ST. JOSEPH S HOSPITAL & MEDICAL CENTER LEVEL 1 TRAUMA CENTER. Trauma Center Guidelines

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ST. JOSEPH’S HOSPITAL &

MEDICAL CENTER

LEVEL 1 TRAUMA CENTER

Trauma Center Guidelines

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PHILOSOPHY:

We believe in the sacredness of all life, and therefore in the human dignity

of the human person and the promotion of human wholeness.

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INDEX OF TRAUMA CENTER GUIDELINES FOR TRAUMA PATIENTS SECTION I:

TRAUMA PROCESS GUIDELINES

Trauma Team Activation-Level I Trauma Patient Identification Trauma Team Member Response

Interfacility Transfer of Burn Trauma

Diversion of EMS Transport of Level I Trauma Patients

Patient Care Guidelines for Resuscitation and Management of Level I Trauma

Patients

Consent of Level I Trauma Patient Treatment

Universal Precautions in Trauma Room and at the Bedside Radiation Protection in Trauma Room and at the Bedside Protection of Chain of Evidence

Trauma Room Lock Box (Valuables) & Personal Belongings Guideline Trauma Surgeon Role

ED Physician Role

Back-Up Trauma Surgeon Role Trauma Resident/Surgical Assist Role Trauma Anesthesiologist Role

Trauma Room Nurse Role

Trauma Room Nurse Scribe Role

Patient Care Tech – Assigned to Trauma Team Role Operating Room Nurse ED/Trauma Room Role Radiology Technician Role

Respiratory Therapist Role Laboratory Phlebotomist Role CT Technician Role

Consults on Trauma Patients Neurosurgery Consult Guideline Pediatric Consult Guideline OB/Trauma Guideline Replantation Guideline

Trauma Room X-rays Profiles Trauma Room Lab Profiles

Emergency Issue Blood Components

Emergency Issue Units Stored in the Trauma Refrigerator Blood Component Return to the Blood Bank

C-Spine Clearance in Trauma Level I Patient Follow-Up

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SECTION II:

TRAUMA PRACTICE MANAGEMENT GUIDELINES • ED Thoracotomy in Adult Trauma Patients

Determination of Route of Nutritional Support

Discontinuing (Weaning) Mechanical Ventilation in Trauma Patients Adult Trauma Ventilator Weaning Guideline

Antibiotic Use in Tube Thoracostomy

Tube Thoracostomy Removal with Algorithm Management of Occult Pneumothoraces

Tracheostomy in Ventilator-Dependent Patients

Diagnosis and Treatment of Ventilator Associated Pneumonia (VAP) in the Adult

Trauma Patient

Tertiary Trauma Survey

Stress Ulcer Prophylaxis in Critically Ill Patients Massive Transfusion Protocol

Red Blood Cell Transfusion

Venous Thromboembolism (VTE) Prophylaxis IVC Filter Removal Guideline for Trauma Patients Alcohol Screening and Brief Intervention Guideline

Management of Alcohol Withdrawal Syndrome in the Trauma Patient Vaccination in Patients with Splenic Injury

Non-operative Management of Isolated Splenic Injuries in Children Update – Intensive Insulin Therapy in Critically Ill Patients

Management of the Head Injured Trauma Patient

Oral Contrast and Abdominal Computed Tomography (CT)

Management of Incidental Finding of an Adrenal Mass (Incidentaloma) Resident Coverage of Trauma Patients Admitted to Pediatric Ward Radiologic Imaging in Pregnant Trauma Patients

Hyponatremia in Trauma, Critically-ill and Brain injured Patients Prevention of Contrast-Induced Nephropathy in Trauma Patients SECTION III:

TRAUMA NURSING GUIDELINES • Patient Infection Control Guidelines Bowel Care

Management of the SCI Patient or Patient in C-Spine Precautions Halo Brace Application and Care (3)

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SECTION I

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TRAUMA GUIDELINE

TRAUMA SERVICE

Trauma Team Activation St. Joseph’s Hospital &

Level I Trauma Patient Identification Medical Center PAGE 1 of 2

February 1983 April 2010

ORIGINAL DATE REVISED DATE

PURPOSE: The Trauma Team is activated to assure an immediate, highly skilled response to major trauma patients (Level I Trauma patients) who are transported to the hospital by ground and air ambulance as well as by private vehicle.

GUIDELINES:

1. The Emergency Clinical RN Supervisor or designee RN receives the prehospital

notification of trauma patient transports and utilizes Level I Trauma Activation Criteria to activate the trauma team. The ED RN answering the patch on all Level I trauma patients completes the Patch Form.

2. For qualifying patients, the ED Clinical Supervisor or designee activates the Trauma Team by calling the Operator on the code line. “Trauma Team I” (one patient in the trauma room) or “Trauma Team II” (more than one patient in the trauma room) should be specified when calling the operator. Or Trauma Team Red (Inclusion criteria: CPR in progress; compromised airway in the field;unstable vital signs;gross deformity or penetrating injury to the head;penetrating injury to the chest, abdomen, or pelvis; crush injury to chest or pelvis; pulseless injured extremity; amputation excluding digits; pregnant patient with signs of abruption; GCS < 8; Quadriplegia; “Hot” offload from helicopter).

3. For qualifying patients with greater than 5 minutes ETA, the Trauma Clinician is

immediately contacted by phone regarding the EMS transport. The ED RN and Trauma Clinician confer on the timing of paging the Trauma Team.

4. The outside facility will contact the Transfer Center by calling 602-406 BEDS) for requests for interfacility transfers of trauma patients

5. The Trauma Team is activated for all of the following (Level I Trauma patients): A. Blunt and penetrating trauma with the following physiological findings:

Measure VS and LOC

GCS < 14 or,

Systolic BP < 90 mmHg (80mmHg<age 8) or,

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B. Injured patients with anatomy of injury as follows:

All penetrating injuries to head, neck, torso, and extremities proximal to elbow and knee

Flail chest

Two or more proximal long bone fractures Crushed, degloved or mangled extremity Amputation proximal to wrist and ankle Pelvic fractures

Open or depressed skull fracture Paralysis

C. Mechanism of injury as follows: Falls

Adults: > 20 feet (one story is equal to 10 feet)

Children: > 10 feet or two or three times the height of the child High Risk auto crash

Intrusion: > 12 inches, occupant site; > 18 inches, any site Ejection (partial or complete) from the vehicle

Death in same passenger compartment

Vehicle telemetry data consistent with high risk of injury

Auto vs. Pedestrian/bicyclist thrown, run over, or with significant ( > 20 mph) impact.

Motorcycle crash > 20 mph D. Age

Older Adults: Risk of injury/death increases after age 55 years

Children: should be triaged preferentially to pediatric-capable trauma centers Anticoagulation and bleeding disorders

Burns

Without other trauma mechanism: Triage to burn facility With trauma mechanism: Triage to trauma center. Time sensitive extremity injury

End-stage renal disease requiring dialysis Pregnancy > 16 weeks

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TRAUMA GUIDELINE

TRAUMA SERVICE Trauma Team Member Response St. Joseph’s Hospital &

Medical Center

PAGE 1 of 2

February 1983 April 2010

ORIGINAL DATE REVISED

PURPOSE: The Trauma Team is activated to assure an immediate, highly skilled response to major trauma patients who are transported to the hospital by ground and air ambulance as well as by private vehicle.

GUIDELINES:

1. The Emergency Physician, the ED Clinical RN Supervisor or the Trauma Clinician or ED RN designee activates the Trauma Team based on the EMS report and the condition on arrival of trauma patients. The Emergency Physician participates on the Trauma Team as dictated by the situation.

