“TMIP” Education

1. “TMIP”Trauma Management Improvement Plan for Duke University HospitalEmergency DepartmentModule Two

2. “TMIP” Education Module Two

3. 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. 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/ResponsibilitiesTrauma 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/ResponsibilitiesEM 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/ResponsibilitiesSupervising Resident • 0601-1800 Trauma Surgery Chief -------1801- 0600 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/ResponsibilitiesAirway Resident • Assesses airway • Requests/orders RSI medications • Manages/directs airway management

14. Roles/ResponsibilitiesAssessment Resident • 0601-1800 Trauma Surgery Resident ----1801- 0600 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/ResponsibilitiesAssessment 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/ResponsibilitiesProcedure 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/ResponsibilitiesRespiratory 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 lllllllllllllllllllllll

20. Roles/ResponsibilitiesED 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/ResponsibilitiesPrimary 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/ResponsibilitiesPrimary Nurse • Pre-arrival • Manages room flow (Pre-Arrival Conference Activities) • Coordinates WHOneeds 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/ResponsibilitiesPrimary 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/ResponsibilitiesPrimary 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/ResponsibilitiesPrimary 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/ResponsibilitiesMonitor/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/ResponsibilitiesMonitor/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/ResponsibilitiesMonitor/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/ResponsibilitiesProcedure 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/ResponsibilitiesProcedure 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/ResponsibilitiesProcedure 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. PICU 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/ResponsibilitiesNursing 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/ResponsibilitiesEDUC 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/ResponsibilitiesEDUC 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/ResponsibilitiesEDUC • 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. “TMIP” Education You have completed Module Two. Exit and proceed to Module Three.