographic imaging protocol has significantly reduced patient exposure to radiation.

Bottom line: Although the proof is not necessarily apparent in the literature, protocol development is important for trauma programs for the reasons outlined above. But don’t develop them for their own sake. Identify common problems that can benefit from consistency. It will turn out to be a very positive exercise and reap the benefits listed above.

IOM Report: Nutrition and Traumatic Brain Injury (TBI)

The Institute of Medicine (IOM) released a report last week summarizing a project that examined the impact of nutrition on head injury. The Department of Defense requested this review because of the significant morbidity and mortality incurred by our armed forces caused by TBI.

The IOM convened a panel of experts that reviewed the available data. As with most such panels, there is a recommendation to engage in additional research. They went a step further, though, and recommended several specific avenues of research, including:

  • Determine optimum levels of blood glucose
  • Study the benefits of insulin therapy
  • Determine the optimal goals for nutrition
  • Look at the effects of supplements and various diets, CDP-choline, creatine, n-3 fatty acids, fish oil and zinc supplements

The most pressing recommendation they made was a call to standardize the feeding regimen for severe TBI patients very early after injury. Specifically, they recommend that nutritional support be started within 24 hours of injury, consisting of 50-100% of the total energy expenditure with 1 to 1.5 g protein per kg body weight. This should be continued for the first 2 weeks after injury. It appears that this intervention limits the intensity of the inflammatory response after TBI and improves outcomes. 

Reference: Nutrition and Traumatic Brain Injury: Improving Acute and Subacute Health Outcomes in Military Personnel. Click to access the document on the IOM site.

Motorcycle Helmets and Reduction of Head Injury and Mortality

There are more than 4000 motorcyclist deaths each year. Per mile traveled, there are 27 times more motorcycle deaths that automobile fatalities. This is primarily due to the lack of protection available to motorcyclists, including failure to use a helmet. About 50% of motorcycle deaths are due to head injury.

Helmet use by motorcyclists varies widely across the US. Only 20 states and the District of Columbia have mandatory helmet laws for all motorcyclists. 27 states require helmets on some riders, usually those less than 17 or 18 years old. Three states (Illinois, Iowa and New Hampshire) do not have any helmet law.

Do helmets work? Do helmet laws work? Many studies have been done, and now the evidence is convincing that the answer to both questions is yes! The Eastern Association for the Surgery of Trauma has just released an evidence based review on motorcycle helmet use. They looked at 45 of the best scientific studies available to reach their conclusions. Following is a summary of their findings:

  • The use of motorcycle helmets decreases the overall death rate of motorcycle crashes as compared to non-helmeted riders
  • The use of motorcycle helmets decreases lethal head injuries as compared to non-helmeted riders
  • The use of motorcycle helmets decreases the severity of non-lethal head injuries as compared to non-helmeted riders
  • Mandatory universal helmet laws reduce mortality and head injury in geographical areas with the law as compared to those without it

Based on this data, the EAST document makes the following recommendations:

  • Level I (supported by highest quality research): All motorcyclists should wear helmets to reduce the incidence of head injury after a crash
  • Level II (supported by high quality research): All motorcyclists should wear helmets to improve overall survival and reduce head-injury related mortality after a crash
  • Level II: Mandatory universal motorcycle helmet laws should be introduced or re-enacted to reduce morality and head injury after a crash

The full text of the EAST review can be downloaded by clicking the link below.

Reference: EAST Evidence Based Review on Helmet Efficacy to Reduce Head Injury and Mortality in Motorcycle Crashes