2. The Trauma Team is notified by pager and overhead paging system (until 10:00 pm) according to the Emergency Department Trauma Team notification process. (See Trauma Team Activation Guideline).

3. The in – house Trauma Team includes two primary teams, Trauma Team I and Trauma Team II. The goal of the team response is to be present at the time of the patient’s arrival to the Trauma Room. Response times are based on a minimum of a five-minute pre-notification by pager and overhead announcement.

4. The following members respond to the Trauma Room for Trauma Team I activations: A. Trauma Surgeon (1)

B. Trauma Anesthesiologist (1)

C. Physician Surgical Assistant / Trauma Residents (1-4) D. Trauma Nurse Clinician (1)

E. Emergency Department Trauma Nurse (1) F. OR Nurse (1)

G. Emergency Department Patient Care Technician (1) H. Radiology Technician (1-2)

I. Respiratory Therapist (1-2) J. Phlebotomist (1)

K. Emergency Department Social Worker / Clergy (1) L. Security (1)

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The following additional members respond when there are two Level I Trauma Patients in the Trauma Room – “Trauma Team II”:

A. SWAT RN (1)

B. Additional scheduled RNs (ICU, ED, SWAT) (1)

5. The following additional members respond when notified for more than two Level I Trauma patients in the Trauma Room:

A. Additional Phlebotomist

B. Additional Respiratory Therapist C. Additional Radiology Technician D. Available RNs

6. For Pediatric trauma patients additional team members include: A. Pediatric Intensivist (1)

B. Pediatric ICU Nurse (1)

7. For OB trauma patients who are seen in the Trauma Room additional team members include:

A. Chief OB Resident / or in-house attending (1) B. OB Nurse (1)

C. NYICU code arrest team for newborn resuscitation in emergency C-sections in the Trauma Room

8. For multiple Level I Trauma patients additional specialty Trauma Team members are called to the Trauma Room as needed by the Trauma Clinician.

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TRAUMA GUIDELINE

TRAUMA SERVICE Inter-facility Transfer of Burn Trauma St. Joseph’s Hospital &

Medical Center

PAGE 1 of 1

August 1985 April 2010

ORIGINAL DATE REVISED

PURPOSE: To identify burn trauma patients who require transfer to a Burn Center for a higher level of care.

GUIDELINES:

1. Trauma patients presenting to the hospital with burns of over 20% of their body will be stabilized and transferred to the closest Level I Burn Center in accordance with the transfer agreement between the facilities.

2. No patient will be transferred to another facility without acceptance by an appropriate specialty physician at the receiving facility. Hospital policy on inter-facility transfers will be followed.

3. The current ATLS standards will be followed for stabilization of burn patients prior to transport to a higher level of care.

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TRAUMA GUIDELINE

TRAUMA SERVICE Diversion of EMS Transport St. Joseph’s Hospital &

of Level I Trauma Patients Medical Center

PAGE 1 of 2

July 1993 April 2010

ORIGINAL DATE REVISED

PURPOSE: To identify criteria for diversion of EMS transports of Level I Trauma patients from the Trauma Center

GUIDELINES:

1. The current hospital policy on Admitting and Receiving Patients will be followed for determining the need for diversion of EMS transport of Level I Trauma patients from the Trauma Center.

A. The decision to initiate diversion of EMS transports for Level I Trauma patients can only be made by the Administrator on call or designee, based on the following criteria:

Trauma surgeon resources are fully committed – i.e. the surgeon, backup and Medical Director or designee are all in-house and in the OR; or anesthesia and their back-ups are all in the OR; or the Trauma Team is saturated with patients and unable to respond to additional Level I trauma team activation’s.

All CT scanners are down and CT is unavailable

An internal disaster has been formally declared (i.e. fire, power or other major plant failure)

The prioritization for hospital closure has been followed and fully committed hospital resources have resulted in closure to all admits and closure to EMS transports of general patients to the Emergency Department and Trauma Room due to fully committed ED and Trauma Team resources holding patients for admission

2. All situations which may warrant consideration of diverting EMS transports of Level I Trauma patients should be immediately communicated to the Administrator on Call who will consult with the Medical Director of the Trauma Service or his designee to determine other options.

3. Emergency Department personnel, Trauma Clinician or the Trauma Surgeon on duty may not unilaterally place the hospital on formal diversion of EMS transports for Level I Trauma patients.

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4. Emergency Department personnel, Trauma Clinician or the Trauma Surgeon on duty may not informally divert EMS transports of Level I Trauma patients either upon radio contact or arrival at the hospital.

5. All patients identified in the field and transported to the hospital as Level I patients will receive a full physical examination by the Trauma Service, with documentation of findings on the Emergency Level I Trauma Flow Sheet. If the Trauma Surgeon feels upon arrival that the patient meets Level II criteria, he will follow the proper procedure for downgrading (see Trauma ED/Triage Assessment Form Guideline for

downgrading/upgrading).

6. Initiation of diversion of EMS transport of Level I Trauma patients from the hospital will be fully documented by the Administrator on call, or the House Manager on the

appropriate reporting forms. The Emergency Department Clinical Supervisor will update the EMSystem appropriately and in a timely manner.

7. The first trauma surgeon and anesthesiologist to become available will notify the Trauma Clinician when they are out of surgery and available. The Trauma Clinician will notify the ED Clinical Supervisor so they may inform the house supervisor and update the EMSystem in a timely manner.

8. All initiations of the diversion of EMS transports of Level I Trauma patients will be reviewed by Trauma Administration and reported monthly at Trauma Committee.

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TRAUMA GUIDELINE

TRAUMA SERVICE Patient Care Guidelines for St. Joseph’s Hospital &

Resuscitation and Management Medical Center

of Level I Trauma Patients

PAGE 1 of 1

January 1999 April 2010

ORIGINAL DATE REVISED

PURPOSE: To provide patient care guidelines for resuscitation and management of the Level I Trauma Patient.

GUIDELINES:

1. The current (2006) American College of Surgeons Committee on Trauma , Advanced Trauma Life Support (ATLS) patient care guidelines are the accepted guidelines for trauma resuscitation and management in the following circumstances:

A. Initial Assessment and Management B. Airway and Ventilatory Management C. Shock

D. Thoracic Trauma E. Abdominal Trauma F. Head Trauma

G. Spine and Spinal Cord Trauma H. Musculoskeletal Trauma I. Injuries Due to Burns and Cold J. Pediatric Trauma

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TRAUMA GUIDELINE

TRAUMA SERVICE Consent for Level I Trauma Patient Treatment St. Joseph’s Hospital &

Medical Center

PAGE 1 of 1

1997 April 2010

ORIGINAL DATE REVISED

PURPOSE: To define the use of consents for treatment of Level I Trauma Patients

GUIDELINES:

1. The St. Joseph's Hospital & Medical Center consent policy applies to Level I Trauma Patients during initial resuscitation and hospitalization.

2. Consent for emergency treatment and diagnostic studies in the Trauma Room are obtained following guidelines set forth in the Arizona Hospital Association Consent Manual. Generally, care in the Trauma Room and inpatient trauma care units requires adult consent, with the following exceptions:

A. Life saving measures will be instituted whenever indicated without express consent. B. Unconscious patients brought into the Trauma Room will be treated immediately

under the responsibility of the Trauma Surgeon.

