ST. JOSEPH S HOSPITAL AND MEDICAL CENTER TRAUMA OPERATIONAL MANAGEMENT GUIDELINES

Transcription

1 ST. JOSEPH S HOSPITAL AND MEDICAL CENTER TRAUMA OPERATIONAL MANAGEMENT GUIDELINES Revewed/Revised January 2013

2 Trauma Team Activation Level I Trauma Patient Identification PAGE 1 of 2 February 1983 January 2013 DATE PURPOSE: The Trauma Team is activated to assure an immediate, highly skilled response to major trauma patients (Level I Trauma patients) who are transported to the hospital by ground and air ambulance as well as by private vehicle. GUIDELINES: 1. The Emergency Clinical RN Supervisor or designee RN receives the prehospital notification of trauma patient transports and utilizes Level I Trauma Activation Criteria to activate the trauma team. The ED RN answering the patch on all Level I trauma patients completes the Patch Form. 2. For qualifying patients, the ED Clinical Supervisor or designee activates the Trauma Team by calling the Operator on the code line. Trauma Team I (one patient in the trauma room) or Trauma Team II (more than one patient in the trauma room) should be specified when calling the operator. Or Trauma Team Red (Inclusion criteria: CPR in progress; compromised airway in the field; unstable vital signs; gross deformity or penetrating injury to the head; penetrating injury to the chest, abdomen, or pelvis; crush injury to chest or pelvis; pulseless injured extremity; amputation excluding digits; pregnant patient with signs of abruption; GCS < 8; Quadriplegia; Hot offload from helicopter). 3. For qualifying patients with greater than 5 minutes ETA, the Trauma Clinician is immediately contacted by phone regarding the EMS transport. The ED RN and Trauma Clinician confer on the timing of paging the Trauma Team. 4. The outside facility will contact the Transfer Center by calling BEDS) for requests for interfacility transfers of trauma patients 5. The Trauma Team is activated for all of the following (Level I Trauma patients): A. Blunt and penetrating trauma with the following physiological findings: Measure VS and LOC GCS < 14 or, Systolic BP < 90 mmhg (80mmHg<age 8) or, Respiratory <10 or >29 or, < 20 in infant aged < one year B. Injured patients with anatomy of injury as follows:

3 All penetrating injuries to head, neck, torso, and extremities proximal to elbow and knee Flail chest Two or more proximal long bone fractures Crushed, degloved or mangled extremity Amputation proximal to wrist and ankle Pelvic fractures Open or depressed skull fracture Paralysis C. Mechanism of injury as follows: Falls Adults: > 20 feet (one story is equal to 10 feet) Children: > 10 feet or two or three times the height of the child High Risk auto crash Intrusion: > 12 inches, occupant site; > 18 inches, any site Ejection (partial or complete) from the vehicle Death in same passenger compartment Vehicle telemetry data consistent with high risk of injury Auto vs. Pedestrian/bicyclist thrown, run over, or with significant ( > 20 mph) impact. Motorcycle crash > 20 mph D. Age Older Adults: Risk of injury/death increases after age 55 years Children: should be triaged preferentially to pediatric-capable trauma centers Anticoagulation and bleeding disorders Burns Without other trauma mechanism: Triage to burn facility With trauma mechanism: Triage to trauma center. Time sensitive extremity injury End-stage renal disease requiring dialysis Pregnancy > 16 weeks EMS provider judgment

4 Trauma Team Member Response PAGE 1 of 2 February 1983 January 2013 PURPOSE: The Trauma Team is activated to assure an immediate, highly skilled response to major trauma patients who are transported to the hospital by ground and air ambulance as well as by private vehicle. GUIDELINES: 1. The Emergency Physician, the ED Clinical RN Supervisor or the Trauma Clinician or ED RN designee activates the Trauma Team based on the EMS report and the condition on arrival of trauma patients. The Emergency Physician participates on the Trauma Team as dictated by the situation. 2. The Trauma Team is notified by pager and overhead paging system (until 10:00 pm) according to the Emergency Department Trauma Team notification process. (See Trauma Team Activation Guideline). 3. The in house Trauma Team includes two primary teams, Trauma Team I and Trauma Team II. The goal of the team response is to be present at the time of the patient s arrival to the Trauma Room. Response times are based on a minimum of a five-minute pre-notification by pager and overhead announcement. 4. The following members respond to the Trauma Room for Trauma Team I activations: A. Trauma Surgeon (1) B. Trauma Anesthesiologist (1) C. Physician Surgical Assistant / Trauma Residents (1-4) D. Trauma Nurse Clinician (1) E. Emergency Department Trauma Nurse (1) F. OR Nurse (1) G. Emergency Department Patient Care Technician (1) H. Radiology Technician (1-2) I. Respiratory Therapist (1-2) J. Phlebotomist (1) K. Emergency Department Social Worker / Clergy (1) L. Security (1)

5 The following additional members respond when there are two Level I Trauma Patients in the Trauma Room Trauma Team II : A. SWAT RN (1) B. Additional scheduled RNs (ICU, ED, SWAT) (1) 5. The following additional members respond when notified for more than two Level I Trauma patients in the Trauma Room: A. Additional Phlebotomist B. Additional Respiratory Therapist C. Additional Radiology Technician D. Available RNs 6. For Pediatric trauma patients additional team members include: A. Pediatric Intensivist (1) B. Pediatric ICU Nurse (1) 7. For OB trauma patients who are seen in the Trauma Room additional team members include: A. Chief OB Resident / or in-house attending (1) B. OB Nurse (1) C. NYICU code arrest team for newborn resuscitation in emergency C-sections in the Trauma Room 8. For multiple Level I Trauma patients additional specialty Trauma Team members are called to the Trauma Room as needed by the Trauma Clinician.

