Tag Archives: Practice guideline

Guidelines

Serial Abdominal Examination: The Practice Guideline

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Last week, I published a preliminary practice guideline for nonoperative management of abdominal stab wounds. Click here to view it. A key part of that guideline is the serial abdominal exam. Surgeons talk about this a lot, but how do you do it? I posted about many of the details here.

The serial exam is nuanced enough so that it deserves its own clinical practice guideline! You won’t find this in any doctor or nursing books. It’s really simple, but the devil is truly in the details.

Click this image or the link below to download the guideline. I’ve also posted a Microsoft publisher version in case you want to modify it to suit your center.

Please feel free to email or post comments and questions in the area below this post!

References:

Abdomen, Guidelines

Nonoperative Management Of Abdominal Stab Wounds: The Practice Guideline!

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In my previous post, I reviewed a new paper that examined the appropriate amount of time that patients should be observed for nonoperative manage of an abdominal stab wound. Many of you know that I am a fanatic of properly crafted clinical practice guidelines (CPG). I decided to make a first pass at converting the LAC+USC group’s paper to something that will be helpful at the bedside.

This CPG incorporates the patient selection and timing information published in the paper. It breaks the process down into easily followed tasks, and fills in the blanks for shift to shift management. The CPG is displayed in an “if this, then do that” format. This firms up decision making and makes it easier for your trauma program to monitor compliance with it.

A note about CPGs: they generally cover about 90% of clinical cases. Obviously, they cannot provide guidance for certain rare combinations of circumstance. In that case, the trauma professional should do what they think is right for that situation. Most importantly, they should document this rationale in a progress note.

Here are answers to some of your questions in advance:

  • Patients should not be kept at bed rest. This is always bad.
  • There is no reason to keep the patient NPO. A very small percentage of patients actually fail. It makes no sense to starve everybody for the one or two patients that need to go to the OR each year. Anesthesiologists at trauma centers are very skilled at providing safe intubation in all patients. As you all know, every trauma activation patient coming into your trauma bay needing intubation has just finished a seven course meal!
  • Give your patient clear discharge instructions! They need to know what they can do, and what to look for if things eventually go awry.

And please leave comments and suggestions for improvements in the reply box below or by email to [email protected]. There are always ways to make CPGs even better! I have also included a Microsoft Publisher file so you can modify this guideline to better suit your trauma center.

In my next post, I’ll publish the serial abdominal observation CPG I mention in this one.

Resources:

  1. Download a pdf file of the guideline
  2. Download a Publisher file of the guideline

 

Complications, Thorax

Retained Hemothorax: The Practice Guideline

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Over the last few days, I’ve reviewed some data on managing hemothorax, as well as the use of lytics. Then I looked at a paper describing one institution’s experience dealing with retained hemothorax, including the use of VATS. But there really isn’t much out there on how to roll all this together.

Until now. The trauma group at Vanderbilt published a paper describing their experience with a home-grown practice guideline for managing retained hemothorax.  Here’s what it looks like:

I know it’s small, so just click it to download a pdf copy. I’ve simplified the flow a little as well.

All stable patients with hemothorax admitted to the trauma service were included over a 2.5 year period. The practice guideline was implemented midway through this study period. Before implementation, patients were treated at the discretion of the surgeon. Afterwards, the practice guideline was followed.

Here are the factoids:

  • There were an equal number of patients pre- and post-guideline implementation (326 vs 316)
  • An equal proportion of each group required an initial intervention, generally a chest tube (69% vs 65%)
  • The number of patients requiring an additional intervention (chest tube, VATS, lytics, etc) decreased significantly from 15% to 9%
  • Empyema rate was unchanged at 2.5%
  • Use of VATS decreased significantly from 8% to 3%
  • Use of catheter guided drainage increased significantly from 0.6% to 3%
  • Hospital length of stay was the same, ranging from 4 to 11 days (much shorter than the lytics studies!)

Bottom line: This is how design of practice guidelines is supposed to work. Identify a problem, typically a clinical issue with a large amount of provider care variability. Look at the literature. In general, find it of little help. Design a practical guideline that covers the major issues. Implement, monitor, and analyze. Tweak as necessary based on lessons learned. If you wait for the definitive study to guide you, you’ll be waiting for a long time.