C. Emancipated minors may give consent for their own treatment.

3. The Physician’s Certificate of Emergency and Medical Necessity (X-MR-5655) will be instituted when the physician judges that the patient’s condition/situation constitutes and emergency and it is impossible to obtain the express consent of the patient or the patient’s legally authorized representative. Two physicians are required to sign this form. When the Physician’s Certificate of Emergency and Necessity form is utilized the

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TRAUMA GUIDELINE

TRAUMA SERVICE Universal Precautions in the Trauma St. Joseph’s Hospital &

Room and Bedside Medical Center

PAGE 1 of 1

January 1993 April 2010

ORIGINAL DATE REVISED

PURPOSE: To define the proper use of personal protective equipment to protect trauma team caregivers in the Trauma Room and bedside care givers in nursing units and treatment or diagnostic areas from exposure to blood born pathogens.

GUIDELINES:

1. The current hospital policy on universal precautions will be followed by Level I trauma patient caregivers in the Trauma Room and other patient treatment and diagnostic areas. A. Resuscitation team members will utilize the following in cases in which blood is

present:

Eye wear/masks Shoe covers Hats

Gloves

Gowns/Aprons and other Protective Clothing

B. Specimens will be transported for processing in closed-labeled containers C. Sharps will be handled and disposed of according to policy

D. Hand washing or the use of hand gel will occur after removing gloves

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TRAUMA GUIDELINE

TRAUMA SERVICE Radiation Protection in the Trauma Room St. Joseph’s Hospital &

and Bedside Medical Center

PAGE 1 of 1

January 1992 April 2010

ORIGINAL DATE REVISED

PURPOSE: To protect trauma team caregivers in the Trauma Room and bedside care givers in nursing units from radiation.

GUIDELINES:

1. Lead aprons/shields will be worn by:

A. Resuscitation team members, others in the Trauma Room and other caregivers outside of the trauma room in nursing units especially those persons who can not move away from the immediate area when x-ray tech announces “x-ray”

B. Pregnant females, female patients of child bearing potential (10-50 years) and males under age 50

2. Lead aprons must be hung up carefully as they are easily cracked. Cracks in the apron allow radiation to penetrate to the wearer. Any cracked aprons should be reported to the x-ray technician immediately.

3. Lead thyroid shields are either attached to the apron, and may not be cut off, or are available on request.

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TRAUMA GUIDELINE

TRAUMA SERVICE

Trauma Team St. Joseph’s Hospital &

Preservation of Evidence Medical Center

PAGE 1 of 2

December 2002 April 2010

ORIGINAL DATE REVISED DATE

PURPOSE: For preservation of the chain of evidence.

GUIDELINES:

1. CLOTHING/BELONGINGS:

Should never be turned over to the family without clearance of law enforcement If possible, do not cut clothing. However, if unavoidable, do not cut through

bullet holes or knife holes if possible. Also, avoid any stains or defects. Do not throw clothing on the floor.

If possible air dry clothes, then fold and place into separate paper bags.

Try to not place clothing in plastic bags. Label all with victim’s name, date, and time.

Never throw away any patient belongings, this includes: blood stained clothes or soiled clothing, hair shaved in preparation of an ventriculostomy, etc.

Any suspicious contraband will be turned over to hospital security for safe- keeping until the appropriate police department can pick it up.

2. BULLETS:

Can be found in clothing.. Wrap in cotton or gauze, place in container and label with patient’s identification. Do not mark on the bullet itself.

Bullet wounds - do not wipe off the soot around the wound until investigators can photograph it, if at all possible.

3. DEATH AT THE HOSPITAL:

Do not wash the body

Do not remove any treatment paraphernalia that was inserted in the Trauma Room Should the case involve a suspected homicide, do not allow any familymembers

to touch the body. Not even if the victim is a child.

4. TRAUMA ROOM AS THE CRIME SCENE:

If an individual dies in the community and is brought to the hospital DOA the trauma room is the crime scene.

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5. REPORTABLE DEATHS:

Injuries by lethal weapons, self-inflicted injuries, overdoses, poisonings, suspected criminal abortions, animal bites, all DOA’s deaths due to blood transfusions, falls, blunt force or crushing injuries, stabbing and sharp force injuries, firearms, electrical shock and lightning, explosions, strangulations and asphyxia, MVCs, drug overdose and poisonings, burns and fires, stillborn or newborn infants, rapid fatal illness, occupational deaths.

Not every death referred to the ME will be autopsied. However, if the ME accepts jurisdiction for examination of the decedent, the family (next of kin) will not have a legal right to grant or deny permission for an autopsy.

6. GSW TO THE HEAD:

If there is reason to believe the wound is self inflicted, cover both hands with paper bags and tape around the wrist.. Try to obtain from the patient’s family whether the patient was right or left hand dominant. (Right handed vs. left-handed)

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TRAUMA GUIDELINE

TRAUMA SERVICE Trauma Room Lock Box Guideline St. Joseph’s Hospital &

Medical Center

PAGE 1 of 2

January 2002 April 2010

ORIGINAL DATE REVISED

PURPOSE: To define a process for the identification, documentation and securing, and protection of valuables belonging to the Trauma Room patient. Valuables are defined as money, jewelry, credit cards, car keys, and wallet.

GUIDELINES:

1. The Trauma Room Scribe will collect and inventory all patient valuables and list them correctly on the Trauma Room Documentation Form.

2. Next, the valuables must be documented on the (White) Patient’s Valuables Deposit Form.

3. After the Registrar obtains the patient’s insurance information, the Valuables Deposit Form will be separated and the yellow copy will be sent with the patient’s chart. 4. The white copy of the Valuables Deposit Form will be folded in half and inserted into

the clear plastic area on the front of the (Silver) Valuables Packet with the patient’s name and account number in clear view. It is important that the part of the form listing the valuables not be shown. The yellow copy goes on the patient’s chart and the pink copy accompanies the patient’s belongings to the floor or morgue.

5. The Trauma Room Scribe will document the date, 7 digit Valuables Packet number, patient’s name, Medical Record number and the initials of the Trauma Room Scribe securing the valuables, in the Trauma Room Ledger Book.

6. The Valuables Packet can now be sealed and dropped into the Lock Box in the Trauma Room.

7. Security is responsible for sending 2 security officers to pick up the valuables twice a day and document the date, time, and signature of the security officer obtaining the valuables, legibly, on the Trauma Room Valuables Ledger Book.

8. It is important to include documentation of any valuables received from a prehospital provider on the trauma documentation form.

9. If more patient belongings are found after the Valuables Packet has been placed in the Trauma Room Lock Box, another Packet must be started and documented in the Ledger. Do not attempt to open the lock box and reopen the first Valuables Packet. 10. All other patient belongings that are not considered valuables should be sent in a

clearly identifiable (labeled) patient belonging bag and sent either to the floor or to the morgue with the patient. (Clothing, cell phones, pagers, shoes, dentures, eyeglasses, etc.) NEVER THROW AWAY ANY CLOTHING OR PATIENT BELONGINGS!

11. If a police officer requests the patient’s valuables and/or belongings for evidence, document items taken on the trauma room documentation form and have the officer sign the form. Also document the police officer’s name and badge number in the appropriate area of the Trauma Room Documentation Form.

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12. Any illegal substances found in the patient’s belongings need to be described in the documentation and given to the Security Officer.

13. Valuables may be released to the patient’s family member with the patient’s

permission. If valuables are given to family members this should be documented on the trauma form. Should a family member request valuables Security should be called to do this.

14. Security will come to the Trauma Room and meet the Trauma Clinician to pick up patient valuables at the pre-arranged time. It is important that patient care not be compromised. If there is a patient in the trauma room when Security comes to pick up the valuables they will make arrangements to come back at an appropriate time.

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TRAUMA GUIDELINE

TRAUMA SERVICE

Trauma Team Roles St. Joseph’s Hospital &

Trauma Surgeon Medical Center

PAGE 1 of 1

February 1992 April 2010

ORIGINAL DATE REVISED

NOTIFIED: Trauma Pager and overhead page

FUNCTIONS:

1. Given a five (5) minute notification by pager and overhead page, is immediately available in the Trauma Room for the arrival of the Level I trauma patient to coordinate the total care of the patient.