6 Inter-facility Transfer of Burn Trauma PAGE 1 of 1 August 1985 January 2013 PURPOSE: To identify burn trauma patients who require transfer to a Burn Center for a higher level of care. GUIDELINES: 1. Trauma patients presenting to the hospital with burns of over 20% of their body will be stabilized and transferred to the closest Level I Burn Center in accordance with the transfer agreement between the facilities. 2. No patient will be transferred to another facility without acceptance by an appropriate specialty physician at the receiving facility. Hospital policy on inter-facility transfers will be followed. 3. The current ATLS standards will be followed for stabilization of burn patients prior to transport to a higher level of care.

7 Diversion of EMS Transport of Level I Trauma Patients PAGE 1 of 2 July 1993 January 2013 PURPOSE: To identify criteria for diversion of EMS transports of Level I Trauma patients from the Trauma Center GUIDELINES: 1. The current hospital policy on Admitting and Receiving Patients will be followed for determining the need for diversion of EMS transport of Level I Trauma patients from the Trauma Center. A. The decision to initiate diversion of EMS transports for Level I Trauma patients can only be made by the Administrator on call or designee, based on the following criteria: Trauma surgeon resources are fully committed i.e. the surgeon, backup and Medical Director or designee are all in-house and in the OR; or anesthesia and their back-ups are all in the OR; or the Trauma Team is saturated with patients and unable to respond to additional Level I trauma team activation s. All CT scanners are down and CT is unavailable An internal disaster has been formally declared (i.e. fire, power or other major plant failure) The prioritization for hospital closure has been followed and fully committed hospital resources have resulted in closure to all admits and closure to EMS transports of general patients to the Emergency Department and Trauma Room due to fully committed ED and Trauma Team resources holding patients for admission 2. All situations which may warrant consideration of diverting EMS transports of Level I Trauma patients should be immediately communicated to the Administrator on Call who will consult with the Medical Director of the Trauma Service or his designee to determine other options. 3. Emergency Department personnel, Trauma Clinician or the Trauma Surgeon on duty may not unilaterally place the hospital on formal diversion of EMS transports for Level I Trauma patients. 4. Emergency Department personnel, Trauma Clinician or the Trauma Surgeon on duty may not informally divert EMS transports of Level I Trauma patients either upon radio contact or arrival at the hospital.

8 5. All patients identified in the field and transported to the hospital as Level I patients will receive a full physical examination by the Trauma Service, with documentation of findings on the Emergency Level I Trauma Flow Sheet. If the Trauma Surgeon feels upon arrival that the patient meets Level II criteria, he will follow the proper procedure for downgrading (see Trauma ED/Triage Assessment Form Guideline for downgrading/upgrading). 6. Initiation of diversion of EMS transport of Level I Trauma patients from the hospital will be fully documented by the Administrator on call, or the House Manager on the appropriate reporting forms. The Emergency Department Clinical Supervisor will update the EMSystem appropriately and in a timely manner. 7. The first trauma surgeon and anesthesiologist to become available will notify the Trauma Clinician when they are out of surgery and available. The Trauma Clinician will notify the ED Clinical Supervisor so they may inform the house supervisor and update the EMSystem in a timely manner. 8. All initiations of the diversion of EMS transports of Level I Trauma patients will be reviewed by Trauma Administration and reported monthly at Trauma Committee.

9 Patient Care Guidelines for Resuscitation and Management of Level I Trauma Patients PAGE 1 of 1 January 1999 January 2013 PURPOSE: To provide patient care guidelines for resuscitation and management of the Level I Trauma Patient. GUIDELINES: 1. The current (2006) American College of Surgeons Committee on Trauma, Advanced Trauma Life Support (ATLS) patient care guidelines are the accepted guidelines for trauma resuscitation and management in the following circumstances: A. Initial Assessment and Management B. Airway and Ventilatory Management C. Shock D. Thoracic Trauma E. Abdominal Trauma F. Head Trauma G. Spine and Spinal Cord Trauma H. Musculoskeletal Trauma I. Injuries Due to Burns and Cold J. Pediatric Trauma K. Trauma in Women

10 Consent for Level I Trauma Patient Treatment PAGE 1 of January 2013 PURPOSE: To define the use of consents for treatment of Level I Trauma Patients GUIDELINES: 1. The St. Joseph's Hospital & consent policy applies to Level I Trauma Patients during initial resuscitation and hospitalization. 2. Consent for emergency treatment and diagnostic studies in the Trauma Room are obtained following guidelines set forth in the Arizona Hospital Association Consent Manual. Generally, care in the Trauma Room and inpatient trauma care units requires adult consent, with the following exceptions: A. Life saving measures will be instituted whenever indicated without express consent. B. Unconscious patients brought into the Trauma Room will be treated immediately under the responsibility of the Trauma Surgeon. C. Emancipated minors may give consent for their own treatment. 3. The Physician s Certificate of Emergency and Medical Necessity (X-MR-5655) will be instituted when the physician judges that the patient s condition/situation constitutes and emergency and it is impossible to obtain the express consent of the patient or the patient s legally authorized representative. Two physicians are required to sign this form. When the Physician s Certificate of Emergency and Necessity form is utilized the circumstances creating the need for OR are clearly documented.

11 Universal Precautions in the Trauma Room and Bedside PAGE 1 of 1 January 1993 January 2013 PURPOSE: To define the proper use of personal protective equipment to protect trauma team caregivers in the Trauma Room and bedside care givers in nursing units and treatment or diagnostic areas from exposure to blood born pathogens. GUIDELINES: 1. The current hospital policy on universal precautions will be followed by Level I trauma patient caregivers in the Trauma Room and other patient treatment and diagnostic areas. A. Resuscitation team members will utilize the following in cases in which blood is present: Eye wear/masks Shoe covers Hats Gloves Gowns/Aprons and other Protective Clothing B. Specimens will be transported for processing in closed-labeled containers C. Sharps will be handled and disposed of according to policy D. Hand washing or the use of hand gel will occur after removing gloves E. Supplies will be kept on carts away from the immediate patient treatment areas.

