Sample Pediatric Solid Organ Guideline: The Good vs The Bad

In order for a clinical practice guideline (CPG) to be both useful and readily used, they need to meet certain criteria. They must be:

  • Evidence-based (as much as that is possible given the current state of the literature) – don’t make stuff up if you don’t have to.
  • Action-oriented – they actually need to tell you what to do. They shouldn’t read like a book chapter.
  • Concise – the shorter the better.

If your CPG meets all three of these, then it’s got a pretty good chance of being followed. Here are samples of two CPGs for management of solid organ injury in kids.

Which one will you actually follow? Which one will make your brain melt?

Example 1

bad-peds-solid-organ

or Example 2?

good-peds-solid-organ

Bottom line: Follow the rules for crafting your own clinical practice guidelines. Or else nobody will follow it!

Related posts:

 

Source: The Trauma Professionals’s Blog

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 number of 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.

Source: The Trauma Professionals’s Blog

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.

Source: The Trauma Professionals’s Blog

The Electronic Health Record And Productivity In The ED

In 2009, the Health Information Technology for Economic and Clinical Health (HITECH) act was passed. This provided an incentive for all US hospitals to demonstrate “meaningful use” of the EHR. For those of you interested in the details, check out the related post link at the end of this article.

Hospitals rushed to comply, shelling out lots of money to try to recoup some of it through these incentives. In theory, using an EHR should allow better record sharing, increase patient satisfaction, reduce unnecessary testing and medical errors, and ideally, improve billing. But does it work?

A community hospital with a medium-sized ED looked at physician productivity in the ED while using an EHR. In this case, the software product was McKesson, and 16 clinicians were monitored prospectively over a 30 hour period.

Here are the factoids:

  • The group consisted of attending physicians, residents, and nurse practitioners / physician assistants
  • The distribution of how they spent their time is shown below:
    ehr-ed-time-study
  • In order to complete an assessment in the EMR, it took an average of 160 mouse clicks
  • On average, clinicians saw 2.12 patients per hour, requiring nearly 4000 mouse clicks to complete their charting

Bottom line: Overall, this is not a very good or coherent or even well-designed study. But it does show us one thing. Clinicians spent only 28% percent of their time seeing patients, and 56% of their time reviewing or entering data into the EHR! Note the blue and green wedges in the pie chart. How can they possibly earn their salaries? Other studies have confirmed that using an EHR does decrease throughput slightly, yet reimbursements increase anyway.

How can this be? EHRs were originally designed to facilitate billing, and it looks like they still do, making up for the fact that fewer patients can be seen. But this seems like a perverse incentive to me. Adopt the EHR, see fewer patients, get paid more!?

Related posts:

Reference: 4000 Clicks: a productivity analysis of electronic medical records in a community hospital ED. Am J E Med 31:1591-1594, 2013.

Source: The Trauma Professionals’s Blog

A Brief History of the Electronic Health Record

The EHR has been around longer than you think. Even before the current desktop style microcomputers existed, a few hospitals implemented early versions of this product. One of the first was the Latter Day Saints Hospital in Salt Lake City. It installed what it called the HELP system, an acronym for Health Evaluation through Logical Programming.

As computing power increased and the size of the computer box and its cost decreased, a series of advances in medical software systems began to occur. In 1983, a software product geared toward resource scheduling was introduced, and became one of the leading applications of its kind. Most people recognize the name Cadence, but few realize that this was one of the earliest product releases from Epic Systems Corporation.

In 1988, the US government contracted out to develop an electronic record system for the military, much of which is still in use today. On a smaller scale, PC type computers were almost 10 years old in 1990 when Microsoft introduced what I consider the first real version of Windows, version 3.0. Epic was once again an innovator, and it released a product called EpicCare for Windows.

Beginning in 2004, there was a move within the government to emphasize implementation of EHRs across the US, spearheaded by President George W. Bush. And as expected, this led to a number of products developed by a variety of software makers. The push to roll out an EHR universally continues to this day, with no end in sight.

Is this a good thing or a bad one? Although much maligned, the EHR can certainly offer benefits. However, like anything touted as a miracle drug or device, there are always downsides. I’ll review both over the course of the week, but my focus will be on one very specific trauma problem: use of the EHR during trauma resuscitation. Many trauma programs either voluntarily adopted the use of an electronic trauma flow sheet (eTFS), or were forced into it by their hospital administration or IT department. Good idea or not?

We shall see…

Source: The Trauma Professionals’s Blog

Trauma And The Electronic Health Record

I’m going to dedicate this week to discussing the impact of the electronic health record (EHR) on trauma care.

First, I’ll talk a little about the history of the EHR, how it came about and why it was “encouraged” of all hospitals. I’ll also look at who the big players are. Next, I’ll review two studies of the impact of the EHR on ED productivity and patient stay.

