Deepika Mohan

Assessing the Feasibility of the American College of Surgeons' Benchmarks for the Triage of Trauma Patients

OBJECTIVE To test the feasibility of accomplishing the American College of Surgeons Committee on Trauma benchmarks of less than 5% undertriage (treatment of patients with moderate to severe injuries at nontrauma centers [NTCs]) and less than 50% overtriage (transfer of patients with minor injuries to trauma centers [TCs]) given current practice patterns by describing transfer patterns for patients taken initially to NTCs and estimating volume shifts and potential lives saved if full implementation were to occur. DESIGN, SETTING, AND PATIENTS Retrospective cohort study of adult trauma patients initially evaluated at NTCs in Pennsylvania (between April 1, 2001, and March 31, 2005). We used published estimates of mortality risk reduction associated with treatment at TCs. MAIN OUTCOME MEASURES Undertriage and overtriage rates, estimated patient volume shifts, and number of lives saved. RESULTS A total of 93,880 adult trauma patients were initially evaluated at NTCs in Pennsylvania between 2001 and 2005. Undertriage was 69%; overtriage was 53%. Achieving less than 5% undertriage would require the transfer of 18,945 patients per year, a 5-fold increase from current practice (3650 transfers per year). Given an absolute mortality risk reduction of 1.9% for patients with moderate to severe injuries treated at TCs, this change in practice would save 99 potential lives per year or would require 191 transfers per year to save 1 potential life. CONCLUSIONS Given current practice patterns, American College of Surgeons Committee on Trauma recommendations for the regionalization of trauma patients may not be feasible. To achieve 5% undertriage, TCs must increase their capacity 5-fold, physicians at NTCs must increase their capacity to discriminate between moderate to severe and other injuries, or the guidelines must be modified.

Determinants of Compliance With Transfer Guidelines for Trauma Patients: A Retrospective Analysis of CT Scans Acquired Prior to Transfer to a Level I Trauma Center

Objective:To identify potential determinants of compliance with the American College of Surgeons Committee on Trauma guidelines for the transfer of trauma patients. Summary of Background Data:Guidelines published by the American College of Surgeons Committee on Trauma outline criteria for the immediate transfer of moderately to severely injured patients to Level I/II Trauma Centers. Acquisition of pretransfer computed tomography (CT) scans violates those guidelines. Methods:Between January 2000 and December 2007, retrospective review of trauma patients meeting the criteria for immediate transfer to a Level I Trauma Center. We used multivariable analyses to explore the determinants of scan acquisition, the association between CT scans and in-hospital mortality, and the association between CT scans and secondary outcomes, such as duration of ventilator dependence, intensive care unit length of stay, and total length of stay. We calculated the number of scans duplicated upon arrival at the Level I center, and estimated charges using the 2008 Medicare physician fee schedule allowance. Results:Of 7713 severely injured patients requiring transfer to a Level I center, 4434 patients (57%) had a pretransfer CT scan. Penetrating wounds, physiologic compromise, and Injury Severity Scores ≥34 were associated with fewer pretransfer CT scans, while older age and being female were associated with more. Pretransfer CT scans were not associated with in-hospital death or worsened secondary outcomes, but increased charges by

Advance care planning norms may contribute to hospital variation in end-of-life ICU use: a simulation study.

3,761,389 (

Physicians' decision-making roles for an acutely unstable critically and terminally ill patient.

488/person transferred with severe injuries). Conclusions:National guidelines for the transfer of severely injured patients are followed less than half the time. Pretransfer CT scans do not improve outcomes yet increase costs.

Validating a vignette-based instrument to study physician decision making in trauma triage.

Background. There is wide variation in end-of-life (EOL) intensive care unit (ICU) use among academic medical centers (AMCs). Our objective was to develop hypotheses regarding medical decision-making factors underlying this variation. Methods. This was a high-fidelity simulation experiment involving a critically and terminally ill elder, followed by a survey and debriefing cognitive interview and evaluated using triangulated quantitative-qualitative comparative analysis. The study was conducted in 2 AMCs in the same state and health care system with disparate EOL ICU use. Subjects were hospital-based physicians responsible for ICU admission decisions. Measurements included treatment plan, prognosis, diagnosis, qualitative case perceptions, and clinical reasoning. Results. Sixty-seven of 111 (60%) eligible physicians agreed to participate; 48 (72%) could be scheduled. There were no significant between-AMC differences in 3-month prognosis or treatment plan, but there were systematic differences in perceptions of the case. Case perceptions at the low-intensity AMC seemed to be influenced by the absence of a do-not-resuscitate order in the context of norms of universal code status discussion and documentation upon admission, whereas case perceptions at the high-intensity AMC seemed to be influenced by the patient’s known metastatic gastric cancer in the context of norms of oncologists’ avoiding code status discussions. Conclusions: In this simulation study of 2 AMCs, hospital-based physicians had different perceptions of an identical case. We hypothesize that different advance care planning norms may have influenced their decision-making heuristics.