12 Radiation Protection in the Trauma Room and Bedside PAGE 1 of 1 January 1992 January 2013 PURPOSE: To protect trauma team caregivers in the Trauma Room and bedside care givers in nursing units from radiation. GUIDELINES: 1. Lead aprons/shields will be worn by: A. Resuscitation team members, others in the Trauma Room and other caregivers outside of the trauma room in nursing units especially those persons who can not move away from the immediate area when x-ray tech announces x-ray B. Pregnant females, female patients of child bearing potential (10-50 years) and males under age Lead aprons must be hung up carefully as they are easily cracked. Cracks in the apron allow radiation to penetrate to the wearer. Any cracked aprons should be reported to the x-ray technician immediately. 3. Lead thyroid shields are either attached to the apron, and may not be cut off, or are available on request.

13 Trauma Team Preservation of Evidence PAGE 1 of 2 December 2002 January 2013 DATE PURPOSE: For preservation of the chain of evidence. GUIDELINES: 1. CLOTHING/BELONGINGS: Should never be turned over to the family without clearance of law enforcement If possible, do not cut clothing. However, if unavoidable, do not cut through bullet holes or knife holes if possible. Also, avoid any stains or defects. Do not throw clothing on the floor. If possible air dry clothes, then fold and place into separate paper bags. Try to not place clothing in plastic bags. Label all with victim s name, date, and time. Never throw away any patient belongings, this includes: blood stained clothes or soiled clothing, hair shaved in preparation of an ventriculostomy, etc. Any suspicious contraband will be turned over to hospital security for safe- keeping until the appropriate police department can pick it up. 2. BULLETS: Can be found in clothing.. Wrap in cotton or gauze, place in container and label with patient s identification. Do not mark on the bullet itself. Bullet wounds - do not wipe off the soot around the wound until investigators can photograph it, if at all possible. 3. DEATH AT THE HOSPITAL: Do not wash the body Do not remove any treatment paraphernalia that was inserted in the Trauma Room Should the case involve a suspected homicide, do not allow any family members to touch the body. Not even if the victim is a child. 4. TRAUMA ROOM AS THE CRIME SCENE: If an individual dies in the community and is brought to the hospital DOA the trauma room is the crime scene.

14 5. REPORTABLE DEATHS: Injuries by lethal weapons, self-inflicted injuries, overdoses, poisonings, suspected criminal abortions, animal bites, all DOA s deaths due to blood transfusions, falls, blunt force or crushing injuries, stabbing and sharp force injuries, firearms, electrical shock and lightning, explosions, strangulations and asphyxia, MVCs, drug overdose and poisonings, burns and fires, stillborn or newborn infants, rapid fatal illness, occupational deaths. Not every death referred to the ME will be autopsied. However, if the ME accepts jurisdiction for examination of the decedent, the family (next of kin) will not have a legal right to grant or deny permission for an autopsy. 6. GSW TO THE HEAD: If there is reason to believe the wound is self-inflicted, cover both hands with paper bags and tape around the wrist.. Try to obtain from the patient s family whether the patient was right or left hand dominant. (Right handed vs. left-handed)

15 Trauma Room Lock Box Guideline PAGE 1 of 2 January 2002 January 2013 REVISED PURPOSE: To define a process for the identification, documentation and securing, and protection of valuables belonging to the Trauma Room patient. Valuables are defined as money, jewelry, credit cards, car keys, and wallet. GUIDELINES: 1. The Trauma Room Scribe will collect and inventory all patient valuables and list them correctly on the Trauma Room Documentation Form. 2. Next, the valuables must be documented on the (White) Patient s Valuables Deposit Form. 3. After the Registrar obtains the patient s insurance information, the Valuables Deposit Form will be separated and the yellow copy will be sent with the patient s chart. 4. The white copy of the Valuables Deposit Form will be folded in half and inserted into the clear plastic area on the front of the (Silver) Valuables Packet with the patient s name and account number in clear view. It is important that the part of the form listing the valuables not be shown. The yellow copy goes on the patient s chart and the pink copy accompanies the patient s belongings to the floor or morgue. 5. The Trauma Room Scribe will document the date, 7 digit Valuables Packet number, patient s name, Medical Record number and the initials of the Trauma Room Scribe securing the valuables, in the Trauma Room Ledger Book. 6. The Valuables Packet can now be sealed and dropped into the Lock Box in the Trauma Room. 7. Security is responsible for sending 2 security officers to pick up the valuables twice a day and document the date, time, and signature of the security officer obtaining the valuables, legibly, on the Trauma Room Valuables Ledger Book. 8. It is important to include documentation of any valuables received from a prehospital provider on the trauma documentation form. 9. If more patient belongings are found after the Valuables Packet has been placed in the Trauma Room Lock Box, another Packet must be started and documented in the Ledger. Do not attempt to open the lock box and reopen the first Valuables Packet. 10. All other patient belongings that are not considered valuables should be sent in a clearly identifiable (labeled) patient belonging bag and sent either to the floor or to the morgue with the patient. (Clothing, cell phones, pagers, shoes, dentures, eyeglasses, etc.) NEVER THROW AWAY ANY CLOTHING OR PATIENT BELONGINGS! 11. If a police officer requests the patient s valuables and/or belongings for evidence, document items taken on the trauma room documentation form and have the officer sign the form. Also document the police officer s name and badge number in the appropriate area of the Trauma Room Documentation Form. 12. Any illegal substances found in the patient s belongings need to be described in the documentation and given to the Security Officer.

16 13. Valuables may be released to the patient s family member with the patient s permission. If valuables are given to family members this should be documented on the trauma form. Should a family member request valuables Security should be called to do this. 14. Security will come to the Trauma Room and meet the Trauma Clinician to pick up patient valuables at the pre-arranged time. It is important that patient care not be compromised. If there is a patient in the trauma room when Security comes to pick up the valuables they will make arrangements to come back at an appropriate time.

