An Institutional Experience of a Traditional Workflow from a Level I Trauma Center in the USA

Executive Summary

This white paper explores the traditional workflow for bedside skeletal traction in the emergency department, identifies key inefficiencies and their impact, and highlights a modern solution to improve the process. By addressing these inefficiencies and adopting a streamlined solution, trauma facilities can ensure timely and effective care for patients, control costs and emergency department throughput, and optimize residents’ time. 

Introduction

Skeletal traction is a crucial procedure performed in the emergency department (ED) for patients suffering from femur fractures, pelvic fractures, and hip dislocations to manage pain and stabilize a bone or joint before surgical repair in the operating room (OR). Unfortunately, the traditional workflow for bedside skeletal traction in the ED is cumbersome and inefficient, leading to delays in patient care, increased and prolonged pain and discomfort for patients, and additional strain on an already overburdened healthcare system. 

Traditional Workflow Steps

The following is a step-by-step overview of a traditional workflow for bedside skeletal traction at a Level I trauma center in the US¹ (Figure 1). This workflow was recorded by a fifth-year resident (PGY-V) and is based on the experiences of both themself and their colleagues:

Figure 1. Traditional workflow for bedside skeletal traction in the emergency department at UC Irvine

Identified Inefficiencies & Impact

Equipment Availability and Delays

The largest source of inefficiency throughout this procedure is time delays due to searching and waiting for equipment. On average, residents spend 45 minutes on a scavenger hunt searching and waiting for equipment, assuming all equipment is available, easily located, and in good working condition^2,3,4,5,6. Delays in the ED cost an average of $10-$30 per minute in salaries and lost revenue, bringing this financial burden to $450-$1,350 per case^2,3,4,5,6. Some of these delays can take many hours on occasion and may increase significantly due to factors such as:

• The required equipment, including power systems and Kirschner bows, may be unavailable to the ED initially due to their use in the OR
  • Conversely, if this equipment is in use in the ED, it may be unavailable for the OR therefore causing costly OR delays at $46.04 per minute⁷.
  • Facilities that use off-the-shelf power tools (DeWALT^®, Milwaukee^®, Makita^®, etc) to avoid OR power delays put the patient as risk of infection and are violating sterilization standards set by the Joint Commission, jeopardizing the facilities accreditation status^8,9
• The required equipment, such as traction beds and frames, are used in multiple locations in the facility and therefore
  • May be in use elsewhere and unavailable for the ED
  • May take longer to locate

Equipment in Poor Working Condition

Since this equipment is so frequently used, especially Kirschner bows between both the ED and OR, it often arrives to the ED damaged and unusable. Not only does this create further delays as providers wait for replacement equipment, but it risks substandard care for the patient if the equipment is not performing to the standard expected of it. Instances of deficient or substandard equipment condition commonly include:

• Traction bed frames become easily bent or damaged due to improper storage
  • Becoming difficult to assemble
  • Causing weight to hang improperly, therefore applying insufficient traction
  • Residents often “jerry-rig” solutions when frames are damaged 
• Traction weights are a suboptimal solution to apply traction
  • Weights are often stored on the ground and become dirty and damaged, which negatively impacts both the brand of the facility and patient experience by risking infection if providers are handling dirty weights while treating their patient
  • Weights are clunky and risk injuring providers if dropped during collection or hanging to apply traction
• Kirschner bows become easily bent or damaged due to frequent use
  • Allows for easy bending and difficulty securing to the traction pin
  • Cause traction pins to slip behind the locking arms, therefore not being securely held by the bow (Figure 2b)
  • Locking teeth become easy stripped (Figure 2c) and no longer securely hold the traction pin, potentially causing slippage, pin bending, skin tearing, and bone fracture

Figure 2. a) Proper tolerance on one arm of a Kirschner bow securely grabs a pin, b) poor tolerancing allowing traction pin to fall behind the arm, c) damaged teeth on locking arm causing pin to slip

Ineffective use of Care Provider Time

For bedside skeletal traction procedures in the ED, residents spend more time searching for equipment than they do performing the procedure⁶. Once they start their scavenger hunt, they begin to involve other staff members including nurses, techs, and other primary care providers. This creates a knock on effect, where the ineffective use of a resident’s time impacts the efficiency of providers and staff members from around the entire facility and leads to:

