Decreasing Mortality in Head Strike Patients on Anticoagulants with a Head Strike Protocol TraumaCon 2017 Society of Trauma Nurses April 5-8, 2017 St. Louis, MO 2.0 hours after onset 6.5 hours after onset Sharon Wacht, BS, RN; Kristin Salottolo, MPH; Michael Thornton, BS, RN; Mary Bailie, BSN,RN; Amy Atnip, RN; Matthew Carrick, MD; & David Bar-Or, MD
Introduction We are Medical City Plano - Formerly The Medical Center of Plano - Tertiary Care Facility just north of Dallas, TX - 493 beds, including a 34 bed Neuro Intensive Care Unit, 28 bed Critical Care Unit, 10 bed Trauma Unit & 10 bed Burn Unit - Just earned Level 1 Trauma Accreditation - 41,000+ ED visits per year - Comprehensive Stroke Center Accreditation 2
Improve Outcomes - Patients who sustain a head injury and are on an anticoagulant are at higher risk of having a traumatic intracranial hemorrhage (ICH) - ICH = Four to five fold higher fatality 1 - Treatment of confirmed ICH requires a reversal blood product to be transfused in a timely fashion - Timely reversal of pre-injury anticoagulation agents have been found to greatly improve outcomes. - 1. I, Mina, AA, 1, Kinipfer, J.F., Park, D.Y., Bair, H.A., Howells, G.A., Benedick, P.J., (2002) ntracranial complications of pre-injury anticoagulation in trauma patients with head injury, The Journal 3 of Trauma, 2002 Oct: 53(4): 668-72
Forecast The population of Americans aged > 65 is expected to double by 2030 Parallel growth is expected in the use of oral anticoagulants/anti-platelets related to cardiovascular disease Between 1998 and 2004, warfarin prescriptions increased 45% alone in the US 1 ARCH INTERN MED/VOL 167 (NO. 13), JULY 9, 2007, p. 1414 4
Improvement Opportunity - Timeliness of the reversal blood products varied from 30 minutes to several hours - No one group took ownership to ensure the blood was transfused in a timely manner - Few time-defined indicators for care of the ICH patient, but it was felt improvement was needed - Our process and protocol was developed by the ED Trauma PI committee 5
Newly Created Time Matrix Process - Identify and activate appropriate Trauma activations for all patients who have blunt force trauma to the head AND are on blood thinners/aspirin products within 10 minutes of arrival - These patients receive CT of the head within 30 mins of arrival - Once a positive head bleed is confirmed, the Head Strike Protocol is activated with the goal is to get the reversal blood product started within 30 minutes of confirmation - This process included educating the EMS service providers in the area 6
Head Strike Process & Protocol Evidence of Head strike with Blood thinners (regardless of age) Patient to CT scan with Primary Nurse ED Physician Activates the Head Strike Protocol and orders Blue Card Blood products Level 2 Trauma Activation CT Tech notifies Radiologist of Level 2 Trauma activation Primary Nurse/Charge Nurse calls in STAT order to blood bank Trauma Team at bedside (draw blood simultaneously) Radiologist calls ED Physician if CT is positive for bleed Primary Nurse assures patient is ready for transfusion (consents, IV lines, VS) Charge nurse arranges for STAT pick up of blood products Primary nurse starts transfusion within 30 mins of notification by Radiologist 7
What difference does this make? - The objective was to streamline and expedite the care of the patients at high-risk of anticoagulation-related tich - Compare time metrics before and after process and protocol implementation - We hypothesize patients treated after the establishment of the process and protocol will have a reduction of time for key metrics and better patient outcomes - We included patients taking anticoagulants AND antiplatelet medication 8
Methods - Study Design: Pre vs. Post retrospective Cohort Study - Setting: Community-based, ACS-verified Level I Trauma Center - metro Dallas area - Sample: Trauma patients admitted for a head injury before and after implementation of the head strike protocol. 1/1/2013 2/28/2014 and 3/1/2014 5/31/2015 - Analysis: We compared key metrics pre and post implementation to measure the effectiveness of the protocol. Demographic variable were also compared between the pre and post implementation populations. 9
Results - N = 226 consecutively admitted patients taking anticoagulants or antiplatelets admitted with a head injury: N=115 Pre N=111 Post - Patients admitted post-protocol were: - Significantly older (81 years vs 77), p=0.04 - Borderline less severe ISS score (13 vs 17), p=0.051 - Presented with SDH more (57% vs. 42%), p=0.02 - No differences in GCS scores, TBI diagnoses of SAH, EDH, contusion, or skull fracture, gender, transfer status, and bleeding disorders pre vs. post-protocol. 10
Key time metrics Post-implementation, patients received blood products more quickly: - CT results to blood products: - 21 min vs 68 min - p < 0.001 - arrival to blood products: - 59 min vs 113 min - p < 0.001 11
Results - Patients treated after establishing the head strike protocol were more likely to have trauma activation (89% vs. 77%, p=0.02) - Mortality overall was similar pre- vs. post-implementation (24% vs. 18%, p=0.24) for all patients, not clinically significant - However, mortality was significantly lower for patients on anticoagulants after establishing the head strike protocol (42% vs. 21%, p=0.02). 12
Discussion - Studies have previously reported improvement when patients taking warfarin were treated with Fresh Frozen Plasma. We were unable to find studies that defined a time frame on the treatment - Our study also included patients taking Aspirin and then treated with Platelets - This comprehensive, nurse-driven reversal protocol presents an algorithm for managing patients with suspected tich taking any pre-injury blood thinners, allowing ownership by the ED staff to ensure there are no delays in initiating reversal blood products 13
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Contact Us Sharon Wacht, RN, BSBA, CEN Quality and Research Coordinator, ED Sharon.wacht@medicalcityhealth.com 972-519-1505 Medical City - Plano Michael Thornton, RN, BS Emergency Nurse Specialist Michael.Thornton@medicalcityhealth.com 972-519-1505 Medical City Plano Kristin Salottolo, MPH Clinical epidemiologist ksalottolo@ampiopharma.com www.trauma-research.com Mary Bailie, BSN, MBA, RN, CPHQ, HACP Director of Clinical Innovation Mary.bailie@medicalcityhealth.com 972-519-1223 Medical City - Plano Amy Atnip, RN Director Trauma Services Amy.Atnip@medicalcityhealth.com 972-519-3800 Medical City - Plano Matthew Carrick, MD Medical Director, Trauma Services Matt.carrick@acutesurgical.com 972-608-2025 Acute Surgical Care Specialist, LLP David Bar-Or, MD Director, Trauma Research Department dbaror@ampiopharma.com www.trauma-research.com 15