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Teamwork in Pediatric Trauma Centers
Teamwork in Pediatric Trauma Centers By Burton H. Harris and Larry J. Butler Colorado Springs, Colorado Various models have been proposed for optimal care of children in the trauma centers of general hospitals. The authors discuss the determinants of successful pediatric trauma care. In-house trauma surgeons, a consensus protocol for the first 20 minutes of resuscitation, real-time involvement of radiologists as part of the trauma team, and professional respect are the basis of teamwork. Copyright © 2001 by W.B. Saunders Company
EVERAL MODELS have been proposed for optimal care of children in the trauma centers of general hospitals. Herein we describe a joint adult and pediatric trauma program and seek to identify the determinants of successful pediatric trauma care.
S
THE MODEL
Memorial Hospital in Colorado Springs is designated by the state Department of Health as a Level 2 center with pediatric commitment. The designation follows a verification site visit from the American College of Surgeons Committee on Trauma. The hospital serves 1,200,000 people in the southeast quadrant of Colorado, 600,000 of whom live in the home counties. The pediatric trauma service is a sole provider in this geographic area; the adult service shares the Level 2 designation with one other center in Colorado Springs. Patients come directly from the scene in the bicounty area and from smaller level 3 and 4 hospitals in the rest of the service area. Twenty-nine percent of the pediatric trauma admissions have an injury severity score (ISS) of greater than 9.
The program admits 1,200 adults and 200 children each year. The pediatric trauma service is administratively part of the main program but clinically separate. By choice, the pediatric trauma medical director reports to the trauma medical director. The 2 services conduct joint committee meetings but generate separate minutes. The trauma nurse coordinator has a dual appointment and serves both services, as does the trauma program office staff. THE PHYSICIAN PANEL
There are no residents. The medical staff for trauma call is drawn from 6 geographic full-time private practice general surgeons, 3 full-time pediatric surgeons, 6 private practice neurosurgeons, and 24 private practice orthopedic surgeons. There are 17 geographic full-time anesthesiologists, 18 emergency physicians, and 9 radiologists, all of whom are members of hospital-based groups with a contractual relationship with the hospital. All physicians on the trauma panel are board certified Seminars in Pediatric Surgery, Vol 10, No 1 (February), 2001: pp 35-37
and voluntarily fulfill the 16 hours per year of continuing medical education and committee attendance requirements. None of these physicians restrict his or her practice to trauma. The general surgeon on trauma call is in house. There are 3 emergency physicians in house, 1 of whom is assigned to the trauma service. The pediatric surgeon is in house during the day and promptly available (20 minutes) at other times. The neurosurgeon and orthopedic surgeon on call have a 30-minute response time. A radiologist is in house from 6:00 AM to midnight and on call at other times, and at least one anesthesiologist is in house around the clock with 2 others on back-up call. PATIENT CARE PROTOCOL
There is a single-tier response for all patients brought in by emergency medical service or helicopter, or transferred from other hospitals. A call is placed to the pediatric surgeon. Initial treatment is rendered by the "adult" trauma surgeon and emergency physician according to a prearranged protocol that is the accepted standard in pediatric trauma centers'! The emergency physician's primary responsibility is airway control, and the trauma surgeon coordinates vascular access, fluid resuscitation, and diagnosis. If immediate operation is required, the trauma surgeon starts the procedure. The trauma surgeons and the pediatric surgeons are all credentialled for initial neurotrauma care and make decisions about appropriate diagnostic studies. When the pediatric surgeon arrives, the "adult" trauma surgeon withdraws as team leader, and a timed transferof-care/assumption-of-care note is written by both surgeons. Hemodynamically stable patients are taken to the radiology department for x-rays and computed tomographic scans by the trauma team, which now includes a pediatric intensive care unit (PICU) nurse. They are joined by the radiologist who stays with the team and the patient until all imaging studies are complete. The pediatric surgeon reviews the films with the radiologist and then requests consultants as needed. From The TraumLl Service, Merrwrial Hospital, Colorado Springs, CO. Presented at the Fifth National Conference on Pediatric Trauma, Vail, Colorado, June 2000. Address reprint requests to Burton H. Harris, MD, Memorial Hos· pital, 1725 E Boulder St, Colorado Springs, CO 80909. Copyright © 2001 by W.E. Saunders Company 1055-8586/01/1001-0011 $10.00/0 doi: 10.1 053/spsu.2001.19392 35
36
HARRIS AND BUTLER