2. Assesses the condition of the patient immediately, and performs or delegates invasive procedures as deemed necessary or clinically indicated to secure airway, establish effective ventilation and treat shock.

3. Defines priorities and orders laboratory and diagnostic tests. 4. Requests additional consultants as clinically indicated.

5. Determines the need to go to the operating room, radiology for computerized tomography or arteriography, and/or the trauma intensive care unit or other nursing unit for ongoing care.

6. Reassesses the patient at the bedside as clinically indicated after review of consulting opinions, diagnostic information and physical finds to determine further disposition. 7. Responsible for ongoing trauma ICU or other nursing unit care, intra-operative care,

postoperative care, and follow up.

8. Responsible for notifying the Trauma Clinician and advises to call in the back-up Trauma Surgeon based on the following:

The on call Trauma Surgeon is going to the OR with a Level I Trauma or emergent general surgery patient and will be in the OR for > 30 minutes

When there are multiple Level I Trauma patients requiring operative intervention When the Trauma Surgeon has an in-patient who warrants a return to the OR for

further surgical intervention. External Disaster

9. Collaborates with trauma clinician to ensure patient confidentiality by limiting access of non-trauma team members to the trauma room and protecting the medical record. 10. Reviews Trauma Documentation Flow Sheet for procedures and diagnostic tests

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TRAUMA GUIDELINE

TRAUMA SERVICE

Trauma Team Roles St. Joseph’s Hospital &

Trauma Resident/PA Surgical Assist Medical Center

PAGE 1 of 2

February 1992 April 2010

ORIGINAL DATE REVISED

TITLE: Trauma Resident/ PA Surgical Assistant

NOTIFIED: Trauma pager and overhead page

FUNCTIONS:

1. Given a five (5) minute notification by pager and overhead page, is immediately available on arrival of the Level I Trauma patient to assist the Trauma Surgeon in coordination of the total care of the patient.

2. Works with the Trauma Clinician to assure an organized approach to trauma care is utilized in the Trauma Room.

3. Assists in immediate and ongoing assessment of the condition of the patient and calls out findingsto the Trauma Room Scribe for documentation purposes.

4. Performs delegated invasive procedures as deemed necessary or clinically indicated to secure the airway, establish effective ventilation and to treat shock (Per ATLS

guidelines). Calls out procedures and results for documentation purposes.

5. Assists in defining priorities and determining the need for laboratory and diagnostic tests and under the guidance of the Trauma Surgeon, orders tests.

6. Participates in determining the need to go to the operating room, radiology for computerized tomography or arteriography, and / or the trauma intensive care unit or other nursing unit for ongoing care.

7. Performs as the trauma assistant when the patient requires surgical intervention. 8. Reassesses the patient at the bedside as clinically indicated after review of consulting

opinions, diagnostic information and physical findings and assists the Trauma Surgeon in determining further disposition.

9. Collaborates daily with the Trauma attending, Trauma Program Manager, Trauma Nurse Practitioner, Trauma Clinician, and the Trauma Social Worker regarding the ongoing care of all Trauma patients currently on the service.

10.Assists the RN with the transport of hemodynamically unstable trauma patients to CT scan, OR, or ICU.

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11.Remain at the bedside of hemodynamically unstable trauma patients for management of these critical patients and updates progress notes.

12.Responsible for rounding on all trauma patients currently on the trauma service daily and performing and documenting of daily assessments, progress notes, daily orders, and procedures. Also responsible for dictating history and physicals, procedures, discharge summaries, etc.

13. Reviews Trauma Documentation Flow Sheet for procedures and diagnostic tests performed, and medications given, then signs the record.

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TRAUMA GUIDELINE

TRAUMA SERVICE

Trauma Team Roles St. Joseph’s Hospital &

Trauma Anesthesiologist Medical Center

PAGE 1 of 1

February 1992 April 2010

ORIGINAL DATE REVISED

TITLE: Trauma Anesthesiologist

NOTIFIED: Trauma pager and overhead page

FUNCTIONS:

1. Given a five (5) minute notification by pager and overhead page, is immediately available in the Trauma Room for the arrival of the Level I trauma patient to assist the trauma surgeon with the care of the trauma patient.

2. Assesses, establishes and maintains the patient’s airway.

3. Provides on-going evaluation of the pulmonary and cardiovascular status of the patient. 4. Assists with:

Placement and maintenance of monitoring lines Maintenance of intravascular volume

Administration of blood products Administration of IV medications

5. Responsible for treatment of arrhythmias and management of ACLS techniques in the event of a cardiac arrest.

6. Provides anesthesia services as needed, for the Level I Trauma patient.

7. Trauma Anesthesia provides backup Trauma Anesthesiologist for multiple patients who require operative procedures simultaneously. The in house Trauma Anesthesiologist is responsible for calling in the back up anesthesiologist.

8. Trauma Anesthesia provides anesthesia services for Trauma Service patients requiring operative procedures after admission.

9. Reviews Trauma Documentation Flow Sheet for procedures performed and medications given, then signs the record.

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TRAUMA GUIDELINE Trauma Team Roles

TRAUMA SERVICE

Emergency Department St. Joseph’s Hospital &

Physician Role in Medical Center

Trauma Room

PAGE 1 of 1

February 1992 April 2010

ORIGINAL DATE REVISED

TITLE: Emergency Department Physician

ROLE: Coordinates and directs all prehospital care. Activates Trauma Team and coordinates care and diagnostic procedures until trauma surgeon is present, in the event that the patient arrives prior to assembly of the Trauma Team.

NOTIFIED: By E.D. Clinical Supervisor or Trauma Nurse Clinician in person, voice page and / or beeper

WHO RESPONDS:

The designated Emergency Department Physician

FUNCTIONS:

1. Responds to and gives advice as needed to ED Clinical Supervisor or ED RN designee answering the Patch radio console.

2. Immediately available on arrival of the trauma victim to help coordinate the care of the patient if needed as indicated by the Trauma Surgeon.

3. Assesses the condition of the patient immediately in the absence of the trauma surgeon.

4. Provides backup for trauma surgeon in case of multiple victims as requested by trauma surgeon.

5. In the cases of multiple victims in trauma room and/or when second call surgeon has been called in but has not yet arrived, the E.D. physician will manage the care of the patient until the back up surgeon has arrived.

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TRAUMA GUIDELINE

TRAUMA SERVICE

Trauma Team Roles St. Joseph’s Hospital &

Back-up Trauma Surgeon Medical Center

PAGE 1 of 1

February 1992 April 2010

ORIGINAL DATE REVISED

TITLE: Back – Up Trauma Surgeon

NOTIFIED: Trauma Clinician or Emergency Department Clinical Supervisor

WHO RESPONDS:

Second Call Trauma Surgeon (Back-up Trauma Surgeon)

FUNCTIONS:

1. Provides trauma surgeon coverage to Level I Trauma patients in the event that the in-house trauma surgeon is not immediately available due to presentation of multiple victims or because of responsibilities in the operating room for another Level I Trauma and/or emergent general surgery patient.

2. When the in-house Trauma Surgeon is committed to another patient (s) and cannot respond immediately to care for a major trauma, he or she will notify the Trauma Clinician or Emergency Department Clinical Supervisor to call in the back-up Trauma Surgeon.

3. Trauma Clinician or Emergency Department Clinical Supervisor will notify the second call Trauma Surgeon. The second call surgeon will report to the hospital within 30 minutes of being notified.

4. The Emergency Department physician when requested will respond to care for Level I trauma patients prior to arrival of the back-up Trauma Surgeon.

