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 intraabdominal injury Complex pelvic fractures High Risk mechanisms of injury Struck, dragged, or run over by a vehicle MVC with high speed impact or 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 800 700 * 600 500 400 300 level 2 admit level 2 total 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 <5 5-10 10-18 Mechanism Blunt Penetrating 137 (21.9%) 203 (32.4%) 287 (45.8%) 598 (95.4%) 10 (1.6%) 617 (22.9%) 698 (25.9%) 1379 (51.2%) 2472 (91.8%) 44 (1.6%) Overall: 0.0040 0.5709 0.0010 0.0146 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 Mechanism Blunt Penetrating 137 (21.9%) 203 (32.4%) 287 (45.8%) 617 (22.9%) 698 (25.9%) 1379 (51.2%) Patients were male in >60% of cases 598 (95.4%) 10 (1.6%) 2472 (91.8%) 44 (1.6%) Overall: 0.0040 0.5709 0.0010 0.0146 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 Mechanism Blunt Penetrating 137 (21.9%) 203 (32.4%) 287 (45.8%) 598 (95.4%) 10 (1.6%) 617 (22.9%) 698 (25.9%) 1379 (51.2%) 2472 (91.8%) 44 (1.6%) Patients were more often older in age Overall: 0.0040 0.5709 0.0010 0.0146 0.0014
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 <5 5-10 10-18 Mechanism Blunt Penetrating 137 (21.9%) 203 (32.4%) 287 (45.8%) 598 (95.4%) 10 (1.6%) 617 (22.9%) 698 (25.9%) 1379 (51.2%) 2472 (91.8%) 44 (1.6%) Overall: 0.0040 0.5709 0.0010 0.0146 0.0014
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 Injuries (N) 0 0 -
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 Injuries (N) Significant reduction in CT scan usage 0 0 -
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 Injuries (N) 0 0 -
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