PI Case Review 2011 Trauma Systems Conference John Bleicher, RN Trauma Coordinator

1. PI Case Review2011 Trauma Systems Conference John Bleicher, RN Trauma Coordinator St. Patrick Hospital

2. 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?

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. What concerns do you have about the care rendered in the field?

11. 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

12. What would your process be for problem-solving these issues and how would all this be documented?

13. 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?

14. What concerns do you have about the care rendered in the ED?

15. 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

16. What would your process be for problem-solving these issues and how would all this be documented?

17. 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?

18. 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!