5. The second call Trauma Surgeon will notify the Trauma Clinician on-duty of his arrival. 6. The in-house Trauma Surgeon will notify the second call Trauma Surgeon and the

Trauma Clinician when he is available to resume first call.

7. When both the in-house and the back-up Trauma Surgeons are in the operating room the Trauma Clinician will notify the Medical Director or his designee if additional Trauma Surgeon coverage is required.

8. Reviews Trauma Documentation Flow Sheet for procedures performed and medications given, then signs the record

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TRAUMA GUIDELINE

TRAUMA SERVICE

Trauma Team Roles St. Joseph’s Hospital &

Trauma Room Nurse Medical Center

PAGE 1 of 2

February 1992 April 2010

ORIGINAL DATE REVISED

TITLE: Trauma Nurse Clinician or Trauma Room Nurse – Trauma Team I & Trauma Team II

NOTIFIED: Trauma pager, Erickson phone, and overhead page by ED Clinical Supervisor

WHO RESPONDS:

The designated Trauma Nurse Clinician, Emergency Department RN, SWAT RN, and/or ICU RN

FUNCTIONS:

1. Responds to the Trauma Room for Trauma Team Activation to assist in preparation of the arrival of the Level I Trauma patient. Signs in on the Trauma Room Documentation form. Trauma Team I activation would include the on-duty Trauma Clinician and the ED RN assigned to the trauma room. Trauma Team II activation would include the SWAT RN and other nursing unit RN assigned by the House Manager.

2. Works with the Trauma Clinician to meet patient care needs. 3. Assists with:

Documentation

Additional resource allocation

Setting up the Trauma Room in anticipation of patient needs

Removing the patient’s clothing and maintaining temperature of patient and the environment

Securing, documenting, and identifying patient belongings

Documenting, identifying, logging and securing patient’s valuables in lock box Assuring venous access and securing blood samples

IV fluid and blood administration Central line insertion

Arterial line placement

Chest tube and drainage system set up – autotransfusion Urinary catheterization

DPL

Open chest procedures Splinting

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Transporting of Level I trauma patients for diagnostic procedures and to the OR, or to a patient care unit as well as providing patient report

Preparation of Trauma Room for next patient in assembling supplies, trays and other equipment as indicated by the prehospital report.

4. Assist in assuring Trauma Team utilizes personal protection as directed by the case. 5. Assumes the role of scribe if other staff is unavailable and assures complete

documentation on the Trauma Room patient record.

6. Assists the Trauma Surgeon with coordination of the Level I Trauma patient’s care. 7. Applies correct Trauma patient identification band to patient’s extremity immediately

upon arrival to the Trauma Room.

8. Assures the Trauma Room patient record is thoroughly completed and signed, and a copy of the Trauma Room report is put in the designated area for Trauma Administration.

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TRAUMA GUIDELINE

TRAUMA SERVICE

Trauma Team Roles St. Joseph’s Hospital &

Operating Room Nurse Medical Center

PAGE 1 of 1

February 1992 April 2010

ORIGINAL DATE REVISED

TITLE: Operating Room Trauma Nurse

NOTIFIED: By beeper and overhead page

WHO RESPONDS:

The designated Operating Room RN

FUNCTIONS:

1. Responds to the Trauma Room when notified of a Level I Trauma and signs in on the trauma room flow sheet.

2. Stands by to assist in the care of the trauma patient as needed, i.e., Trauma Scribe, any emergency surgical or invasive procedure to be done in the trauma room, other care requested by the Trauma Clinician or the ED Trauma Room Nurse.

3. Consults with Trauma Surgeon as to necessity of trauma operating room.

4. Knows which operating room is available for trauma. If the trauma operating room is needed, relays information to the operating room staff and returns to assist in setup if not needed in trauma room for emergency surgical procedures.

5. If assisting as Trauma Scribe, reports to Trauma Room Nurse on status of documentation prior to leaving the Trauma Room.

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TRAUMA GUIDELINE

TRAUMA SERVICE

Trauma Team Roles St. Joseph’s Hospital &

Trauma Room RN Scribe Medical Center

PAGE 1 of 2

February 1992 April 2010

ORIGINAL DATE REVISED

TITLE: Trauma Room RN Scribe

NOTIFIED: Trauma beeper, overhead page, Erickson Phone

WHO RESPONDS:

The Trauma Clinician or ED RN, OR RN, or SWAT RN

FUNCTIONS:

1. Obtains information from individual receiving patch information for prehospital events and treatment, and from prehospital providers on arrival.

2. Completes the Trauma Room patient record: A. All team members and arrival times

B. Brief etiology of the injury including medic agency name and field treatment C. The patient’s condition on EMS arrival

D. Treatments and procedures rendered, times and outcome E. Medications given, times and the results

F. All diagnostic tests ordered completed including times

G. All other documentation applicable to the patients care and assures Trauma Room patient record is complete

3. Assists in limiting access to the trauma room to team members only.

4. Documents patient’s personal belongings and assists in valuables documentation process per Trauma Valuables Guideline.

5. Responsible for contacting the Blood Bank for:

Ordering of uncrossmatched O Negative red blood cells on assigned trauma patient. Accepting blood bank blood cooler containing uncrossmatched O Negative red blood

cells.

Having Emergency Release Form completed and signed by RN or Physician and ready for blood bank personnel upon their arrival with the uncrossmatched red blood cell.

6. If not the ED Trauma Nurse or Trauma Clinician, when leaving the Trauma Room hands-off Trauma Room patient record to Trauma Room Nurse to complete.

7. Contacts bed placement for bed assignment.

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TRAUMA GUIDELINE

TRAUMA SERVICE

Trauma Team Roles St. Joseph’s Hospital &

Radiology Technician Medical Center

PAGE 1 of 1

February 1992 April 2010

ORIGINAL DATE REVISED

TITLE: Radiology Technician

NOTIFIED: Trauma beeper, overhead page

WHO RESPONDS:

The designated Radiology Technician

FUNCTIONS:

1. Assures radiology equipment in the Trauma Room is operational for Level I Trauma cases.

2. Coordinates the standard Trauma X-ray exam(s) with the emergent care of the patient. Performs other studies as directed by the Trauma Surgeon.

3. Notifies Trauma Team of X-ray exam(s) with the emergent care of the patient. Performs other studies as directed by the Trauma Surgeon.

4. Notifies Trauma Team of rays being performed by announcing “XRAY” and type of x-ray prior to taking a film.

5. Notifies the Trauma Surgeon when the films have been completed.

6. Requests back-up from radiology department for multiple Level I Trauma Patients. 7. Responsible for inventorying and restocking of xray contrast solution used for diagnostic

radiology procedures in the Trauma Room Omnicells. 8. Signs in on Trauma Room Documentation Flow Sheet

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TRAUMA GUIDELINE

TRAUMA SERVICE

Trauma Team Roles St. Joseph’s Hospital &

CT Technician Medical Center

PAGE 1 of 1

January 2002 April 2010

ORIGINAL DATE REVISED

TITLE: CT Technician

NOTIFIED: Trauma beeper, overhead page

WHO RESPONDS:

The designated CT Technician

FUNCTIONS:

1. Assures radiology equipment in the CT ED/Trauma Room area is operational for Level I Trauma cases.

2. Assures there are an adequate number of protective aprons, thyroid shields and gloves available in good condition in the CT Room.

3. Verifies patency of IV site prior to injection of contrast and confirms NGT/OGT placement before administering contrast barium for study.

4. Coordinates the Trauma CT studies with the emergent care of the patient. Performs other studies as directed by the Trauma Surgeon.

