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
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