Sources of non-compliance with clinical practice guidelines in trauma triage: a decision science study

Objectives:There is substantial variation in use of life sustaining technologies in patients near the end of life but little is known about variation in physicians’ initial ICU admission and intubation decision making processes. Our objective is to describe variation in hospital-based physicians’ communication behaviors and decision-making roles for ICU admission and intubation decisions for an acutely unstable critically and terminally ill patient. Design:We conducted a secondary analysis of transcribed simulation encounters from a multi-center observational study of physician decision making. The simulation depicted a 78-year-old man with metastatic gastric cancer and life threatening hypoxia. He has stable underlying preferences against ICU admission and intubation that he or his wife will report if asked. We coded encounters for communication behaviors (providing medical information, eliciting preferences/values, engaging the patient/surrogate in deliberation, and providing treatment recommendations) and used a previously-developed framework to classify subject physicians into four –mutually-exclusive decision-making roles: informative (providing medical information only), facilitative (information + eliciting preferences/values + guiding surrogate to apply preferences/values), collaborative (information + eliciting + guiding + making a recommendation) and directive (making an independent treatment decision). Setting:Simulation centers at 3 US academic medical centers. Subjects:Twenty-four emergency physicians, 37 hospitalists, and 37 intensivists. Measurements and Main Results:Subject physicians average 12.4 years (SD 9.0) since graduation from medical school. Of 98 physicians (39%), 38 physicians sent the patient to the ICU, and 9 of 98 (9%) ultimately decided to intubate. Most (93 of 98 [95%]) provided at least some medical information, but few explained the short-term prognosis with (26 of 98 [27%]) or without intubation (37 of 98 [38%]). Many (80 of 98 [82%]) elicited the patient’s intubation preferences, but few (35 of 98 [36%]) explored the patient’s broader values. Based on coded behaviors, we categorized 1 of 98 (1%) as informative, 48 of 98 (49%) as facilitative, 36 of 98 (37%) as collaborative, and 12 of 98 (12%) as directive; 1 of 98 (1%) could not be placed into a category. No observed physician characteristics predicted decision-making role. Conclusions:The majority of the physicians played a facilitative or collaborative role, although a greater proportion assumed a directive role in this time-pressured scenario than has been documented in nontime-pressured ICU family meetings, suggesting that physicians’ roles may be context dependent.

Thought outside the box: intensive care unit freakonomics and decision making in the intensive care unit.

Background . The evidence supporting the use of vignettes to study physician decision making comes primarily from the study of low-risk decisions and the demonstration of good agreement at the group level between vignettes and actual practice. The validity of using vignettes to predict decision making in more complex, high-risk contexts and at the individual level remains unknown. Methods . We had previously developed a vignette-based instrument to study physician decision making in trauma triage. Here, we measured the retest reliability, internal consistency, known-groups performance, and criterion validity of the instrument. Thirty-two emergency physicians, recruited at a national academic meeting, participated in reliability testing. Twenty-eight trauma surgeons, recruited using personal contacts, participated in known-groups testing. Twenty-eight emergency physicians, recruited from physicians working at hospitals for which we had access to medical records, participated in criterion validity testing. We measured rates of undertriage (the proportion of severely injured patients not transferred to trauma centers) and overtriage (the proportion of patients transferred with minor injuries) on the instrument. For physicians participating in criterion validity testing, we compared rates of triage on the instrument with rates in practice, based on chart review. Results . Physicians made similar transfer decisions for cases (κ = 0.42, P < 0.01) on 2 administrations of the instrument. Responses were internally consistent (Kuder-Richardson, 0.71–0.91). Surgeons had lower rates of undertriage than emergency physicians (13% v. 70%, P < 0.01). No correlation existed between individual rates of under- or overtriage on the vignettes and in practice (r = −0.17, P = 0.4; r = −0.03, P = 0.85). Conclusions . The instrument developed to assess trauma triage decision making performed reliably and detected known group differences. However, it did not predict individual physician performance.

