The University of Kansas Hospital
Corporate Policy Manual
Volume: 2
Section: Care of Patients
POLICY: Trauma Activation Management
Signature:___________________________________________________________________
Tammy Peterman / Executive Vice-President, Chief Operating Officer,
and Chief Nursing Officer
Formulation: 9/2009
Date
Revised: ________
Date
Reviewed___________
Date
Contact person for Policy Updates: Tracy Rogers, RN, MSN, CCRN, Trauma Program Manager
PURPOSE:
To provide an optimal trauma care delivery system. By this coordinated effort each patient is assured of
optimal care.
POLICY:
Patients, who have experienced trauma will be cared for based on the defined levels of Trauma Activation
management as outlined by the American College of Surgeons Resources for Optimal Care of the Injured
Patients and the procedures outlined below.
PROCEDURE:
1) Notification of Trauma Team Activation
a) Upon notification that The University of Kansas Hospital will be receiving a trauma patient or
upon patient arrival if patient self-presents, the Emergency Medicine Physician or designee will
notify page operator to initiate either Type 1, Type 2 trauma activation or trauma consult as
defined by the Trauma Team Activation and Trauma Consult Criteria Policy.
b) The trauma activation alphanumeric message will include the following information:
i)
Type 1 or Type 2
ii)
Age
iii)
Sex
iv)
Mechanism of Injury
v)
Stable or Unstable
vi)
Mode of Arrival (ground or air)
vii)
Referring facility if a transfer
viii) Estimated time of arrival (ETA)
c) The trauma activation alpha-numeric message is sent by the page operator to the following:
i)
Attending Trauma Surgeon on call
ii)
Senior level Resident
iii)
Post Graduate Year 2 or Post Graduate Year 3
iv)
Post Graduate Year 1
v)
Anesthesia Resident
vi)
Respiratory Therapist
vii)
Radiology technician
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viii) OR (Unit Coordinator)
ix)
Blood Bank
x)
Trauma Case Managers
xi)
Nursing Administrative Coordinator (NAC)
xii)
Trauma Resource Nurse (TRN) from the SICU
xiii) Pediatric Trauma Pager
2) Patient arrival in the Emergency Department
a) Upon arrival, Emergency Department staff will assist EMS with transport to designated trauma
resuscitation room
b) Personnel protection:
o Any personnel who performs or assists in invasive procedures or has patient contact will
utilize universal precautions. This will include: mask, gloves, eye covering and impervious
gowns.
o A lead apron should be worn under the impervious gown. Thyroid shields are available and
encouraged to be used.
3) Roles and Responsibility of Resuscitation: The Trauma Service at The University of Kansas
Hospital utilizes a sequential and simultaneous resuscitation process as outlined in the ATLS
curriculum. The trauma team is composed of multidisciplinary providers with distinct and sometimes
overlapping roles.
i) Attending Trauma Physician:
(a) Must be present in the trauma resuscitation room within 15 minutes of patient arrival
for all Type 1 trauma activations. (ACS COT)
(b) Directs and supervises the overall resuscitation of the patient, determines plan of care
(c) Directs or assists surgical residents with procedures; is the physician of record for
procedures done by residents in his/her presence
(d) Responsible for traffic control, takes report from EMS
(e) Responsible for ordering blood according to the Emergency Release of Blood Protocol
and Massive Transfusion Protocol
ii) Emergency Medicine Physician
(a) Must be present upon patient arrival for Type 2 activations or until arrival of Trauma
Attending.
(b) Directs and supervises the overall resuscitation of the patient, determines plan of care
(c) Directs or assists surgical residents with procedures; is the physician of record for
procedures done by residents in his/her presence
(d) Responsible for traffic control, takes report from EMS
(e) If anesthesia is not present initially, may intubate the patient as necessary
iii) Senior Level Surgery Resident, Post Graduate Year 4 or 5
(a) Coordinates resuscitation of trauma patient for all levels of activation
(b) Must be present upon patient arrival
iv) Surgery Resident, Post Graduate Year 2 or Post Graduate Year 3
(a) Conducts primary and secondary survey of the trauma patient for all levels of activation
(b) Must be present upon patient arrival
(c) Accompanies patient to diagnostic testing until area of definitive care is determined
v) Surgery Resident, Post Graduate Year 1
(a) Supports the Post Graduate Year 2 or 3 as directed in care of the patient
vi) Trauma Nurse 1
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(a) Give report either to the Unit Coordinator or to another primary care nurse as
designated by the Unit Coordinator.
(b) Receive report from the Unit Coordinator regarding field information about the
incoming trauma patient. Primary Trauma Nurse will relay this information to other
members of the trauma team as they arrive in the ED.
