Transcript The Evolving Role of Mechanical Circulatory Support in Patients

“TMIP”
Trauma Management
Improvement Plan
for
Duke University Hospital
Emergency Department
Module Three
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“TMIP” Education
Module Three
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Section 3. cont.
The Trauma
Resuscitation Team
Roles & Responsibilities
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Roles/Responsibilities
Social Worker
• Assists with locating and notifying family members of
patient arrival if indicated
• Manages patient’s family and significant others’ location
and movement during acute phase of care by balancing
their right to see the patient with not impeding critical
patient care
• Facilitates flow of information from Supervising Resident to
family and significant others
• Supports the family and significant others’ emotional
response to patient’s traumatic injury
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Roles/Responsibilities
Child Life Specialist
• Provides age-appropriate communication with pediatric
patients
• Assistance with patient preparation and diversion for
painful procedures as clinically indicated based on
developmental age of patient
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Section 4.
Trauma Stabilization
Performance Sequence
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Trauma Continuum of Care
Communication
Trauma Stabilization
Performance Sequence
Emergency Department
Continuum of Care
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Phase I – Pre Arrival
Conference
Phase II – Pt Arrival
Phase III – Definitive Care
Trauma Stabilization
Performance Sequence
• Identifies the continuum of care
and events (Phases of Care) in
the ED
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Phase I
• Pre-arrival
– Trauma Team activation
– Pre-arrival conference
•
•
•
•
Information sharing
Role assignment
Preliminary plan of care
Room preparation
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Components of
Pre-Arrival Conference
• Any team member can initiate the Pre-Arrival
Conference however the preliminary plan of care is
established by the trauma resuscitation team led by the
Supervising Resident
• The goal is that it is done and the conversation is
focused solely on preparation of the team for the
arriving patient
• Available information is relayed to team members
• Trauma Resuscitation Team roles are assigned
• Trauma members don PPE attire and apply “Role
Stickers”
cont.
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Components of
Pre-Arrival Conference
• Contingency plans are determined such as need
for emergency release or MTP blood products,
specialty consultants who are not part of trauma
activation page (i.e. Neurosurgery, Thoracic
Surgery), any specialized equipment
• Personnel not required for patient care are
excused
• Appropriate number of “observers” (students)
are determined and positioned unobtrusively in
the room
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Phase II
• Patient arrival
– Pre-hospital provider report if applicable
– ATLS
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•
•
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•
•
•
Primary survey
Interventions/Procedures
AMPLE History
Secondary Survey
Interventions/Procedures
Team notification of initial plan of care
Documentation
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Characteristics of Pre-hospital
Provider’s Bedside Report
• The Trauma Team will be silent while
pre-hospital staff provide report to the
team and answers questions primarily
from Assessment Resident or Primary
Nurse
– “Sterile Cockpit” approach to patient handoff
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Additional Points to
“Airway” in Primary Survey
• Additional airway management
support as determined by EM
Attending may be obtained by calling:
– “Anesthesia Emergency Airway Team”
via 115 paging system or the
– “Emergency Tracheotomy Team” via
115 paging system to perform emergent
surgical airway interventions
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Additional Points to
“Disability” in Primary Survey
• Assessment components include AVPU,
PERRL, GCS
• Assessment Physician will begin to
determine need for Neurosurgery consult
at this point
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Additional Points to
Secondary Survey
• Second full set of vital signs are obtained
• Head to toe/front to back
• Patient should be removed from spine board at time of log roll and
after posterior aspect is inspected, radiograph plates should be
positioned for chest and pelvis radiographs and patient log rolled
back to supine position
– Radiograph plates should not be shoved under patient while
supine
• Gastric tube insertion needs to occur PRIOR to obtaining chest
radiograph
• Foley will be inserted prior to CT
• FAST Ultrasound and limited “spot” radiographs as ordered by
Orthopedic Resident can also be obtained at this time prior to
patient going to CT scan
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Components of
Initial Plan of Care
• Assessment Resident confirms findings of
initial evaluation with trauma team to
assure accuracy and completeness
• Supervising Resident in conjunction with
the Primary Nurse will then implement the
plan of care
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Physician Documentation
• The Trauma Surgery Assessment
Resident will document on the Trauma
Assessment History & Physical Form
• The EM Assessment Resident will
document ED History & Physical
electronically
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Nurse Documentation
• The Trauma Nursing Record is generated
for all trauma alert activations and is
completed according to established
documentation guidelines found on the ED
On-Line Resource.
http://marlowe.duhs.duke.edu/ed/emergency
handbook.nsf/a515f3ab62e482b985256ab
f004cb197/852570f4007170b0852576880
045b987?OpenDocument
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Phase III
• Definitive Care
– Ongoing reassessment of primary and secondary
survey components
– Ongoing communication between team members
– Consultation
– Diagnosis
– Comprehensive care and management
– Operative intervention
– Determination of Level of care (ICU, OR, Intermediate
or Step-down unit, discharge)
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Physician Documentation
• For patients with extended LOS in the ED
after disposition, the patient care
resident(s) will document and update the
patient’s on-going plan of care in a
specified area of the patient’s eBrowser
where the entire team has access to
review.
