Adult Trauma System Activation Protocol

Transcription

1 Adult Trauma System Activation Protocol Hershey Medical Center Trauma Program Manual Policy Number: 017TPM Replaces: April 2015 Effective: September 2016 Authorized: Scott B. Armen, MD, FACS, FCCP, FCCM Adult Trauma Program Medical Director Approved: Eleanor F. Dunham, MD, MBA, FACEP Medical Director, Department of Emergency Medicine Michael Lloyd, MS, RN Adult Trauma Program Manager Purpose, The purpose of this policy is to insure appropriate response by the Trauma Team and supporting services (such as OR, Radiology, and laboratory) for patients with serious injuries or the potential for having serious injury. The team response will be based on triage criteria outlined in this policy, and in most situations, be activated by the emergency physician (EP) based on prehospital report. The EP or Trauma Surgeon can also activate Trauma Team response upon subsequent Emergency Department assessment or with inter-facility transfers to Hershey Medical Center. Definitions There are three levels of Trauma/ED team activations: 1. Level I Response Indicated for patients with physiologic or anatomic abnormalities that indicate serious life- or limb-threatening injury requiring immediate intervention. A level I response mobilizes the full Trauma Team, notifies the Operating Room and Blood Bank, and prioritizes Radiology and Laboratory studies. 2. Level II Response Indicated for patients with evidence of significant injury who do not otherwise meet level I criteria. When clinical assessment warrants, there should be no hesitation upgrading to Level I response. A Level II response mobilizes the Trauma Team, including OR and prioritizes Radiology and Laboratory studies. 3. Level III ED Expedited Trauma Response Indicated for patients that meet the attached clinical criteria, based on demographics (e.g. age), risk factors (e.g. anticoagulation) or mechanism of injury that would benefit from an expedited evaluation to determine the presence or absence of significant injury. A Level III response mobilizes an ED core team and prioritizes Radiology and Laboratory studies. 1

2 General Principles For All Levels: 1. Parameters only valid when they are attributed to traumatic injury 2. Maintain high levels of vigilance for patients with comorbidities: a) Advanced age ( 65 y/o) b) Bleeding diathesis (ie: antiplatelet or anticoagulant medications, ESRD, liver disease, alcoholism, genetic bleeding disorders) c) Severe osteoporosis 1) Level I Trauma Response criterion: a) Activation Parameters i) Physiologic Parameters 1) Prehospital intubation (Patients intubated in the ED for hemodynamic instability or respiratory failure will be upgraded to Level I) 2) Compromised respiratory status (e.g. resp rate < 10/min or > 30/min) 3) Systolic BP <90 mm Hg at any time 4) Tachycardia of >120 bpm, sustained 5) GCS <9 Motor 5 (unable to follow commands) Deteriorating by 2 or more points 6) Core temperature < 28 C (82 F) ii) Anatomic Parameters 1) Airway compromise or high risk of impending airway compromise such as: (a) Significant intraoral/airway bleeding (b) Inhalation injury with respiratory compromise (c) Hanging/strangulation (d) Facial burns (e) Vomiting with altered mental status/combative behavior 2) Respiratory compromise or high risk of impending respiratory compromise such as, but not limited to: (a) Massive subcutaneous emphysema (b) Absent or unequal breath sounds (c) Chest wall instability/flail chest (d) Intubated patient from the scene 3) Burns involving > 25% BSA (2 nd and 3 rd degree) 4) Head, neck or back injury associated with neurologic deficit (e.g. paraplegia, quadriplegia) 5) Penetrating injuries to head, neck, chest, abdomen, or extremity proximal to the elbow or knee 6) Amputation proximal to wrist or ankle 7) Crushed, de-gloved, mangled or pulseless extremity Other reported signs or symptoms that suggest an immediate life- or limb-threatening injury 2

3 iii) System Logistics 1) Simultaneous arrival of three (3) or more trauma patients 2) Emergency Physician/Trauma Surgeon discretion 3) Transfer patients who meet criteria above or require specific interventions to prevent deterioration a. Receiving blood products or vasopressors to maintain hemodynamics b. Intubated with ongoing respiratory compromise b) Level I Response Team Upon activation of Level I response, Trauma Team members will be alerted by established notification procedure (policy #71TPM ) and must respond immediately to the resuscitation bay in the Emergency Department. The goal of the Level I response is to be readily available upon the patient's arrival. Core team members must be physically present in the trauma resuscitation area within ten (10) minutes from time of notification. *Trauma Surgeon Radiologist *Emergency Physician Respiratory Therapist *Emergency Nurse Trauma Resident PGYIV (2-Primary/Recording) Emergency Medicine Resident * Radiologic Technologists Emergency Medicine Physician *ED/Trauma Tech and ED Clerk OR Personnel (1) *Core team members--at bedside for patient's arrival The Trauma Attending is expected on arrival of trauma activations but no later than 15 minutes of patient s arrival. This expectation can be fulfilled by a PGY-IV Surgery Resident to expedite the resuscitation until arrival of the Trauma Surgeon. 2) Level II Trauma Response Criterion: a) Activation Parameters i) Physiologic Parameters 1) GCS 13 with persistent altered mental status ii) Anatomic Parameters 1) Penetrating extremity injury distal to the knee and elbow with active hemorrhage 2) 2 or more proximal long bone fractures (humerus or femur) 3) Open long bone fracture (humerus or femur) 4) Open or depressed skull fracture 5) Paralysis spinal cord injury 6) Suspected pelvic fracture instability 7) Burns 10 to 24% TBSA (2 nd or 3 rd degree without respiratory compromise) 8) Pregnancy > than 20 weeks gestation 9) Falls greater than 20 feet or 2 stories 10) High risk automobile crash Ejection (partial or complete) Death in the same compartment Passenger compartment intrusion including the roof 3

