THE Research to Practice column is intended to elevate the research critique skills of the advanced practice nurses (APNs) and to assist with translation of research to practice. For each column, a topic and a particular research study are selected. The stage is set by introducing the importance of the topic. The research article is then reviewed and critiqued, and finally, the implications for translation into practice are discussed. In this column, the following research article is reviewed: Tasse, Janzen, Ahmed, & Chang (2008), “Screening Laboratory and Radiology Panels for Trauma Have Low Utility and Are Not Cost Effective.” The implications of these findings for APNs are discussed.
It was a typical, spring, Friday afternoon in the emergency department (ED) of the trauma center. I was preparing to leave work for the weekend when the charge nurse called and said, “We are going to need some help. We have multiple patients coming in from a multivehicle crash on the interstate. There was a fatality at the scene.” As I arrived at the trauma rooms, staff were assembling into teams and preparing for each respective patient. The charge nurse had pulled four of the preregistered trauma packets and proceeded to order our standard trauma panel laboratory tests, radiographs, and computed tomography (CT) scans. At our institution, the standard trauma panel consists of tests for venous blood gases; complete blood cell count (CBC); prothrombin time with international normalized ratio (INR) and partial thromboplastin time (PT/PTT); comprehensive metabolic panel (sodium, potassium, chloride, CO2, BUN[blood urea nitrogen], creatinine, glucose, calcium, albumin, total bilirubin, total protein, alkaline phosphatase, SGOT [serum glutamic-oxaloacetic transaminase], and SGPT [serum glutamic-pyruvic transaminase] levels and amylase); type and screen. A pregnancy test is obtained on women of childbearing age. Routing radiographic studies include a portable chest radiograph, portable pelvis (when indicated), and CT scan of the head, neck, chest, abdomen, and pelvis. With these CT scans, we are able to obtain reconstructed images of the thoracic and lumbar spine.
The first patient to arrive was a young, adult man. He was alert but confused and combative when the prehospital providers arrived. Because of his deteriorating mental status, prehospital personnel elected to intubate him. This patient had lacerations and abrasions on his face and a seat belt mark across the chest and abdomen; however, his extremities were atraumatic. On arrival to the trauma resuscitation area, his vital signs were within normal limits with the exception of the heart rate of 124.
The second patient to arrive was a 24-year-old man. He was alert and oriented with multiple facial abrasions and a deformity to the left arm. He complained of left-sided chest, abdominal, and pelvic pain. He also complained of midthoracic back pain on physical examination; however, he had no pain in the cervical or lumbar spine region. His vital signs were within normal parameters.
The third patient to arrive was also a 24-year-old man. He was alert and oriented with only a brief loss of consciousness. He had an obvious open fracture of his right ankle and abrasions on his face and right arm. He had no cervical, thoracic, or lumbar spine tenderness on physical examination nor any findings to suggest intrathoracic or intra-abdominal injury. Other than being mildly tachycardic, his vital signs were within normal limits.
The fourth patient was alert but confused. He had a large laceration across his nose and trauma to the periorbital areas (no visual deficits). He had other facial lacerations but no airway compromise. This patient had no obvious chest or abdominal trauma, nor pain on physical examination of his cervical, thoracic, or lumbar spine. He did have multiple lacerations and abrasions to his upper extremities, bilaterally. This patient's heart rate was in the 130s, but other vital signs were within normal parameters. Along with these four patients, we were also anticipating the arrival of two to three additional patients from the crash.
Each patient was assessed by our trauma team by using the standard primary and secondary assessment as recommended by the American College of Surgeons Committee on Trauma's Advanced Trauma Life Support Course for physicians (ATLS) and the Emergency Nurses Association's Trauma Nursing Core Course (TNCC). Blood samples were quickly drawn by the ED nursing team member for the laboratory studies described above. The portable chest radiograph was obtained as part of the primary assessment, and each patient was then prepared for transport to the CT scanner.
The scenario above is common in many EDs. Many institutions have standard panels of diagnostic studies that are ordered for all trauma patients who meet certain activation criteria as well as for other complaints or diagnoses (e.g., chest pain). What does the research tell us about the usefulness of these standard panels? How can nurses, particularly APNs, help to ensure that adequate diagnostic information is obtained while maintaining fiscal responsibility?
Tasse, J. L., Janzen, M. L., Ahmed, N. A., & Chang, R. S. (2008). Screening laboratory and radiology panels for trauma have low utility and are not cost effective. Journal of Trauma, 65, 1114–1116.
The purpose of this study was to evaluate the utility and cost-effectiveness of the standard laboratory and radiographic screening panels used at a level-2 trauma center. Healthcare providers and payers are raising questions about the need for such a broad-based approach in the evaluation and diagnosis of critically ill and injured patients. One rationale for casting a wide net is to reduce the potential for missed injuries that increase morbidity and mortality. In addition, it is well documented that significant incidental findings (e.g., lung mass, horseshoe kidney) are often first identified in these screening studies during trauma (Paluska et al., 2007). In the study, of 289 incidental findings in 848 patients, 144 (49.8%) were considered significant and required immediate management/referral or follow-up within 2 weeks.