And finally, I’ll really dig into using an electronic trauma flow sheet that interfaces with the EHR. My thinking has slowly been changing, but not by much. I’ll review my reasons, and talk about the (few) success stories that are out there.

Stay tuned!

Source: The Trauma Professionals’s Blog

Why Do They Call It: The Surgical Neck of the Humerus?

Anatomy is complex and confusing at times. Pretty much everything you can find in the human body has a name. Sometimes it makes sense. Sometimes it’s named after someone famous. And sometimes, it’s just a head-scratcher.

Let’s take the surgical neck of the humerus. Here’s an image of the proximal humerus:

proximal_humerus-14a181ca9b3646a88cc1

Notice there are two different “necks” of the humerus. You are probably familiar with the anatomic neck from your anatomy classes. But if you are a resident, an orthopedic surgeon, or someone who deals with fractures regularly, you are more familiar with the surgical neck.

The surgical neck of the humerus is the most common fracture site on the proximal humerus.  But here’s the kicker. It’s a misnomer!

Just because you see a fracture of the surgical neck of the humerus doesn’t meed it needs surgery! Indeed, many of these fractures are now successfully treated with immobilization in a sling. Your friendly neighborhood orthopedic surgeons will assess fracture stability by looking at the mechanism, exact location, involvement of the tubercles, and motion. Then they will decide on their treatment plan.

Bottom line: Don’t get suckered when someone asks you what operation is usually needed for a fracture of the surgical neck of the humerus!

Related posts: 

Source: The Trauma Professionals’s Blog

How Fast Can You Warm Up A Hypothermic Patient?

‘Tis the season to see hypothermic patients again! The optimal way to warm them up has been debated for years. A number of very interesting techniques have been devised. Ever wonder how fast / effective they are?

I’ve culled data from a number of sources, and here is a summary what I found. And of course, the disclaimer: “your results may vary.”

Warming Technique Rate of Rewarming
Passive external (blankets, lights) 0.5° C / hr
Active external (lights, hot water bottle) 1 – 3° C / hr
Bair Hugger 2.4° C / hr
Hot inspired air in ET tube 1° C / hr
Fluid warmer 2 – 3° C / hr
GI tract irrigation (stomach or colon, 40° C fluid, instill for 10 minutes, then evacuate) 1.5 -3° C / hr
Peritoneal lavage (instill for 20-30 minutes) 1 – 3° C / hr
Thoracic lavage (2 chest tubes, continuous flow) 3° C / hr
Continuous veno-venous rewarming 3° C / hr
Continuous arterio-venous rewarming 4.5° C / hr
Mediastinal lavage (thoracotomy) 8° C / hr
Cardiopulmonary bypass 9° C / hr
Warm water immersion (Hubbard or therapy tank) 20° C / hr

Source: The Trauma Professionals’s Blog

Why Is NPO The Default Diet For Trauma Patients?

I’ve watched it happen for years. A trauma patient is admitted with a small subarachnoid hemorrhage in the evening. The residents put in all the “usual” orders and tuck them away for the night. I am the rounder the next day, and when I saunter into the patient’s room, this is what I find:

They were made NPO. And this isn’t just an issue for patients with a small head bleed. A grade II spleen. An orbital fracture. Cervical spine injury. The list goes on.

What do these injuries have to do with your GI tract?

Here are some pointers on writing the correct diet orders on your trauma patients:

  • Is there a plan to take them to the operating room within the next 8 hours or so? If not, let them eat. If you are not sure, contact the responsible service and ask. Once you have confirmed their OR status, write the appropriate order.
  • Have they just come out of the operating room from a laparotomy? Then yes, they will have an ileus and should be NPO.
  • Are they being admitted to the ICU? If their condition is tenuous enough that they need ICU level monitoring, then they actually do belong to that small group of patients that should be kept NPO.

But here’s the biggest offender. Most trauma professionals don’t think this one through, and reflexively write for the starvation diet.

  • Do they have a condition that will likely require an emergent operation in the very near future? This one is a judgment call. But how often have you seen a patient with subarachnoid hemorrhage have an emergent craniotomy? How often do low grade solid organ injuries fail if they’ve always had stable vital signs? Or even high grade injuries? The answer is, not often at all! So let them eat!

Bottom line: Unless your patient is known to be heading to the OR soon, or just had a laparotomy, the default trauma diet should be a regular diet! 

Source: The Trauma Professionals’s Blog

New Trauma MedEd Newsletter Released Soon!

I’m just putting the finishing touches on the next newsletter. It contains everything that you really want to know about Trauma in Pregnancy. Here are the contents:

  • Predicting outcomes
  • Tips & Tricks (for EMS and physicians)
  • Imaging
  • Peri-mortem C-section: when, with what, and how?

I’m going to release this issue to subscribers on Halloween. Everyone else can pick it up here on the blog about 10 days later.

If you want to get it as soon as it is released, please subscribe by clicking here! And you can pick up back issues when you follow the link, too!

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Source: The Trauma Professionals’s Blog

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