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TRAUMA GUIDELINE

TRAUMA SERVICE

Trauma Team Roles St. Joseph’s Hospital &

Respiratory Therapist Medical Center

PAGE 1 of 1

February 1992 April 2010

ORIGINAL DATE REVISED

TITLE: Respiratory Therapist

NOTIFIED: Trauma pager, overhead page

WHO RESPONDS:

The designated Respiratory Therapists

FUNCTIONS:

1. Assures respiratory supplies are present in the Trauma Room.

2. Assists the anesthesiologist with the airway and ventilatory support of the Level I Trauma patient in the Trauma Room.

3. Maintains O2 support per physician’s orders and obtains Pulse-Ox reading, End-tidal CO2 reading, and reports to Trauma Surgeon and Scribe.

4. Assist with or draws ABGs as ordered, performs analysis and reports to the Trauma Surgeon and Scribe.

5. Performs basic CPR as indicated.

6. Follows the respiratory-dependent patient and RN to CT, ICU, or the OR as directed. 7. Is available to assist in ICU or in surgery.

8. Performs arterial line placement per physician’s orders. 9. Signs in on Trauma Room Documentation Flow Sheet

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TRAUMA GUIDELINE

TRAUMA SERVICE

Trauma Team Roles St. Joseph’s Hospital &

Patient Care Tech Medical Center

PAGE 1 of 2

November 1996 April 2010

ORIGINAL DATE REVISED

TITLE: Patient Care Tech – Assigned to the Trauma Team

NOTIFIED: Overhead page or pager

WHO RESPONDS:

The designated Emergency Department Patient Care Tech

FUNCTIONS:

1. Complete Trauma Room Checklist at beginning of shift.

2. Assembles supplies, trays and other equipment as directed by the Trauma Clinician or Trauma Surgeon.

3. Assures personal protection supplies are out and available for the Trauma Team members.

4. Assists with removal of patient’s clothing and providing warmed blanket or other external warming devices.

5. Applies non-invasive patient monitoring devices upon the patient’s arrival and assures readings are registering – reports first reading to the Scribe or Trauma Room Nurse. 6. Assists with assembling and setting up trays and equipment for:

Urinary catheterization IV fluid administration Central line insertion Arterial line placement

Chest tube insertion and drainage system set up – autotransfusion

DPL

Open chest procedures

Other procedures as indicated

7. Assembles other supplies and equipment as directed by the Trauma Nurse.

8. Assists with transporting the Level I Trauma patient for diagnostic procedures, to the OR, or admission to a patient care unit, as directed by the Trauma Room RN.

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9. Using the PCT Trauma Room Checklist, assures the Trauma Room Omnicells and supplies are thoroughly restocked after each Level I Trauma case and at the beginning of each shift.

10.Assures the Trauma Room, gurneys, etc are clean after each Level I Trauma. 11.Assists/performs splinting of extremities as required.

12.Performs 12-lead EKGs as required.

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TRAUMA GUIDELINE

TRAUMA SERVICE

Trauma Team Roles St. Joseph’s Hospital &

Laboratory Phlebotomist Medical Center

PAGE 1 of 1

February 1992 April 2010

ORIGINAL DATE REVISED

TITLE: Laboratory Phlebotomist

NOTIFIED: Trauma beeper, overhead page

WHO RESPONDS:

The designated Phlebotomist

FUNCTIONS:

1. Assures blood drawing equipment is available for Level I Trauma cases. 2. Coordinates drawing blood samples with the emergent care of the patient.

3. Draws a full set of blood tubes and places the blood band on the patient. Obtaining blood samples should be coordinated with IV starts especially with pediatric patients.

4. Clarifies with the Trauma Surgeon which Trauma Lab Profile to order: A. Basic

B. Expanded C. Obstetric

5. Clarifies with the Trauma Surgeon the need for Type and Crossmatch and number of units of blood to order.

6. Orders Trauma Lab in computer and returns the samples to the lab and blood bank for processing. Notifies the blood bank.

7. Requests back-up from the Lab for multiple Level I Trauma Patients.

8. Notifies Trauma Surgeon and Trauma Room Scribe RN if unable to draw specimen. 9. Notifies Trauma Room Scribe RN of all labs drawn and time of draw.

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TRAUMA GUIDELINE

TRAUMA SERVICE Consults on Trauma Patients St. Joseph’s Hospital &

Medical Center

PAGE 1 of 1

1989 April 2010

ORIGINAL DATE REVISED

PURPOSE: To provide a mechanism for obtaining consults on Trauma Service patients.

GUIDELINES:

1. All patients identified under the Trauma Team Activation – Level I Trauma Patient Identification guidelines (transported from the scene, from referring hospital Emergency Departments and from in-patient beds in non-Level I facilities) are admitted to the Trauma Service for evaluation and initial management.

2. When specialty care is indicated, other Services and subspecialty physicians are consulted.

3. For the following Level I Trauma patient categories a subspecialty physician consult is automatic:

A. neurologically impaired patients - Neurological Service B. spinal cord injured patients - Neurological Service

C. OB patients - OB Service

D. Pediatric patients - Pediatric Intensivist

4. For other Level I Trauma patient categories subspecialty consults are determined by the Trauma Service physicians.

5. In all cases, physician contact is required to initiate a consult and to sign off patients to a subspecialty or return care to the Trauma Service.

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TRAUMA GUIDELINE

TRAUMA SERVICE

Trauma Team Roles St. Joseph’s Hospital &

Neurosurgery Consultation Medical Center

PAGE 1 of 2

February 1992 April 2010

ORIGINAL DATE REVISED

TITLE: Neurosurgeon Consultation

NOTIFIED: Neurosurgery consults requested from the trauma room will be done by pager using the 746-7600 pager. Pager message will read: Neuro to Trauma Room. Critical care areas and/or floors requesting otherneurosurgery consults per the Trauma Service, will page the neurosurgery resident via this pager number.

WHO RESPONDS: Neurosurgical resident on call. Neurosurgical attending is promptly available for consultation.

PURPOSE: The purpose of this guideline is to define when prompt neurosurgical consultation is required in order to assure optimal care of the neurologically injured patient.

GUIDELINES FOR NEUROSURGICAL CONSULTATION:

I. Neurosurgical team is consulted emergently for any of the following and returns the call to the Trauma Room within 5 minutes of notification at the request of the Trauma Surgeon on-call, and responds within 30 minutes of notification:

Patients transferred from outside facilities with known intracranial lesions, or spinal cord injuries.

Patients with known spine fractures.

Patients that the on-call neurosurgeon has accepted in transfer with an ill-defined head and/or potential other injuries.

Patients with a Glasgow Coma Scale score of < 10. Penetrating wounds to the head.

Patients who have sustained a significant/prolonged loss of consciousness.

Patients who have a focal neurologic deficit.

Patients who have an identifiable lesion or fracture on computerized tomography.

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II. When the neurosurgery resident is needed for consultation he/she will answer the page within 5 minutes and be available to see the patient within 30

minutes of notification at the request of the Trauma Surgeon/resident on-call. III. A neurosurgical attending should evaluate the patient within 24 hours of

consultation.

FUNCTIONS:

1. Once consulted, responds directly to the Trauma Room to assess the Level I Trauma patient.

2. Assesses the neurological status/neurosurgical needs of the patient and coordinates care with the Trauma Surgeon.

3. Responsible for all on-going neurological/neurosurgical care of the patient. 4. Performs invasive procedures involved with neurological monitoring, i.e.,

ventriculostomy.