17 Trauma Team Roles Trauma Surgeon PAGE 1 of 1 February 1992 January 2013 NOTIFIED: Trauma Pager and overhead page FUNCTIONS: 1. Given a five (5) minute notification by pager and overhead page, is immediately available in the Trauma Room for the arrival of the Level I trauma patient to coordinate the total care of the patient. 2. Assesses the condition of the patient immediately, and performs or delegates invasive procedures as deemed necessary or clinically indicated to secure airway, establish effective ventilation and treat shock. 3. Defines priorities and orders laboratory and diagnostic tests. 4. Requests additional consultants as clinically indicated. 5. Determines the need to go to the operating room, radiology for computerized tomography or arteriography, and/or the trauma intensive care unit or other nursing unit for ongoing care. 6. Reassesses the patient at the bedside as clinically indicated after review of consulting opinions, diagnostic information and physical finds to determine further disposition. 7. Responsible for ongoing trauma ICU or other nursing unit care, intra-operative care, postoperative care, and follow up. 8. Responsible for notifying the Trauma Clinician and advises to call in the back-up Trauma Surgeon based on the following: The on call Trauma Surgeon is going to the OR with a Level I Trauma or emergent general surgery patient and will be in the OR for > 30 minutes When there are multiple Level I Trauma patients requiring operative intervention When the Trauma Surgeon has an in-patient who warrants a return to the OR for further surgical intervention. External Disaster 9. Collaborates with trauma clinician to ensure patient confidentiality by limiting access of non-trauma team members to the trauma room and protecting the medical record. 10. Reviews Trauma Physician Assessment and Order Form for procedures and diagnostic tests performed, and medications given, then signs the record.

18 Trauma Team Roles Trauma Resident/PA Surgical Assist PAGE 1 of 2 February 1992 January 2013 TITLE: Trauma Resident/ PA Surgical Assistant NOTIFIED: Trauma pager and overhead page FUNCTIONS: 1. Given a five (5) minute notification by pager and overhead page, is immediately available on arrival of the Level I Trauma patient to assist the Trauma Surgeon in coordination of the total care of the patient. 2. Works with the Trauma Clinician to assure an organized approach to trauma care is utilized in the Trauma Room. 3. Assists in immediate and ongoing assessment of the condition of the patient and calls out findings to the Trauma Room Scribe for documentation purposes. 4. Performs delegated invasive procedures as deemed necessary or clinically indicated to secure the airway, establish effective ventilation and to treat shock (Per ATLS guidelines). Calls out procedures and results for documentation purposes. 5. Assists in defining priorities and determining the need for laboratory and diagnostic tests and under the guidance of the Trauma Surgeon, orders tests. 6. Participates in determining the need to go to the operating room, radiology for computerized tomography or arteriography, and / or the trauma intensive care unit or other nursing unit for ongoing care. 7. Performs as the trauma assistant when the patient requires surgical intervention. 8. Reassesses the patient at the bedside as clinically indicated after review of consulting opinions, diagnostic information and physical findings and assists the Trauma Surgeon in determining further disposition. 9. Collaborates daily with the Trauma attending, Trauma Program Manager, Trauma Nurse Practitioner, Trauma Clinician, and the Trauma Social Worker regarding the ongoing care of all Trauma patients currently on the service. 10. Assists the RN with the transport of hemodynamically unstable trauma patients to CT scan, OR, or ICU.

19 11. Remain at the bedside of hemodynamically unstable trauma patients for management of these critical patients and updates progress notes. 12. Responsible for rounding on all trauma patients currently on the trauma service daily and performing and documenting of daily assessments, progress notes, daily orders, and procedures. Also responsible for dictating history and physicals, procedures, discharge summaries, etc. 13. Reviews Trauma Physician Assessment and Order Form for procedures and diagnostic tests performed, and medications given, then signs the record.

20 Trauma Team Roles Trauma Anesthesiologist PAGE 1 of 1 February 1992 January 2013 TITLE: Trauma Anesthesiologist NOTIFIED: Trauma pager and overhead page FUNCTIONS: 1. Given a five (5) minute notification by pager and overhead page, is immediately available in the Trauma Room for the arrival of the Level I trauma patient to assist the trauma surgeon with the care of the trauma patient. 2. Assesses, establishes and maintains the patient s airway. 3. Provides on-going evaluation of the pulmonary and cardiovascular status of the patient. 4. Assists with: Placement and maintenance of monitoring lines Maintenance of intravascular volume Administration of blood products Administration of IV medications 5. Responsible for treatment of arrhythmias and management of ACLS techniques in the event of a cardiac arrest. 6. Provides anesthesia services as needed, for the Level I Trauma patient. 7. Trauma Anesthesia provides backup Trauma Anesthesiologist for multiple patients who require operative procedures simultaneously. The in house Trauma Anesthesiologist is responsible for calling in the back up anesthesiologist. 8. Trauma Anesthesia provides anesthesia services for Trauma Service patients requiring operative procedures after admission. 9. Reviews Trauma Physician Assessment and Order Form for procedures performed and medications given, then signs the record.

21 Trauma Team Roles Emergency Department Physician Role in Trauma Room PAGE 1 of 1 February 1992 January 2013 TITLE: ROLE: Emergency Department Physician Coordinates and directs all prehospital care. Activates Trauma Team and coordinates care and diagnostic procedures until trauma surgeon is present, in the event that the patient arrives prior to assembly of the Trauma Team. NOTIFIED: By E.D. Clinical Supervisor or Trauma Nurse Clinician in person, voice page and / or beeper WHO RESPONDS: The designated Emergency Department Physician FUNCTIONS: 1. Responds to and gives advice as needed to ED Clinical Supervisor or ED RN designee answering the Patch radio console. 2. Immediately available on arrival of the trauma victim to help coordinate the care of the patient if needed as indicated by the Trauma Surgeon. 3. Assesses the condition of the patient immediately in the absence of the trauma surgeon. 4. Provides backup for trauma surgeon in case of multiple victims as requested by trauma surgeon. 5. In the cases of multiple victims in trauma room and/or when second call surgeon has been called in but has not yet arrived, the E.D. physician will manage the care of the patient until the back up surgeon has arrived.

