Monday September 26 th, 2016
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1 Monday September 26 th, 2016
2 trauma NOUN Injury to human tissues and organs resulting from the transfer of energy from the environment
3 Optimizing Tar Heel Trauma Care: The Golden Hour Daryhl Johnson MD MPH FACS Elizabeth Schroeder BSN RN CEN TCRN Alberto Bonifacio MHA BSN RN
4 Trauma is the leading cause of death for individuals up to the age of fortyfour, costing the US an estimated $671 billion in healthcare costs and lost productivity. 1,2 1. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web based Injury Statistics Query and Reporting System (WISQARS) [online]. Accessed February 17, Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS) 2015 [cited /26/15].
5 Sentinel Event Data Root Causes by Event Type
6
7
8 Aim: improve the consistency, efficiency and reliability of trauma resuscitations
9 KEY Physician Adult Trauma Positions ED Attending Airway MD Supervisory Staff Nurse Support Ancillary Staff Nursing Assistant Bedside Physician Respiratory Therapist Secondary RN (T2) Procedure Physician Pharmacy X-Ray1 X-Ray 2 Trauma Attending Trauma Captain Primary RN (T1) Hot Line HUC UNC PD Chaplain Air Care/ EMS AirCare/ EMS Charge RN
10
11 Role Specific Full Alert Trauma Drills
12 It was so cool to be included in the Trauma group and to truly see the patient s care from accident to discharge. I learned a lot about what each department s role is during our patient s recovery journey here at UNC. I believe we are a great team.
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14 Teamwork, Communication and Leadership Each individual behaviour will improve teamwork and performance Perceived rudeness is the KILLER of Teamwork
15 Post-sim Debriefing
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17 What Didn t Work? Adhesive role tags Red bouffant worn by trauma captain Electronic feedback system Role reversals Collaboration w/ pediatrics
18 Accomplishments New trauma resuscitation process Capabilities for immediate feedback Culture change with increased engagement and support from physician and administrative leadership Continuum of Care Conference Documentation, accountability, safety Defined leadership and staff roles with use of closed-loop communication Decreases in under-triage, patient complications, and risk adjusted mortality related to shock Consistent trauma paging notification Standardization of set-up for trauma bay Revitalization of ED Trauma Committee Decreased times to: manual BP, HR, O2 sats, X-ray, CT, and OR Implementation of monthly multidisciplinary in-situ trauma simulations Strengthened interdisciplinary relationships Expansion of the Trauma Survivor s Network Use of cognitive aids, advanced technology Launch of Integrated Emotional Support Program (IESP)
19 Comprehensive Improvement in Trauma Resuscitation Pre Go-Live Post Go-Live 96% 67% 77% 75% 80% 87% 67% 65% 60% 86% 55% 71% 45% 27% 34% 27% 9% 8% Trauma Bay Preparation Pre-arrival Huddle Sequential Primary Strong Teamwork Defined Leadership Closed-Loop Communication Met VS Time Requirements X-ray w/in 5 mins CT w/in 20 mins
20 Time (minutes) Decreased Time to Log-Roll INTERVENTION: Lecture and Sim with Surgery Residents Pre Go- Live 7/1 8/2 9/6 11/1 12/21 1/16 2/7 3/6
21 Time (minutes) 16 Decreased Time to Chest X-ray INTERVENTION: Implementation of Radiology Stretchers Pre Go- Live 7/23 8/2 9/6 10/1 11/1 12/8 1/16 2/7 3/6
22 Sustainment FY 18 Improve the consistency, reliability and efficiency of trauma resuscitation through the implementatio n of a standardized process in the Emergency Department Consistent Resuscitation following UNC Consistent Education and Training Direct Observation and Performance Feedback Continuum of Care Conference Trauma Program Manager Trauma Medical Director ED Nurse Educator Residency Coordinators Trauma Adult Coordinator Eye Tracking Research Trauma Nurse Educator
23
24 Thank you Project Team Liz Dreesen MD FACS Daryhl Johnson MD MPH Alberto Bonifacio RN BSN MHA Elizabeth Schroeder RN BSN CEN Kelly Revels MSN CEN Nikki Waller MD Christian Lawson RN BSN Gene Hobbs CHES Katelyn Hausfeld RN BSN Tar Heel Trauma Team Disaster Preparedness Dalton Sawyer Emergency Services Jeff Phillips Michelle Pladsen Kayla Wilkerson Carolina Air Care Emergency Trauma Committee Respiratory Therapy Pharmacy Radiology Sheila Leviner Lauren Burton Radiology Team and to so many other incredible team members
25
26 SUPPLEMENT SLIDES
27 Optimizing Tar Heel Trauma Care METHODS
28 The UNC Institute for Healthcare Quality Improvement (IHQI) Seed Grant Program promotes the development of experience and expertise in quality improvement at UNC Hospitals, Faculty Physician practices and Physician Network practices.
