Return On Investment: 30 Years Of Commitment To The Injured Child - - PowerPoint PPT Presentation

Return On Investment: 30 Years Of Commitment To The Injured Child Has Become A Pathway To Success. J.J. Tepas III MD, FACS, FAAP

Korean Conflict

• Air Ambulances
• Return to Larrey (MASH)
• Vascular Repair
• ARF (Acute Renal Failure)

Wilbur Mills’ “Three layered Cake” Medicare Part A – hospitalization Medicare Part B – physicians fees Medicaid – state shared coverage of poor

7/30/65

Return of a “social agenda”

Vietnam Conflict

Air Ambulances unopposed ARF solved (Shires/Moyer) New problem: Danang lung

From this point on, cost control!!!

CPI 79.7% rise Hospital costs 237% rise!

Chrysler:

• $600 Million for healthcare
• More than for steel and rubber
• Inpatient maternity twice as long as average
• Podiatrists: one toe at a time!

Civilian Trauma Systems

The Surgeon and The Injured Child

APSA May 1984 NPTR April 1 1985

• Mt. Blanc / Imo

12/6/17 Halifax Harbor

Wesson et al

Hospital for Sick Children

Harbinger?

First Comparison of Pediatric to Adult Centers

Score Wars!!

1988

Res esour

• urces

ces an and d Training aining

“It’s hard to believe that once there was a time-even in this century – when retirement was nearly synonymous with poverty, and older Americans died in our streets.”

WJC, 9/22/93

1,342 pages of undecipherable technical jargon Harry and Louise take to the airwaves

Republicans: against employer mandate, favor individual mandate! 1996 HIPAA – limit coverage denial 1997 SCHIP – uninsured children

Cuts to Existing FFS System

• Market basket reductions
• DHS cuts
• Nonpayment for anything

preventable or unnecessary.

Transform Existing System

• Bundled Payments
• Innovation Center

Demonstrations Accountable Care Organizations

REFORM’S “STRATEGIC” PLAN

Track 1 Track 2

Injury Pre-hospital Resuscitation Evaluation Critical Care Convalescence Recovery

Delay Hypoxia ?? procedures Wrong triage Cold Hypoxia Contamination Improper ventilation Inappropriate studies Cold No leader Fluid/Electrolyte anomaly PNA Slow D/C planning Poor family support Out of sight, out of mind.

Cracks In The System

Trauma Systems

“If you build it, they will come” DOES NOT APPLY!

2005: Pediatric Criteria 58 L1; 44 PTRC 24 L2; 21 PTRC

65; 41 out 14 New PTC

Session: XI: Quickshots Paper QS16: 9:46-9:52 PEDIATRIC TRAUMA CENTERS AND AMERICAN COLLEGE OF SURGEONS COMMITTEE ON TRAUMA VERIFICATION: IMPACT ON MORTALITY Emily E. Murphy MD, Mark D. Cipolle* MD,Ph.D., Glen Tinkoff* MD, Stephen Murphy MD, Barry Hicks* MD, Gerard Fulda* MD, Christianacare Health Services Invited Discussant: Jeremy Cannon, MD Introduction: Pediatric mortality is lower in states with American College of Surgeons Committee on Trauma (ACS COT) verified pediatric trauma centers (PTC) compared to states without verified PTCs. We hypothesize that mortality rates will be lower for severely injured children cared for at a PTC that is ACS verified. Methods: Children ≤14 years old with an injury severity score (ISS) >15 were selected from the 2010 National Trauma Databank research dataset (NTDB RDS). Entries with missing ISS

• r age information were excluded. Patients who were dead on arrival were excluded. Univariate

analysis was performed for age, gender, mortality, ACS adult verification and ACS pediatric

• verification. Significant variables were subsequently assessed by logistic regression. A subset

analysis was performed on freestanding pediatric hospitals. A p-value of <0.05 was considered significant. Results: The 2010 NTDB RDS included 11,859 pediatric patients with an ISS > 15.

Univariate analysis was statistically significant for the primary outcome of mortality among

the following variables: race, payment type, ISS, region, ACS adult verification and ACS pediatric verification. Other variables (gender, age, ethnicity, location of injury, hospital type and teaching status) were not statistically significant and were not included in logistic

• regression. The results of the logistic regression are displayed in table 1. ISS, region, race,

payment and ACS pediatric level were significant among patients with an ISS >15. Subset analysis of freestanding pediatric hospitals demonstrated that ACS pediatric level (p=.007), ISS (p<0.001) and payment (p<0.001) had a significant impact on mortality, while region, race, gender and teaching status were non-significant.

Conclusions: ACS pediatric verification is associated with decreased mortality of severely injured children in ACS verified adult trauma centers as well as in freestanding pediatric hospitals. ACS adult verification alone does not confer this mortality benefit. Race, payment and region are additional factors that impact pediatric trauma mortality.