• Patients having to wait in the ED with untreated injury until the resident gathers all equipment
  • Patient suffers, which can also cause stress to other patients that are waiting to receive care
• Residents treating less patients
  • Residents do not spend as much time learning how to perform procedures
  • Slow patient treatment directly impacts ED throughput and revenue generation

Inefficient Patient Transfers

Patients that require skeletal traction must be transferred from their original bed to a traction bed when the resident is ready to begin the procedure. This can cause many complications, waste time, and create logistical inefficiencies, including:

• Transferring a patient with an untreated injury can cause an increase in morbidity and mortality¹⁰
• Transfers between traction beds post procedure may require a provider to disassemble the bed frame from the original bed, move it to the new bed, and rehang the weight
  • The patient is taken out of traction, causing more pain and discomfort
• Providers must ensure the bed with the traction frame can safely fit within their elevators when they need to move a patient post procedure to a different part of the facility
  • Otherwise, they must find a different elevator that can accommodate the length of the traction bed, which may not be near the ED

Costly Sterilization of Equipment

Skeletal traction in the ED requires the unplanned usage of sterile equipment including power systems, pin trays, and Kirschner bows which must be requested from the sterile processing department (SPD). This contributes to added cost and procedural inefficiencies including:

• Equipment shared with the OR may not be available for the ED
• The equipment must be reprocessed after each case before being sent to the ED/OR
  • It must be returned to SPD for processing, cleaning and resterilization, which costs an average of $105 per tray¹¹
  • The unplanned usage of this equipment in the ED adds additional burden to an already overburdened department¹²

Lack of Streamlined Procedure

Skeletal traction at the bedside in the emergency department lacks a standardized and streamlined procedure and can cost an average of $1,744 to complete per patient, when considering wasted time, resources, and departmental burdens^{3,4,5,6,11,,13,14,15}. This missing continuity of care creates inefficiencies that negatively impact patient throughput in the ED, such as:

• Requiring five staff across four departments, including orthopaedics, nursing, sterile processing, and bed control
• Residents spending an average of 45 minutes and taking up to 10 trips to gather equipment
  • This delays patient treatment which can prolong the time a patient spends in pain
  • Multiple trips in and out of the trauma bay may stress the patient as they become unsure when they will receive care 
  • This also increases the chance of frustrated family members interrupting providers work to inquire about care time, further delaying when the patient can receive care
• Negatively impacted ED throughput produces increased risk of higher mortality and morbidity rates for patients
• Reduced preparedness to handle mass casualty scenarios presenting high patient volumes can lead to a domino effect of negative impacts across all departments of a facility and put multiple patients at risk

Solution

TrakPak® is a modern solution for bedside skeletal traction in the ED that addresses every pain point that exists with the traditional workflow. TrakPak® consists of a reusable FDA approved DeWALT^Ⓡ pin driver that requires no sterile processing, and a low cost procedure kit that includes everything needed for bedside skeletal traction, except for lidocaine and gloves (Figure 3). With TrakPak®, a single provider is able to place a patient in skeletal traction without involving bed control or sterile processing. 

Figure 3. The contents of the Power System and Procedure Kit for TrakPak®

Eliminate the Scavenger Hunt and Equipment Delays

TrakPak® is stored in the ED and includes everything needed for bedside skeletal traction, except for lidocaine and gloves, shortening equipment gathering time to just minutes by removing the need to travel to SPD to collect trays, or search the facility for traction frames and weights. TrakPak® guarantees equipment availability for skeletal traction procedures and completely eliminates delays caused by equipment availability issues through:

• An FDA cleared DeWALT^Ⓡ pin driver replaces traditional sterile OR power
• A single use tension bow, QuikBow®, replaces Kirschner bows
• QuikLine™ system that eliminates bed frames and allows for weight to be hung off the end of any bed

Improved Equipment Design

Every TrakPak® procedure kit includes a 2mm fine traction wire with a quick connect system, and a new fully functional QuikBow® that renders traditional k-bows and traction bed frames obsolete. This improved equipment design provides many benefits to both patients and providers, such as:

• Fine wire traction is easier to perform and is better for patient care
  • The proprietary quick connect system allows for a resident to connect the traction wire to and remove it from the pin driver with one hand in a matter of seconds (Figure 4)
  • 2 mm fine wires leave a smaller hole in the patient’s bone compared to larger 4mm+ thick traction pins, reducing the risk of pin site fracture
    • Some facilities switch to thicker pins to avoid using Kirschner bows as weight can be hung directly from a thick pin

Figure 4. Quick connect drill and pin system allow for easy connection/removal of the traction pin

• QuikBow® is secured to the traction wire by two spring loading locking cams (Figure 5)
  • This allows for a single provider to apply traction 
  • When the user releases the locking levers, the spring loaded cams automatically grab onto the traction wire

Figure 5. Spring loaded cams on QuikBow® that automatically secure to the traction wire

• QuikLine™ uses two ropes connected to the underside of the QuikBow® and to a water bag at the other end to apply traction
  • The water bag is hung over the end of any bed, with or without a footboard (Figure 6a)
  • Applying traction will lift the bow off of the tibia, preventing pressure ulcers (Figure 6b)
  • The height of the water bag is easily adjustable on the QuikLine™ ropes to ensure it is not resting on the ground

Figure 6. a) QuikLine™ being used on a bed with a footboard. b) QuikBow® lifting off the tibia when traction is applied

Optimize Residents Time

Residents are more efficiently able to place patients in traction and can use their saved time to treat other patients. Their ability to administer care to other patients improves ED throughput, potentially freeing up patient beds sooner. This also provides residents with more opportunity to learn as they have the time to experience more cases. 

Simplify Patient Transfers

QuikLine™ eliminates the need for traditional traction bed frames which simplifies patient transfers, meaning that:

• Patients can be transferred between beds by guiding the ropes while the patient is being transferred
  • Allows for the patient to remain in traction during the transfer since the provider can manually pull on the QuikLine™ ropes. 
  • QuikLine™ can also be easily unclipped while the patient is being transferred and then re-secured in seconds
• Patients can be moved around the hospital utilizing any elevator that is large enough for a standard patient bed since QuikLine™ does not add any extra length to patient beds

Eliminate Sterile Processing

TrakPak® requires no sterile processing, saving time and cost for skeletal traction procedures through:

• The FDA cleared DeWALT^Ⓡ pin driver is covered with the sterile drape included in the TrakPak® procedure kit in order to be used sterilly at the bedside
  • The drape can be disposed of after the case and the pin driver can be cleaned with a disinfectant wipe before being returned to its bag for the next case
• Every item in the procedure kit is consumable and requires no reprocessing
  • The QuikBow® is made of a bio-based polymer and can be disposed of with the rest of the supplies
  • Arbutus Medical also offers a QuikBow® recycling program at no cost to the facility

Streamline the Procedure

TrakPak® provides facilities with a standardized and streamlined procedure for skeletal traction in the ED (Figure 7), which provides many benefits including:.

• Allowing for a solo provider to place a patient in skeletal traction without involving sterile processing or bed control
• Saving residents over 45 minutes searching for equipment and letting them instead focus on patient care

Figure 7. Time savings using TrakPak® for bedside skeletal traction procedures

Considering the cost of TrakPak®, time to gather and open supplies, and time to apply traction, the procedure would cost only $1,129 per case, saving facilities $615 over traditional methods (Figure 8).

Figure 8. A cost summary table highlighting the potential savings with TrakPak®

Conclusion

The traditional method for skeletal traction in the emergency department is inefficient in personnel, equipment and resources, time, and cost, which ultimately lead to a decreased standard of patient care and a financial burden on the facility. Adopting a modern solution for skeletal traction in the emergency department that streamlines the procedure by eliminating delays and searching for equipment, simplifies the procedure, and reduces the amount of personnel and departments involved will allow facilities to control costs and ED throughput, ultimately improving patient care and maximizing revenue. 

Disclaimer: The costs used in this analysis are for illustrative purposes only, and may vary. Costs may change over time and may vary depending on geography. Please contact Arbutus Medical if you require assistance in conducting your hospital’s own cost analysis of skeletal traction.

References

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