29
30 Optimizing Tar Heel Trauma Care TAR HEEL TRAUMA
31 Level 1 Adult and Pediatric Trauma Center Manage the public health problem of injury (prevention) Reduce the degree of injury Optimize the outcome from injury Reduce mortality and morbidity Optimal care for the trauma patient across continuum of trauma care.
32 Dual Trauma Designation
33 Tar Heel Trauma Mission: Maintain UNC s Level I Adult and Pediatric Trauma Verification and ultimately work to ensure trauma patients receive optimal care. Vision: Move the needle of trauma-related morbidity and mortality in the Region in ten years.
34
35 Vision Timeline Year 1-2 Brand Baseline Fundamentals Survey Year 3-5 Geriatric Trauma Trauma Survivors Local / State Partners RAC Epidemiology Year 5-8 National Partners National Recognition Tipping Point Year 9-10 Post Data Publish Tar Heel Trauma 2035
36
37 Optimizing Tar Heel Trauma Care THE BURNING PLATFORM
38 Comfort and Confidence in Trauma Roles How comfortable or confident are you when performing your role? (0 = very uncomfortable 100 = very comfortable) T1 (Primary Trauma Nurse) T2 (Secondary / Bedside Trauma Nurse) NA (Nursing Assistant Nurse)
39 Quality N=38 83 Disagree (0) Agree (100) I feel we provide the highest quality nursing care for trauma patients.
40 Barriers 1. Trauma Process not followed (13) The trauma process is followed inconsistently and variably causing sense of disorganization, degradation of teamwork, inability to anticipate team's actions, disorderly communication of findings, orders shouted simultaneously, inability to adequately chart, and causes general frustration. 2. Ineffective leadership in trauma (10) Generally ineffective leadership and management in traumas. Specifically leader at times unclear or multiple leaders attempting to manage resulting in assessments and orders being given at the same time. Delegation also at times ineffective. 3. Observers Disruptive (6) Observers and others not directly involved in trauma care are often disruptive. 4. EPIC Problematic (5) Electronic charting in EPIC is problematic due to registration, user interface, inconsistency with trauma process and general usability. 1. Redesign T1 assignment (12) 2. Improve adherence to trauma process (7) Improve consistency and adherence to ATLS / TNCC trauma assessment process. 3. Provide more trauma education (6) Provide (and perhaps require) more trauma education and hands-on practice. 4. Improve EPIC documentation process (4) EPIC documentation process MUST be improved or consider return to paper documentation. 5. Reduce interference from observers (4) 6. Establish pre-trauma huddle (3) 5. Ineffective communication (5) Generally ineffective communication during traumas (e.g. unclear orders and plan of care)
41 Baseline
42 Morbidity Complications Blunt Multi-system TBI Elderly (complications) Elderly Blunt Multisystem
43
44
45 Phase: Sign-in / Preparation / Huddle Phase: Patient Arrival / Report Timeout Tar Heel Trauma Resuscitation Process Phase: Primary Survey Phase: Log Roll Phase: Secondary Survey and Other Adjuncts Phase: Disposition / Prepare for Transport Prep Identify and Fix Shock Secondary Survey Dispo. TRAUMA CAPTAIN CHIEF / FELLOW Lead Team Huddle Takes Repor t Directs Interventions Determines Disposition Lead Shared Mental Model AIRWAY PHYSICIAN EM3 Prep: airway equip, suction Patient Comfort A B Secures C-spine May Assist with Assessment of Head; Patient Comfort HUC and Family BEDSIDE PHYSICIAN PGY2 Prep resusc. equip Assists Transfer C D* Back Head to Toe* Prepare for Transport PROCEDURE PHYSICIAN INTERN Prep resusc. equip Assists Transfer Assist with procedures (chest tube, central line, etc.) Log Roll