“TMIP”
Trauma Management
Improvement Plan
for
Duke University Hospital
Emergency Department
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Clinical Education & Professional Development
Module Two
“TMIP” Education
Module Two
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Section 3. cont.
The Trauma
Resuscitation Team
Roles & Responsibilities
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Trauma Team PPE
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Trauma Team Personal Protective
Equipment Responsibilities
• For the purpose of this document, PPE is defined at the
minimum as protective gown, gloves, and face shield. Hat
and shoe covers are required for trauma patient transports
into the OR.
• PPE will be donned for all L1 and L2 trauma activations
through the entirety of the primary survey, secondary survey,
and all invasive procedures: (i.e. femoral stick, chest tubes,
intubation, resuscitative thoracotomy, emergent laceration
intervention, DPL, wound irrigation and debridement,
manipulation of open fractures)
• PPE will be donned for L3 trauma activations when there is
potential for body fluid exposure and all invasive procedures
described above
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Trauma Team Attendance
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Attendance Limit in Room &
Role Identification
• Trauma Team members only
– Located in pre-determined positions
• Trauma Team members will wear brightly
colored sticker delineating their role,
placed on their disposable gown over their
left deltoid area
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Know the roles you could be
playing in a trauma & the
responsibilities of that role
and…….
Know other team members’ roles and
responsibilities to help create an efficient,
orchestrated team working together to
optimize patient outcomes and
meet ED patient flow time goals…..
Striving to be
ONE of the BEST……!
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Physician Trauma Team
Member Roles
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Roles/Responsibilities
Trauma Attending
• Provides ultimate oversight and
direction of patient resuscitation and
team performance
– Excuses unneeded personnel, monitors
PPE adherence
• Responds per pre-established
guidelines
• Accepts transfer of care from EM
Attending
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Roles/Responsibilities
EM Attending/Pediatric EM Attending
• Supervises and provides airway management
• Provides oversight and direction of patient
resuscitation and team performance in absence
of the Trauma Attending
– Excuses unneeded personnel, monitors PPE
adherence
• Transfers care and patient information to
Trauma Attending
• Provides ongoing patient surveillance while
patient is in the ED
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Roles/Responsibilities
Supervising Resident
•
•
•
•
•
•
•
•
•
•
•
0601-1800 Trauma Surgery Chief -------1801- 0600 EM Resident
Provides guidance to resuscitation team
Leads resuscitation according to ATLS standards
Provides direct orders during resuscitation
Provides oversight of the patient resuscitation
Directs the operations/actions of the resuscitation team
Verifies plan for final disposition of patient with all trauma team members
before leaving the patient room
Attains the supervisory skill set to become an attending physician
Directs, performs, or delegates resuscitation procedures
Completes order forms in patient room leaving yellow copy with primary
nurse, white copy will be presented to EDUC.
Communicates (may delegate) patient’s status, plan of care with family
and significant others
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Roles/Responsibilities
Airway Resident
• Assesses airway
• Requests/orders RSI medications
• Manages/directs airway management
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Roles/Responsibilities
Assessment Resident
• 0601-1800 Trauma Surgery Resident ----1801- 0600 EM Resident
• Pre-arrival
– Participates in Pre-Arrival conference
• Upon patient arrival
– Performs the primary and secondary survey in order of ATLS priority
– Relays assessment information in a clear & audible manner for team to hear
and for scribe to document on trauma record
– Documents complete evaluation on Trauma H&P form, EM Resident will
document H&P in electronic ED template
– Assures that assessment and management priorities are followed as
delineated
– Establishes and maintains communication with the patient
– Coordinates plan of care with nursing and medical staff
– Determines the need for consultations
cont.
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Roles/Responsibilities
Assessment Resident
• Continuation of care
– Coordinates efficient progression of plan of care
• Documents, including time and communicates the trauma
patient plan of care to the Primary Nurse and the EM
physician staff
• Notifies consultants and documents time and discussions
• Documents updated plan of care while in ED
• Notifies appropriate radiologist of specialty studies
• Reassesses patient and documents reassessments until
disposition is made
• Monitors trauma patient ED LOS and investigates
variance with the team members
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Roles/Responsibilities
Procedure Resident
• Obtains lab specimens (femoral stick on
all Level 1 patients)
• Performs diagnostics/interventions as
directed (Chest tube insertion, arterial line,
suturing, etc.)