4 >than 12 inches occupant side >than 18 inches any site 11) Auto vs pedestrian/bicyclist thrown, run over, or with significant (>20 mph) impact 12) Motorcycle crash>20 mph iii) System Logistics 1) Emergency physician/trauma surgeon discretion 2) Transfer patients deemed appropriate by trauma and emergency physicians b) Level II Response Team Upon activation of Level II Trauma Alert the Trauma Response Team is notified by established procedures and must respond immediately to the trauma bays. Core team members must be physically present in the trauma resuscitation area within ten (10) minutes from time of notification. *Trauma Surgeon Radiologist *Emergency Physician Respiratory Therapist *Trauma Resident PGY IV Chaplain *Emergency Nurses (2) ED Clerk (MOI) OR Personnel (1) ED Tech *Core Team--At bedside for patients arrival Team member roles are identical to those described in the Level I Response section of this protocol. The Trauma Attending is expected on arrival of trauma activations but no later than 15 minutes after patient s arrival. This expectation can be fulfilled by a PGY-IV Surgery Resident to expedite the resuscitation, until arrival of the Trauma Surgeon. There will be communication between the Trauma Attending and the Surgery Resident/ED Attending within 30 minutes after arrival of injured patient meeting the Level II response criteria. Guidelines for Level I and Level II Trauma Activation ED Discharges Any patient that has met the above activation criteria and is found to not have injuries requiring acute care admission will be observed in the Emergency Department for a clinically appropriate period of time. These patients will remain the responsibility of the Trauma Team. In collaboration with the ER nursing staff, they will receive necessary and appropriate management (e.g. pain medications, reassessments including vital signs, consultations). It will be the responsibility of the Trauma Team to complete a tertiary exam on all these patients prior to discharge. The Trauma Team will complete the tertiary survey document and discharge the patient with the appropriate follow-up, discharge plans, and prescriptions/medications. 3) Level III ED Expedited Trauma Response criterion: a) Indicated for patients that do not meet Level I or II response criteria, but would benefit from an expedited evaluation to determine the presence of significant injury b) Transfer patients not meeting other criteria and determined appropriate by trauma attending and emergency medicine attending during transfer call with patient logistics 4

5 Level III ED Expedited Trauma Response: Upon activation of Level III ED Expedited Trauma response: The Emergency Department Physician (Attending and/or Senior Resident) and nursing staff will respond immediately to the patient s room. This response should be within 10 minutes of ED bed assignment. The registration process will be completed as all other ED patients. Every attempt should be made to utilize the trauma bay if not occupied by higher acuity patient requiring resuscitation. The ED physician will assume the role of Team Leader and supervise the care and expedited work up. The resuscitation will include primary and secondary trauma surveys, performance and review of all diagnostic radiographs. Nursing and physician documentation will reflect assessments, monitoring and procedures in the EMR as other ED patients but maintain hourly vital signs and complete neurological examinations until downgraded by the ED physician. If there is a deterioration in status and/or the ED Attending finds that the patient meets criterion for Level I or II an upgrade in status will be implemented and should have the same documentation requirements initiated. (Trauma Flow Sheet implemented, Trauma H&P) If an injury requiring admission or management by the Trauma Team is discovered, that doesn t meet Trauma activation criteria, a Trauma consult will be initiated and care will be transferred to the Trauma Service or the appropriate designated subspecialty service, after cleared by the Trauma Service. The Trauma Service physician should evaluate these patients within 30 minutes of consultation. If, after evaluation, the patient can be treated and released home from the ED, the responsibility for management and discharge will remain with the ED. It is the team leader responsibility to determine disposition and direct communication to the appropriate consultants as needed. *Emergency Physician ED Social Worker *Emergency Resident PGY II-III ED Clerk (MOI) *Emergency Nurses (1) *Core Team At bedside for patient s arrival 4) Trauma Consultation Trauma surgery is always available for consultation on and injured Emergency Department patient. 5) Admission Guidelines Any patient admitted solely for an injury or injuries must be admitted under the care of a Trauma Surgeon, Orthopedist, Neurosurgeon, or other surgical service as appropriate. A Trauma Surgeon consultation is required if a patient has sustained injury within the prior 72 hours and: the history reveals that the patient sustained blunt trauma by a mechanism, which had the potential to cause significant injury OR two or more injured systems (excluding skin) requiring admission are present. (e.g. cerebral concussion with vertebral compression fracture) 5