DESIGN, SETTING, AND SUBJECTS
This was a retrospective study conducted at a busy (1,500 trauma patients annually) level-2 community trauma center. Only trauma patients were used for medical record review. For the purposes of this study, screening panels were defined as anatomic tests obtained from all trauma patients, regardless of mechanism of injury, history, or severity of injury. Tests ordered on the basis of clinical indications (defined as targeted tests) were not included in the study. The authors defined clinical significance as a finding that led to a change in management of the patient or a result that was abnormal. Clinical significance of each diagnostic test was also defined (e.g., the chest radiograph was considered significant if a pneumothorax, hemothorax, widened mediastinum, or fractures were identified; CBC was significant if the hemoglobin or hematocrit level led to transfusion or if the platelet count was less than 50,000.
During a 3-month period, the medical records of 410 consecutive trauma patients were reviewed and data collected, including injury diagnoses, treatment, outcome, complications, the findings of all screening tests (normal vs. abnormal), charges for the tests performed, and the relevance of findings to the patient's outcome. Data for the screening tests were analyzed for clinical significance or for just being abnormal. Costs of tests with abnormal results, costs for tests that were clinically significant, and potential savings were calculated.
During the 3-month study period, a total of 3,982 “screening” tests were performed on the 410 trauma patients reviewed. Abnormal results were found in 1,292 (32%) of the tests; however, only 253 (6%) of these were considered clinically significant. The authors also reported abnormalities and clinically significant results for each test performed. For example, CBC test was performed on 367 patients, with an abnormal result reported 156 (42%) times. Yet, only once was the abnormality considered clinically significant. Of the 373 comprehensive metabolic panels performed, only 32 (0.08%) had clinically significant abnormalities. Results for serum amylase and CPK (creatine phosphokinase) demonstrated that there is little benefit of having these tests as part of screening panels. There were 341 serum amylase tests performed, of which 39 were reported abnormal values. Of these, none were considered clinically significant. Similar results for serum CPK were found.
When evaluating the actual costs of the tests included in the screening panel, the authors found major opportunities for cost savings. Total cost for the 3,982 screening tests was $417,839. Cost of the 253 clinically significant tests was a mere $36,703, making the potential savings $381,136. The potential savings for unnecessary CBC tests was calculated to be $20,983; serum amylase, $27,444; and serum CPK, $17,150. The greatest area of potential cost savings was with unnecessary comprehensive metabolic panel ($56,391), chest radiograph ($55,851), and cross-table cervical spine ($53, 845). The authors also extrapolated annual total savings of $1,524,544 if tests were selectively ordered rather than as standard panels for all trauma patients.
LIMITATIONS AND GENERALIZABILITY OF THE STUDY
There are several limitations to this study. The data were obtained from a consecutive number of patients over a relatively short period. The authors used a 3-month period from April 1, 2006, through June 30, 2006. In many trauma centers, trauma patient volume significantly increases during the spring and summer months (Rising, O'Daniel, & Roberts, 2006). Extrapolating an annualized cost savings based on the patient volume during these months may result in a projected dollar figure higher than that if the sample had been based on both high- and low-volume periods. A second limitation is the potential for bias. Only the authors were involved in the management of trauma patients during the study period. Results might have been somewhat different had independent reviewers analyzed the data. One could surmise that decision-making/ordering patterns might be different across the full panel of trauma surgeons practicing at this institution. Finally, this study was only conducted at one institution. Replicating this as a multi-institutional study would be challenging because of the variation in standard screening panels as well as the costs and charges for the same diagnostic studies. Despite these limitations, there have been a number of other studies looking at the utility of specific laboratory tests and all have demonstrated similar conclusions.
This study raises several relevant points to consider for APNs. Despite the noted limitations, this study raises the question of cost-effectiveness when patients receive a standard order set. Is there value in obtaining “protocol-based order sets” for specific patient populations? As emergency care providers struggle with becoming more efficient in an increasingly crowded environment, protocol-driven care is one way to help efficiency. Trauma patients, especially those in need of level I or level II trauma center care, typically receive treatment promptly. There may be circumstances when standardization of diagnostic testing facilitates prompt recognition of and intervention for injuries. This study emphasizes the need to consider minimizing trauma panels to those diagnostic tests that have proven utility in the trauma setting.
Most trauma centers, regardless of level of designation/verification, have standard screening tests routinely ordered on trauma patients, particularly those that are the most critically injured and meet the institution's highest level of trauma activation. It could be inferred that there will be some degree of overuse of selected tests in any institution. It is important to determine baseline values, as many trauma patients' medical history is not available on initial examination. Obtaining some standard screening examinations is valuable and may reduce missed injuries or clinically significant laboratory test values, thus impacting outcome.
Does standardization across settings improve care? Standardization has increasingly become the expectation from a care perspective. The Joint Commission emphasizes that standardization reduces the potential for error and missed care opportunities. Facility-specific protocols are often developed because practitioners recognize that they routinely order certain diagnostic tests based on patient complaint although every patient is unique and may need additional laboratory or radiologic studies.
