Introduction

1. EARLY IDENTIFICATION OF BLUNT CARDIAC INJURY THROUGH AN EVIDENCE BASED QUALITY IMPROVEMENT INITIATIVE ILEAN GENRICH, RN-BC; SUSAN O’MARA, APN-CNS ALGH Introduction Literature Review Anticipated Outcomes Need for an Evidence-Based Order Set Blunt cardiac injury (BCI) in the setting of blunt chest trauma brings about much discussion because of a lack of a “gold standard” for diagnosis. The greatest challenge is the variety of criteria used to diagnose a BCI and early identification depends on the method chosen. The importance of a timely diagnosis of BCI is the significance of cardiac complications with the resulting medical and nursing interventions that must be provided. An opportunity to modify the order set existed at LGH. The purpose of this presentation is to present the new evidence-based trauma order set and discuss the ongoing study to compare this evidence-based practice (EBP) trauma order set to prior practice in identifying blunt cardiac injury (BCI) in blunt chest trauma patients. • 21 studies were reviewed that included retrospective studies, expert consensus, literature summaries, case studies and prospective studies examining the identification and management of BCI. • The studies examined what reliable test or combination of tests would predict a BCI the most efficiently, allowing for more astute assessments and improving patient outcomes Tests evaluated included ECG, CPK-MB, echocardiography, serum cardiac troponins. • CPK-MB and Echocardiography • CPK-MB is affected by a wide variety of diseases and as • such is not specific for BCI • Echocardiography as a screening tool is not cost effective • Troponin and ECG • Troponin levels were examined independently for their • predictive value, as were ECG for indications of BCI • Individually, their predictive values were inconsistent • When used in conjunction with astute monitoring, their • combined predictive value was significantly higher • It was documented that when both troponin and ECG were • negative, the probability of BCI was 0% • When both tests were positive, almost 2/3rds of patients • showed signs of myocardial dysfunction • Study outcomes evaluating a potential BCI consistently • reinforced that troponin levels would be positive at • admission, or within 6 hours. • No positive conversions of troponins occurred after 6 hrs • Study limitations- • Only 4 studies out of 21 were nurse-based studies, indicating a clear gap in nursing research • Of the 4 studies, 1 was a review of literature, and 3 were small cases studies • Early Identification of BCI through the study trauma order set may lead to the following outcomes • Elimination of multiple lab tests • Decreased blood draws • Decreased time on continuous cardiac monitoring • Decreased risks from cardiac complications • Resource reduction • Reduction in patient length of stay Current trauma protocol has delayed identification of BCI, and gaps in practice have led to inconsistency in the care of these patients. In many cases, over-use of resources occurs and timely discharges are affected. To address this concern, the investigators developed the evidence-based study order set and are currently collecting data. Transitioning Research to Bedside Purpose of the Study In caring for the BCI patient, nursing research can be a change agent in improving quality outcomes for this population. • Improve the care of BCI patients through a standardized • order set • Provide earlier monitoring of troponin levels and a focused • response to an abnormal troponin level • Create a process to discontinue continuous telemetry where • appropriate • Decrease resource utilization, and expedite throughput, • increasing patient satisfaction Background • No topic in trauma management has generated greater controversy than the diagnosis, care and treatment of patients with a suspected BCI or blunt cardiac injury.(Flynn et al.1999) • Salim et al.( 2001) suggest that the true importance of blunt cardiac trauma is related to the cardiac complications that can occur, and utilizing diagnostic tests to identify these complications may allow for earlier and more aggressive monitoring, or early discharge. • Complications of BCI • BCI has the potential to lead to significant cardiac complications including: • ECG changes such as AV blocks, ectopies, changes in ST • segment or T-waves, and ventricular arrhythmias • Decreased cardiac function resulting from impeded • myocardial contractility • Decreased cardiac output due to valvular dysfunction • Pericardial effusion • Intracardiac structural damage • Cardiac rupture • Accurate identification through reliable tests of patients with risk for BCI is essential for improved patient outcomes. The leading cause of BCI is MVA Future Steps Data Analysis Advocate system-wide implementation of the evidence-based trauma protocol Submission for publication to a peer-reviewed journal Methods IRB approved study evaluating prior practice in caring for BCI patients to new evidence based quality improved order set began 03/2010 Sample Group 1 80 retrospective chart reviews between 1/1/09 and 12/31/09 using previous trauma protocol. Group 2 80 prospective chart reviews between 4/1/10 and 12/31/10 using study trauma protocol. Protocol References Rajan, G., Zellweger, R. (2004). Cardiac Troponin I as a Predictor of Arrhythmia and Ventricular Dysfunction in Trauma Patients with Myocardial Contusion. Journal of Trauma , 57, 801-807. Salim,A, Velmahos,G, Jindal,A, Chan, L, Vassiliu, P, Belzberg, H, Asensio,J, Demetriades, D (2001). Clinically Significant Blunt Cardiac Trauma: Role of Serum Troponin Levels Combined with Electrocardiographic Findings. The Journal of Trauma, 50(2). Plautz, C, Perron, A, Brady, W. (2005) Electrocardiographic ST-segment elevation in the trauma patient: acute myocardial infarction vs myocardial contusion. The American Journal of Emergency Medicine, 23, 510 – 516.   Collins,J, Cole,F, Weirete,L, Riblet, J, Britt, L (2001). The Usefulness of Serum Troponin Levels in Evaluating Cardiac Injury. The American Surgeon, 67(9), 821-832. Claire,P, Andrew,P, William, B (2005). Electrocardiographic ST-segment elevation in the trauma patient: acute myocardial infarction vs myocardial contusion. The American Journal of Emergency Medicine, 23, 510-516. Bansal, M, Maraj, S, Chewaproug, D, Amanullah, A (2005). Myocardial contusion injury: redefining the diagnostic algorithm. Emergency Medicine Journal, 22, 465-469. II • Study Protocol • Continuous cardiac monitoring • EKG in a.m. • Repeat troponin level 6 hours after • 1st ED draw • Evaluate need for echocardiogram • if troponin is ≥0.05ng/mL • Evaluate need for cardiac • monitoring if BCI is ruled out • Previous Protocol • Cardiac enzymes q 8 hours x3 • EKG in a.m. • No identification of BCI • protocol, nor was continuous • telemetry included Right Ventricle most common site of BCI