Managing Moderately Injured Trauma Patients without Immediate - - PowerPoint PPT Presentation

Managing Moderately Injured Trauma Patients without Immediate Surgeon Presence: 10 years later

Laura A Boomer, MD

Jason Nielsen, MD, Wendi Lowell, Kathy Haley, MS, BSN, RN, Carla Coffey, BSN, RN, Katherine Nuss, MD, Benedict Nwomeh, MD, MPH, Jonathan Groner MD

Background

• Trauma is common in children
• Standard trauma team has included immediate

evaluation by a surgeon

• Many have a two-tiered system of trauma

activation with different teams

• Reduced resident work hours and decreasing

resident availability have made coverage challenging

Background

• In 2003, the Pediatric Emergency

Medicine physicians assumed responsibility as the team leader for level 2 trauma resuscitations

• The surgical resident and attending

physician became consultants

Purpose

To review a decade’s experience of eliminating immediate surgeon presence from the evaluation of moderately injured children

Trauma Activation Criteria

• Free standing level 1 pediatric trauma center

within a statewide trauma system

• Trauma patients are triaged using a two-tiered

system

• Trauma response is activated by an ED charge

RN or a TNL

• Non-activated patients are evaluated by the ED

physicians

Level I Activation Criteria

• Trauma Arrest
• Airway and Breathing
• Airway or respiratory

compromise

• Airway or breathing maintained

maneuvers, adjuncts or ETT

• Pneumothorax
• Facial or neck injury with

potential for airway or cervical spine injury

• Circulation
• Tachycardia with poor perfusion
• Hypotension
• Need for more than 2 fluid

boluses

• Patients who require blood

products

• Disability
• GCS <9, or ‘P’ or ‘U’ on AVPU

scale

• Paralysis
• Smoke Inhalation with any of

the above criteria

• 2° or 3° Burns > 30% TBSA
• Penetrating wounds
• Limb threatening injuries
• Consider high risk

mechanisms of injury

• Ejection from vehicle
• Death of occupant of same

vehicle

Level II Activation Criteria

• Head
• GCS 9-14, combativeness,

disorientation or confusion

• Abdomen
• Blunt abdominal trauma with

suspicion for intra-abdominal injury

• Penetrating wounds
• Through 2 or more distal

extremities

• Burns
• 2° or 3° burns, 15-30% TBSA
• Extremity
• Suspected or confirmed femur

fracture with high risk mechanism

• Transfer Patients
• Open or depressed skull

fracture or intracranial bleed

• Pulmonary contusion
• Known or suspected intra-

abdominal injury

• Complex pelvic fractures
• High Risk mechanisms of

injury

• Struck, dragged, or run over

by a vehicle

• MVC with high speed impact
• r rollover
• Falls > 20 feet
• Motorized

cycle/dirtbike/bicycle

• All terrain vehicles

Materials and Methods

• Prior to Jan 1, 2003, all trauma

resuscitations were run by a surgical PGY- 4, fellow or attending surgeon

• After April 1, 2003, Pediatric EM

physicians assumed responsibility as trauma team leader for all level 2 activations

Materials and Methods

• Previously collected and published data of

admitted patients were used as a historical comparison

– Period 1 (April 1, 2001 – December 31, 2002)

• Jan 1, 2003 through Mar 31, 2003 data

were excluded (transition period)

• April 1, 2003 to March 31, 2013 data were

extracted from the trauma registry (Period 2)

Results

• Period 1: 714 admitted patients met

trauma criteria (88% level II activations)

• Period 2: 7355 total patients met trauma

criteria (78% level II)

– 4976 admitted patients (70% level II)

Over-triage/Under-triage

• Level 1 Alerts

– 10% downgraded to level II – 2.6% downgraded to non-alert

• Level II Alerts

– 7% upgraded to level I – 8% downgraded to non-alert

• Missed Alerts

– Period 1: 118 (5.6 per month) – Period 2: 124 (1 per month)

Over-triage/Under-triage

• Level 1 Alerts

– 10% downgraded to level II – 2.6% downgraded to non-alert

• Level II Alerts

– 7% upgraded to level I – 8% downgraded to non-alert

• Missed Alerts

– Period 1: 118 (5.6 per month) – Period 2: 124 (1 per month)

Over-triage/Under-triage

• Level 1 Alerts

– 10% downgraded to level II – 2.6% downgraded to non-alert

• Level II Alerts

– 7% upgraded to level I – 8% downgraded to non-alert

• Missed Alerts

– Period 1: 118 (5.6 per month) – Period 2: 124 (1 per month)