• Assists with central IV access
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Roles/Responsibilities
Respiratory Therapist
•
•
•
•
Ongoing assessment of airway patency
Ongoing assessment of breathing
Assists Airway Resident or performs intubation
Provides ventilatory support; makes changes in
response to blood gas values and communicates to
Primary Nurse for documentation in trauma record
• Documents interventions and ongoing changes to
therapy
• Places gastric tube as directed by physician
• Establishes and maintains communication with patient
as indicated for procedure
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Radiology Technologist
• Responds with adequate radiograph plates to perform
portable radiographs per protocol or physician order
• Observes for opportunity to place PCXR and Pelvis
plates beneath patient after completion of posterior
aspect assessment and prior to log roll to supine position
• Develops PCXR and transitions into PACS viewer
• Prepares CT area to receive the patient
• Time Goals:
– 10 mins: PCXR to PACS viewing
– 15 mins: door to PCXR
– 20 mins: door to CT scan
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ED
ED Charge
Charge
Nurse
Nurse
lllllllllllllllllllllll
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Role
Roles/Responsibilities
ED Charge Nurse
• Receives pre-hospital Trauma Activation/EMS report
– Assigns trauma activation level for non-participating pre-hospital
providers and patients who arrive unannounced by POV and for
patients who meet Level I and II criteria, relays EMS report to EM
Physician to activate Level III
• Notifies EDUC to initiate trauma team activation page
• Notifies EM Attending of Trauma Alert Activation
• Assigns RRN roles per shift and facilitates assignment coverage
• Confers with Primary Nurse for resource and patient care plan
– Notifies RRN, Social Worker, etc.
• Facilitates bed assignment
• Assists with monitoring of trauma patient ED LOS and investigates
variance with the team members
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Primary Nurse
STICKERS
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Roles/Responsibilities
Primary Nurse
• Pre-arrival
– Confirms time of trauma activation with EDUC
– Documents time of activation, alert type (Adult
v. Peds), level, mechanism on trauma record
– Writes trauma patient report with ETA on
assigned Resus Room glass door
– Documents times of trauma team member
arrival on trauma record
cont.
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Clinical Education & Professional Development
Roles/Responsibilities
Primary Nurse
• Pre-arrival
– Manages room flow (Pre-Arrival Conference Activities)
• Coordinates WHO needs to be in the room, WHERE they should be positioned in
the room, and WHAT their duties are to PERFORM
• Enforces PPE adherence for everyone in the room providing direct patient care
with assistance from Physician Leadership
• Enforces application of Role Stickers to left deltoid area of team’s PPE
gowns
• Excuses personnel who are not required for patient care
• Communicates with Residents of all services, associate RNs, and NCAs
performance expectations for patient flow time goals (See Module 3, Slide 24)
• Coordinates assistance requirements with Charge Nurse
• Directs Emergency Release Blood and/or MTP Protocol (Per Attending) by
ensuring the order is acknowledged and completed. IDENTIFIES person to
retrieve the products.
• Participates and provides oversight of GENERAL PREP of the Resus Room
cont.
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Roles/Responsibilities
Primary Nurse
•
Upon patient arrival
– Role Room Location - Stands at foot of stretcher utilizing top of bedside table to
write on
– Acts as scribe during Primary & Secondary Survey
• Initiates and completes Trauma record documentation
– Coordinates care with Supervising Resident, Attendings
– Assures that emergency release blood/MTP blood process is implemented through to
completion
– Documents verbal medication orders for physician signature following resuscitation
– Reviews and communicates Shock Panel results to team prior to transport to CT
scanner
– Coordinates and travels with patient to scans/tests/procedures
• Delegates retrieval of Transport Pack for availability of vital supplies during
transport
• Dons lead apron and thyroid shield to attend to all Level I Trauma Alert
patients during radiology procedures (CT scan, skeletal radiographs,
angiography to include interventional procedures)
cont.