6 This consultation request should be made concurrent with the consultation request to the orthopedic, neurosurgical, or other surgical service. A Trauma Service physician should evaluate these patients within 30 minutes of consultation. Note: Patients admitted solely for medical work-up after an injury do not necessarily meet trauma definitions. A patient admitted for syncope, CVA, or MI coupled with an injury that would have been treated as an outpatient is not considered a trauma patient. Performance Improvement Triage decisions are closely monitored. Over and undertriage are captured in the POPIMS PI database for trauma patients. While overtriage of 15% to 50% is tolerated to create a system to readily identify and treat critical trauma patients; undertriage is less desirable. Undertriage cases require a written analysis from the triaging EP or ED Liaison and are closely evaluated by the Trauma Service PI Program. Concurrent trauma case management will review all patients admitted with traumatic injuries for appropriate admission to a surgical service best suited to manage the patient's injury(ies) and assure Trauma Service involvement from admission to discharge. Reference: PTSF, 2011 Standards for Trauma Center Accreditation, Standard XVII, C, 1-3. Reviewed: 12/11, 8/14, 4/15, 9/16 Revised: 09/11, 10/13,8/14, 4/15 Trauma Program Manager Policy Number: 017TPN Trauma System Activation Protocol Effective: September

7 Level I Response Criteria 1) Triage Parameters a. Physiologic Parameters 1. Prehospital or ED intubation 2. Compromised respiratory status (e.g. resp rate < 10/min or > 30/min) 3. Systolic BP < 90 Hg at any time 4. Sustained tachycardia of > 120 bpm 5. GSC <9 Motor 5 (unable to follow commands) Deteriorating by 2 or more points 6. Core temp <28c (82f) b. Anatomic Parameters 1. Airway compromise or high risk of impending airway compromise such as: (a) Significant intraoral/airway bleeding (b) Inhalation injury with respiratory compromise (c) Hanging/strangulation (d) Facial burns (e) Vomiting with altered mental status/combative behavior 2. Respiratory compromise or high risk of impending respiratory compromise such as, but not limited to: (a) Massive subcutaneous emphysema (b) Absent or unequal breath sounds (c) Chest wall instability/flail chest (d) Intubated patient from the scene 3. Burns involving > 25% BSA (2 nd and 3 rd degree) 4. Head, neck or back injury associated with neurologic deficit (e.g. paraplegia, quadriplegia) 5. Penetrating injuries to head, neck, chest, abdomen, or extremity proximal to the elbow or knee 6. Amputation proximal to wrist or ankle 7. Crushed, de-gloved, mangled or pulseless extremity *Other reported signs or symptoms that suggest an immediate life- or limb-threatening injury c. System Logistics 1.Simultaneous arrival of three (3) or more trauma alert patients 2.Emergency Physician/Trauma Surgeon discretion 3.Transfer patients who meet criteria above or require specific interventions to prevent deterioration 4.Receiving blood products or vasopressors to maintain hemodynamics 5.Intubated with ongoing respiratory compromise Level II Trauma Response Criteria a) Activation Parameters i) Physiologic Parameters 1) GCS 13 with persistent altered mental status ii) Anatomic Parameters 1) Penetrating extremity injury distal to the knee and elbow with active hemorrhage 2) 2 or more proximal long bone fractures (humerus or femur) 3) Open long bone fracture (humerus or femur) 4) Open or depressed skull fracture 5) Paralysis spinal cord injury 6) Suspected pelvic fracture instability 7) Burns 10 to 24% TBSA (2 nd or 3 rd degree without respiratory compromise) 8) Pregnancy > than 20 weeks gestation 9) Falls greater than 20 feet or 2 stories 10) High risk automobile crash Ejection (partial or complete) Death in the same compartment Passenger compartment intrusion including the roof >than 12 inches occupant side >than 18 inches any site 11) Auto vs pedestrian/bicyclist thrown, run over, or with significant (>20 mph) impact 7 12) Motorcycle crash>20 mph iii) System Logistics 1) Emergency physician/trauma surgeon discretion 2) Transfer patients deemed appropriate by trauma and emergency physicians Level III Trauma Response Criteria a) Indicated for patients that do not meet Level I or II response criteria, but would benefit from an expedited evaluation to determine the presence of significant injury b) Transfer patients not meeting other criteria and determined appropriate by trauma attending and emergency medicine attending during transfer call with patient logistics Trauma Consult a) Trauma Surgery is always available for consultation on any injured emergency department patient General Principles for all levels a.) Parameters only valid when they are attributed to traumatic injury b). Maintain high levels of vigilance for patients with comorbidities: 1.) Advanced age ( 65 y/o) 2.) Bleeding diathesis (ie: antiplatelet or anticoagulant medications, ESRD, liver disease, alcoholism, genetic bleeding disorders) 3.) Severe osteoporosis