Pediatric ATLS?

Poor Policy Invites Unintended Consequences

Stewardship

Care Event Phase Acute Professional Rehabilitation Reintegration Chronic Payer INS, MCR, MCD, Subs INS, MCR, MCD, ?Subs INS, MCR MCR-SSI, INS, MCR, MCD Fed Taxpayer FMAP Fed & State Taxpayer Cost shift = Premium rise. Higher Co- pay and Deductible = Medical Debt

Three Opportunities

• Data: the glue that binds and the fuel that drives
• Tele-medical Resuscitation

Support

• Care of the Injured Brain

Impact of Poor EMR Design

60% of clinical questions go unanswered 50% of those answers would have had direct impact 33% of clinical time spent searching/organizing data 80% of encounters lack important information 40% of clinical data resides in “white space”

Current Dysfunctional Clinical Data Ecosystem

Limited data liquidity due to:

 Lack of interoperable data standards/API data infrastructure  Limited business case for improved data flow and better quality for care

7

Functional Clinical Data Ecosystem Use Cases

Data FROM Stage Surgeon Record Data TO

1 Initial Assessment 2 Therapeutic Plan Devised 3 Risk Calculation 4 Risk Review/Documentation 5 Counseling/Consent 6 Pre-Surgery Care 7 Pre-op evaluation/review 8 Intra-operative Care 9 PACU Care 10 Post-operative Care 11 Follow-up Care 12 Long-term Management

ACS ACS ACS ACS ACS ACS

FIRST: Surgical Continuum of Care APP

Disease, Procedure, Specialty focused APPs ACS “APP suite” THEN:

Build APPS designed to use ecosystem to optimize surgical care!

Surgical Procedures – NPTR II&III

Abdominal Surgery Organ Did Looked ExLap 1013 17 SB 349 Colon 199 Liver 154 Stomach 103 Appendix 97 Duodenum 68 Pancreas 35

• Mes. Repair

35 Rect 22 Enteric Access Feed Jej 66 PEG 58 Gastrostomy 152 86 DPL 384

ABDOMIN DOMINAL AL I INJ NJURIES URIES

Splenic Trauma

Upadhyaya & Simpson 1968 Howman-Giles, et al 1978

Wesson, et al 1981

MASSIVE BLEEDING OR ASSOCIATED INJURY

SPLENIC INJURY NO BLEEDING MODERATE BLEEDING TRANSFUSION (UP TO 40ML/KG) OBSERVATION O.R. FURTHER BLEEDING (>40 ML/KG)

Splenic Procedures

Splenic Surgery

Partial splenectomy 10% Splenorraphy 36% Splenectomy 54%

Angiography with two foci

• f active extravasation

Angiography status post proximal splenic artery embolization

Pediatric (age<18) 11 0 (0%) 4 0 (0%) 1 Adult (age≥18) 34 11 (32.4%) 61 3(4.9%) 0.003*

AE: Angioembolization; NOM: Non-operative management * p<0.05

• No role for AE in pediatric

patients regardless of grade of injury

• Reemphasizes that successful NOM

in pediatric patients is based on hemodynamic stability alone

Blunt Abdominal Trauma:

Liver

VS

Spleen

0% 1% 2% 3% 4% 5% 6% 7% 8% 9%

Splenic Hepatic L/S

Results – Mortality Rates

n=2553 n=2543 n=347

p < 0.05

0.7% 2.5% 8.7%

Hepato-splenic injury combination is a marker of even greater mortality potential.

Imaging: How To Decide?

Hypotensive? Yes Belly Pain? CT No OR No Positive Negative Observe FAST Negative Positive Yes Out Transient Sustained

BAT Unstable Stable OR FAST Neg POS Non Specific Fluid Non Renal Injury? ? Renal Injury CDS Multiple or severe?” CT Tender Distracted Non Tender

A L A R A

As Low As Reasonably Achievable

Acutely

Later

As Reason Asserts

BAT Unstable Stable OR FAST Neg POS Non Specific Fluid Non Renal Injury? ? Renal Injury CDS Multiple or severe?” CT Tender Distracted Non Tender

A L A R A

As Low As Reasonably Achievable

Acutely

Later

As Reason Dictates

Proposed Algorithm

Observe No CT Scan

• Abdominal wall or lower chest

bruising.

• Abdominal pain or tenderness.
• Low blood pressue – not shock.
• 1. Positive Ultrasound
• 2. Increased AST/ALT >

200/125.

• 3. Hematuria > 5 RBC/hpf.

Yes No Yes

Pediatrictraumasociety.org

The Triumph of Reason Over Ritual

Is the patient stable? Free Air on Cxr? Peritonitis? Is the belly tender? Bleeding in the belly? Patient distracted?

