The ICU Bounce Back

We’ve all experienced it. A seriously injured trauma patient is admitted to the ICU and begins the process of recovery. Everything looks well, and after a few days they’re transferred to a ward bed. But then they languish, never really doing what we expect. Finally (and usually in the middle of the night), they begin to look bad enough where we have to transfer them back to the ICU. Before or after the call to the Rapid Response Team. Yes, it’s the feared “unexpected readmission to ICU.”

What’s the problem here? A failure of the ICU team? Did they send the patient out too soon? Did we all miss something about the patient? And is there any way we can avoid this problem? The major issue is that these “bounce backs” tend to do poorly compared to patients who successfully stay in their ward bed. Estimates are that mortality for patients successfully and finally discharged from the ICU range from 4-8%, whereas the mortality in bounce back patients is 20-40%!

Researchers at the Medical University of South Carolina in Charleston looked at the characteristics that defined the bounce back patient. They reviewed nearly 2000 patients discharged from their trauma ICU and analyzed the variables that predicted an unplanned bounce back. They noted the following interesting factoids:

  • More than two thirds of bounce backs occurred within 3 days
  • Males, patients with an initial GCS < 9, transfer during the day shift  were the major risk factors
  • More comorbidities was associated with a higher chance of bounce back
  • Mortality in the bounce back group was 20%
  • The most common immediate factors causing bounce back were respiratory failure or bleeding

Bottom line: This is an intriguing single-institution study that supports my own personal observations. Fewer bounce backs occur at night because staffing tends to be lower and there is more resistance to transfers out of the ICU then. Both the ICU team and the ward team need to scrutinize every transfer carefully. Significant head injury or the presence of medical comorbidities should trigger a careful assessment to make sure that the transfer is appropriate. Otherwise, your patient may be placed in unnecessary jeopardy.

Next, I’ll discuss when an unexpected return to ICU is not an unexpected return!

Reference: Intensive care unit bounce back in trauma patients: An analysis of unplanned returns to the intensive care unit. J Trauma 74(6):1528-1533, 2013.

Source: http://thetraumapro.com/2017/07/19/the-icu-bounce-back-3/

Surgical Residents And The Danger Of Social Media

Social media usage is ubiquitous, and has a higher prevalence of usage in younger age groups. When the paper I am reviewing was written, 71% of adults with internet access reported using Facebook, and two thirds checked it daily. And now, three years later, I’m sure it’s used even more.

Unfortunately, many people don’t have a good sense of what is appropriate or not. And coupled with confusion about privacy settings, some post things that they probably shouldn’t. And unfortunately, everyone else on the internet can view them.

As a resident, it is more common to be “fired” from residency for unprofessional conduct, not cognitive failure or malpractice. When one is under investigation, the professional organization conducting it may look at prior behavior. And these days, that behavior may be years old and posted for all to see.

Is this a problem? Surgeons at the University of Nebraska were interested in how Facebook was used by surgical residents. They identified surgical residencies at 12 states in the Midwest region. They found all surgical residencies within the region and searched their program websites for the names of active residents. Facebook accounts were then created by the authors and were used to determine which of these residents had their own accounts.

The researchers then viewed those pages and classified the content into three categories: professional, potentially unprofessional, and clearly unprofessional.  Definitions were based on criteria from the ACGME and the AMA. Accounts that were not accessible to the public were judged professional.

A total of 57 surgical residencies were identified, and 40 provided an institutional website with a current roster of their residents. Of 996 surgical residents, the accounts of 319 residents could be evaluated.

Here are the factoids:

  • One third of residents had identifiable Facebook accounts
  • About 74% had only professional content on their site
  • This means that a quarter had potentially or clearly unprofessional content on their sites
  • Clearly unprofessional content included:
    • binge drinking (5 pints of beer in front of a dinner plate, keg stands, comments about being drunk or hung over)
    • sexually suggestive photos (simulated oral sex, female residents in bikinis pointing to their breasts, simulating intercourse on a large cannon)
    • HIPAA violations

Bottom line: Be careful! The use of social media is pervasive. Inappropriate or unprofessional can end a career, or can come back to haunt you years later. And this phenomenon is not limited to surgical residents. All professionals, even attending physicians, may succumb to its charms.

Know the social media policy for your hospital or residency program. Be very careful, and think very carefully about everything you post. Take advantage of built-in privacy settings for the platform you are using. But don’t assume that using them will keep inappropriate material from getting out.  If in doubt, show your potential post to a trusted and reliable friend for a “second opinion.” Otherwise you may find your (not so) friendly “compliance police” knocking on your door. And possibly ending your career.

Reference: An assessment of unprofessional behavior among surgical residents on Facebook: a warning of the dangers of social media. J Surg Educ 71(6):e28-e32, 2014.

Source: http://thetraumapro.com/2017/07/18/surgical-residents-and-the-danger-of-social-media/

The July 2017 Trauma MedEd Newsletter Is Here!

Welcome to the current newsletter. This one is dedicated to all of you out there who receive incoming trauma patient transfers from other hospitals. Here’s the scoop on what’s inside:

  • Can Transfer Patients Actually Pay Their Bills?
  • EMS Documentation In Transfer Patients
  • Technology To Reduce Radiation Exposure
  • The Value Of Reinterpreting Outside CT Scans
  • Optimizing Feedback to Referring Hospitals

To download the current issue, just click here! Or copy this link into your browser: http://bit.ly/TME201707

I’ve also included a sample transfer feedback form so you don’t forget anything when you send the patient. There is also a link to a Word version so you can customize it for your center. The link is:
http://bit.ly/trauma-fb

To view and download back issues, just click here.

Newsletter

Source: http://thetraumapro.com/2017/07/17/the-july-2017-trauma-meded-newsletter-is-here/