FAST Other Procedure s Prepare for Transport PRIMARY NURSE (T1) Pre-report Manage Prep. Asst. Team Huddle Takes Report Directs RN Care Documents Manages Transport / Handover SECONDARY NURSE (T2) NURSING ASSISTANT Prep: IV, IVF, Bair Hugger, Meds Prep: Monitor, O2, Bed, Foley Patient Comfort Assists Transfer VS (Manual BP) E Expose Pt Monitor PIVx2; IVF; Blood; Meds VS q5; Blankets; Bair Hugger Rectal temp. LSB Rectal Temp Meds; Labs; OGT Send Labs; Foley; UPT Prepare for Transport Prepare for Transport RESPIRATORY THERAPY Prep Vent Assists Transfer Asst. with Airway Breathing Secure s ETT Airway Management / ABG Prepare for Transport RADIOLOGY TECH Pre-set Plates Chest X-ray Pelvis X-ray Process and Deliver Films Minutes * Airway Physician may assist with assessment of head per Bedside Physician / Trauma Captain
46 Identify and Fix Shock A-B-C-D-E IDENTIFIES A-T-O-M-I-C Airway Obstruction Tension Pneumothorax Open Pneumothorax Massive Hemothorax I (Flail Chest) Cardiac Tamponade Early Log Roll (Blunt / Penetrating / Spinal) Fix Shock Assessment Findings Airway Patent Breathing Labored Trachea Midline No JVD Lung Sounds Clear, Equal Bilaterally Chest Wall Deformity Heart Sounds Muffled Central Pulses Strong Responder Transient Responder Non- Responder
47 Pre-Trauma Huddle Report: known MIVT on board Team: names, roles, responsibilities Equipment and Environment Alert: CT / ICU / OR as needed Most Important Thing Shared Mental Model: after 2 nd ax
48 Optimizing Tar Heel Trauma Care RESULTS
49
50 Percentage (%) Percentage (%) 1.4 Decrease in Trauma Patient Complications Pre Go-Live Post Go-Live GCS <8 w/out intubation Cardiac arrest w/ CPR Missing warming measures documentation Risk-adjusted mortality r/t shock Improvements in Trauma Documentation & Triage Documentation Deficiencies Undertriage Pre Go-Live Post Go-Live
51 Optimizing Tar Heel Trauma: Metrics Table Metric % Meeting Protocol Before n % Meeting Protocol After n Mean/ Avg Time Before Mean/ Median Median Avg Time Before After After Min Before Min After Max Before Max After Preparation "Yes" "Yes" Bay Stocked smaller n = after checksheet "Go-Live" Bay Cleaned Team Prep "Yes" "Yes" Plan Relayed Team Met cases excluded when "unobservable" or N/A (did not occur) Roles Defined Report Received Primary Obtained w/in 5 minutes of arrival Obtained w/in 5 minutes of arrival Airway Breathing Circulation Disability (GCS) Exposure Vital Signs Obtained w/in 5 minutes of arrival Obtained w/in 5 minutes of arrival Blood Pressure Heart Rate Temperature Pulse Ox Secondary Head & Face Neck Chest Abdomen Perineum Extremities Spine Studies X-ray w/in 5 FAST w/in 10 CT w/in 20 X-ray w/in 5 FAST w/in 10 CT w/in 20 X-Ray FAST CT "Entire 55Team" Communication "Usually and Always" "Yes" Debrief Closed- Loop Followed Leader
52 Trauma Registry Data : Pre and Post Go-Live Comparison Red Yellow All GCS < 8 and pt. not intubated % GCS < 8 and pt. not intubated Cardiac arrest w/ CPR % Cardiac arrest w/ CPR No documentation - temp w/in 20 mins % No documentation - temp w/in 20 mins No documentation - warming measures % No documentation - warming measures Pt. in shock (systolic </= 90) who didn't receive any blood % Pt. in shock (systolic </= 90) who didn't receive any blood Pt. in shock (systolic </= 90) who didn't receive blood w/in 1 hr % Pt. in shock (systolic </= 90) who didn't receive blood w/in 1 hr Pre Post Under triage cribari # cribari % Pre Jan Feb Mar Apr May Jun Average Post Jul Aug Sep Oct Nov Dec avg. time to OR (min) % doc deficiencies Pre Go-Live Period: 11/3/2015-7/3/2016 Post Go-Live Period: 7/4/2016 4/4/2017 Average 13 14
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