Reducing pressure ulcers is just one SMRTAC goal

The Southern Minnesota Regional Trauma Advisory Committee (SMRTAC) is committed to improving care of injured patients in southeastern and south central Minnesota. To meet that goal, SMRTAC helps support performance improvement and the creation of practice management guidelines at the regional level.

One notable result of those efforts has been a reduction in the number of stage III decubitus ulcers — from 21 in 2010 to six in 2013. The change is the result of new practice management guidelines for adult and pediatric spine immobilization adopted in 2011.

Jane Gisslen, R.N., director of emergency and urgent care at Mayo Clinic Health System in Red Wing, Minn., and co-chair of SMRTAC's Performance Improvement subcommittee, says the ulcer statistics reflect the willingness of a multidisciplinary group of regional providers to work together to improve patient care.

The new protocols, which apply to both pre-hospital and hospital providers, reinforce the documentation of spine board times by EMS and the use of towels, blankets or commercial devices to protect the spines of high-risk patients and those transported long distances.

In the emergency department, trauma patients must, in most circumstances, be removed from a spine board after the primary and secondary survey — ideally within 20 minutes of arrival — and before any imaging tests. "We had patients on spine boards for hours, and other hospitals did too, because we didn't want to take them off until they were totally cleared, but that's much too long," Gisslen explains.

She adds that it is possible to protect the spine during clinical clearance using commercial devices such as the Back Raft, an air mattress that can be placed under patients to reduce tissue pressure on the head and scapula — an especially important practice for undernourished older adults with fragile skin. The region has purchased some of these mattresses and distributed them to EMS and smaller hospitals for patients undergoing longer transport.

Gisslen stresses the importance of including the full spectrum of emergency and trauma care providers in the improvement process. "Prevention has to start from moment one, through transport, the emergency department, and pre- and postoperative patient care," she says. "Once we, and especially EMS, became aware of the problem, we changed the whole process, which made a significant difference, and we have every right to be proud. But it wasn't an easy change. We were all taught that spine boards save spines, so to reframe everyone's thinking was a significant paradigm shift. And our work isn't done yet. We still had six incidents, so we'll continue to review and update our practice management guidelines."

Tackling other issues

SMRTAC is addressing other important issues, including the ability of small hospitals without blood bank capabilities to obtain blood products promptly from a blood bank or nearby hospital.

Work is also beginning on the standardization of trauma team activation criteria across the region. Having a specific set of trauma alert criteria used by every regional provider has improved undertriage rates in Texas and elsewhere, Gisslen says, but the process of achieving consensus and buy-in is far from easy.

"We have large health systems like HealthPartners and Mayo as well as EMS and independent providers, and though everyone has a passion for trauma, they also have different training and beliefs. So as with anything else, it's a matter of bringing people together and looking at best practices and then trying to implement them, she explains. "Standardization is difficult. It's hard to let go of old ways and embrace change, especially when change flies in the face of everything you believe. But the spine board is a really good example that the process works and can make a tangible difference in patient care."

For more information

Practice management guideline: Spine immobilization (spine motion restriction). Southern Minnesota Regional Trauma Advisory Committee (SMRTAC).

Consensus-driven trauma criteria key to region's success. Trauma Physician Update e-Edition. January 2014.