General Tips by XM46j3gN

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									   PI Case Review
2011 Trauma Systems Conference


         John Bleicher, RN
        Trauma Coordinator
        St. Patrick Hospital
                   General Tips

Goal: Prevention of bad practices/outcomes in the future
The sooner, the better – if you review a case at committee 6
months after the events, people will not remember the
specifics and will care less than if the review had been more
timely
This is not just about extracting data for the Registry…it’s
about evaluating the care delivered to the patient
Don’t miss the forest for the trees…you must consider the big
picture: how did this flow, were reasonable decisions made
and were PHTLS/ATLS guidelines followed?
                       General Tips
   It’s not about how the patient did, it’s about how we did
      From a care standpoint – some people live in spite of our

        poor efforts while others die in spite of exemplary care
      From a PI standpoint – the State/ACS don’t expect your

        care to be perfect…..they expect you to be able to
        identify your issues, make a good faith effort to solve
        them and document this process well - they will accept
        occasional poor care – they are really more interested in
        how you (your organization) responded
   It’s not about retribution for this one, it’s about improved
    care for the next one
   Start by presuming that the system failed, not a person
        Which Issues Matter To You?
   You probably know what some of the issues are now
   Talk to people in your organization – but it can’t all be up to
    them (esp. the loud, assertive ones)
   Talk to people in the facilities you transfer patients to
   Look at what others are doing:
      Listserve

      PI module of Trauma Coordinator Course on EMS

       website
      ACS “Resources for Optimal Care of the Injured Patient

       2006”
   Make sure the issues you choose to work on are important
    and that there is some chance of success – not all problems
    can be fixed
   Decide after critically reviewing your own cases
    How Will You Conduct Yourself?

As the “new sheriff in town”
As “mommy/daddy who makes it all better”
As the “detached professional”

My contention: Just be yourself and solve the problem
                    Scenario
 Single vehicle rollover ejection ~15 miles from
  hospital
 EMS response per BLS crew
 Nearest Level II Trauma Center with helicopter
  service is >45 miles away
 Incident occurs at 2300 on a cold, clear winter
  night with snow on the ground

As we review this case, please take notes
 recording your concerns with the care
 rendered
                              EMS
   Find 50 year old morbidly obese male prone in the snow
    about 25 feet from the roadway with P 128, R 48 (blood
    and secretions in airway), palpable radial pulse, GCS 6,
    suspected major trauma to chest/abdomen/pelvis with
    obvious closed R femur fx
   Have 25 minute scene time with spinal stabilization – O2
    per NRB – suction - traction splint application all prior to
    transport
   O2 sat 90%
   Patient transported with cold, wet clothes still on, no
    passive warming measures – no sheet applied to pelvis
                              ED

Pt arrives at 2400: P 120, R 48, BP 108/60, GCS 6
Intermittent suction – O2 per NRB – O2 sats low 90s
Clothes removed – Bair Hugger on
Two 16 gauge peripheral IVs established with NS infusing
   wide open – standard labs drawn
CXR: multiple fx ribs bilaterally with large right hemothorax -
   chest tube inserted with return ~350cc blood
Pt moving/wiggling on board – Estimated weight 300 lb (136
   Kg) - Succinylcholine 1.5 mg/kg (200 mg) - 7.5 oral ETT
No temp recorded
0045: To CT head/neck/chest/abdomen/pelvis
                                     ED
   0115: Return to ED - call for helicopter transport with
    report of:
        Mild closed head injury with no mass lesions or midline shift
        Multiple fx ribs bilaterally with significant R hemothorax and
        bilateral pulmonary contusion
        Grade II to III liver injury with active extravasation
        Open book pelvis fx (no stabilization applied)
        Closed right femur fx and left tib/fib fx
       ETT appropriately placed (no ETCO2 monitor utilized for
        confirmation - no ABGs drawn)
 Total crystalloid given prior to flight team arrival: 5 liters
 No blood products administered
 Discharge vitals: P 132, BP 104/54
What concerns do you have about the care rendered in the field?
        My Concerns With EMS Care

   Traction splint application prior to/delaying transport
   O2 per NRB (no assisted ventilations)
   Patient transported with cold, wet clothes still on, no
    passive warming measures (no attempt to stop further
    heat loss)
   No sheet applied to pelvis
What would your process be for problem-solving these
 issues and how would all this be documented?
           For each issue, determine…
    Provider or system or both?
    Can any simply be trended? How do you do that?
    Education required? How and by whom? Documented
    how?
    Policy/guideline required? What would the process be for
    researching current best practice? How would you go about
    incorporating the changes? Documented how?
    Do any letters need to be written?
    Need for review at a committee? Which one(s)? How
    would you decide and how would you prepare for that
    review? How would that be documented?
    Would review with the RTAC &/or STCC be
    appropriate/beneficial?
What concerns do you have about the care rendered in the ED?
           My Concerns With ED Care
   Succinylcholine only prior to ETT - (no Etomidate or
    Norcuron)
   No temp recorded
   45 minutes to get to CT
   Return to ED/call for helicopter at 0115 - (1 hr, 15 min after
    arrival)
   No ETCO2 monitor utilized for ETT confirmation
   No ABGs drawn
   No pelvic stabilization
   5 liters crystalloid given prior to flight team arrival
   No blood products administered
What would your process be for problem-solving these
 issues and how would all this be documented?
           For each issue, determine…
    Provider or system or both?
    Can any simply be trended? How do you do that?
    Education required? How and by whom? Documented
    how?
    Policy/guideline required? What would the process be for
    researching current best practice? How would you go
    about incorporating the changes? Documented how?
    Do any letters need to be written?
    Need for review at a committee? Which one(s)? How
    would you decide and how would you prepare for that
    review? Documented how?
    Would review with the RTAC &/or STCC be
    appropriate/beneficial?
                         Summary

  Choose wisely – don’t waste your valuable time and
  limited political capital chasing after issues that are either
  not that important or can’t be solved
 Most issues are system issues
 Review care in a timely fashion
 It’s not about how the patient did, it’s about how we did
 Your goal is to improve trauma care - if you make this
  review process punitive, you will fail
 Be yourself
 You can succeed!

								
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