1. Duke University Health System Clinical Education & Professional Development “TMIP” Trauma Management Improvement Plan for Duke University Hospital Emergency Department Module Three

2. Duke University Health System Clinical Education & Professional Development “TMIP” Education Module Three

3. Duke University Health System Clinical Education & Professional Development Section 3. cont. The Trauma Resuscitation Team Roles & Responsibilities

4. Duke University Health System Clinical Education & Professional Development Roles/Responsibilities Social Worker Assists with locating and notifying family members of patient arrival if indicated Manages patient’s family and significant others’ location and movement during acute phase of care by balancing their right to see the patient with not impeding critical patient care Facilitates flow of information from Supervising Resident to family and significant others Supports the family and significant others’ emotional response to patient’s traumatic injury

5. Duke University Health System Clinical Education & Professional Development Roles/Responsibilities Child Life Specialist Provides age-appropriate communication with pediatric patients Assistance with patient preparation and diversion for painful procedures as clinically indicated based on developmental age of patient

6. Duke University Health System Clinical Education & Professional Development Section 4. Trauma Stabilization Performance Sequence

7. Duke University Health System Clinical Education & Professional Development Trauma Continuum of Care Communication Phase I – Pre Arrival Conference Phase II – Pt Arrival Phase III – Definitive Care Trauma Stabilization Performance Sequence Emergency Department Continuum of Care

8. Duke University Health System Clinical Education & Professional Development Trauma Stabilization Performance Sequence Identifies the continuum of care and events (Phases of Care) in the ED

9. Duke University Health System Clinical Education & Professional Development Phase I Pre-arrival –Trauma Team activation –Pre-arrival conference Information sharing Role assignment Preliminary plan of care Room preparation

10. Duke University Health System Clinical Education & Professional Development Components of Pre-Arrival Conference Any team member can initiate the Pre-Arrival Conference however the preliminary plan of care is established by the trauma resuscitation team led by the Supervising Resident The goal is that it is done and the conversation is focused solely on preparation of the team for the arriving patient Available information is relayed to team members Trauma Resuscitation Team roles are assigned Trauma members don PPE attire and apply “Role Stickers”cont.

11. Duke University Health System Clinical Education & Professional Development Components of Pre-Arrival Conference Contingency plans are determined such as need for emergency release or MTP blood products, specialty consultants who are not part of trauma activation page (i.e. Neurosurgery, Thoracic Surgery), any specialized equipment Personnel not required for patient care are excused Appropriate number of “observers” (students) are determined and positioned unobtrusively in the room

12. Duke University Health System Clinical Education & Professional Development Phase II Patient arrival –Pre-hospital provider report if applicable –ATLS Primary survey Interventions/Procedures AMPLE History Secondary Survey Interventions/Procedures Team notification of initial plan of care Documentation

13. Duke University Health System Clinical Education & Professional Development Characteristics of Pre-hospital Provider’s Bedside Report The Trauma Team will be silent while pre-hospital staff provide report to the team and answers questions primarily from Assessment Resident or Primary Nurse –“Sterile Cockpit” approach to patient handoff

14. Duke University Health System Clinical Education & Professional Development Additional Points to “Airway” in Primary Survey Additional airway management support as determined by EM Attending may be obtained by calling: –“Anesthesia Emergency Airway Team” via 115 paging system or the –“Emergency Tracheotomy Team” via 115 paging system to perform emergent surgical airway interventions

15. Duke University Health System Clinical Education & Professional Development Additional Points to “Disability” in Primary Survey Assessment components include AVPU, PERRL, GCS Assessment Physician will begin to determine need for Neurosurgery consult at this point

16. Duke University Health System Clinical Education & Professional Development Additional Points to Secondary Survey Second full set of vital signs are obtained Head to toe/front to back Patient should be removed from spine board at time of log roll and after posterior aspect is inspected, radiograph plates should be positioned for chest and pelvis radiographs and patient log rolled back to supine position –Radiograph plates should not be shoved under patient while supine Gastric tube insertion needs to occur PRIOR to obtaining chest radiograph Foley will be inserted prior to CT FAST Ultrasound and limited “spot” radiographs as ordered by Orthopedic Resident can also be obtained at this time prior to patient going to CT scan

17. Duke University Health System Clinical Education & Professional Development Components of Initial Plan of Care Assessment Resident confirms findings of initial evaluation with trauma team to assure accuracy and completeness Supervising Resident in conjunction with the Primary Nurse will then implement the plan of care

18. Duke University Health System Clinical Education & Professional Development Physician Documentation The Trauma Surgery Assessment Resident will document on the Trauma Assessment History & Physical Form The EM Assessment Resident will document ED History & Physical electronically

19. Duke University Health System Clinical Education & Professional Development Nurse Documentation The Trauma Nursing Record is generated for all trauma alert activations and is completed according to established documentation guidelines found on the ED On-Line Resource. http://marlowe.duhs.duke.edu/ed/emergency handbook.nsf/a515f3ab62e482b985256ab f004cb197/852570f4007170b0852576880 045b987?OpenDocument

20. Duke University Health System Clinical Education & Professional Development Phase III Definitive Care –Ongoing reassessment of primary and secondary survey components –Ongoing communication between team members –Consultation –Diagnosis –Comprehensive care and management –Operative intervention –Determination of Level of care (ICU, OR, Intermediate or Step-down unit, discharge)

21. Duke University Health System Clinical Education & Professional Development Physician Documentation For patients with extended LOS in the ED after disposition, the patient care resident(s) will document and update the patient’s on-going plan of care in a specified area of the patient’s eBrowser where the entire team has access to review.