(c) Prepare for patient arrival in the trauma room by gathering and setting up supplies and
equipment necessary for anticipated patient care.
(d) Upon arrival of the Trauma Patient
(a) Assess the immediate condition of the patient to ensure the ABC’s of life support
are in place. Performs initial and secondary survey in conjunction with the trauma
surgical team.
(b) Communicate pertinent information to the trauma scribe for documentation during
trauma care.
(c) Ensure, or delegate, that vital signs are obtained, at least 2 large bore (18g or larger)
IV access sites, and ensure that lab specimens are collected & sent, to include two
(2) blood bank specimens. All
(d) Type 1 trauma activations require that all lab specimens be drawn from a Femoral
Arterial Puncture unless contraindicated by patient condition.
(e) Administer IV fluids, blood products, and all medications as ordered by the Trauma
Team supervising physician.
(f) Ensure that appropriate consents are obtained for treatment and procedures when
patient is able to give informed consent.
(g) Assist with emergent procedures such as intubation, chest tube placement,
defibrillation, thoracotomy, and others as appropriate.
(h) Communicate with patient during trauma resuscitation to gather assessment
information, explain procedures, and provide emotional support.
(i) Perform ongoing assessment of vital signs and patient status every 5 minutes (until
downgraded) to monitor changes and evaluate effectiveness of interventions.
(j) Informs family members of patient status and plan of care.
(e) Supports the physicians as directed and anticipates procedures and needs
(f) If TRN or Trauma Case Manager is unavailable for any reason, accompanies patient or
designates qualified nursing staff to accompany patient to diagnostic testing or final
destination
(g) Draws lab and blood bank specimens and labels with proper ID.
(a) Confirmation Blood Type (CBT) must independently be labeled by another nurse to
allow for error detection.
(h) Notifies the final destination (OR, SICU, etc.) and provides the staff there with the
patient report. This may be designated to Trauma Nurse 2.
vii) Trauma Nurse 2
(a) Supports the Trauma Nurse 1 and physicians as directed
viii) Trauma Resource Nurse (TRN) or Trauma Case Manager
(a) Respond to all Type I and Type II traumas
(b) Documentation of all times, names, procedures, vital signs and patient findings on the
trauma flow sheet as directed by MD or trauma nurse
(c) Secure patient belongings, labels and sends labs (via the pneumatic tube system), calls
for orders, accepts EMS run sheets.
(d) Will have a radio at all times during the trauma so that they may communicate with the
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ED Unit Coordinator, Unit Secretary, and other staff members.
(e) Will assume the responsibilities of the Scribe while in the trauma bay. (See role
description)
(f) Will assume the responsibilities of the Transport Nurse when leaving the trauma bay.
(See role description)
(g) Functions as communicator/ facilitator with all nursing units, admitting, support
services and ancillary departments to facilitate the most efficient and effective
treatment of the patient and movement of the patient through the system.
(h) The TRN will actively look for and eliminate barriers to best care.
(i) Will anticipate the needs of the patient and coordinate the resources to meet those
needs before required.
(j) Demonstrates knowledge of trauma room environment, supplies, equipment,
procedures, and policies.
(a) TRN may delegate the ED tech to secure patient belongings
(k) Relays lab results to the physician in charge
(l) Travels with patient to diagnostic testing and final destination
ix) Anesthesia
(a) Clears/maintains patient airway; intubates/ participates in complicated airway
maneuver
(b) Accompanies patient to OR if needed
x) Respiratory Therapist
(a) Assist in the management of the airway, sets up ventilator as needed
(b) Accompanies the ventilated patient to procedures off the unit and to receiving units
(c) Monitor breathing/assisted ventilation to evaluate adequacy maintained throughout the
resuscitation
(d) Run ABG Plus for all Type 1 Activations on i-stat machine (point of care testing) with
results delivered back to Trauma Bay and given to the Trauma Resource Nurse
xi) Radiology technician
(a) Brings a portable x-ray machine to the resuscitation bay with sufficient film cassettes
for an AP CXR and AP pelvis
(b) Completes the requested films, processes the films and returns to the trauma bay
notifying the trauma team leader that the films are available on PACS
(c) Completes additional films as requested
xii) Blood bank
(a) Transports a cooler containing 2 units O negative blood from blood bank for unstable
Type 1 Activations
(b) MTP packs are picked up from the Blood Bank to allow the laboratory staff to procure
sufficient inventory and begin preparing the next MTP pack.
