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

2. Duke University Health System Clinical Education & Professional Development Why? Goal for whole team –Continuous quality improvement program for trauma patients in the ED –Improve consistency Management guidelines for ED Resuscitation Rooms Definition of team roles Focus on team orchestration Focus on coordination to prevent breakdown of communication

3. Duke University Health System Clinical Education & Professional Development Why? Long Term Goal –To be ONE of the best trauma centers in the region, state, country and the world –We have the…….. Ability Resources Support Reputation and the…… Motivation

4. Duke University Health System Clinical Education & Professional Development Who? Multi-specialty, multidisciplinary –Emergency Department staff –Trauma Center staff –Respiratory Care staff –Radiology staff –Laboratory staff –Social Work staff –Child Life Specialist

5. Duke University Health System Clinical Education & Professional Development What? Trauma Alert Leveling Criteria Comprehensive Trauma Management Guidelines Trauma Documentation Nursing Record, Universal Physician Trauma Orders, Electronic Plan of Care Trauma Process Critique & Monitoring Supplies & Equipment

6. Duke University Health System Clinical Education & Professional Development How? Oversight Committees/Groups Critical Care/Trauma Committee of ED Trauma Service and Emergency Medicine Physician Leadership ED Nursing and Trauma Program Leadership Selected members who participated in Rapid Improvement Event (RIE) Patient Safety

7. Duke University Health System Clinical Education & Professional Development How? Retrospective monitoring Oversight Committees –Trauma Alert Leveling –Trauma Guidelines adherence

8. Duke University Health System Clinical Education & Professional Development Your Responsibility Each new Trauma Team Member is expected to complete TMIP orientation by reviewing the TMIP Guidelines via this Slide Show during initial on- boarding to their role Continue to familiarize themselves with the TMIP Guidelines and utilize the guidelines consistently when caring for trauma patients in the ED

9. Duke University Health System Clinical Education & Professional Development “TMIP” Education Module One

10. Duke University Health System Clinical Education & Professional Development Trauma Management Guidelines for Duke University Hospital Emergency Department

11. Duke University Health System Clinical Education & Professional Development Introduction The DUH Trauma Management Guidelines provide predetermined principles for an interdisciplinary, multispecialty team approach to initial care and management of the adult and pediatric trauma patient Delineates roles & responsibilities Outlines ATLS principles as standard of care Reference to establish and maintain clear lines of communication

12. Duke University Health System Clinical Education & Professional Development Section 1. Trauma Alert Activation “Alerting the Team”

13. Duke University Health System Clinical Education & Professional Development Trauma Alert Activation PEDIATRIC? TRAUMA ALERT ADULT? TRAUMA ALERT LEVEL 1? LEVEL 2? LEVEL 3?

14. Duke University Health System Clinical Education & Professional Development For any level, the Trauma Alert should specify if this is an adult (>/= 16 years of age) or pediatric (< 16 years of age) patient.

15. Duke University Health System Clinical Education & Professional Development Pre-arrival Trauma Activation Process Level I & II Participating pre-hospital providers activate Level I & II ED Charge Nurse activates Level I & II for non-participating pre-hospital providers and patients who arrive unannounced by POV

16. Duke University Health System Clinical Education & Professional Development Participating Pre-hospital Providers Duke University Hospital LifeFlight Durham County EMS –Includes Parkwood EMS

17. Duke University Health System Clinical Education & Professional Development Pre-Arrival Trauma Activation Process Level III LifeFlight activates Level III for trauma patient transports EM Physician activates Level III for all other trauma patients who meet that criteria prior to arrival or …..after arrival

18. Duke University Health System Clinical Education & Professional Development Trauma Alert Activation after Patient Arrival (Consult/Upgrade/Downgrade) The EM physician may activate a trauma alert after patient arrival for findings once the assessment and/or diagnostic studies are completed. The EM physician first notifies the Primary Care Nurse of the decision to activate/upgrade/downgrade the trauma team response The EM physician second notifies the EDUC to call the 115 paging system to notify them of the appropriate trauma alert page The EM physician third notifies the ED charge nurse of the change in patient status

19. Duke University Health System Clinical Education & Professional Development Trauma Alert Activation after Patient Arrival (Consult/Upgrade/Downgrade) Cont. Once notified of change in patient status, the Primary Care Nurse will proceed to the patient room for patient care priorities and begin the transition from electronic documentation to documentation on the trauma nursing record. (Refer to: Phase II Patient Arrival Section under Documentation) The EM physician provides bedside hand off of patient information when trauma resident arrives.