Trauma triage in the emergency departments of nontrauma centers: An analysis of individual physician caseload on triage patterns

BackgroundUnited States trauma system guidelines specify when to triage patients to specialty centers. Nonetheless, many eligible patients are not transferred as per guidelines. One possible reason is emergency physician decision-making. The objective of the study was to characterize sensory and decisional determinants of emergency physician trauma triage decision-making.MethodsWe conducted a decision science study using a signal detection theory-informed approach to analyze physician responses to a web-based survey of 30 clinical vignettes of trauma cases. We recruited a national convenience sample of emergency medicine physicians who worked at hospitals without level I/II trauma center certification. Using trauma triage guidelines as our reference standard, we estimated physicians’ perceptual sensitivity (ability to discriminate between patients who did and did not meet guidelines for transfer) and decisional threshold (tolerance for false positive or false negative decisions).ResultsWe recruited 280 physicians: 210 logged in to the website (response rate 74%) and 168 (80%) completed the survey. The regression coefficient on American College of Surgeons – Committee on Trauma (ACS-COT) guidelines for transfer (perceptual sensitivity) was 0.77 (p<0.01, 95% CI 0.68 – 0.87) indicating that the probability of transfer weakly increased as the ACS-COT guidelines would recommend transfer. The intercept (decision threshold) was 1.45 (p<0.01, 95% CI 1.27 – 1.63), indicating that participants had a conservative threshold for transfer, erring on the side of not transferring patients. There was significant between-physician variability in perceptual sensitivity and decisional thresholds. No physician demographic characteristics correlated with perceptual sensitivity, but men and physicians working at non-trauma centers without a trauma-center affiliation had higher decisional thresholds.ConclusionsOn a case vignette-based questionnaire, both sensory and decisional elements in emergency physicians’ cognitive processes contributed to the under-triage of trauma patients.

Assessing the validity of using serious game technology to analyze physician decision making.

Despite concerted efforts to improve the quality of care provided in the intensive care unit, inconsistency continues to characterize physician decision making. The resulting variations in care compromise outcomes and impose unnecessary decisional regret on clinicians and patients alike. Critical care is not the only arena where decisions fail to conform to the dictates of logic. Behavioral psychology uses scientific methods to analyze the influence of social, cognitive, and emotional factors on decisions. The overarching hypothesis underlying this “thought outside the box” is that the application of behavioral psychology to physician decision making in the intensive care unit will demonstrate the existence of cognitive biases associated with classic intensive care unit decisions; provide insight into novel strategies to train intensive care unit clinicians to better use data; and improve the quality of decision making in the intensive care unit as characterized by more consistent, patient-centered decisions with reduced decisional regret and work-related stress experienced by physicians.

Communication Practices in Physician Decision-Making for an Unstable Critically Ill Patient with End-Stage Cancer

BACKGROUND Treatment at Level I/II trauma centers improves outcomes for patients with severe injuries. Little is known about the role of physicians’ clinical judgment in triage at outlying hospitals. We assessed the association between physician caseload, case mix, and the triage of trauma patients presenting to nontrauma centers. METHODS A retrospective cohort analysis of patients evaluated between January 1, 2007, and December 31, 2010, by emergency physicians working in eight community hospitals in western Pennsylvania. We linked billing records to hospital charts, summarized physicians’ caseloads, and calculated rates of undertriage (proportion of patients with moderate-to-severe injuries not transferred to a trauma center), and overtriage (proportion of patients transferred with a minor injury). We measured the correlation between physician characteristics, caseload, and rates of triage. RESULTS Of 50 eligible physicians, 29 (58%) participated in the study. Physicians had a mean (SD) of 16.8 (10.1) years of postresidency clinical experience; 21 (72%) were board certified in emergency medicine. They evaluated a median of 2,423 patients per year, of whom 148 (6%) were trauma patients and 3 (0.1%) had moderate-to-severe injuries. The median undertriage rate was 80%; the median overtriage rate was 91%. Physicians’ caseload of patients with moderate-to-severe injuries was inversely associated with rates of undertriage (correlation coefficient, −0.42; p = 0.03). Compared with physicians in the lowest quartile, those in the highest quartile undertriaged 31% fewer patients. CONCLUSION Emergency physicians working in nontrauma centers rarely encounter patients with moderate-to-severe injuries. Caseload was strongly associated with compliance with American College of Surgeons’ Committee on Trauma guidelines. LEVEL OF EVIDENCE Therapeutic/care management, level IV.