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 Disability   GCS <9, or ‘P’ or ‘U’ on AVPU Airway and Breathing scale  Airway or respiratory  Paralysis compromise   Smoke Inhalation with any of Airway or breathing maintained maneuvers, adjuncts or ETT the above criteria  Pneumothorax  2° or 3° Burns > 30% TBSA  Facial or neck injury with  Penetrating wounds potential for airway or cervical  Limb threatening injuries spine injury   Circulation Consider high risk  mechanisms of injury Tachycardia with poor perfusion   Hypotension Ejection from vehicle   Need for more than 2 fluid Death of occupant of same boluses vehicle  Patients who require blood products

Level II Activation Criteria   Head Transfer Patients  GCS 9-14, combativeness,  Open or depressed skull disorientation or confusion fracture or intracranial bleed   Pulmonary contusion Abdomen  Known or suspected intra-  Blunt abdominal trauma with abdominal injury suspicion for intra-abdominal  Complex pelvic fractures injury   Penetrating wounds High Risk mechanisms of  injury Through 2 or more distal extremities  Struck, dragged, or run over  by a vehicle Burns  MVC with high speed impact  2° or 3° burns, 15-30% TBSA or rollover  Extremity  Falls > 20 feet  Suspected or confirmed femur  Motorized fracture with high risk cycle/dirtbike/bicycle mechanism  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 800 * 700 600 500 level 2 admit 400 level 2 total 300 ED census 200 100 0

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

Results Period 1 Period 2 p Total Patients (N) 627 2694 Male Sex 397 (63.3%) 1727 (64.1%) 0.7113 Age, in years Overall: 0.0040 <5 137 (21.9%) 617 (22.9%) 0.5709 5-10 203 (32.4%) 698 (25.9%) 0.0010 10-18 Patients were male in >60% of cases 287 (45.8%) 1379 (51.2%) 0.0146 Mechanism Blunt 598 (95.4%) 2472 (91.8%) 0.0014 Penetrating 10 (1.6%) 44 (1.6%)

Results Period 1 Period 2 p Total Patients (N) 627 2694 Male Sex 397 (63.3%) 1727 (64.1%) 0.7113 Age, in years Overall: 0.0040 <5 137 (21.9%) 617 (22.9%) 0.5709 5-10 203 (32.4%) 698 (25.9%) 0.0010 10-18 287 (45.8%) 1379 (51.2%) 0.0146 Mechanism Blunt 598 (95.4%) 2472 (91.8%) 0.0014 Penetrating 10 (1.6%) 44 (1.6%) 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 Blunt trauma presenting mechanism in >90% Age, in years Overall: 0.0040 <5 137 (21.9%) 617 (22.9%) 0.5709 5-10 203 (32.4%) 698 (25.9%) 0.0010 10-18 287 (45.8%) 1379 (51.2%) 0.0146 Mechanism Blunt 598 (95.4%) 2472 (91.8%) 0.0014 Penetrating 10 (1.6%) 44 (1.6%)

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, 135 191 <0.05 mean Mortality (N, %) 1 (0.16%) 2 (0.07%) 0.52 Missed Abdominal 0 0 - 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, 135 191 <0.05 mean Significant reduction in CT scan usage Mortality (N, %) 1 (0.16%) 2 (0.07%) 0.52 Missed Abdominal 0 0 - 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 %) No missed abdominal injuries ED LOS in min, 135 191 <0.05 mean Mortality (N, %) 1 (0.16%) 2 (0.07%) 0.52 Missed Abdominal 0 0 - Injuries (N)

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 of 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