5. Involved with and coordinates cerebral resuscitation protocols/procedures for patients with craniocerebral trauma.

6. Consults on patients admitted to the Trauma Service with neurological problems in the critical care unit.

7. Assures Trauma patient referrals from other outlying hospital Emergency Departments and in patient transfers from non-Level I Trauma Centers are admitted to the Trauma Service with Neurosurgery consultation until such time as the attending neurosurgeon and trauma surgeon agree the patient does not have multi-system trauma care needs.

8. Reviews Trauma Documentation Flow Sheet for procedures performed and medications given, then signs the record.

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TRAUMA GUIDELINE

TRAUMA SERVICE Pediatric Consult Guideline St. Joseph’s Hospital &

Medical Center

PAGE 1 of 2

February 1992 April 2010

Original Date Revised

TITLE: Pediatric Team Trauma Consultation Response

NOTIFIED: Pediatric consults requested from the Trauma Room will be done by paging the PICU nursing supervisor on pager 746- 7949 and calling the PICU Intensivist on the Ascom phone X:6-4422. Telecommunications will proceed with the overhead paging of the TRAUMA TEAM and display the pager message: “PEDS to Trauma Room”.

WHO RESPONDS:

Pediatric Intensivists and Pediatric ICU Clinical Supervisor or designee.

PURPOSE: The Trauma Surgeon is responsible for the overall care of the trauma patient. The purpose of this guideline is to define when emergent or prompt pediatric consultation is required in order to assure optimal care of the injured pediatric patient.

GUIDELINES FOR PEDIATRIC CONSULTATION:

A. The pediatric trauma team may be consulted emergently at the request of the Trauma Surgeon on call and reports to the Trauma Room when notified by the pager message “PEDS to Trauma Room” for any of the following:

B. All pediatric patients transferred from outside facilities with known traumatic injuries (ages 0-14 years old or depending on patient requirements).

C. Pediatric patients that the on-call pediatric intensivist has accepted

who have known or potential traumatic injuries. (The intensivist should sign in on Trauma Room Documentation Flow Sheet

notify the attending trauma surgeon as soon as possible.)

Any pediatric patient meeting Level I triage criteria as described by ACS Triage guidelines.

FUNCTIONS:

1. Pediatric Intensivist

1. Coordinates care with the Trauma Surgeon.

2. Collaborates with the Trauma Service Team for management of the critical care pediatric patient.

3. Performs invasive pediatric specialty procedures as required. 4. Involved with and coordinates resuscitation

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5. Responsible for making sure all pediatric patient referrals with multi-system injuries accepted by the pediatric service from outlying facilities, are admitted to the Trauma Service with pediatric consultation until such time as the attending pediatric physician and trauma surgeon agree the patient does not have multi-system trauma care needs.

6. Reviews Trauma Documentation Flow Sheet for procedures performed and medications given, then signs the record 2. Pediatric ICU Clinical Supervisor

1. Assists the Pediatric Intensivist with assessment of the trauma patient.

2. Assists with invasive pediatric specialty procedures such as placement of peripheral vascular access, NGT/OGT, Foley catheterization, and/or blood draws.

3. The PICU Clinical Supervisor will assist in administration of drugs and fluids.

4. If the pediatric trauma patient is hemodynamically unstable the PICU RN will assist with the transfer of this patient to ICU or the operating room.

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TRAUMA GUIDELINE

TRAUMA SERVICE

OB Consult - Trauma St. Joseph’s Hospital &

Medical Center

PAGE 1 of 2

August 1991 April 2010

ORIGINAL DATE REVISED

PURPOSE: To provide immediate response and the highest quality of care for pregnant patients sustaining trauma and are 16 weeks or greater gestation, who are triaged to the hospital in accordance with EMS system standards or arrive by private transportation.

STAFFING: The in-house Trauma Team, OB attending physician and/or OB Resident, OB RN and the in-house Emergency Physician

GUIDELINES:

1. All pregnant patients, who present with a history of blunt trauma and are at or > 16 weeks gestation, or with the fundus at the level of the umbilicus and are transported to the hospital by EMS system or via private transportation, will constitute Level I Trauma Team activation, including immediate notification of the chief OB resident.

2. Pregnant patients, who present with a history of penetrating abdominal trauma at or > 16 weeks gestation or with the fundus at the level of the umbilicus, who arrive via EMS or private transportation will constitute Level I Trauma Team activation, including immediate notification of the chief OB resident.

3. The Trauma Surgeon and senior OB resident or in-house OB attending or perinatologist will evaluate Level I Trauma patients in the Trauma Room.

A. The senior OB resident will be notified by the Emergency Department of the Level I patient’s arrival, or pending arrival. (The Labor and Delivery Clinical Lead will be notified at ext. 67945 and in turn will contact the most senior OB/GYN resident, in-house OB Attending, and the nursery ICU Clinical Lead). In the event the OB physicians are unavailable, an experienced Labor and Delivery Nurse will evaluate the patient in the Trauma Room along with the Trauma Surgeon.

4. Ultrasound will be utilized in the Trauma Room to evaluate gestational age and fetal viability. The OB Ultrasound machine, Fetal Monitoring machine and C-Section cart is available in the Trauma Room and is checked daily by the OB/GYN staff.

5. Fetal monitoring will be initiated in the Trauma Room by the OB nurse and monitor continuously or as directed by the OB chief resident.

6. The OB nurse(s), and Trauma Resident and/or attending will accompany the Level I patient for radiographic tests, during transport to ICU and the OR. The OB Resident or

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in-house Attending will stay with the patient until medically cleared from an OB standpoint.

7. Level I patients, who require admission for close clinical monitoring, are admitted to the Trauma Service with OB consulting. Hemodynamically unstable patients will be

admitted to an adult or pediatric ICU. Stable patients may be admitted to OB. 8. The OB resident accepting the Trauma patient consult will advise the attending OB

physician on call of the consult and the location of the patient.

9. The OB on-call attending physician, resident, and NYICU code arrest team will be called to respond for newborn resuscitation in emergency C-sections in the Trauma Room. 10.If the OB patient is unstable and admitted to any ICU (adult or pediatric), the in-house

attending OB physician will continue to consult and treat this patient in the ICU. 11.All pediatric OB patients should have a perinatologist consult following the patient up

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TRAUMA GUIDELINE

TRAUMA SERVICE

Replantation - Trauma St. Joseph’s Hospital &

Medical Center

PAGE 1 of 2

December 1989 April 2010

ORIGINAL DATE REVISED

PURPOSE: To define a process for utilizing the replantation team for traumatic amputation and the process for limb care for replant candidates.

GUIDELINES:

1. Patients with partial or complete amputation of a limb caused by traumatic injury are possible candidates for the replantation program.

2. Upon notification from a referring facility, of a patient with partial or complete traumatic amputation that may be potential for replantation, the Trauma Surgeon should be notified. 3. The Trauma Surgeon will talk directly with the referring facility and the replant surgeon

on call to determine if the patient is a viable candidate.

4. Replant candidates will be Level I trauma patients and will be seen in the Trauma Room including a Trauma Team activation if:

A. they meet general Level I activation criteria

B. the amputation is above the wrist or of a lower extremity

5. Replant candidates will be Level I trauma consults but can be held in the ED for replantation evaluation for digit and partial hand or partial foot amputations if without Level I trauma mechanism.

6. Referring facilities should be instructed by the Trauma Surgeon or the replant Surgeon regarding preservation of the amputated or partially amputated limb as follows:

A. the amputated part should be wrapped in moist gauze and placed in a sterile container (specimen jar, plastic specimen bag)

B. the container or bag should be placed on ice

C. THE AMPUTATED PART SHOULD NEVER BE PLACED DIRECTLY ON ICE or IMMERSED IN ANY TYPE OF PHYSIOLOGICAL SOLOUTION D. Partially amputated limbs should be covered with sterile saline soaked gauze

dressings, loosely dressed with gauze to keep the soaks in place and loosely wrapped with sterile towels, assuring that any open tissue is covered and kept very moist during transport

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E. THE PARTIALLY AMPUTATED LIMB SHOULD NOT BE KEPT

IMMERSED IN ANY TYPE OF PHYSIOLOGICAL SOLUTION DURING TRANSPORT

7. The Replant Surgeon will order lab, medications, etc., upon evaluation or upon

discussion with a referring physician. Tetanus prophylaxis and antibiotics are commonly ordered on partial and total amputations.