20. Duke University Health System Clinical Education & Professional Development Level I Criteria Active airway management (BVM,ETI,BIAD,NPA,OPA) or SaO 2 < 90% Needle decompression of the chest Systolic BP < 90 mmHg, < 70+2 X age in yrs for children  10 yrs old Respiratory rate 29 BPM, < 20 in infants less than 1 yr GCS < 13 Penetrating injury to head, neck, torso, or extremities proximal to elbow and knee Amputation proximal to wrist and ankle Visibly open pelvic fracture

21. Duke University Health System Clinical Education & Professional Development Level II Criteria Flail chest or pneumothorax Two or more proximal long-bone fractures Seatbelt sign transversely across abdomen or on the soft tissue of neck Visibly open or depressed skull fracture Paralysis Crushed, degloved, or mangled extremity Critical or serious burns (per EMS Burn Protocol) Ejection from a motor vehicle Inter-facility transfer requiring a Critical Care Transport team

22. Duke University Health System Clinical Education & Professional Development Level III Criteria Pregnancy > 20 weeks Taking anticoagulant or known bleeding disorder Fall –Adults > 20 ft, Children > 10 ft MVC –Intrusion > 12 inches – occupant side –Intrusion > 18 inches – any side –Death in same compartment –High risk crash per vehicle telemetry Auto vs. pedestrian/bicyclist thrown, run over Motorcycle crash > 20 mph Inter-facility transfer requiring an ALS or BLS transport team

23. Duke University Health System Clinical Education & Professional Development Section 2. Trauma Care Areas

24. Duke University Health System Clinical Education & Professional Development Trauma Care Areas Trauma patients will be managed in the Resuscitation Rooms in the ED for all ages Critical Care/Crisis Rooms in the Care Pods will be used for overflow ED Charge Nurse will proactively manage trauma patient flow Resuscitation Team Leader will maintain ready rooms with supplies/equipment at least twice daily (last 3 hrs of shift)

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

26. Duke University Health System Clinical Education & Professional Development Trauma Resuscitation Team Members As delineated in the following roles, a minimum academic level has been determined for participation in the delivery of trauma patient care. Students of all disciplines and all specialties may observe in a peripheral appropriate location as assigned.

27. Duke University Health System Clinical Education & Professional Development Leadership of the Trauma Resuscitation Team The Trauma Team will be lead through collaborative supervision by the Trauma Surgery Attending, the EM Attending or Pediatric EM Attending, and the Trauma Surgery Chief Resident

28. Duke University Health System Clinical Education & Professional Development The Physician Trauma Team

29. Duke University Health System Clinical Education & Professional Development Trauma Resuscitation Team Members Physicians –Supervising Resident (Trauma Surgery Chief/Senior EM Resident) –Assessment Resident/Physician (minimum level JAR/Second Year EM) –Procedure Resident/Physician (minimum level JAR/Second Year EM) –Airway Resident (minimum level Second Year EM) –Orthopedic Resident (Level 1 and 2 Trauma Activations only)

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

31. Duke University Health System Clinical Education & Professional Development Trauma Resuscitation Team Members ED Nurses –Charge Nurse –Primary Nurse –Associate Nurse(s) Monitor/Medication Nurse (Rapid Response Nurse[s] from Pods) Procedure Nurse (Rapid Response Nurse[s] from Pods)

32. Duke University Health System Clinical Education & Professional Development Trauma Resuscitation Team Members Nursing Care Assistant

33. Duke University Health System Clinical Education & Professional Development Trauma Resuscitation Team Members EDUC

34. Duke University Health System Clinical Education & Professional Development Trauma Resuscitation Members

35. Duke University Health System Clinical Education & Professional Development Trauma Resuscitation Team Members Ancillary Departments –Respiratory Therapist(s) –Radiology Technologist(s)

36. Duke University Health System Clinical Education & Professional Development Trauma Resuscitation Team Members Supportive Personnel –Consulting physicians –PICU Nurse –ECG technician –Police/Public Safety Officers –ED Clerical Staff –Pastoral Service Staff –Social Worker –Child Life Specialist –ES Clinical Pharmacist –ES Clinical Nurse Specialist

37. Duke University Health System Clinical Education & Professional Development “TMIP” Education You have completed Module One. Exit and proceed to Module Two.