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Practice guidelines

EAST Practice Management Guidelines: Elderly Falls Prevention

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The Eastern Association for the Surgery of Trauma (EAST) has published their most recent set of practice management guidelines. This one addresses prevention of falls in the elderly.

All trauma centers and trauma professionals are seeing more and more elderly patients, and the increase in the number of falls among these individuals is alarming. Most trauma centers are already engaging in some kind of prevention activity. However, their falls prevention efforts are all over the map, and there has been little guidance regarding what works and what does not.

So what can be done? The EAST practice management guideline group performed a methodical sweep of the literature to try to give us some objective information to shape prevention efforts. They addressed six specific questions. I have listed them below, with comments on what the literature shows us about the answers.

Question 1: Should bone mineral-enhancing agents be used? Conditional recommendation. A meta-analysis suggests that giving Vitamin D and calcium supplements tends to decrease fall-related injuries. The optimal dosing was not clear, but cholecalciferol doses of 400-800 IU daily and calcium dosing of 1000 to 1500 mg/day were most commonly used. There was a trend toward improved muscle strength and balance.

Question 2: Should hip protectors be used? Conditional recommendation. 
The evidence does show that wearing protectors decreases fall-related injury. However, compliance is usually an issue because they don’t look very cool. See below:

Question 3: Should exercise programs be used? Conditional recommendation. The literature on exercise routines shows a tremendous amount of variability in terms of the specific routines used. However, most studies do demonstrate a reduction in injury with implementation of an exercise program.

Question 4: Should physical environment modifications be made? Conditional recommendation. Conditions in the household are one of the biggest factors for causing falls. Clutter, throw rugs, poorly placed furniture all increase the risk of injury. The literature is extremely variable in the methods or equipment used, so the results are quite variable as well. Overall, home modifications such as grab bar placement, clutter removal, etc. appear to be of benefit.

Question 5: Should risk factor screening be used? Conditionally recommended. Screening for risk factors is not a specific intervention. However, it can and should be used to identify at-risk patients and direct interventions toward specific risk factors (see next question).

Question 6: Should multiple, tailored interventions be used? Strongly recommended. Research shows that if risk factor screening is applied to individuals or larger populations, and interventions directed at the specific factors identified are implemented, very favorable results are possible.

Bottom line: The best results I have personally seen at other trauma centers have been accomplished through risk factor screening and the use of multiple targeted interventions. Many centers address a single factor, or give talks to groups of older, non-injured patients. Although these activities may make us feel good, they probably don’t have the full effect that multifactorial interventions do, as addressed in Question 6. 

Elderly falls are a huge problem (and growing). Every trauma center should work on implementing a comprehensive and multi-factorial falls reduction program. And don’t try to reinvent the wheel. Many centers are already doing this, so don’t be shy about borrowing their program components!

Reference: 

Prevention of fall-related injuries in the elderly: An Eastern Association for the Surgery of Trauma practice management guideline. J Trauma 81(1):192-206, 2016.

General

EAST Practice Guideline: Rectal Trauma

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EAST just published their newest practice management guideline, which pertains to rectal trauma. They sought to answer three questions that pertain to nondestructive penetrating trauma to the extraperitoneal rectum. 

Trauma dogma from the 80′s and 90′s mandated that these injuries undergo three things: proximal diversion, distal rectal washout, and presacral drainage. The latter two have had waning interest over the intervening years, and questions have even been raised as to whether diversion is really necessary.

Practice Guideline Committee members at EAST performed a thorough and well documented review of the existing literature to determine what we really should be doing with these injuries.

Here are the factoids:

  • Proximal diversion. The major fear that prompts surgeons to divert is the possibility of infectious complications in the area of the rectal injury itself, or death. The literature consisted of 14 papers, most of which were retrospective and observational. Although there was no difference in mortality (about 0%), the incidence of infections doubled in patients without diversion. The recommendation was that patients with these injuries receive a proximal diverting colostomy.
  • Presacral drains. Only 17 papers addressed this question, and they were of low quality with few patients. There is not enough evidence to recommend this practice. And from a logistical standpoint, I could never figure out why this should work. The drain is placed in the presacral space, adjacent to the posterior rectum. How can this do anything for an anterior injury?
  • Distal rectal washout. In the good old days, this was performed through the distal portion of the newly created colostomy. There were all kinds of fancy ways to do it, and it required converting to lithotomy position and stationing someone (hint: intern) with a bag or bucket to catch the effluent. Very messy and unpleasant. Only 13 papers addressed this practice, and could not convincingly demonstrate a benefit. Not recommended.

Some additional tips of my own:

  • Do not violate the peritoneal reflection in the pelvis while doing the laparotomy. If the injury is isolated to the distal rectum, you will create a conduit for infection in the deep pelvis. You will have a hard time repairing an injury from above, especially in the usual narrow male pelvis. Don’t look at it; just let it heal on its own.
  • Create a standard end colostomy. Surgeons argue that a loop colostomy is convenient because it may be possible to close it later without reopening the midline incision. This is not always the case, and the bridge that is necessary to keep the loop above the skin makes colostomy care very difficult. Patients frequently complain about smelly leaks.

Bottom line: EAST guidelines are helpful in figuring out what to do in certain clinical situations, but they do not provide detailed guidance. This guideline provided answers (as best they could) to just three questions about rectal trauma. They justify not doing things that most surgeons have not been doing for some time. But don’t try to talk yourself out of not doing the diverting colostomy.

Reference: 

Management of penetrating extraperitoneal rectal injuries: An Eastern Association for the Surgery of Trauma practice management guideline. J Trauma 80(3):546-551, 2016.