The article we reviewed specifically addressed laboratory studies. In the literature, the use of broad-based radiologic screening continues to be controversial. Proponents of this approach cite depressed/altered mental status, unreliable physical examination, earlier hospital discharge, and the lack of sensitivity of plain radiographs as reasons for the use of liberal CT scanning, sometimes called a “pan scan” (Salim et al., 2006; Livingston, Lavery, Passannante, Skurnick, Fabian, et al., 1998; Livingston, Lavery, Passannante, Skurnick, Baker, et al., 2000). Salim et al. (2006) found that out of 592 patients who were pan scanned based on only the mechanism, 120 (20.3%) had a change in their treatment course on the basis of findings of the initial thoracic or abdominal CT scans. Treatment course changed in 19% of the entire patient cohort. In the last decade, the use of plain radiographs, particularly chest and spine radiographs, as a diagnostic modality has been challenged. High-speed, helical CT scanners and the associated software for data manipulation, such as multidimensional reconstructions, now provide the clinician with greater information and higher sensitivity for injury. Manthen et al. (2007) found that plain spine radiographs failed to identify 55.5% of clinically significant cervical spine fractures. Berry et al. (2005) found similar results when evaluating the sensitivity of plain radiographs of the thoracic and lumbar spine in comparison with abdominal CT with a sensitivity and specificity of 100% and 97% for CT scans and only a 73% sensitivity of plain radiographs. Huber-Wagner et al. (2009) found that implementing “whole-body” CT scanning improved the probability of survival in severely injured adult patients with multisystem injuries.
One of the arguments against the approach of pan scanning the critically ill or injured patients is the increased risk for cancer from the associated radiation exposure. The dose of radiation associated with CT scans is significantly higher than that associated with conventional radiographs. Although the increased risk of one full-body CT scan for an adult patient may be relatively modest (0.08%; Brenner & Elliston, 2004), one must consider that over the course of a critical illness/injury or even the adult life span, an individual will likely undergo multiple diagnostic CT scans. The risk to infants and small children is higher (Brenner & Hall, 2007). In today's society, even self-referred whole-body imaging is on the rise (Kalish, Bhargavan, Sunshine, & Forman, 2004). With a health conscious society, individuals may access this technology multiple times, making it even more difficult to accurately predict the increased cancer risk in some persons.
A second argument against broad-based radiographic screening is certainly resource utilization and cost. One must question if the data will be clinically useful to decision making. In a study of ED patients with altered mental status, a chest radiograph is part of the standard diagnostic workup. In 83 of 100 patients, the chest radiograph did not contribute to the management of the patient (Birkemeier, Nipper, & Williams, 2008). In the study by Salim et al. (2006), the authors predicted a cost savings of approximately $2,000 per patient had stricter guidelines been followed.
BETH'S BRIEFS: THE ROLE OF THE APN
As our technology and capabilities for rapid diagnostic testing increase, we must be keenly aware that just because a new technology is available does not mean that it is necessary for good patient care. The article reviewed specifically focused on the cost-effectiveness of screening laboratory studies. On the basis of this and other studies, the use of broad-based laboratory screening panels may not be cost-effective. However, when considering the utility and cost-effectiveness of broad-based radiographic screening, the jury is still out. Certainly, in the critically ill or injured patient who is unable to cooperate/participate in the examination process, broad-based diagnostic studies may provide clinicians with useful information. In the patient who presents with only minor injuries or is hemodynamically stable, a directed approach to diagnostic screening based on history and physical examination may be more appropriate. The APN plays a key role in developing and evaluating diagnosis/complaint-specific protocols that are both clinically beneficial and cost-effective.
The APN's knowledge of both facility-specific protocols and interpretation of lab values as they relate to each specific patient is important in ensuring optimal outcomes for the trauma patient population. Initial diagnostic findings may provide adequate data or could indicate that additional investigation is needed.
Laboratory and radiologic study results often contribute to an increased length of stay in an already crowded department (Bradley, 2005). The availability of the APN to follow up on care initiated through protocols may reduce some of the associated delays and improve throughput. Communication and coordination of care are important roles of the APN. Early consultation with specialists, coordination with ED and inpatient charge nurses, and initiation of admission orders may reduce ED length of stay. Communication with the patient and family regarding illness/injuries and the plan of care often bridges the gap among the multiple specialists frequently involved in the management of a patient. APNs have demonstrated improved patient and family satisfaction in a variety of settings (Kleinpell, 2005; Laurant, Reeves, Hermens, Braspenning, Grol, & Sibbald, 2005).
APNs should play a key role in the development, implementation, and evaluation of diagnosis-specific protocols. The APN has the knowledge base to evaluate the evidence as protocols are developed. Education of staff, both nursing and medical, along with monitoring of adherence to protocol use are other important functions of the APN. The APN is often considered the “consistent” team member in a department or service that is frequently in a constant state of transition with new residents, medical students, and even attending physicians.
Finally, once a protocol is implemented, the APN is instrumental in the evaluation, revision, and reevaluation of the protocol. APNs have the research foundation and statistical insight to evaluate protocols for utility and cost-effectiveness.
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