All patients are admitted to the pediatric trauma service with the pediatric surgeon as the physician-ofrecord. All patients are taken to the PICU where they are seen in consultation by 1 of the 3 pediatric intensivists. Admission orders are written by the pediatric surgeon, and the intensivists consult on all patients. The pediatric surgeon remains in charge, and, by mutual agreement, the pediatric intensivist supervises minute-to-minute care (especially ventilators) when necessary. Intensivists are authorized to change orders or initiate treatment, subject to later review. This is an easy, comfortable relationship, and provides a welcome layer of oversight otherwise lacking in nonteaching situations. Conceptually, all patients are regarded as multiple trauma patients until occult injuries have been excluded by diagnostic tests and serial evaluation. A pediatric neurologist sees all head injury patients in consultation, and a physiatrist sees many patients. After a suitable period of observation, patients may be transferred to the service of the specialist most appropriate for care of their predominant injury. RESULTS
In 1999, the first full year of these protocols, there were 202 patients admitted with 5 deaths, 10 complications, and 2 nonburn transfers out to a level 1 pediatric trauma center. The 202 patients had 81 operations. Twenty-one cases were reviewed by the Performance Improvement (PI) Committee based on audit filters and 2 system problems were identified-admission to nontrauma services, and slow response by some consultants. Changes were made, and both situations are now being monitored by the PI process. TEAMWORK- THE DETERMINANT OF SUCCESS
The arrangements described are a local solution devised to reconcile our belief about the importance of in-house doctors with the reality that pediatric surgeons are a scarce resource. For up to the first 20 minutes of resuscitation, the adult trauma surgeon is the team leader. The team leader's job is to convert the trauma victim to a patient, keep the group focused on the ABCs (airway, breathing, circulation), save life and limb, and make major diagnoses. Our experience is that "adult" trauma surgeons and pediatric surgeons think alike and are equally prepared for this role. Both groups use the same treatment sequence for the first 20 minutes, and our general surgical colleagues have done an excellent job with resuscitation of the pediatric patients. Because we all agree on the "20 minute drill," whether the pediatric surgeon arrives in 2 minutes or 20 minutes, the handoff is seamless. There is a distinct advantage to having 2 physicians present with a new patient. Emergency physicians can
use their special training in airway control, freeing the trauma surgeon to concentrate on other problems. Because over 1,400 admissions a year is a mean of 4 per day, skills stay sharp and roles are frequently practiced. Knowing the other team members is far more efficient than working with a pick-up team of rotating residents. The second 20 minutes is spent in the radiology department because few cases of blunt trauma in children require an immediate operation. Most of the important decisions are made from the findings of the imaging studies, and one of the key relationships on our team is the bond between the pediatric surgeons and radiologists. They work together to obtain the most useful studies in the correct order, sometimes changing plans in midstream. When the patient leaves the radiology department the definitive diagnoses are both made and known to the clinicians. Our radiologists enjoy their participation in clinical decision making. The distinctions in management between children and adults-patterns of injury, fluid balance, blood replacement, closed head injury, congenital anomalies, and many others-are most striking in the third 20 minutes, which is the beginning of treatment in the PICU. The teamwork between pediatric surgeons and pediatric intensivists, contentious in some institutions, is collegial in ours. The pediatric surgeons recognize their inability to be in the PICU around the clock, and our intensivists agree to fill the void. The absence of trainees may be a plus because the specialists know they get mature management decisions from each other. The ambiance of a pediatric intensive care unit contributes to good family care as well as good patient care. Pediatric nurses make a big difference, and their contributions are a strong argument for caring for children in special units. COMMITMENT
Very little teamwork would be possible without a deep institutional commitment to trauma care. Our hospital loves its trauma program because it has changed the hospital into a 24-hour tertiary care institution. The medicalleadership and the administration both recognize that a hospital that can handle trauma can handle anything, and the community now sees us as the "go-to" hospital. The trauma service gets what it needs, from a new emergency department, new intensive care units, and rapid computed tomography scanners to a full complement of personnel in the supporting departments and priority of access to hospital services. THE TAKE-HOME LESSONS
The classification of trauma centers into levels can create unintended comparisons about quality of care. We believe that second only to commitment and expertise, teamwork is the essential ingredient in good trauma care.
