Cynthia A. Blank-Reid

Improved emergency department efficiency with a three-tier trauma triage system

This pilot study was carried out to determine whether converting from a two-tier to a three-tier in-hospital trauma triage system improves the efficiency of emergency department (ED) care and minimizes inappropriate triage. Patients at an urban, Level 1 trauma centre were triaged using either a two-tier (months 1-3; n = 197) or three-tier (months 4-6; n = 240) trauma response system. Patients were assessed for triage type, age, sex, injury severity score, Glasgow coma score, post-ED disposition, total ED time, survival, complication rate, probability of survival and unexpected death. Comparisons were made by ANOVA table analysis; significance was assumed for p < 0.05. Two-tier (n = 197) and three-tier patients (n = 240) were matched with respect to mean age, sex, mean injury severity score, mean Glasgow coma score, post-ED disposition, survival and probability of survival. Two-tier patients were triaged to give 20% alerts [criteria = physiological derangement (PD) and/or injury mechanism (MOI)] and 80% consults; three-tier patients were triaged as 20% category I (criteria = PD), 18% category II (criteria = MOI) and 62% consults. Total ED time decreased from two-tier (3.98 +/- 2.81 h) to three-tier triage (3.53 +/- 2.14 h, p = 0.001). There was no difference between two-tier alert and three-tier category I times (2.09 +/- 1.64 vs. 1.95 +/- 1.75 h; p = 0.72). Category II patients (3.28 +/- 1.98 h; p = 0.009) spent less time in the ED than did two-tier consults (4.36 +/- 2.65 h). The mean ED three-tier consult time significantly decreased as well (3.95 +/- 2.42 h, p = 0.008 vs. two-tier consult). Complications per patient were unchanged from two-tier to three-tier triage (0.17 +/- 0.52 vs. 0.12 +/- 0.48; p = 0.15). Under-triage (5%) and over-triage (7.5%) were minimal under three-tier triage. It is concluded that using a three-tier triage system results in an increase in the early involvement of the trauma service while decreasing emergency department time and minimizing over-triage.

ATLANTO-OCCIPITAL DISLOCATION: AN UNUSUAL LETHAL AIRBAG INJURY

Airbag-induced injury fatality is increasing in frequency. We present the case of a 6-year-old passenger who sustained a fatal atlanto-occipital dislocation associated with airbag deployment in a low-speed motor vehicle crash. The current literature regarding airbag fatalities and methods to ameliorate airbag-induced injury are reviewed.

Sudden severe barotrauma from self-inflating bag-valve devices

Self-inflating bag-valve devices are commonly used for the ventilation of intubated patients, especially during resuscitation and transport. These devices are generally safe, but minor deviations in their recommended use can expose patients to airway pressures greater than 135 cm H2O. We present a patient in whom a sudden tension pneumothorax developed during ventilation with a bag-valve device. We believe that this complication resulted from high airway pressures generated in the bag-valve device. The ability of the device in question to cause barotrauma was confirmed by bench-top measurements of the peak airway pressures generated by minor deviations from proper use of the device.

Video recording trauma resuscitations: a guide to system set-up, personnel concerns, and legal issues.

Video recording trauma resuscitations has great merit with respect to healthcare-provider education, clinical research, and quality improvement. This paper addresses systems equipment problems, provider concerns, and legal issues that surround the implementation of a video recording system in the resuscitation suite.

A system for working with unidentified trauma patients

Problems can occur when trauma centers receive severely injured unidentified patients who require immediate interventions. Most health care facilities rely on computerized databases to keep patient records and to requisition care. Although computerization of records increases accuracy and efficiency, it is a disadvantage in an emergency setting if the database requires complete identification to issue a chart and medical record number. A method that allows for unique identification of unknown patients is presented along with how it is implemented and changed once the patients identity is found.

System improvements for the use of neuromuscular blocking agents.

Neuromuscular blocking agents (NMBA) are commonly used in the emergency department, operating room, and intensive care unit. After two separate incidents in which NMBA were not immediately available in an emergency, a quality assurance process was used to identify the method for controlling distribution and availability of NMBA use in the emergency department. The new system uses a pharmacy-stocked paralytic agent box and transport bag. The benefits of this system have included (1) 100% availability of NMBA when needed in the emergency department, (2) better availability of supplies and ease in transporting for times when a patient needs to be moved within the hospital, and (3) more efficient billing and tracking of controlled substances by the pharmacy department.