Trauma Program

Message from the Trauma Program Manager

Tracy J. Johns, MSN, RN-BC, CPHQ
Tracy J. Johns, MSN, RN-BC, CPHQ
"AHN Trauma Services delivers evidence-based quality of care through the hard work of our talented providers and administrative team. Our program was built on and continues to rest on the shoulders of giants, and we truly have a bright future."
~ Tracy Johns

What an eventful year! We’ve experienced a pandemic, ever increasing momentum in patient improvement and patient safety (PIPS), a 5% increase in trauma volumes, a surge in research activity, and staff changes.

COVID Pandemic

To adapt to the ‘new’ normal while protecting one another, our trauma surgeons, residents and advanced practice providers divided into a larger number of teams with fewer members. This cut down on the chance of cross-contamination and accidental spread of the virus. The call schedule was revised to have fewer people in the hospital at any one time. Our residents and critical care boarded physicians provided care as the number of COVID ICUs increased. Protocols were developed for IV heparin and tPA use with COVID patients with worsening respiratory function Heparin and tPA use, including patient outcomes, was published and there is an ongoing, prospective randomized trial comparing treatment outcomes. Our providers also participated in the creation of an Atrium, multi-institutional COVID care protocol.

Trauma Care

Even through the pandemic, our trauma patient volume increased 5% from 2019 to 3,984 patients (avg 332 patients/month) with 76% (3014) of all patients admitted and an average injury severity score of 8. Mechanism of injury types show 80% blunt, 14% penetrating and 6% other or burn injuries. The most common causes of injury show 32% motor vehicle and motor- cycle accidents followed by 35% falls (22% ground level falls). Patients arriving from scene of injury comprised 64% our population while the remaining 36% of patients were transferred from an outside facility. With a transfer rate this high, it is not surprising that our trauma team treated patients injured in 72 Georgia counties, 45% of all Georgia counties.

Performance Improvement and Patient Safety (PIPS)

As mentioned in the 2020 report, our trauma PIPS program continues to demonstrate effectiveness and maturity as evidenced by:

  • Venous thrombolytic (VTE) prophylaxis: Compared to pre-intervention (fall 2017), our 2019 and 2020 trauma quality improvement program reports (TQIP) indicated the pulmonary embolus odds ratio dropped as low as to 0.56, lowering the benchmark decile from 10 (worst) to one or two (best). Patients receiving no chemoprophylaxis decreased to 23% and was lower than all hospitals (32%). With publication of updated trauma VTE prophylaxis guidelines, Western Trauma Association (2020) and eastern association of surgery in trauma (later in 2021), VTE prophylaxis guidelines updates are planned.
  • Whole Blood Use: Starting June 2020, whole blood has been available only for trauma use, primarily tier 1 trauma team activations. By the end of 2020, 103 units, avg 14 units/month, were transfused and no adverse events were reported. Whole blood may be used individually or as the beginning of the massive transfusion protocol (MTP). There were 55 trauma MTP activations in 2020.
  • PEG Tube Securement: From a case reviewed early 2020, an opportunity for improvement was identified related to procurement of percutaneous endoscopic gastrostomy (PEG) tubes. Our PIPS coordinator, Jo C, lead an interdepartmental effort to identify best practice, find a device (PEG protect), obtain approval for evaluation and pilot use. Best practice includes use of the PEG protect securement device and an abdominal binder. The pilot started in September 2020 and has been adopted into practice for all patients. Since then, there has been a decrease in PEG tube dislodgement. PEG tube securement continues to be monitored 100% for trauma patients.
  • Pediatric Imaging: As part of a state trauma system initiative, a state pediatric trauma imaging guideline was established to decrease unnecessary imaging and decrease radiation exposure in pediatric trauma patients. Compliance with the pediatric imaging guideline continues to be monitored for all pediatric trauma patients.
  • Rib Fracture Care Guideline: In January 2020, trauma services initiated a best-practice guideline for care of patients with rib or sternal fractures with a focused patient cohort at high risk for respiratory compromise. The guideline addresses everything from incentive spirometry use, multi-modal analgesia, end-tidal CO2 monitoring, to indications for surgical stabilization of fractures with post-op outpatient care recommendations. While many variables may affect these 2 complications, a before and after comparison does show a statistically significant decreased incidence for unplanned ICU admits as shown below:
    National Trauma Data Bank Complication 2019
    n = 3005    		 2020
    n = 3014    		 p value
    Unplanned ICU admits 58 39 0.05
    Unplanned Intubations 51 36 0.102
    Data Source: trauma registry; n = trauma admits; N-1 Chi-squared test for proportions used for statistical analysis.

Trauma Research

Beginning with the start of our Trauma Research Coordinator, Rajani Adiga, research infrastructure blossomed in 2020. Through a talented administrative team in the lead, we now better to support research by:

REDCap Use

REDCap is HIPPA compliant database that was built by a team at Vanderbilt through a national institutes of health (NIH) grant. It is used in > 5,000 institutions in 141 countries and use is free for non-profit organizations. Late in 2019, the facility went live with REDCap. The trauma department has 4 research studies, 1 PIPS initiative and 2 department projects supported in this platform.

Trauma Research Intranet

With a research process description, links to the Institutional Review Board (IRB) website and forms, we have mapped out a quick ‘how to’ for those wanting to start research. Trauma/Surgery IRB Member: Recognizing the leadership in trauma and surgery research, Dr. Ashley became a member of the facility’s IRB in 2020.

Grant Support

Through two state and an organizational grant, we have financial support for 2 trauma (Rib Plating and TEG) and 2 COVID related research studies supported.

Expanded Research Participation

Starting last year, research participation increased at a state and international level. In a multi-institutional state study led by researchers at Grady, we are examining tourniquet use for Georgia trauma patients. We are an invited participant for a national study related to trauma patients with a history of direct oral anticoagulant with a diagnosis of intracerebral hemorrhage. The study’s goal is to identify the best time to resume the patient’s anticoagulant medication.

Lead for a Multi-Institutional Study

In January, a multi-institutional, grant support study was started exploring the predictive value of thrombo-elastography (TEG) for venous thromboembolic events for trauma patient. The TEG study has put trauma services ‘on the map’ since this is the first-time researcher from our hospital have functioned as the lead facility in a multi-institutional research project.

  • Biostatistician – Med Ed: Surgery and Trauma Services has been honored by Dr. Anne Montgomery’s support with her statistical analysis in 2020. Dr. Montgomery is a faculty member of the Mercer University School of Medicine and a member of the Population Health and Medical Research Committee. She has worked on studies including the effects of insurance status on cancer patients, residency education on airway control, and a variety of general surgery and trauma topics.