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Clinical Education & Professional Development
Roles/Responsibilities
Primary Nurse
• Upon patient arrival
–
–
–
–
Reviews and communicates lab value results to team
Assumes care of patient after stabilization complete
Gives patient report to inpatient unit and transports patient to inpatient unit
Monitors and communicates patient flow time goals including ED LOS
• Within 15 mins.: all team members documented on arrival
• 5 mins.: MTP order to time of initiation
• 5 mins.: documentation of full set of vital signs
• 10 mins.: door to lab SENT
• 15 mins.: door to PCXR and spot radiographs
• <20 mins.: door to Shock Panel results reviewed and communicated
to team
• 20 mins.: door to CT scanner
• 40 min.: door to lab value results reviewed and communicated to team
• ED LOS – (L1 3 hrs) (L2 4 hrs) (L3 5 hrs)
cont.
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Roles/Responsibilities
Primary Nurse
•
Continuation of Care
– Assumes nursing responsibility for the patient until disposition is made. Additional nursing
staff will be assigned as needed.
– A complete nursing assessment will be documented frequently based on patient acuity, at
minimum every 6 hours
– Vital signs including pain level and RASS score will be documented frequently based on
patient acuity, at minimum every 4 hours
– Observations and/or patient updates on the plan of care are to be performed frequently
based on patient acuity and documented frequently based on patient acuity, at minimum
every 2 hours
– Monitors trauma patient ED LOS and investigates variance with the team members
– Routinely informs team members of patient condition and documents action
– Instructs NCA to return emergency release blood if not required
– Provides handoff report to receiving RN (Step-down or intermediate unit, ICU or OR)
– Completes an orange “Resuscitation Debrief” evaluation located in the Red Trauma Packet
– Provides patient advocacy – Continuously informs patient of process, procedures, plan of
care
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Monitor/Medication
Nurse
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Roles/Responsibilities
Monitor/Medication Nurse
•
Pre-arrival
– Prepares monitor; attaches electrodes, BP cuff ready, pulse-ox, temp
probe/cable, art line cable if needed
– Ensures manual BP is ready and working and a stethoscope is ready to use
– Places full O2 tank under stretcher
– Ensures suction canister tubing, yankeur or suction catheters set up, suction
unit in ON position and tested for functionality
– Primes 2 liters of warm LR/Saline and has 2 liter pressure bags available
– Ensures Level 1 Rapid infuser and tubing available
– The following medications will be made immediately available:
• RSI medications
• Fentanyl
• Lidocaine for local anesthesia
– Ensures warm blankets are available
cont.
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Clinical Education & Professional Development
Roles/Responsibilities
Monitor/Medication Nurse
• Upon patient arrival
– Role Room Location - Stands on Medication Dispensary side of
room
IN THIS ORDER:
– Applies O2 by NRB (all trauma patients require O2 until otherwise
determined)
– Performs manual BP
– Puts patient on cardiac monitor
– Applies automated blood pressure cuff, pulse oximetry
– Completes full set of vital signs
– Ensures automated BP cuff is cycling q 2-5 mins.
– Communicates heart rate, O2 sat, oxygen requirements, temperature in
an audible manner to the trauma team and the scribe
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cont.
Clinical Education & Professional Development
Roles/Responsibilities
Monitor/Medication Nurse
• Upon patient arrival
– Manages
• Level 1 Rapid Infuser
• Medication administration (May require an additional RRN to assist if patient needs
Level I Rapid Infuser)
–
–
–
–
RSI medications
Pain/sedation medications
Tetanus toxoid administration prior to CT
Antibiotics administered prior to CT
• Fluids
• Blood products
– Time goals to be achieved by Monitor/Medication Nurse
• 5 mins.: first full set of vital signs obtained with manual BP
• 10 mins.: second full set of vital signs obtained
– Provides patient advocacy – Continuously informs patient of process,
procedures, plan of care
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Procedure
Procedure
Nurse
Nurse
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Role
Roles/Responsibilities
Procedure Nurse (RRN)
• Pre-arrival
– Sets out supplies for Fem-stick/IV insertion/Phlebotomy (Blood tubes, transfer
device, functional label gun)
– Unlocks supply dispensary doors
– Unlocks Physician’s Cart door
– Obtains intraosseous (IO) equipment if pre-hospital IV access is tenuous or
unknown
– Has temp foley kit and monitor connecting cable in the room
– Heats room (Closes doors, increases room thermostat, other warming
considerations)
– Discusses additional equipment needs based upon the EMS report
– Collects the equipment/supplies or delegates team members to perform the task
– Communicates with the EM Resident/Trauma team during pre-conference
• Recommends procedures based on report received
• Delineates WHO the Procedure Resident will be to perform procedures, and
assembles additional requested items in the room
cont.
