- Email: [email protected]
The Trauma Report Nurse: A Trauma Triage Process Improvement Project
PRACTICE IMPROVEMENT
THE TRAUMA REPORT NURSE: A TRAUMA TRIAGE PROCESS IMPROVEMENT PROJECT Authors: Lisa Jelinek, BSN, RN, CEN, CFRN, NREMT-B, Carol Fahje, MS, RN, BC, Carol Immermann, BSN, RN, CEN, and Terri Elsbernd, MS, RN, CEN, CPEN, Rochester, MN Introduction: Accurate trauma triage is imperative to facilitate
appropriate resource mobilization for severely injured trauma patients. A critical window of opportunity exists to prevent secondary injury or death. Timely assessment with a multidisciplinary trauma team is essential to facilitate rapid diagnosis and treatment. However, consistent and accurate trauma triage proved daunting at our institution, resulting in instances of undertriage.
pediatric trauma patients. In parallel, improvements were made to the prehospital report format, increasing standardization and clarifying hand-off verbiage. Results: Undertriage rates dropped from 14% to 4.8%.
Qualitative data demonstrated acceptance and support of the TRN role among physicians, nurses and nursing and ancillary staff.
Methods: A process improvement strategy aimed at improving trauma triage accuracy was implemented. An innovative role, the trauma report nurse (TRN), was created and became the trauma nurse expert. The TRN was responsible for assigning a trauma triage level to all incoming adult and
Discussion: Designating trauma triage to an ED registered
ore than 30 million people seek trauma care in the United States annually. 1 A critical window of opportunity exists to stop bleeding and the irreversible damage that ensues. 2 Severe chest and abdominal trauma can result in death within 60 minutes of injury. 3 Assessment with a multidisciplinary trauma team is essential for the severely injured patient because it facilitates rapid diagnosis and treatment. However, patients with lesser injuries may not require a full team response. Although a certain amount of overtriage is required to ensure that potential life-threatening injuries are not missed, overactivation can divert providers from other critically ill patients. Correct trauma triage is important for optimal resource utilization. 4
M
Trauma triage is a process of matching patient presentation with defined objective criteria, based on the American College of Surgeons recommendations, to determine the appropriate resource response. Nationally, nomenclature for defining trauma team responses is quite variable (eg, level 1, trauma red, and highest tier). At our hospital, patients are triaged into 1 of 3 categories, with level 1 being the most severely injured and level 3 the least severely injured. Timely and accurate triage had proven to be a daunting task for many years. Six months prior to the process change, undertriage rates averaged an unacceptable 14%. This article will describe a process improvement strategy that was put in place to increase the trauma triage accuracy and properly direct our trauma team response to these high-acuity patients.
Lisa Jelinek, Member, Zumbro Valley Chapter, is ED Registered Nurse, Mayo Clinic, Rochester, MN. Carol Fahje is ED Nursing Education Specialist, Mayo Clinic, Rochester, MN.
Clinical Setting
Carol Immermann is Trauma Center Nurse Manager, Mayo Clinic, Rochester, MN. Terri Elsbernd is Pediatric Trauma Coordinator, Mayo Clinic, Rochester, MN. For correspondence, write: Lisa Jelinek, BSN, RN, CEN, CFRN, NREMTB, 504 11th Ave NE, Stewartville, MN 55976; E-mail: [email protected].
nurse proved to reduce undertriage rates. By providing staff education, infrastructure improvements, and leadership support, the role continues to thrive, resulting in improved care for severely injured trauma patients.
Saint Marys Hospital–Mayo Clinic is a rural level I adult and pediatric trauma center located in Rochester, MN, serving southeast Minnesota, western Wisconsin, and northern Iowa. The trauma centers facilitate care of approximately 2500 patients per year, of which 50% are referred from other facilities.
J Emerg Nurs ■.