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Section 5.
Trauma Performance Metrics
Patient Flow Time Goals
Door….. to….. Transfer
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An orchestrated performance….
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PERFORMANCE THAT “COUNTS”……..
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Section 6.
Additional Trauma
Performance Practices
Communication
Consultations
Diagnostic Imaging
Patient Transport
Debriefing/Critique
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Communication
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Communication
• There will be an established continuous flow of
information between the Assessment Resident,
Primary Nurse, and Supervising Resident. All will
be informed of information concerning
assessment, diagnostic findings, condition
changes, and alterations in the plan of care.
– The EM Assessment Resident will provide report to
the Trauma Chief or designee for continuation of
trauma patient care after resuscitation and
stabilization. Sunday – Saturday 1801-0600.
cont.
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Communication
• The patient care resident/Attending will
communicate patient care information via
phone to the accepting ICU care provider.
• The patient care resident will attend
patient transport to the ICU for
participation in patient care handoff to the
receiving team.
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Consultations
• Consultants should allow for completion of
primary and secondary survey.
Consultants will verbally communicate with
the trauma resuscitation team regarding
evaluation, plan of care and any changes
to the plan. They will complete
appropriate, required documentation of
consultation.
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Trauma Radiology
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Diagnostic Imaging
• Radiologists consultation and image review will be
provided
• Radiology priorities and imaging sequences should
be confirmed. Subsequent changes to the imaging
sequence should be reviewed with the
Supervising Resident with oversight of the Trauma
Attending.
• PCXR performance goal – 15 mins.: door to
performance
• CT performance goal – 20 mins.: door to CT room
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Diagnostic Imaging
• To impact ED LOS, delays in achieving CT and
plain films should be minimized for the trauma
patient. While in the first Radiology area, the
primary nurse can ask the Radiology Technologist
to call ahead to the next Radiology area to secure
a ready room for the patient. This facilitation of
patient flow should eliminate the patient going back
and forth to Radiology from the ED.
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Transporting Trauma Patients
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Patient Transport
• If diagnostic procedures require the patient to be
transported out of the ED, the Assessment
Resident will inform the Primary Nurse. A
minimum of five minutes is needed for
packaging the patient for transport. Preparing
the patient for transport includes:
– Monitoring equipment
– Stabilization of cervical spine and immobilization if
required (c-collar application prior to patient transport)
– Transport pack with warm fluids to accompany patient
– Medications (pain, sedation, paralytic, etc.)
cont.
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Patient Transport
• The Primary Nurse will transport. Respiratory
Therapy will be available to maintain adequate
ventilation and oxygenation during transport as
required.
• Patient stability will be established prior to
transport out of the ED. If an unstable patient
defined by established guidelines (Trauma
Transport Protocol) is to be transported, they
will be accompanied by the Trauma Chief or
designee.
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Monitoring and Measuring
Quality of ED Trauma Care
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Debriefing/Critique
• Any member of the Trauma Resuscitation
Team may call for a debriefing or critique
• A debriefing is helpful in dealing with the
emotional responses to the victim or the
circumstances of the injury. The purpose of a
debriefing is to help members of the team
cope with normal human responses to
tragedy.
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Debriefing/Critique
• A critique is a procedural review that provides a forum to discuss
the positive aspects of the resuscitation and identify problems or
a need for procedural changes. Critiques are meant to facilitate
communication and problem resolving. Forums that are available
are:
– Weekly Trauma or monthly Pediatric Trauma Management
Conferences
• A request for review may be made to the Trauma Center office
– The evaluation of the “Resuscitation Debrief” will be submitted to
Trauma Coordinator for review of performance improvement
opportunities
• A monthly performance review will be completed by the ED Critical
Care/Trauma Committee with performance improvement
recommendations submitted to participating disciplines
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Thank you!
This is a very exciting time to be part of DUH
ED and Trauma Center.
We are very happy you are part of this great
team, all of us working together to continue
to improve the care we provide to our
trauma patients and our work to become
one of the best trauma centers.
Thank you for your time & attention and your
help in making this a successful endeavor.
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“Building Success Together”
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“TMIP” Education
You have completed Module Three.
Proceed to Quiz.
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