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Clinical Education & Professional Development
Roles/Responsibilities
Procedure Nurse (RRN)
• Upon patient arrival
– Role Room Location - Stands on Supply Dispensary side of
room
IN THIS ORDER:
–
–
–
–
Assists exposure
Obtains IV access (consider IO early)
Assures that blood samples have been obtained AND sent to lab
Inserts foley immediately following secondary survey (when
indicated) and prior to CT
– Ensures urine HCG is performed and communicated to team and
scribe who documents results
– Ensures NG/OG inserted and connected to suction prior to PCXR
– Removes all jewelry prior to radiology studies
cont.
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Roles/Responsibilities
Procedure Nurse (RRN)
• Upon patient arrival
– Facilitates Radiology Technician(s) to enter room to
complete portable radiographs
– Ensures C-collar applied/exchanged to Miami J prior to CT
– Prepares for and assists with procedures as needed (i.e.
central line, chest tubes)
– Time goals to be achieved by Procedure Nurse
•
•
•
•
5 mins.: 1 large bore IV access obtained
10 mins.: blood samples sent to lab
15 mins.: door to PCXR (and Pelvis XR)
Prior to 20 mins.: Foley insertion (when indicated)
– Provides patient advocacy – Continuously informs patient of
process, procedures, plan of care
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PICU
Data Gatherer for
PICU Admission
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PICU
Nurse
Nurse
Role
Roles/Responsibilities
PICU Nurse
• Responds to Pediatric Trauma Alert
Levels I and II
• Signs in with Primary Nurse
• Identifies patient’s weight and
secures requested pediatric
medications
• Gathers patient information required
for PICU admission preparation
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Roles/Responsibilities
Nursing Care Assistant (NCA)
IN THIS ORDER:
•
•
•
•
•
•
•
•
•
Retrieves blood from Transfusion Services if directed
Transports labeled blood tubes to EDUC
Collects and labels urine specimen
Dips urine specimen for blood and reports results to primary nurse
Transports labeled urine to EDUC
Performs chest compressions if indicated
Secures and labels clothing/patient articles
Returns uncross matched blood to Transfusion Services as directed
Stocks and restocks trauma supplies every shift and after each trauma
activation
– Stocking will occur within the last 3 hours of the shift at a minimum or
as directed
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Roles/Responsibilities
EDUC
IN THIS ORDER:
• Enters the Trauma Activation level into the paging
system and completes trauma log documentation
• Facilitates timely registration of patient for order entry
capability
• Assigns “Unknown” registration for unidentified patient
• Delivers patient identification bracelet to Primary
Nurse
cont.
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Clinical Education & Professional Development
Roles/Responsibilities
EDUC
IN THIS ORDER:
•
Enters diagnostic study orders
– Adult Trauma Alert Levels I and II which will include:
• Shock panel and Type & Screen
• Toxicology Screen, ETOH, PT/PTT, ABC, BMP, UA
• Serum HCG (Women of childbearing age 12 – 50 yrs)
• PCXR, Portable pelvis
• Trauma CT package
– Pediatric Trauma Alert Levels I and II which will include:
• ABC and Type & Screen
• PCXR
• Notifies radiology for portable chest and/or pelvis radiographs
• Diagnostic study orders will be individualized for
– Adult and Pediatric Trauma Alert Level III
– Any additional orders for Adult or Pediatric Trauma Alert Levels I and II
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cont.
Roles/Responsibilities
EDUC
• Ensures lab specimen distribution from ED to lab by placing
yellow immediate slip in specimen bag (10 min. goal for door to
blood sent to lab)
• Obtains old ECGs if applicable
• Erases patient report on glass door once patient goes to
CT/OR
• Maintains Trauma Red Packet (Ensuring all forms are included
and identified with patient’s addressograph plate)
• Copies Trauma Red Packet documents at the time of trauma
patient ED disposition for Trauma Registry collection every 24
hours
• Places radiology study CDs of transferred patient received from
outside hospitals in the dedicated wooden box located at the
EDUC desk in Resuscitation
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“TMIP” Education
You have completed Module Two.
Exit and proceed to Module Three.
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