The Trauma Team 0099-1767/$36.00 Copyright © 2014 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2013.12.018
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A level 1 trauma activation elicits trauma surgeons, emergency medicine (EM) physicians, trauma residents, EM residents, respiratory therapists, pharmacists, emergency nurses,
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intravenous (IV) transfusion nurses, radiology technicians, laboratory technicians, operating room (OR) charge nurses, and anesthesia providers. The team is modified for a level 2 response with IV transfusion nurses, an OR charge nurse, and anesthesia providers “on call” but not required to report immediately. The trauma surgeon has up to 6 hours to see the patient, but generally evaluates him or her within an hour. For pediatric activations (ie, for patients younger than 15 years), the response to both levels includes pediatric specialists in the majority of the responder categories. A Need for Standardization
A review of trauma triage decisions identified several communication issues from the field to the trauma bay. All incoming radio traffic was taken by the Emergency Communication Center (ECC) and then relayed to the emergency department via multiple pathways (ie, text pages or phone calls). The ECC is located in a separate building across the street from the emergency department. This remote location, coupled with an intermediary who obtained the trauma patient report, posed a unique challenge, because the ED staff did not directly communicate with prehospital providers. Before the standardized process was implemented, trauma patients were triaged either by prehospital providers, EM physicians, or not at all. The EM physicians were already responsible for supervising the highest acuity patients in the emergency department and often were not available to take prehospital report. The variable levels of training, ranging from first responders to advanced flight nurses, proved to be another challenge. The result was providers with wide-ranging knowledge of the trauma activation criteria. The process and knowledge variability across the continuum resulted in a high level of undertriage. Decreasing the undertriage rate was the most sought-after outcome. Improving staff satisfaction was another goal of the implementation team. These outcomes would be measured by reviewing staff surveys and by comparing triage rates before and after the intervention with use of the Fisher exact test. Intervention DEFINING AND NAMING THE ROLE
An innovative role, the trauma report nurse (TRN), was created. This trauma nurse expert was responsible for assigning a trauma triage level to all injured adult and pediatric patients and activating the appropriate trauma team. The TRN maintained situational awareness over 12 ED critical care beds, prepared for incoming patients,
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mentored novice nurses, coordinated bed assignments, prepared the trauma bays/equipment, and facilitated patient dispositions. In essence, the TRN functioned as an assistant charge nurse of the ED critical area. TRN SELECTION PROCESS
TRN selection was based on one or more of the following criteria: charge nurse experience, involvement with the ED Nursing Trauma Committee, completion of the Advanced Trauma Care for Nurses course, and trauma ICU or prehospital experience. TRNs were also expected to have a positive attitude toward change, flexibility with an evolving process, and strong communication skills. Likewise, critical thinking skills and decisiveness were imperative to synthesize incoming information, utilize the trauma triage criteria (Figure 1) and activate the optimal team response. The initial group was limited to 28 nurses so changes to the pilot program could be made quickly and efficiently. This number was chosen to ensure each TRN would have adequate experience to develop proficiency while maintaining coverage 24 hours a day, 7 days a week. EDUCATION
All TRNs and ED charge nurses were required to attend a 1hour course. Formal staff education was conducted utilizing several methodologies. The class covered roles, responsibilities, leveling criteria, policies, procedures, and radio etiquette. Case studies applying the knowledge were also incorporated. These case studies included the patient’s age, mechanism of injury, vital signs, and injuries found. The TRN students were then required to assign a level and provide the rationale. ED charge nurses were included because they were the designated backup in the rare case the TRN was unavailable. Radio communication with prehospital providers was a new skill for many registered nurses (RNs). A script was developed to aid in this learning curve, which began with “Gold Cross Ambulance, this is the trauma nurse. Go ahead with report.” The following types of replies were possible: 1. If all the necessary information was received to accurately assign a triage level to the patient, a typical response was, “Copy patient report. See you in 10 minutes.” 2. If information was still needed, a typical response was, “Copy patient report. What is the patient’s GCS?” 3. If the report was unclear, a typical response was, “Copy patient report. Please verify BP.” After formal education was completed, several valuable strategies were incorporated into the pilot phase reinforcing
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Mayo Clinic Trauma Centers Trauma Team Activation Criteria LEVEL 1 Airway & Breathing Intubated patients Grunting or stridor in child Respiratory distress/flail chest Threatened or compromised airway Hypoxia (O2 saturation < 93%) with signs of respiratory distress Respiratory Rate 6 years – adult < 10 or > 30 2 - 5 years < 10 or > 40 12 – 24 months < 16 or > 50 0 – 12 months < 20 or > 60 Circulation Pulse > SBP (Age > 15 only) Transfer patients receiving blood to maintain vital signs Heart Rate Adult (> 18 years) >120 6 – 17 years <60 or >160 2 – 5 years <60 or >180 12 – 24 months <70 or >180 0 – 12 months <80 or >180 Hypotension – Confirmed SBP <90 at any time in adults or age specific in children > 6 years < 90 2 – 5 years < 80 12 – 24 months < 75 Infant under 1 < 70 LEVEL 2 Injuries found Open fractures 2 or more proximal long bone fractures (bilateral femur fractures = Level 1) Mechanism of Injury Ejection from motorized vehicle Pedestrian stuck by motor vehicle Death of restrained passenger in same vehicle Major auto deformity, intrusion into passenger compartment Fall > 20 feet Pediatric falls > twice their height
Disability GCS < 12 Open or depressed skull fracture Paralysis or focal neurologic deficit Mechanism of Injury Trauma with full thickness burns >10% body surface area High voltage electrocution (including lightning) Penetrating injury to torso, neck, head, or proximal to elbow or knee Gunshot wounds Stabbing Other Unstable pelvic fracture Bilateral femur fractures Pulseless extremity/threatened limb Traumatic amputation/mangled limb (excluding isolated hand/foot)
Consider activation for High Risk Patients: Age > 65 or < 5 Multiple co-morbidities Blood thinners or other bleeding/clotting disorders
FIGURE 1 Mayo Clinic Trauma Centers triage criteria. GCS, Glasgow Coma Scale; SBP, systolic blood pressure. a Data provided by the Mayo Clinic Trauma Center.