22 Trauma Team Roles Back-up Trauma Surgeon PAGE 1 of 1 February 1992 January 2013 TITLE: Back Up Trauma Surgeon NOTIFIED: Trauma Clinician or Emergency Department Clinical Supervisor WHO RESPONDS: Second Call Trauma Surgeon (Back-up Trauma Surgeon) FUNCTIONS: 1. Provides trauma surgeon coverage to Level I Trauma patients in the event that the in-house trauma surgeon is not immediately available due to presentation of multiple victims or because of responsibilities in the operating room for another Level I Trauma and/or emergent general surgery patient. 2. When the in-house Trauma Surgeon is committed to another patient (s) and cannot respond immediately to care for a major trauma, he or she will notify the Trauma Clinician or Emergency Department Clinical Supervisor to call in the back-up Trauma Surgeon. 3. Trauma Clinician or Emergency Department Clinical Supervisor will notify the second call Trauma Surgeon. The second call surgeon will report to the hospital within 30 minutes of being notified. 4. The Emergency Department physician when requested will respond to care for Level I trauma patients prior to arrival of the back-up Trauma Surgeon. 5. The second call Trauma Surgeon will notify the Trauma Clinician on-duty of his arrival. 6. The in-house Trauma Surgeon will notify the second call Trauma Surgeon and the Trauma Clinician when he is available to resume first call. 7. When both the in-house and the back-up Trauma Surgeons are in the operating room the Trauma Clinician will notify the Medical Director or his designee if additional Trauma Surgeon coverage is required. 8. Reviews Trauma Physician Assessment and Order Form for procedures performed and medications given, then signs the record

23 Trauma Team Roles Trauma Room Nurse PAGE 1 of 2 February 1992 January 2013 TITLE: Trauma Nurse Clinician or Trauma Room Nurse Trauma Team I & Trauma Team II NOTIFIED: Trauma pager, Erickson phone, and overhead page by ED Clinical Supervisor WHO RESPONDS: The designated Trauma Nurse Clinician, Emergency Department RN, SWAT RN, and/or ICU RN FUNCTIONS: 1. Responds to the Trauma Room for Trauma Team Activation to assist in preparation of the arrival of the Level I Trauma patient. Signs in on the Trauma Physician Assessment and Order Form. Trauma Team I activation would include the on-duty Trauma Clinician and the ED RN assigned to the trauma room. Trauma Team II activation would include the SWAT RN and other nursing unit RN assigned by the House Manager. 2. Works with the Trauma Clinician to meet patient care needs. 3. Assists with: Documentation Additional resource allocation Setting up the Trauma Room in anticipation of patient needs Removing the patient s clothing and maintaining temperature of patient and the environment Securing, documenting, and identifying patient belongings Documenting, identifying, logging and securing patient s valuables in lock box Assuring venous access and securing blood samples IV fluid and blood administration Central line insertion Arterial line placement Chest tube and drainage system set up autotransfusion Urinary catheterization DPL Open chest procedures Splinting Other patient care

24 Transporting of Level I trauma patients for diagnostic procedures and to the OR, or to a patient care unit as well as providing patient report Preparation of Trauma Room for next patient in assembling supplies, trays and other equipment as indicated by the prehospital report. 4. Assist in assuring Trauma Team utilizes personal protection as directed by the case. 5. Assumes the role of scribe if other staff is unavailable and assures complete documentation on the Trauma Room patient record. 6. Assists the Trauma Surgeon with coordination of the Level I Trauma patient s care. 7. Applies correct Trauma patient identification band to patient s extremity immediately upon arrival to the Trauma Room. 8. Assures the Trauma Room patient record is thoroughly completed and signed, and a copy of the Trauma Room report is put in the designated area for Trauma Administration.

25 Trauma Team Roles Operating Room Nurse PAGE 1 of 1 February 1992 January 2013 TITLE: Operating Room Trauma Nurse NOTIFIED: By beeper and overhead page WHO RESPONDS: The designated Operating Room RN FUNCTIONS: 1. Responds to the Trauma Room when notified of a Level I Trauma and signs in on the Trauma Physician Assessment and Order Form. 2. Stands by to assist in the care of the trauma patient as needed, i.e., Trauma Scribe, any emergency surgical or invasive procedure to be done in the trauma room, other care requested by the Trauma Clinician or the ED Trauma Room Nurse. 3. Consults with Trauma Surgeon as to necessity of trauma operating room. 4. Knows which operating room is available for trauma. If the trauma operating room is needed, relays information to the operating room staff and returns to assist in setup if not needed in trauma room for emergency surgical procedures. 5. If assisting as Trauma Scribe, reports to Trauma Room Nurse on status of documentation prior to leaving the Trauma Room. 6. Assumes normal RN duties for Level I Trauma cases in the OR.