22. Duke University Health System Clinical Education & Professional Development Section 5. Trauma Performance Metrics Patient Flow Time Goals Door….. to….. Transfer

23. Duke University Health System Clinical Education & Professional Development An orchestrated performance….

24. Duke University Health System Clinical Education & Professional Development PERFORMANCE THAT “COUNTS”……..

25. Duke University Health System Clinical Education & Professional Development Section 6. Additional Trauma Performance Practices Communication Consultations Diagnostic Imaging Patient Transport Debriefing/Critique

26. Duke University Health System Clinical Education & Professional Development Communication

27. Duke University Health System Clinical Education & Professional Development Communication There will be an established continuous flow of information between the Assessment Resident, Primary Nurse, and Supervising Resident. All will be informed of information concerning assessment, diagnostic findings, condition changes, and alterations in the plan of care. –The EM Assessment Resident will provide report to the Trauma Chief or designee for continuation of trauma patient care after resuscitation and stabilization. Sunday – Saturday 1801-0600. cont.

28. Duke University Health System Clinical Education & Professional Development Communication The patient care resident/Attending will communicate patient care information via phone to the accepting ICU care provider. The patient care resident will attend patient transport to the ICU for participation in patient care handoff to the receiving team.

29. Duke University Health System Clinical Education & Professional Development Consultations Consultants should allow for completion of primary and secondary survey. Consultants will verbally communicate with the trauma resuscitation team regarding evaluation, plan of care and any changes to the plan. They will complete appropriate, required documentation of consultation.

30. Duke University Health System Clinical Education & Professional Development Trauma Radiology

31. Duke University Health System Clinical Education & Professional Development Diagnostic Imaging Radiologists consultation and image review will be provided Radiology priorities and imaging sequences should be confirmed. Subsequent changes to the imaging sequence should be reviewed with the Supervising Resident with oversight of the Trauma Attending. PCXR performance goal – 15 mins.: door to performance CT performance goal – 20 mins.: door to CT room

32. Duke University Health System Clinical Education & Professional Development Diagnostic Imaging To impact ED LOS, delays in achieving CT and plain films should be minimized for the trauma patient. While in the first Radiology area, the primary nurse can ask the Radiology Technologist to call ahead to the next Radiology area to secure a ready room for the patient. This facilitation of patient flow should eliminate the patient going back and forth to Radiology from the ED.

33. Duke University Health System Clinical Education & Professional Development Transporting Trauma Patients

34. Duke University Health System Clinical Education & Professional Development Patient Transport If diagnostic procedures require the patient to be transported out of the ED, the Assessment Resident will inform the Primary Nurse. A minimum of five minutes is needed for packaging the patient for transport. Preparing the patient for transport includes: –Monitoring equipment –Stabilization of cervical spine and immobilization if required (c-collar application prior to patient transport) –Transport pack with warm fluids to accompany patient –Medications (pain, sedation, paralytic, etc.) cont.

35. Duke University Health System Clinical Education & Professional Development Patient Transport The Primary Nurse will transport. Respiratory Therapy will be available to maintain adequate ventilation and oxygenation during transport as required. Patient stability will be established prior to transport out of the ED. If an unstable patient defined by established guidelines (Trauma Transport Protocol) is to be transported, they will be accompanied by the Trauma Chief or designee.

36. Duke University Health System Clinical Education & Professional Development Monitoring and Measuring Quality of ED Trauma Care

37. Duke University Health System Clinical Education & Professional Development Debriefing/Critique Any member of the Trauma Resuscitation Team may call for a debriefing or critique A debriefing is helpful in dealing with the emotional responses to the victim or the circumstances of the injury. The purpose of a debriefing is to help members of the team cope with normal human responses to tragedy.

38. Duke University Health System Clinical Education & Professional Development Debriefing/Critique A critique is a procedural review that provides a forum to discuss the positive aspects of the resuscitation and identify problems or a need for procedural changes. Critiques are meant to facilitate communication and problem resolving. Forums that are available are: –Weekly Trauma or monthly Pediatric Trauma Management Conferences A request for review may be made to the Trauma Center office –The evaluation of the “Resuscitation Debrief” will be submitted to Trauma Coordinator for review of performance improvement opportunities A monthly performance review will be completed by the ED Critical Care/Trauma Committee with performance improvement recommendations submitted to participating disciplines

39. Duke University Health System Clinical Education & Professional Development Thank you! This is a very exciting time to be part of DUH ED and Trauma Center. We are very happy you are part of this great team, all of us working together to continue to improve the care we provide to our trauma patients and our work to become one of the best trauma centers. Thank you for your time & attention and your help in making this a successful endeavor.

40. Duke University Health System Clinical Education & Professional Development “Building Success Together”

41. Duke University Health System Clinical Education & Professional Development “TMIP” Education You have completed Module Three. Proceed to Quiz.