This study did not significantly change outcomes like hospital stay or complications. But it did decrease the number of more invasive procedures and decreased variability of care, with the attendant benefits from both of these. It also dictates more selective (and intelligent) use of additional tubes, catheters, and lytics. 

I like this so much that I’ve incorporated parts of it into the chest tube guideline at my center!

Download the practice guideline here.

Related posts:

Reference: Use of an evidence-based algorithm for patients with traumatic hemothorax reduces need for additional interventions. J Trauma 82(4):728-732, 2017.

Thorax

Practice Guideline: Chest Tube Management (Part 2)

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In my last post, I went over the rationale for developing a practice guideline for something as simple and lowly as chest tube management. Today, I’m posting the details of the guideline that’t been in use at my hospital for the past 15 years. I’ve updated it to reflect two lessons learned from actually using it.

Here’s an image of the practice guideline. Click to open a full-size copy in a new window:

Here are some key points:

  • Note the decision tree format. This eliminates uncertainty so that the clinician can stick to the script. There are no hedge words like “consider” used. Just real verbs.
  • We found that hospital length of stay improved when we changed the three parameters from daily monitoring to three consecutive shifts. We are prepared to pull the tube on any shift, not just during the day time. And it also allows this part of the guideline to be nursing driven. They remind the surgeons that criteria are met so we can immediately remove the tube.
  • Water seal is only used if there was an air leak at some point. This allows us to detect a slow ongoing leak that may not be present during our brief inspection of the system on rounds.
  • The American College of Surgeons Committee on Trauma expects trauma centers to monitor compliance with at least some of their guidelines. This one makes it easy for a PI nurse or other personnel to do so.
  • The first of the “new” parts of this guideline is: putting a 7 day cap on failure due to tube output greater than 150cc per three shifts. At that point, the infectious risks of keeping a tube in begin to outweigh its efficacy. Typically, a small effusion may appear the day following removal, then resolves shortly.
  • The second “new” part is moving to VATS early if it is clear that there is visible hemothorax that is not being drained by the system. Some centers may want to try irrigation or lytics, but the data for this is not great. I’ll republish my posts on this over the next two days.

Click here to download a copy of this practice guideline for adults.

Click here to download the pediatric chest tube practice guideline.

Thorax

Practice Guideline: Chest Tube Management (Part 1)

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I’m devoting the next series of posts to revisiting the management of hemo- and/or pneumothorax. These clinical issues are some of the most common sources of variability in how trauma professionals approach them. Let’s start with the seemingly simple chore of managing a lowly chest tube.

Management of chest tubes is one of those clinical situations that are just perfect for practice guideline development: commonly encountered, with lots of variability between trauma professionals. There are lots of potential areas for variation:

  • How long should the tube stay in?
  • What criteria should be used to determine when to pull it?
  • Water seal or no?
  • When should followup x-rays be done?

Every one of these questions will have a very real impact on that patient’s length of stay and potential for complications.

We developed a chest tube clinical practice guideline (CPG) at Regions Hospital way back in 2004! Of course, there was little literature available to guide us in answering the questions listed above. So we had to use the clinical experience and judgment of the trauma faculty to settle on a protocol that all were comfortable with.

Ultimately, we answered the questions like this:

  • The tube stays in until three specific criteria are met
  • The criteria are: <150 cc drainage over 3 shifts, no air leak, and no residual pneumothorax (or at least a small, stable one)
  • Use of water seal is predicated on whether there was ever an air leak
  • An x-ray is obtained to determine whether any significant pneumo- or hemothorax is present prior to pulling the tube, and 6 hours after pulling it

This CPG has been in effect for over 15 years with excellent results and dramatically shortened lengths of stay.  However, as with any good practice guideline, it needs occasional updates to stay abreast of new research literature or clinical experiences. We recognized that occasional patients had excessive drainage for an extended period of time. This led us to limit the length of time the tube was in to seven days. And we also noted that a few patients had visible hemothorax on their pre-pull imaging. These patients were very likely to return with clinical symptoms of lung entrapment, so we added a decision point to consider VATS at the end of the protocol.

I’ll share the full protocol tomorrow and provide a downloadable copy that you can modify for your own center. I’ll also give a little more commentary on the rationale for the key decision points in this CPG.

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