26 Trauma Team Roles Trauma Room RN Scribe PAGE 1 of 2 February 1992 January 2013 TITLE: Trauma Room RN Scribe NOTIFIED: Trauma beeper, overhead page, Erickson Phone WHO RESPONDS: The Trauma Clinician or ED RN, OR RN, or SWAT RN FUNCTIONS: 1. Obtains information from individual receiving patch information for prehospital events and treatment, and from prehospital providers on arrival. 2. Completes the Trauma Room patient record: A. All team members and arrival times B. Brief etiology of the injury including medic agency name and field treatment C. The patient s condition on EMS arrival D. Treatments and procedures rendered, times and outcome E. Medications given, times and the results F. All diagnostic tests ordered completed including times G. All other documentation applicable to the patients care and assures Trauma Room patient record is complete 3. Assists in limiting access to the trauma room to team members only. 4. Documents patient s personal belongings and assists in valuables documentation process per Trauma Valuables Guideline. 5. Responsible for contacting the Blood Bank for: Ordering of uncrossmatched O Negative red blood cells on assigned trauma patient. Accepting blood bank blood cooler containing uncrossmatched O Negative red blood cells. Having Emergency Release Form completed and signed by RN or Physician and ready for blood bank personnel upon their arrival with the uncrossmatched red blood cell. 6. If not the ED Trauma Nurse or Trauma Clinician, when leaving the Trauma Room hands-off Trauma Room patient record to Trauma Room Nurse to complete. 7. Contacts bed placement for bed assignment. 8. Signs in on Trauma Physician Assessment and Order Form

27 Trauma Team Roles Radiology Technician PAGE 1 of 1 February 1992 January 2013 TITLE: Radiology Technician NOTIFIED: Trauma beeper, overhead page WHO RESPONDS: The designated Radiology Technician FUNCTIONS: 1. Assures radiology equipment in the Trauma Room is operational for Level I Trauma cases. 2. Coordinates the standard Trauma X-ray exam(s) with the emergent care of the patient. Performs other studies as directed by the Trauma Surgeon. 3. Notifies Trauma Team of X-ray exam(s) with the emergent care of the patient. Performs other studies as directed by the Trauma Surgeon. 4. Notifies Trauma Team of x-rays being performed by announcing XRAY and type of x-ray prior to taking a film. 5. Notifies the Trauma Surgeon when the films have been completed. 6. Requests back-up from radiology department for multiple Level I Trauma Patients. 7. Responsible for inventorying and restocking of xray contrast solution used for diagnostic radiology procedures in the Trauma Room Omnicells. 8. Signs in on Trauma Physician Assessment and Order Form

28 Trauma Team Roles CT Technician PAGE 1 of 1 January 2002 January 2013 TITLE: CT Technician NOTIFIED: Trauma beeper, overhead page WHO RESPONDS: The designated CT Technician FUNCTIONS: 1. Assures radiology equipment in the CT ED/Trauma Room area is operational for Level I Trauma cases. 2. Assures there are an adequate number of protective aprons, thyroid shields and gloves available in good condition in the CT Room. 3. Verifies patency of IV site prior to injection of contrast and confirms NGT/OGT placement before administering contrast barium for study. 4. Coordinates the Trauma CT studies with the emergent care of the patient. Performs other studies as directed by the Trauma Surgeon. 5. Requests back-up from radiology department as needed.

29 Trauma Team Roles Respiratory Therapist PAGE 1 of 1 February 1992 January 2013 TITLE: Respiratory Therapist NOTIFIED: Trauma pager, overhead page WHO RESPONDS: The designated Respiratory Therapists FUNCTIONS: 1. Assures respiratory supplies are present in the Trauma Room. 2. Assists the anesthesiologist with the airway and ventilatory support of the Level I Trauma patient in the Trauma Room. 3. Maintains O 2 support per physician s orders and obtains Pulse-Ox reading, End-tidal CO 2 reading, and reports to Trauma Surgeon and Scribe. 4. Assist with or draws ABGs as ordered, performs analysis and reports to the Trauma Surgeon and Scribe. 5. Performs basic CPR as indicated. 6. Follows the respiratory-dependent patient and RN to CT, ICU, or the OR as directed. 7. Is available to assist in ICU or in surgery. 8. Performs arterial line placement per physician s orders. 9. Signs in on Trauma Physician Assessment and Order Form

30 Trauma Team Roles Patient Care Tech PAGE 1 of 2 November 1996 January 2013 TITLE: Patient Care Tech Assigned to the Trauma Team NOTIFIED: Overhead page or pager WHO RESPONDS: The designated Emergency Department Patient Care Tech FUNCTIONS: 1. Complete Trauma Room Checklist at beginning of shift. 2. Assembles supplies, trays and other equipment as directed by the Trauma Clinician or Trauma Surgeon. 3. Assures personal protection supplies are out and available for the Trauma Team members. 4. Assists with removal of patient s clothing and providing warmed blanket or other external warming devices. 5. Applies non-invasive patient monitoring devices upon the patient s arrival and assures readings are registering reports first reading to the Scribe or Trauma Room Nurse. 6. Assists with assembling and setting up trays and equipment for: Urinary catheterization IV fluid administration Central line insertion Arterial line placement Chest tube insertion and drainage system set up autotransfusion DPL Open chest procedures Other procedures as indicated 7. Assembles other supplies and equipment as directed by the Trauma Nurse. 8. Assists with transporting the Level I Trauma patient for diagnostic procedures, to the OR, or admission to a patient care unit, as directed by the Trauma Room RN. 9. Using the PCT Trauma Room Checklist, assures the Trauma Room Omnicells and supplies are thoroughly restocked after each Level I Trauma case and at the beginning of each shift. 10. Assures the Trauma Room, gurneys, etc are clean after each Level I Trauma.