37
TEAMWORK IN PEDIATRIC TRAUMA
Our experience suggests: (1) a pediatric trauma service can thrive as a component of a general hospital trauma service, each energizing and learning from the other; (2) because trauma care is labor and resource intensive, economies of scale can be achieved by combining adult and pediatric services; (3) professional respect is the basis of teamwork; (4) in-house doctors promote teamwork; (5) real-time involvement of the radiologist facil-
itates rapid clinical decision making; (6) in the first 20 minutes, children are small adults; (7) local solutions can be the best solutions. REFERENCE 1. Harris BH, Latchaw LA, Murphy RE, etal: A protocol for pediatric trauma receiving units. J Pediatr Surg 24:419-422, 1989
EVERAL MODELS have been proposed for optimal care of children in the trauma centers of general hospitals. Herein we describe a joint adult and pediatric trauma program and seek to identify the determinants of successful pediatric trauma care.
S
THE MODEL
Memorial Hospital in Colorado Springs is designated by the state Department of Health as a Level 2 center with pediatric commitment. The designation follows a verification site visit from the American College of Surgeons Committee on Trauma. The hospital serves 1,200,000 people in the southeast quadrant of Colorado, 600,000 of whom live in the home counties. The pediatric trauma service is a sole provider in this geographic area; the adult service shares the Level 2 designation with one other center in Colorado Springs. Patients come directly from the scene in the bicounty area and from smaller level 3 and 4 hospitals in the rest of the service area. Twenty-nine percent of the pediatric trauma admissions have an injury severity score (ISS) of greater than 9.
The program admits 1,200 adults and 200 children each year. The pediatric trauma service is administratively part of the main program but clinically separate. By choice, the pediatric trauma medical director reports to the trauma medical director. The 2 services conduct joint committee meetings but generate separate minutes. The trauma nurse coordinator has a dual appointment and serves both services, as does the trauma program office staff. THE PHYSICIAN PANEL
There are no residents. The medical staff for trauma call is drawn from 6 geographic full-time private practice general surgeons, 3 full-time pediatric surgeons, 6 private practice neurosurgeons, and 24 private practice orthopedic surgeons. There are 17 geographic full-time anesthesiologists, 18 emergency physicians, and 9 radiologists, all of whom are members of hospital-based groups with a contractual relationship with the hospital. All physicians on the trauma panel are board certified Seminars in Pediatric Surgery, Vol 10, No 1 (February), 2001: pp 35-37
and voluntarily fulfill the 16 hours per year of continuing medical education and committee attendance requirements. None of these physicians restrict his or her practice to trauma. The general surgeon on trauma call is in house. There are 3 emergency physicians in house, 1 of whom is assigned to the trauma service. The pediatric surgeon is in house during the day and promptly available (20 minutes) at other times. The neurosurgeon and orthopedic surgeon on call have a 30-minute response time. A radiologist is in house from 6:00 AM to midnight and on call at other times, and at least one anesthesiologist is in house around the clock with 2 others on back-up call. PATIENT CARE PROTOCOL
There is a single-tier response for all patients brought in by emergency medical service or helicopter, or transferred from other hospitals. A call is placed to the pediatric surgeon. Initial treatment is rendered by the "adult" trauma surgeon and emergency physician according to a prearranged protocol that is the accepted standard in pediatric trauma centers'! The emergency physician's primary responsibility is airway control, and the trauma surgeon coordinates vascular access, fluid resuscitation, and diagnosis. If immediate operation is required, the trauma surgeon starts the procedure. The trauma surgeons and the pediatric surgeons are all credentialled for initial neurotrauma care and make decisions about appropriate diagnostic studies. When the pediatric surgeon arrives, the "adult" trauma surgeon withdraws as team leader, and a timed transferof-care/assumption-of-care note is written by both surgeons. Hemodynamically stable patients are taken to the radiology department for x-rays and computed tomographic scans by the trauma team, which now includes a pediatric intensive care unit (PICU) nurse. They are joined by the radiologist who stays with the team and the patient until all imaging studies are complete. The pediatric surgeon reviews the films with the radiologist and then requests consultants as needed. From The TraumLl Service, Merrwrial Hospital, Colorado Springs, CO. Presented at the Fifth National Conference on Pediatric Trauma, Vail, Colorado, June 2000. Address reprint requests to Burton H. Harris, MD, Memorial Hos· pital, 1725 E Boulder St, Colorado Springs, CO 80909. Copyright © 2001 by W.E. Saunders Company 1055-8586/01/1001-0011 $10.00/0 doi: 10.1 053/spsu.2001.19392 35
36
HARRIS AND BUTLER