xiii) Operating room charge nurse (Unit Coordinator)
(a) Carries trauma pager
(b) Upon notification of need for OR collects pertinent information to prepare room
(c) Notifies and gives report to the OR staff and initiates notification of anesthesia if not
already done
xiv) Observers
(a) Stand physically apart from patient care area; do not cross red line
(b) Peripheral conversations are distracting and will not be allowed
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(c) Admittance to Trauma Room will be limited and enforced by Attending or designee
b) PRIMARY SURVEY
i) Airway/C-spine
(a) Responsibility of surgery senior resident (PGY 4 or 5) to assess airway patency
and direct care
(b) Anesthesia: see roles of resuscitation
(c) Nursing: See roles of resuscitation
(d) Respiratory Therapist: see roles of resuscitation
(e) Immobilization of the spines maintained until cleared by attending physician
(a) The patient’s rigid cervical extrication collar will be changed in the trauma
bay/emergency department to a rigid cervical collar intended for long-term
immobilization.
ii) Breathing
(a) Responsibility of senior resident to assess breathing and direct care
(b) Nursing: see roles of resuscitation
(c) Anesthesia/Respiratory Therapist will operate BVM and set up appropriate oxygen
equipment
iii) Circulation
(a) Responsibility of Resident to assess pulses, sources of bleeding and direct care
(a) Physician to utilize FAST scan for all patients as needed
(b) Trauma RN will establish two large (14 or 16 gauge) intravenous catheters and initiate
infusion of warm normal saline; inform doctor if requiring assistance.
(a) When appropriate, a smaller gauge of intravenous catheters may be inserted.
(b) TRN will keep the physician in charge notified of the amount of crystalloids
administered. TRN will document the total amount of fluid infused and fluid output
prior to patient's transfer from the emergency department.
(c) Trauma RN will draw blood specimens for trauma work-up which include a complete
metabolic panel, PT/PTT, hematology, drug screen, and ABG for Type I activations.
Urine analysis will include urine dipstick, and urine pregnancy test for women of child
bearing age.
(a) Femoral arterial puncture should be used for Type 1 activations, if not
contraindicated
(d) Trauma RN will attach patient to cardiac monitor, place foley, nasogastric, orogastric
tubes, or set up equipment as needed
(e) Trauma RN will administer medications and blood products as ordered
(f) Trauma RN to assess vital signs (blood pressure, pulse, respiration, oxygen saturation
and temperature), inform TRN or scribe to document. Pulse, blood pressure,
respiration, GCS, pupils and oxygen saturation will be evaluated every 15 minutes or
more often as patient's condition requires for the first hour and hourly thereafter until
definitive care disposition. A second temperature will be evaluated prior to patient's
discharge from Trauma bay.
iv) Deficit
(a) Glasgow Coma Scale (Best Eye Opening, Best Verbal, and Best Motor response) will
be assessed by senior surgery resident upon arrival
(b) Pupils will be assessed upon arrival and PRN by the senior surgical resident
v) Expose
(a) Cut and remove all clothing. Ensure protection from hypothermia by use of warm, dry
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blankets, Bair Hugger, heat lamps, make sure ambient temperature is up and delivery
warm fluids.
(b) Clothing, evidence and valuable collection according to Nursing Policy and Procedure.
c) SECONDARY SURVEY
i) Secondary survey will be the responsibility of the mid-level surgical resident (PGY 2-3)
ii) Head to toe assessment
iii) Radiological Exam
(1) Chest x-ray
(2) Pelvic x-ray
iv) Mid-level surgical resident will be responsible for identification of need and notification of
consulting services
4) Identification of patient/Notification of Next-of-Kin
a) ED Unit Coordinator will obtain information from EMS and notify next-of-kin of trauma patient's
entrance into the hospital system only, not patient's condition
i) If unable to identify patient, nursing staff to utilize hospital resources to identify patient
as quickly as possible
b) Upon next-of-kin arrival, the senior physician will advise next-of-kin of patient's condition.
5) Registration
a) Alias to be given to Type 1 Activations or unknown patients (Quick Registration) to expedite
patient care
b) Medical Records to provide Emergency Room Registrar with list of names per hospital policy
c) Alias name will be changed according to hospital policy
d) If patient is a victim of violence, emergency room registrars to notify KU police to implement
denial status per hospital policy
6) Trauma Room Disposition
a) The disposition of all activated trauma patients will be to a dedicated trauma resuscitation area
equipped with necessary emergency equipment as outlined by the American College of Surgeons
b) Patient destination will be decided within one hour of arrival or transferred to another room within
the emergency department.
c) All Trauma Team Activation patients that are admitted are assigned to the Trauma Service
REFERENCES:
Committee on Trauma American College of Surgeons: Resources for Optimal Care of the Injured Patient:
2006.
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