Activation Data by Year

100 200 300 400 500 600 700 800

level 2 admit level 2 total ED census

*

Results

Period 1 Period 2 p Total Patients (N) 627 2694 Male Sex 397 (63.3%) 1727 (64.1%) 0.7113 Age, in years <5 5-10 10-18 137 (21.9%) 203 (32.4%) 287 (45.8%) 617 (22.9%) 698 (25.9%) 1379 (51.2%) Overall: 0.0040 0.5709 0.0010 0.0146 Mechanism Blunt Penetrating 598 (95.4%) 10 (1.6%) 2472 (91.8%) 44 (1.6%) 0.0014

Results

Period 1 Period 2 p Total Patients (N) 627 2694 Male Sex 397 (63.3%) 1727 (64.1%) 0.7113 Age, in years <5 5-10 10-18 137 (21.9%) 203 (32.4%) 287 (45.8%) 617 (22.9%) 698 (25.9%) 1379 (51.2%) Overall: 0.0040 0.5709 0.0010 0.0146 Mechanism Blunt Penetrating 598 (95.4%) 10 (1.6%) 2472 (91.8%) 44 (1.6%) 0.0014

Patients were male in >60% of cases

Results

Period 1 Period 2 p Total Patients (N) 627 2694 Male Sex 397 (63.3%) 1727 (64.1%) 0.7113 Age, in years <5 5-10 10-18 137 (21.9%) 203 (32.4%) 287 (45.8%) 617 (22.9%) 698 (25.9%) 1379 (51.2%) Overall: 0.0040 0.5709 0.0010 0.0146 Mechanism Blunt Penetrating 598 (95.4%) 10 (1.6%) 2472 (91.8%) 44 (1.6%) 0.0014

Patients were more often older in age

Results

Period 1 Period 2 p Total Patients (N) 627 2694 Male Sex 397 (63.3%) 1727 (64.1%) 0.7113 Age, in years <5 5-10 10-18 137 (21.9%) 203 (32.4%) 287 (45.8%) 617 (22.9%) 698 (25.9%) 1379 (51.2%) Overall: 0.0040 0.5709 0.0010 0.0146 Mechanism Blunt Penetrating 598 (95.4%) 10 (1.6%) 2472 (91.8%) 44 (1.6%) 0.0014

Blunt trauma presenting mechanism in >90%

Results

Period 1 Period 2 P value Total patients 627 2694 ISS, mean + SD 8.5 + 7.3 8.0 + 6.0 0.048 CT Abdomen (N, %) 336 (53.6%) 1127 (41.8%) <0.001 ED LOS in min, mean 135 191 <0.05 Mortality (N, %) 1 (0.16%) 2 (0.07%) 0.52 Missed Abdominal Injuries (N)

Results

Period 1 Period 2 P value Total patients 627 2694 ISS, mean + SD 8.5 + 7.3 8.0 + 6.0 0.048 CT Abdomen (N, %) 336 (53.6%) 1127 (41.8%) <0.001 ED LOS in min, mean 135 191 <0.05 Mortality (N, %) 1 (0.16%) 2 (0.07%) 0.52 Missed Abdominal Injuries (N)

• Significant reduction in CT scan usage

Results

Period 1 Period 2 P value Total patients 627 2694 ISS, mean + SD 8.5 + 7.3 8.0 + 6.0 0.048 CT Abdomen (N, %) 336 (53.6%) 1127 (41.8%) <0.001 ED LOS in min, mean 135 191 <0.05 Mortality (N, %) 1 (0.16%) 2 (0.07%) 0.52 Missed Abdominal Injuries (N)

• No missed abdominal injuries

Changes

• Trauma nurse leaders began making the

decision about level of activation

• The AIS coding has changed, driving

some changes in ISS

• Further restrictions in work hours
• New hospital and trauma bays

Limitations

• Some details of discharged patients not

available

• Information regarding reasons for

increased LOS not available

• Possibility of alert creep

– Unable to define reason for increased number

• f level 2 activations

Conclusions

• Pediatric EM physicians serving as the

trauma team leader for level II alerts is safe and has led to:

– Reduced Abdominal CT scans – Reduced Admission Rate – Reduced Mortality Rate – NO Missed Abdominal Injuries – Increased ED LOS

Thank You