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TRAUMA GUIDELINE

TRAUMA SERVICE X-ray – Trauma Room Profile St. Joseph’s Hospital &

Medical Center

PAGE 1 of 1

June 1992 April 2010

ORIGINAL DATE REVISED

PURPOSE: To define basic and extended set of x-rays studies for Level I trauma patients.

GUIDELINES:

1. There will be standard initial trauma x-ray panel for Level I trauma patients.

Trauma Profile – Basic (Adult and Pediatric)

CXR (1 view) AP Pelvis (1 view) AP

C-Spine Radiographs (4 views) - AP, lateral, odontoid, swimmers OR

C-spine CT Scan

2. Upon arrival and assessment of the Level I Trauma Patient, the Trauma Surgeon or Trauma Resident will order a Trauma Profile – Basic.

3. The Trauma Surgeon or Trauma Resident will order additional imaging as indicated. 4. The radiology technician on duty and assigned to the trauma team will clarify the

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TRAUMA GUIDELINE

TRAUMA SERVICE

Lab – Trauma Room Profile St. Joseph’s Hospital &

Medical Center

PAGE 1 of 2

June 1997 April 2010

ORIGINAL DATE REVISED

PURPOSE: To define basic and expanded trauma room lab profiles for Level I trauma patients.

GUIDELINES:

1. The Trauma Surgeon will order a Basic Trauma Lab Profile on all Level I Trauma Patients. The Expanded Trauma Lab Profile and/or the Obstetric Trauma lab Profile are optional and may be added by the Trauma Surgeon based on the acuity of the patient.

Basic Trauma Lab Expanded Trauma Lab Obstetric Trauma Lab

Hemogram BMP D-Dimer

Type and Screen Amylase Fibrinogen

Blood Alcohol Protime Fibrin Split Products

UA (dip in ED) PTT K-B Stain

Urine Toxicology Urinalysis -Drug Screen (ages 12 and older) Serum HCG (females 10-50 yrs)

*Urine Pregnancy test may be ordered by the physician

2. The Phlebotomist will ask the Trauma Physician if either or both of the optional profiles or any additional single tests are to be ordered.

3. When the Expanded Trauma Lab Profile is ordered, the Phlebotomist will ask the Trauma Physician if a Blood Type and Crossmatch should also be ordered and the number of units requested.

4. After drawing the Level I trauma patient’s blood, Lab Phlebotomist assigned to the Trauma Team will enter the initial trauma profile orders including any initial blood orders, into the computer ordering system.

5. A full set of blood tubes will be drawn on all Level I patients for additional testing as needed. The patient will be blood banded by the Phlebotomist when blood samples are drawn.

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6. The Trauma Room RN assigned to the trauma patient will dip urine specimens collected in the trauma room and send the urine for toxicology (drug) screen and complete UA when ordered. If no urine is collected in the trauma room, the admitting floor will be notified, by the Trauma Room RN transporting the patient, to send the first urine collected for urine toxicology – drug screen.

7. Lab technicians will call the Trauma Resident pager with the results of each Level I Trauma patient’s CBC and for critical values immediately after test results are available.

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TRAUMA GUIDELINE

TRAUMA SERVICE Emergency Issue of Blood Components St. Joseph’s Hospital &

SJHMC Laboratory Guideline Medical Center

PAGE 1 of 4 April 2009

Original Date

Policy:

The Blood Bank Department at St. Joseph’s Hospital & Medical Center will issue

appropriate blood components in an emergent situation where the patient’s blood type is not known or compatibility testing has not bee completed.

Purpose:

To assure that the Blood Bank will provide appropriate components in a timely manner when an emergent need for blood exists. This will include using the Laboratory Information

System (Cerner) and manual methods to provide as safe a product as possible for transfusion.

Procedure:

1. When there is an urgent need for blood and no time for compatibility testing to be completed, the physician (or his/her designee) must sign the Blood Bank

Downtime/Emergency Release form (XBUS-40A) in order to receive

uncrossmatched blood. The name of the physician requesting uncrossmatched blood must be documented. If the requesting location does not have a form available, offer to tube one up STAT or explain that the nurse can take the responsibility to sign for the physician and this can be done at the issue window. There are two classifications of “uncrossmatched blood”.

a. Uncrossmatched – This will always be blood group “O” and Rh “Neg”, when the blood type of the patient is in doubt. If Rh “Neg” is in short supply or if the request is for a large quantity of units, Rh “Pos” may be supplied. If at all possible, Rh “Neg” will be reserved for females of child bearing age (less than 50 years old) and pediatric patients. Once the specimen from the intended recipient is received and blood typing has been performed, Rh specific blood components will be selected for transfusion. The decision to give Rh incompatible blood components will be up to the discretion of the technologist. Group “O” red blood cells will always be given if the immediate spin crossmatch has not been performed. b. Crossmatch Incomplete – This product is available after blood typing and an immediate–spin crossmatch has been performed. ABO and Rh specific blood products are supplied but testing for unexpected antibodies has not yet been completed. An immediate-spin crossmatch will physically be performed and these units issued.

2. The emergency issue process is initiated after a phone call is received requesting emergency issue of blood or if nursing personnel arrives at the issuance window with

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the Emergency release for requesting emergency issue of blood. The requesting location will provide the Blood Bank with the following information:

a) Patient name (Doe name/number, if a trauma situation) b) Medical Record Number (MR#)

c) Gender (assume female if unknown) d) Total number of units needed

e) Requesting physician

f) Requesting location blood is to be delivered to

Blood Bank personnel will record this information on a trauma call sheet and use it to issue the blood components in Cerner. (For blood requests from the trauma room, refer to POL I:4.6 Emergency Issue Units Stored in Trauma Refrigerator).

3. Laboratory Support Services is notified (ext. 64686 of the need for a “trauma runner” to transport the cooler with blood to the requesting location or an overhead page (ext. 1964 is made for a “trauma runner”. Blood is delivered by laboratory personnel only for trauma patients. All other locations must present to the Blood Bank for pick up of the emergency issue blood.

4. Hemo components are issued using the emergency issue procedure. Refer to CERN:5.1 DIS – Emergency Issue in the Cerner Computer Manual.

5. Affix a RED “UNCROSSMATCHED BLOOD” label to each component of group O Rbcs issued prior to completion of an immediate spin crossmatch.

6. Affix a RED “CROSSMATCH COMPLETE” label to each component if the immediate spin crossmatch has been performed by the antibody screen is not yet complete.

7. Affix a YELLOW “ALERT Type specific blood, Non group O patient” label to each component if the unit is a type other than group O and an immediate spin crossmatch has been completed by the antibody screen is still in progress. 8. Obtain a cooler and pack the “blue ice” per the procedure. Refer to POL I: 4.4 Cooler Transport and Storage of Blood Components.

9. Issue the blood components with the trauma runner or with another technologist following the normal issuance policy. Emergency issue will be performed with a maximum of TWO technologists, or one technologist and the person who is

obtaining the blood at the window.

a. The trauma runner will not have the usual “sticker” with patient information for issuance. The information obtained from the phone call, or from the individual at the issuance window requesting uncrossmatched blood, will be substituted.

Figure

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