1. “TMIP” Trauma Management Improvement Plan for Duke University Hospital Emergency Department Module Two

2. “TMIP” Education
Module Two

3. The Trauma Resuscitation Team Roles & Responsibilities
Section 3. cont.
The Trauma
Resuscitation Team
Roles & Responsibilities

4. Trauma Team PPE

5. 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

6. Trauma Team Attendance

7. 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

8. meet ED patient flow time goals…..
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……!

9. Physician Trauma Team Member Roles

10. 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

11. 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

12. Roles/Responsibilities Supervising Resident
Trauma Surgery Chief 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

13. Roles/Responsibilities Airway Resident
Assesses airway
Requests/orders RSI medications
Manages/directs airway management

14. Roles/Responsibilities Assessment Resident
Trauma Surgery Resident 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.

15. 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

16. 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

17. 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

18. 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

19. ED Charge
Nurse
ED Charge Nurse Role
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20. 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

21. Primary Nurse
STICKERS

22. 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.

23. 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.

24. 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.

25. 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.

26. 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

27. Monitor/Medication Nurse

28. 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.

29. 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
cont.

30. 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

31. Procedure
Nurse
Procedure Nurse Role

32. 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.

33. 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.

34. 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

35. Data Gatherer for PICU Admission
Nurse
PICU Nurse Role
Data Gatherer for PICU Admission

36. 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

37. 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

38. 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.

39. 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
cont.

40. 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

41. You have completed Module Two. Exit and proceed to Module Three.
“TMIP” Education
You have completed Module Two. Exit and proceed to Module Three.