Tag Archives: guidelines

Opioids In Trauma Care: A Suggestion?

In my last post, I reviewed a paper that showed how disorganized we are at responsibly prescribing and providing instructions for use of opioid pain medications. Today, I’ll look at a paper that attempts to provide a bit more concrete guidance on what to do.

This study was performed at Dartmouth, and consisted of a questionnaire sent to a group of patients who had undergone an inpatient general surgical procedure during a 6-month period. These were not trauma procedures, but included gastric bypass, sleeve gastrectomy, lap or open ventral hernia repair, laparoscopic fundoplication, hepatectomy, lap or open pancreatectomy, and lap, open, or robotic colectomy. The authors specifically looked at opioid use before discharge, length of stay and complications, and opioid prescriptions and refills.

After excluding patients who had preop opioid use or abuse, and those who developed postop complications, there were 234 study patients. Here are the factoids:

  • Overall, 85% patients were given opioid prescriptions, and only 38% of the medication prescribed was taken
  • Patients discharged on postop day 1 had different requirements from those who were discharged later, and were studied separately
  • 88% of patients discharged on day 1 had their opioid needs satisfied by 15 pills
  • For patients discharged after day 1, there was a very strong correlation with home needs and the amount of opioid required on the before discharge
  • 41% of patients took no pills the day prior to discharge, 33% took 1 to 3, and 26% took more than 4
  • Proper disposal of unused meds was extremely variable

Based on this information, the authors calculated that 85% of patients’ home opioid use would be met by using the following guideline:

  • If no pills were used the day prior to discharge, none were prescribed
  • If 1-3 were taken, 15 were prescribed
  • If 4 or more were taken, 30 were prescribed

The authors estimated that, if these guidelines had been followed in the patients reviewed, the number of pills prescribed would have decreased by about 40%.

Bottom line: This is an interesting attempt to answer our questions about opioid use after discharge. Of course, there are limitations in extrapolating this to the trauma population. The pain patterns in patients with fractures, chest trauma, or multiple injuries are very different than those with abdominal general surgical procedures,  especially those performed with a laparoscope  or robot. But it does demonstrate some key concepts:

  • It should be possible to systematize discharge prescribing in a significant number of patients
  • We need to provide guidelines and expectations to our patients to help them minimize their use of opioids after discharge
  • We also need to make sure that our patients know what to do if they run out of medication
  • These guidelines must include safe disposal instructions for unused meds so they can’t be diverted for inappropriate use

I’m looking forward to more papers that help quantify these concepts. In the meantime, I guess I’ll hit the drawing board and start sketching out an interim guideline to tide me over until that happens!

Guidelines for Consultants to the Trauma Service

Trauma surgeons often rely on consultants to assist in the care of their patients. Orthopedic surgeons and neurosurgeons are some of the more frequent consultants, but a variety of other surgical and medical specialists may be needed. I have found that providing a set of guidelines to consultants helps to ensure quality care and provide good communication between caregivers and patients / families.

We have disseminated a set of guidelines to our colleagues, and I wanted to touch on some of the main points. You can download the full document using the link at the bottom of this post.

In order to deliver the highest quality and most cost-effective care, we request that services we consult do the following:

  • Please introduce yourself to our patient and their family, and explain why you are seeing them.
  • Although you may discuss your findings with the patient, please discuss all recommendations with a member of the trauma service first. This avoids patient confusion if the trauma team chooses not to implement any recommendations due to other patient factors you may not be aware of.
  • Document your consultation results in writing (paper or EMR) in a timely manner.
  • If additional tests, imaging or medications are recommended, discuss with the trauma service first. We will write the orders or clear you to do so if appropriate, and will discuss the plan with the patient.
  • We round at specific times every day and welcome your attendance and input.
  • Please communicate any post-discharge instructions to us or enter in the medical record so we can expedite the discharge process and ensure all followup visits are scheduled.

Bottom line: A uniform “code of behavior” is important! Ensuring good patient communication is paramount. They need to hear the same plans from all of their caregivers or else they will lose faith in us. One of the most important lessons I have learned over the years is that you do not need to implement every recommendation that a consultant makes. They may not be aware of the most current trauma literature, and they will not be familiar with how their recommendations may impact other injuries.