Y N Y Y Y Y Y N N N N

FAST

POS NEG END

O R

CT

Clinical Evaluation

e

d

e=expeditious d=delayed

Start N

What happens to the brain cells after TBI?

Head Injury/Primary Injury Biological Response/ Secondary Injury Cell Injury/Cell Death Suppressed Cellular Function Cognitive Impairment/ Motor Disability We are here!

Immediate Challenges of Traumatic Brain Injury

• Excitatory Imbalance

 Immediate receptor blockade

• Perfusion Anomaly

 ICP/CPP  BBB permeability - autoregulation

• Pro-inflammatory Cytokine Cascade

 Pre-emptive management of S.I.R.S.

Level III Recommendations

ICP

Brain Brain Brain Art Blood Art Blood Art Blood

CSF Venous

MASS/ EDEMA MASS/ EDEMA

CSF Ven Normal Compensated Uncompensated

10 30 50

Munro-Kellie Doctrine

TBI Current Therapeutic Goals ICP < 20 CPP > 60 PbO2 > 25 PaCO2 ~ 32 - 34 Rectal Temp 36.5 – 37.5 Hb > 9, INR < 1.5

In Practical Terms: Understanding the global stress response Orchestrating multiple disciplines Optimizing recovery: Aggressive neurocare Precise fluid management Effective ventilator care Adequate nutritional care

Injury Control: The Surgical Perspective

Paralytic Abx Steroid Analgesic Pressor/Pent Sedation Ulcer Prophylaxis Seizure Prophylaxis Diuretics

PASS A SPUD!

Paralytics: Norcuron 0.1mg/kg Analgesic: MSO4 0.1mg/kg Sedation: Versed 0.1 mg/kg Seizure Rx: Fosphentoin/Phenobarb- load and measure

Antibiotics: Carefully!

Steroids: SCI protocol ??? BPD Pressors/Pent: Dopamine 3-20/Pentobarb. 0.5-5mg/hr Ulcer prophylaxis: Carafate, not Zantac Diuretics: HTS/Mannitol 0.25-1 gm/kg

Critical Management of TBI

Status

T1 T2 T3 SaO2    IV    Analges/Sed   Foley   Tube feeds   Vent  ICP/EVDD  HTS/Man  Press/Pent 

T1 T2 T3

Paralytics



Analgesic

 

Sedation

  

Seizure Rx

 

Antibiotics Careful! Steroids: Rarely! Pressors/Pent



Ulcer pro.

 

Diuretics

 

GCS: 15 13 - 8 <8

23.4 %HYPERTONIC SALINE

Bolus NOT Drip

Delta Na =5 → 5x.6BW = amount of Na meq 23.4% HS → 4 Meq /cc approximates .75BW!

• Hemodynamic
• Vasoregulatory
• Decreases Neutrophil Activation
• Stimulates Lymphocyte Proliferation
• Macrophages/ Monocytes:

Inhibits Pro-inflammatory Cytokines Stimulates Anti-inflammatory Cytokines

Pharmacologic treatment of intracranial hypertension Requires: Na<150 meq/l; Measured Osm <310

Dose = BW x .75 in cc over 30 min in CVL

Monocyte CD14++/CD16- (90%) CD14+/CD16++(10%)

HTS Data

240 doses in 22 patients with severe TBI (within 96

hours of injury)

No Response 41 (35%) 22 (18%) Mean Decrease 6.2 ± 8.2 8.3 ± 7.5

Mannitol N = 118 23.4% HTS N=120

Cell ll Type pe ~ Neur uron

• n or
• r Gl

Glia ial Process rocess – Necr crosis

• sis or
• r Apop
• ptosis
• sis

Cell ell lo locu cus-body body, , ax axon

• n or
• r sy

synapse apse

Biomarker Mapping

N C

Repeat XI

aII-spectrin

PEST

• 280 kDa

CaM

150 kDa -

• 150 kDa

145 kDa -

• 120 kDa

Calpain-specific SBDPs Caspase-3-specific SBDPs

280 kD 150 kD 145 kD

Time

Western Blot 120 kD

• calpain/caspase-3
• calpain
• caspase-3

1 2 3 4

aII-Spectrin is a part of the TBI degradome

CSF Serum Tau MAP MBP UCH-L1 S100β TNFα IL1 IL6 IL8 IL10 sPLA2

50 100 150 200 250 300 20 40 60 80 Serum Urine

DDAVP

Acute Sodium Flux

Survived

Proposed Monitoring Process

Point post Injury sNa uNa Na- in sCl uCL

Cl-in sOsm

UOsm

Fluid IN Urine OUT

1 2 3 4 5 6 7 8 9

Pillars of Care

• Success is related to a seamless continuum of

care.

• The first 48 hours are still most critical.
• Effective treatment is based on preemptive

restoration of homeostasis, using evidence based, standardized processes of care.