General

Practice Guidelines And Tincture Of Time

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Most trauma centers have at least a few practice guidelines to help the standardize the way they manage common injuries. Solid organ injury. Elder trauma. Chest tube management. But they are all designed for use in patients who present shortly after their injury.

What about someone who presents a day or two, or more, after their injury?  That changes the picture entirely. Most guidelines have a time component built in. A TBI protocol requires a repeat head CT after a certain period of time. Solid organ injury patients may have restricted activity or frequent vital signs for a while. 

But all too often, trauma professionals treat the patient with delayed presentation exactly the same as fresh trauma. For example, a patient falls and bumps their head. They have a persistent headache, and after two days decide to visit their local ED. The CT scan shows a small amount of subarachnoid blood in the area of the impact. Your practice guidelines says to admit for observation, frequent neruo checks, and repeat head CT in 12 hours.

Or a young male playing sports took a hit to his left flank. After 3 days, he’s just tired of the pain and comes to the ED for some pain medication. CT scan shows a grade III spleen injury with a small amount of hemoperitoneum. Your protocol says to admit, make NPO, liimit activity, and observe for 2 days.

What would I do in these cases? Think about it! If the patients had presented right after the event, they would have gone through your guideline and would have been discharged already. So I would review the images, talk to the patients about their injuries, then send them home from the ED with followup. They’ve already passed!

Bottom line: Remember, practice guidelines are not etched in stone. Variances are possible, but need to be well thought out in advance. And hopefully documented in the chart to expedite the inevitable trauma performance improvement inquiry. If the requisite amount of time has gone by, and the history and exam are reasonable, the patient has already passed your protocol. Send them home.

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General

How To Craft A Practice Guideline

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All US trauma centers verified by the American College of Surgeons are required to have clinical practice guidelines (CPG). Trauma centers around the world generally have them, but may not be required to by their designating authority. But don’t confuse a policy about clinical management, say for head injury, with a real CPG. Policies are generally broad statements about how you (are supposed to) do things, whereas a CPG is a specific set of rules you use when managing a specific patient problem.

  1. Look around; don’t reinvent the wheel! This is the first mistake nearly every center makes. It seems like most want to spend hours and hours combing through the literature, trying to synthesize it and come up with a CPG from scratch. Guess what? Hundreds of other centers have already done this! And many have posted theirs online for all to see and learn from. Take advantage of their generosity. Look at several. Find the one that comes closest to meeting your needs. Then “borrow” it.
  2. Review the newest literature. Any existing CPG should have been created using the most up to date literature at the time. But that could have been several years ago. Look for anything new (and significant) that may require a few tweaks to the existing CPG.
  3. Create your draft, customizing it to your hospital. Doing things exactly the same as another center doesn’t always make sense, and it may not be possible. Tweak the protocols to match your resources and local standards of care. But don’t stray too far off of what the literature tells you is right.
  4. Make sure it is actionable. It should not be a literature summary, or a bunch of wishy-washy statements saying you could do this or consider doing that. Your CPG should spell out exactly what to do and when. (see examples below)
  5. Get buy-in from all services involved. Don’t try to implement your CPG by fiat. Use your draft as a launching pad. Let everyone who will be involved with it have their say, and be prepared to make some minor modifications to get buy-in from as many people as possible.
  6. Educate everybody! Start a campaign to explain the rationale and details of your CPG to everyone: physicians, nurses, techs, etc. Give educational presentations. You don’t want the eventual implementation to surprise anyone. Your colleagues don’t like surprises and will be less likely to follow along.
  7. Roll it out. Create processes and a timeline to roll it out. Give everyone several months to get used to it.
  8. Now monitor it! It makes no sense to implement something that no one follows. Create a monitoring system using your PI program. Include it in your reports or dashboards so providers can see how they are doing. And if you really want participation, let providers see how they are doing compared to their colleagues. Everyone wants to be the top dog.

Some sample CPGs:

Guidelines, Thorax

ED Thoracotomy: Practice Management Guideline

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I still encounter a quite a bit of confusion about ED thoracotomy: when to do it, when to stop. A nice set of guidelines was developed by the Subcommittee on Outcomes of the American College of Surgeons Committee on Trauma about 10 years ago. And really, things haven’t changed very much since then.

In general, the literature on this topic has been all over the place. Most studies are retrospective with very little statistical validation. But there’s a lot of it out there. The subcommittee used fairly standard methods to evaluate the literature and come up with some recommendations.

The overall survival rate for all comers was 8% (11% for penetrating, 1.6% for blunt). About 15% of survivors (no breakdown of blunt vs penetrating) suffered from neurologic impairment. Penetrating cardiac injury had the best survival (31%). In the 4 studies on children, the survival numbers paralleled the adults.

Because of the relatively weak quality of the data, only level II recommendations were given. They were:

  • Don’t consider ED thoracotomy in blunt trauma patients unless the patient arrests in front of you. Otherwise, meaningful survival is almost nonexistent.
  • Consider ED thoracotomy for penetrating chest injury if there were witnessed signs of life and a short transport time (5-10 minutes max, in my opinion). Look for pupillary response, spontaneous respirations, palpable pulse, or a narrow complex cardiac rhythm.
  • ED thoracotomy for penetrating abdominal injuries has a low survival rate, but can be considered if the injury may involve the chest.
  • Consider thoracotomy for suspected abdominal vascular injury, but survival is also very low.
  • The guidelines above apply equally to children.

Practical tips: ED thoracotomy is a seldom used and dangerous procedure. There are many opportunities for injury to trauma professionals, so be selective and take precautions. Assign someone to run the chemical code while the surgeons open the chest. Watch out for broken ribs and scalpels gone wild!

I’ll post pictures and specific pointers over the next three days.

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Reference: Practice management guidelines for emergency department thoracotomy. JACS 193(3):303-309, 2001.