31 11. Assists/performs splinting of extremities as required. 12. Performs 12-lead EKGs as required. 13. Signs in on Trauma Physician Assessment and Order Form

32 Trauma Team Roles Laboratory Phlebotomist PAGE 1 of 1 February 1992 January 2013 TITLE: Laboratory Phlebotomist NOTIFIED: Trauma beeper, overhead page WHO RESPONDS: The designated Phlebotomist FUNCTIONS: 1. Assures blood drawing equipment is available for Level I Trauma cases. 2. Coordinates drawing blood samples with the emergent care of the patient. 3. Draws a full set of blood tubes and places the blood band on the patient. Obtaining blood samples should be coordinated with IV starts especially with pediatric patients. 4. Clarifies with the Trauma Surgeon which Trauma Lab Profile to order: A. Basic B. Expanded C. Obstetric 5. Clarifies with the Trauma Surgeon the need for Type and Crossmatch and number of units of blood to order. 6. Orders Trauma Lab in computer and returns the samples to the lab and blood bank for processing. Notifies the blood bank. 7. Requests back-up from the Lab for multiple Level I Trauma Patients. 8. Notifies Trauma Surgeon and Trauma Room Scribe RN if unable to draw specimen. 9. Notifies Trauma Room Scribe RN of all labs drawn and time of draw. 9. Signs in on Trauma Physician Assessment and Order Form

33 Consults on Trauma Patients PAGE 1 of January 2013 PURPOSE: To provide a mechanism for obtaining consults on Trauma Service patients. GUIDELINES: 1. All patients identified under the Trauma Team Activation Level I Trauma Patient Identification guidelines (transported from the scene, from referring hospital Emergency Departments and from in-patient beds in non-level I facilities) are admitted to the Trauma Service for evaluation and initial management. 2. When specialty care is indicated, other Services and subspecialty physicians are consulted. 3. For the following Level I Trauma patient categories a subspecialty physician consult is automatic: A. Neurologically impaired patients - Neurological Service B. spinal cord injured patients - Neurological Service C. OB patients - OB Service 4. For other Level I Trauma patient categories subspecialty consults are determined by the Trauma Service physicians. 5. In all cases, physician contact is required to initiate a consult and to sign off patients to a subspecialty or return care to the Trauma Service.

34 Trauma Team Roles Neurosurgery Consultation PAGE 1 of 2 February 1992 January 2013 TITLE: NOTIFIED: WHO RESPONDS: PURPOSE: Neurosurgeon Consultation Neurosurgery consults requested from the trauma room will be done by pager using the pager. Pager message will read: Neuro to Trauma Room. Critical care areas and/or floors requesting other neurosurgery consults per the Trauma Service, will page the neurosurgery resident via this pager number. Neurosurgical resident on call. Neurosurgical attending is promptly available for consultation. The purpose of this guideline is to define when prompt neurosurgical consultation is required in order to assure optimal care of the neurologically injured patient. GUIDELINES FOR NEUROSURGICAL CONSULTATION: I. Neurosurgical team is consulted emergently for any of the following and returns the call to the Trauma Room within 5 minutes of notification at the request of the Trauma Surgeon on-call, and responds within 30 minutes of notification: Patients transferred from outside facilities with known intracranial lesions, or spinal cord injuries. Patients with known spine fractures. Patients that the on-call neurosurgeon has accepted in transfer with an ill-defined head and/or potential other injuries. Patients with a Glasgow Coma Scale score of < 10. Penetrating wounds to the head. Patients who have sustained a significant/prolonged loss of consciousness. Patients who have a focal neurologic deficit. Patients who have an identifiable lesion or fracture on computerized tomography.

35 II. III. When the neurosurgery resident is needed for consultation he/she will answer the page within 5 minutes and be available to see the patient within 30 minutes of notification at the request of the Trauma Surgeon/resident on-call. A neurosurgical attending should evaluate the patient within 24 hours of consultation. FUNCTIONS: 1. Once consulted, responds directly to the Trauma Room to assess the Level I Trauma patient. 2. Assesses the neurological status/neurosurgical needs of the patient and coordinates care with the Trauma Surgeon. 3. Responsible for all on-going neurological/neurosurgical care of the patient. 4. Performs invasive procedures involved with neurological monitoring, i.e., ventriculostomy. 5. Involved with and coordinates cerebral resuscitation protocols/procedures for patients with craniocerebral trauma. 6. Consults on patients admitted to the Trauma Service with neurological problems in the critical care unit. 7. Assures Trauma patient referrals from other outlying hospital Emergency Departments and in patient transfers from non-level I Trauma Centers are admitted to the Trauma Service with Neurosurgery consultation until such time as the attending neurosurgeon and trauma surgeon agree the patient does not have multi-system trauma care needs. 8. Reviews Trauma Physician Assessment and Order Form for procedures performed and medications given, then signs the record.

36 OB Consult - Trauma PAGE 1 of 2 August 1991 January 2013 PURPOSE: STAFFING: To provide immediate response and the highest quality of care for pregnant patients sustaining trauma and are 16 weeks or greater gestation, who are triaged to the hospital in accordance with EMS system standards or arrive by private transportation. The in-house Trauma Team, OB attending physician and/or OB Resident, OB RN and the in-house Emergency Physician GUIDELINES: 1. All pregnant patients, who present with a history of blunt trauma and are at or > 16 weeks gestation, or with the fundus at the level of the umbilicus and are transported to the hospital by EMS system or via private transportation, will constitute Level I Trauma Team activation, including immediate notification of the chief OB resident. 2. Pregnant patients, who present with a history of penetrating abdominal trauma at or > 16 weeks gestation or with the fundus at the level of the umbilicus, who arrive via EMS or private transportation will constitute Level I Trauma Team activation, including immediate notification of the chief OB resident. 3. The Trauma Surgeon and senior OB resident or in-house OB attending or perinatologist will evaluate Level I Trauma patients in the Trauma Room. A. The senior OB resident will be notified by the Emergency Department of the Level I patient s arrival, or pending arrival. (The Labor and Delivery Clinical Lead will be notified at ext and in turn will contact the most senior OB/GYN resident, in-house OB Attending, and the nursery ICU Clinical Lead). In the event the OB physicians are unavailable, an experienced Labor and Delivery Nurse will evaluate the patient in the Trauma Room along with the Trauma Surgeon. 4. Ultrasound will be utilized in the Trauma Room to evaluate gestational age and fetal viability. The OB Ultrasound machine, Fetal Monitoring machine and C-Section cart is available in the Trauma Room and is checked daily by the OB/GYN staff. 5. Fetal monitoring will be initiated in the Trauma Room by the OB nurse and monitor continuously or as directed by the OB chief resident. 6. The OB nurse(s), and Trauma Resident and/or attending will accompany the Level I patient for radiographic tests, during transport to ICU and the OR. The OB Resident or in-house Attending will stay with the patient until medically cleared from an OB standpoint.

