EAST Guidelines Review: Issue 4 - Summer 2024
In this issue review of the following EAST Guidelines published in 2024:
(scroll down to see summaries)
Guideline 1 reviewed by Justin Cirone, MD MS
Whole Blood Resuscitation for Injured Patients Requiring Transfusion: A Systematic Review, Meta-Analysis, and Practice Management Guideline from the Eastern Association for the Surgery of Trauma
Guideline 2 reviewed by Asanthi Ratnasekera, DO FACS
Handoffs and Transitions of Care: A Systematic Review, Meta-Analysis, and Practice Management Guideline from the Eastern Association for the Surgery of Trauma
| Guideline 1: Whole Blood Resuscitation for Injured Patients Requiring Transfusion: A Systematic Review, Meta-Analysis, and Practice Management Guideline from the Eastern Association for the Surgery of Trauma Meizoso JP, Cotton BA, Lawless RA, Kodadek LM, Lynde JM, Russell N, Gaspich J, Maung A, Anderson C, Reynolds JM, Haines KL, Kasotakis G, Freeman JJ. Whole Blood Resuscitation for Injured Patients Requiring Transfusion: A Systematic Review, Meta-Analysis, and Practice Management Guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2024 Mar 27. doi: 10.1097/TA.0000000000004327. Epub ahead of print. PMID: 38531812. Relevant Background: Hemorrhage is the leading cause of death among injured patients and, despite advances in the management of the traumatically injured patient, mortality from hemorrhagic shock still accounts for one third of all trauma-related deaths. Whole blood has recently re-emerged as an option for resuscitation with a growing body of research comparing whole blood resuscitation to balanced 1:1:1 (RBC, plasma, platelets) resuscitation PICOs: PICO 1: In adult civilian trauma patients receiving blood transfusions (P), should resuscitation with whole blood (I) be used versus resuscitation with component therapy alone (C) to decrease mortality (O1), transfusion requirements (O2), infectious complications (O3), or intensive care unit (ICU) length of stay (LOS) (O4)? Recommendations: PICO 1: Overall, the working group conditionally recommends using whole blood in adult civilian trauma patients requiring blood transfusing in the acute phase given the reduction in early and 24- hour transfusion volumes and demonstrated survival benefit in the one available randomized clinical trial. After the early stage of resuscitation is complete an individualized, goal-directed transfusion strategy is recommended. Clinical Application: This article supports the use of whole blood in the acute resuscitation of the traumatically injured adult civilian patient at centers where whole blood is available. The authors note that the quality of evidence if very low, however, the risk-to-benefit ratio was considered acceptable to support the use of whole blood.
Guideline 2: Handoffs and Transitions of Care: A Systematic Review, Meta-Analysis, and Practice Management Guideline from the Eastern Association for the Surgery of Trauma Appelbaum RD, Puzio TJ, Bauman Z, Asfaw S, Spencer A, Dumas RP, Kaur K, Cunningham KW, Butler D, Sawhney JS, Gadomski S, Horwood CR, Stuever M, Sapp A, Gandhi R, Freeman J. Handoffs and Transitions of Care: A Systematic Review, Meta-Analysis, and Practice Management Guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2024 Feb 26. doi: 10.1097/TA.0000000000004285. Epub ahead of print. PMID: 38407300.
Relevant Background: Handoff of patient care is an important aspect of transition of care between providers, services and levels of care.In the early 2000s, the Joint Commission and the Institute of Medicine identified communication failure as a key root cause of preventable adverse events in medicine. Passive listening, perceived disinterest in the receiving staff, competing interests (such as the ongoing resuscitation of the patient), non-standardized transfer tools, and interruptions are some of the barriers to effective communication during these critical time points that have been previously identified in the literature PICOs: PICO 1: In the setting of ACS, specifically perioperative interactions (P), should a standardized handoff be performed (I) versus the currently established process (C) to help reduce clinical complications, the rate of handoff errors, the rate of medical errors, and preventable adverse events (O)? PICO 2: In the setting of ACS, specifically EMS and trauma team interactions (P), should a standardized handoff be performed (I) versus the currently established process (C) to help reduce clinical complications, the rate of handoff errors, the rate of medical errors, and preventable adverse events (O)? PICO 3: In the setting of ACS, specifically intra/inter floor and ICU interactions (P), should a standardized handoff be performed (I) versus the currently established process (C) to help reduce clinical complications, the rate of handoff errors, the rate of medical errors, and preventable adverse events (O)? Recommendations: The study included two prospective, randomized controlled studies, six prospective cohort studies, two retrospective cohort studies, and one case-control study. Overall, the quality of evidence was very low. The implementation of a standardized handoff is considered likely beneficial in the setting of ACS, specifically perioperative interactions, EMS and trauma team interactions, and intra/inter floor and ICU interactions. In addition, development and implementation of a standardized handoff takes into account an institution’s current state/processes to optimize pre-existing infrastructure as well as feedback after initial implementation. In order to enact long term change, a larger culture shift towards improved patient safety is required. Clinical Application: Based on the aforementioned group consensus and expert opinion, the authors conditionally recommend a standardized handoff in the field of ACS, including perioperative interactions, EMS and trauma team interactions, as well as intra-inter floor and ICU interactions. Based on the available evidence, a structured approach to handoffs decreased the rate of handoff errors, clinical complications and probably adverse events. Although the included studies in the review had heterogenous hand off tools and implementation methods, and did not standardize these methods across studies, the authors emphasized the need for institutional practice change by implementation of a structured handoff tool. |