All patients are admitted to the pediatric trauma service with the pediatric surgeon as the physician-ofrecord. All patients are taken to the PICU where they are seen in consultation by 1 of the 3 pediatric intensivists. Admission orders are written by the pediatric surgeon, and the intensivists consult on all patients. The pediatric surgeon remains in charge, and, by mutual agreement, the pediatric intensivist supervises minute-to-minute care (especially ventilators) when necessary. Intensivists are authorized to change orders or initiate treatment, subject to later review. This is an easy, comfortable relationship, and provides a welcome layer of oversight otherwise lacking in nonteaching situations. Conceptually, all patients are regarded as multiple trauma patients until occult injuries have been excluded by diagnostic tests and serial evaluation. A pediatric neurologist sees all head injury patients in consultation, and a physiatrist sees many patients. After a suitable period of observation, patients may be transferred to the service of the specialist most appropriate for care of their predominant injury. RESULTS
In 1999, the first full year of these protocols, there were 202 patients admitted with 5 deaths, 10 complications, and 2 nonburn transfers out to a level 1 pediatric trauma center. The 202 patients had 81 operations. Twenty-one cases were reviewed by the Performance Improvement (PI) Committee based on audit filters and 2 system problems were identified-admission to nontrauma services, and slow response by some consultants. Changes were made, and both situations are now being monitored by the PI process. TEAMWORK- THE DETERMINANT OF SUCCESS
The arrangements described are a local solution devised to reconcile our belief about the importance of in-house doctors with the reality that pediatric surgeons are a scarce resource. For up to the first 20 minutes of resuscitation, the adult trauma surgeon is the team leader. The team leader's job is to convert the trauma victim to a patient, keep the group focused on the ABCs (airway, breathing, circulation), save life and limb, and make major diagnoses. Our experience is that "adult" trauma surgeons and pediatric surgeons think alike and are equally prepared for this role. Both groups use the same treatment sequence for the first 20 minutes, and our general surgical colleagues have done an excellent job with resuscitation of the pediatric patients. Because we all agree on the "20 minute drill," whether the pediatric surgeon arrives in 2 minutes or 20 minutes, the handoff is seamless. There is a distinct advantage to having 2 physicians present with a new patient. Emergency physicians can
use their special training in airway control, freeing the trauma surgeon to concentrate on other problems. Because over 1,400 admissions a year is a mean of 4 per day, skills stay sharp and roles are frequently practiced. Knowing the other team members is far more efficient than working with a pick-up team of rotating residents. The second 20 minutes is spent in the radiology department because few cases of blunt trauma in children require an immediate operation. Most of the important decisions are made from the findings of the imaging studies, and one of the key relationships on our team is the bond between the pediatric surgeons and radiologists. They work together to obtain the most useful studies in the correct order, sometimes changing plans in midstream. When the patient leaves the radiology department the definitive diagnoses are both made and known to the clinicians. Our radiologists enjoy their participation in clinical decision making. The distinctions in management between children and adults-patterns of injury, fluid balance, blood replacement, closed head injury, congenital anomalies, and many others-are most striking in the third 20 minutes, which is the beginning of treatment in the PICU. The teamwork between pediatric surgeons and pediatric intensivists, contentious in some institutions, is collegial in ours. The pediatric surgeons recognize their inability to be in the PICU around the clock, and our intensivists agree to fill the void. The absence of trainees may be a plus because the specialists know they get mature management decisions from each other. The ambiance of a pediatric intensive care unit contributes to good family care as well as good patient care. Pediatric nurses make a big difference, and their contributions are a strong argument for caring for children in special units. COMMITMENT
Very little teamwork would be possible without a deep institutional commitment to trauma care. Our hospital loves its trauma program because it has changed the hospital into a 24-hour tertiary care institution. The medicalleadership and the administration both recognize that a hospital that can handle trauma can handle anything, and the community now sees us as the "go-to" hospital. The trauma service gets what it needs, from a new emergency department, new intensive care units, and rapid computed tomography scanners to a full complement of personnel in the supporting departments and priority of access to hospital services. THE TAKE-HOME LESSONS
The classification of trauma centers into levels can create unintended comparisons about quality of care. We believe that second only to commitment and expertise, teamwork is the essential ingredient in good trauma care.
37
TEAMWORK IN PEDIATRIC TRAUMA
Our experience suggests: (1) a pediatric trauma service can thrive as a component of a general hospital trauma service, each energizing and learning from the other; (2) because trauma care is labor and resource intensive, economies of scale can be achieved by combining adult and pediatric services; (3) professional respect is the basis of teamwork; (4) in-house doctors promote teamwork; (5) real-time involvement of the radiologist facil-
itates rapid clinical decision making; (6) in the first 20 minutes, children are small adults; (7) local solutions can be the best solutions. REFERENCE 1. Harris BH, Latchaw LA, Murphy RE, etal: A protocol for pediatric trauma receiving units. J Pediatr Surg 24:419-422, 1989