37 7. Level I patients, who require admission for close clinical monitoring, are admitted to the Trauma Service with OB consulting. Hemodynamically unstable patients will be admitted to an adult or pediatric ICU. Stable patients may be admitted to OB. 8. The OB resident accepting the Trauma patient consult will advise the attending OB physician on call of the consult and the location of the patient. 9. The OB on-call attending physician, resident, and NYICU code arrest team will be called to respond for newborn resuscitation in emergency C-sections in the Trauma Room. 10. If the OB patient is unstable and admitted to any ICU (adult or pediatric), the in-house attending OB physician will continue to consult and treat this patient in the ICU. 11. All pediatric OB patients should have a perinatologist consult following the patient up until discharge.

38 Replantation - Trauma PAGE 1 of 2 December 1989 January 2013 PURPOSE: To define a process for utilizing the replantation team for traumatic amputation and the process for limb care for replant candidates. GUIDELINES: 1. Patients with partial or complete amputation of a limb caused by traumatic injury are possible candidates for the replantation program. 2. Upon notification from a referring facility, of a patient with partial or complete traumatic amputation that may be potential for replantation, the Trauma Surgeon should be notified. 3. The Trauma Surgeon will talk directly with the referring facility and the replant surgeon on call to determine if the patient is a viable candidate. 4. Replant candidates will be Level I trauma patients and will be seen in the Trauma Room including a Trauma Team activation if: A. they meet general Level I activation criteria B. the amputation is above the wrist or of a lower extremity 5. Replant candidates will be Level I trauma consults but can be held in the ED for replantation evaluation for digit and partial hand or partial foot amputations if without Level I trauma mechanism. 6. Referring facilities should be instructed by the Trauma Surgeon or the replant Surgeon regarding preservation of the amputated or partially amputated limb as follows: A. the amputated part should be wrapped in moist gauze and placed in a sterile container (specimen jar, plastic specimen bag) B. the container or bag should be placed on ice C. THE AMPUTATED PART SHOULD NEVER BE PLACED DIRECTLY ON ICE or IMMERSED IN ANY TYPE OF PHYSIOLOGICAL SOLOUTION D. Partially amputated limbs should be covered with sterile saline soaked gauze dressings, loosely dressed with gauze to keep the soaks in place and loosely wrapped with sterile towels, assuring that any open tissue is covered and kept very moist during transport

39 E. THE PARTIALLY AMPUTATED LIMB SHOULD NOT BE KEPT IMMERSED IN ANY TYPE OF PHYSIOLOGICAL SOLUTION DURING TRANSPORT 7. The Replant Surgeon will order lab, medications, etc., upon evaluation or upon discussion with a referring physician. Tetanus prophylaxis and antibiotics are commonly ordered on partial and total amputations. 8. All replant candidates should be kept N.P.O.

40 X-ray Trauma Room Profile PAGE 1 of 1 June 1992 January 2013 PURPOSE: To define basic and extended set of x-rays studies for Level I trauma patients. GUIDELINES: There will be standard initial trauma x-ray panel for Level I trauma patients. Trauma Profile Basic (Adult and Pediatric) CXR (1 view) AP Pelvis (1 view) AP C-Spine Radiographs (4 views) - AP, lateral, odontoid, swimmers C-spine CT Scan OR Upon arrival and assessment of the Level I Trauma Patient, the Trauma Surgeon or Trauma Resident will order a Trauma Profile Basic. The Trauma Surgeon or Trauma Resident will order additional imaging as indicated. The radiology technician on duty and assigned to the trauma team will clarify the x-ray orders and perform the studies.

41 Lab Trauma Room Profile PAGE 1 of 2 June 1997 January 2013 PURPOSE: To define basic and expanded trauma room lab profiles for Level I trauma patients. GUIDELINES: 1. The Trauma Surgeon will order a Basic Trauma Lab Profile on all Level I Trauma Patients. The Expanded Trauma Lab Profile and/or the Obstetric Trauma lab Profile are optional and may be added by the Trauma Surgeon based on the acuity of the patient. Basic Trauma Lab Expanded Trauma Lab Obstetric Trauma Lab Hemogram BMP D-Dimer Type and Screen Amylase Fibrinogen Blood Alcohol Protime Fibrin Split Products UA (dip in ED) PTT K-B Stain Urine Toxicology Urinalysis -Drug Screen (ages 12 and older) Serum HCG (females yrs) *Urine Pregnancy test may be ordered by the physician 2. The Phlebotomist will ask the Trauma Physician if either or both of the optional profiles or any additional single tests are to be ordered. 3. When the Expanded Trauma Lab Profile is ordered, the Phlebotomist will ask the Trauma Physician if a Blood Type and Crossmatch should also be ordered and the number of units requested. 4. After drawing the Level I trauma patient s blood, Lab Phlebotomist assigned to the Trauma Team will enter the initial trauma profile orders including any initial blood orders, into the computer ordering system. 5. A full set of blood tubes will be drawn on all Level I patients for additional testing as needed. The patient will be blood banded by the Phlebotomist when blood samples are drawn. 6. The Trauma Room RN assigned to the trauma patient will dip urine specimens collected in the trauma room and send the urine for toxicology (drug) screen and complete UA when ordered. If no urine is collected in the trauma room, the admitting floor will be notified, by the Trauma Room RN transporting the patient, to send the first urine collected for urine toxicology drug screen.