Click here to download the full copy of the Regions Hospital Trauma Services consultant guidelines.

Helicopter EMS: The Risks

Yesterday, I wrote about the (unclear) benefits of helicopter EMS transports. Today, I’ll cover the risks. The number of medical helicopters in the US has grown dramatically since 2002.

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As can be expected, the number of mishaps should go up as well.

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Although it looks like the fatal and injury accidents peaked and then declined, it does not look as good when compared to the rest of the aviation industry. Consequently, being on a helicopter EMS (HEMS) crew has become one of the more dangerous professions.

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And unfortunately, the numbers have not improved much during the past five years. So what to do? Make it a big PI project. Approach it systematically, analyze the issues, and create some guidelines and protocols for all to follow.

Tomorrow, I’ll review  guidelines for HEMS released by the American College of Surgeons Committee on Trauma.

Reference: Medical helicopter accidents in the United States: a 10 year review. J Trauma 56:1325-1329, 2004.

Helicopter EMS (HEMS): The Benefits?

I’m going to kick off 4 days of information on helicopter emergency medical services (HEMS).

The use of medical helicopters has grown at an astonishing rate in the 10+ years since Medicare got involved with payment for this service. All high level trauma centers have helicopter landing facilities, and many either own or are a part owner in at least one helicopter EMS service (HEMS).

Here’s a state by state breakdown of the number of medical helicopters:

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It’s gotten to the point where the indication for summoning a HEMS service seems to be the presence of a patient to ride on it! 

A lot of papers have been published in the past 20 years trying to justify the benefits of using these services. As is the usually case when a lot of papers are published on one subject, most of them are not very good. Many studies have been performed to try to justify their use, and most were not successful. The following items have been scrutinized:

  • Interfacility transfers
  • Trauma
  • Pediatric transfers
  • Pediatric trauma
  • Burns
  • OB
  • Neonatal
  • Rural trauma

Most of these papers found little, if any, benefit. The ones that did tended to be published by institutions that owned these services, raising the significant question of bias. The one thing that was always significantly different was the cost. HEMS costs at least 5-10 times more than ground EMS transport.

So the benefits are not very clear. What about the risks? I’ll talk about those in my next post.

Click here to view the interactive state map of medical helicopters. See where your state is with respect to number of ships and services, and how busy they are.

Guidelines for Consultants to the Trauma Service

Trauma surgeons often rely on consultants to assist in the care of their patients. Orthopedic surgeons and neurosurgeons are some of the more frequent consultants, but a variety of other surgical and medical specialists may be needed. I have found that providing a set of guidelines to consultants helps to ensure quality care and provide good communication between caregivers and patients / families.

We have disseminated a set of guidelines to our colleagues, and I wanted to touch on some of the main points. You can download the full document using the link at the bottom of this post.

In order to deliver the highest quality and most cost-effective care, we request that services we consult do the following:

  • Please introduce yourself to our patient and their family, and explain why you are seeing them.
  • Although you may discuss your findings with the patient, please discuss all recommendations with a member of the trauma service first. This avoids patient confusion if the trauma team chooses not to implement any recommendations due to other patient factors you may not be aware of.
  • Document your consultation results in writing (paper or EMR) in a timely manner.
  • If additional tests, imaging or medications are recommended, discuss with the trauma service first. We will write the orders or clear you to do so if appropriate, and will discuss the plan with the patient.
  • We round at specific times every day and welcome your attendance and input.
  • Please communicate any post-discharge instructions to us or enter in the medical record so we can expedite the discharge process and ensure all followup visits are scheduled.

Bottom line: A uniform “code of behavior” is important! Ensuring good patient communication is paramount. They need to hear the same plans from all of their caregivers or else they will lose faith in us. One of the most important lessons I have learned over the years is that you do not need to implement every recommendation that a consultant makes. They may not be aware of the most current trauma literature, and they will not be familiar with how their recommendations may impact other injuries.

Click here to download the full copy of the Regions Hospital Trauma Services consultant guidelines.