all educational components. These enhancements will be discussed in the procedure section. PROCEDURE
On April 27, 2009, a 3-month pilot phase was initiated. The TRNs were given a dedicated phone and were instructed that
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their priority was to answer all trauma calls. They were to remain in the emergency department rather than transporting patients to other areas for procedures. When prehospital crews called the ECC regarding a trauma patient, the ECC notified the TRN via the dedicated phone line. The TRN received radio report, then assigned a trauma level based on the established criteria. The ECC also listened to the report and
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FIGURE 2 The Vital signs, Origin (hospital vs. scene), Mechanism, Injuries, and Treatment (VOMIT) report tool used by prehospital providers, the trauma report nurse, and the entire trauma team. BP, Blood pressure; IV, intravenous; RA, room air; RR, respiratory rate; SAT, saturation; SBP, systolic blood pressure. a Data provided by the Mayo Clinic Trauma Center.
activated the trauma team via a text page, based on the level assigned by the TRN. All members of the trauma team received a text page including the transport agency, age, sex, reason for level (eg, “level 1 GSW to neck”), vital signs, and estimated time of arrival. Once the trauma team assembled in
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the trauma bay, the TRN provided prehospital report, which ideally occurred 15 minutes prior to the patient’s arrival. A standard prehospital report format was developed for giving and receiving trauma information. The data included Vital signs, Origin (hospital vs. scene), Mechanism, Injuries, and
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Gold Cross Ambulance calls in with the following report: 31 year old female restrained driver of a car highway speed front end impact Major auto deformity c/o chest and abdominal pain HR 124, RR 24, BP 101/64 + seatbelt sign GCS 15 Does the patient meet any activation criteria? Think about mechanism – major auto deformity Think about HR Think about HR as compared to SBP THIS PATIENT IS A LEVEL 1 BASED ON 2 FACTORS: HR > 120 in an adult patient is level 1 criteria HR > SBP in an adult patient is level 1 criteria What are your next steps? Page out Level 1 trauma (include time of injury) Call Trauma surgeon phone 71GUN (71486)
FIGURE 3 A sample case study provided during trauma report nurse ongoing training. BP, Blood pressure; c/o, complains of; GCS, Glasgow Coma Scale; HR, heart rate; RR, respiratory rate; SBP, systolic blood pressure. a Data provided by the Mayo Clinic Trauma Center.
Treatment (VOMIT). This framework was adopted by prehospital providers, the TRN, and the entire trauma team (Figure 2). During the pilot phase, all VOMIT report tools were reviewed. Analyses found gaps in the prehospital report causing suboptimal patient trauma triage. At other times, excessive report led to prolonged radio time and yielded little value-added information. To address these challenges, realtime feedback was provided by the implementation team, along with ongoing education through monthly case studies. The case studies highlighted unique and challenging scenarios that had been encountered by TRNs (Figure 3). The decision was made to collect feedback for the duration of the pilot phase before making significant changes to the process in an attempt to avoid knee-jerk reactions to initial feedback. An online blog was started that delivered weekly updates, answered frequently asked questions, and kept participants abreast of real-time issues.
TRN group. Quantitative data were measured to evaluate overtriage and undertriage rates (Figure 5). The pilot was deemed successful based on 2 metrics. First, ED nursing leadership witnessed increased acceptance and support of the TRN role. Second, the undertriage rates dropped from 14% to 10%. Demonstrating the overwhelming success of the role, undertriage rates decreased even further 3 years later to 4.8% (P b .001). The ED staff considered the TRNs very supportive and reported an increased knowledge of incoming trauma patients. Education on the trauma team activation process was also provided to triage nurses who were not serving in the TRN role regarding patients arriving via private vehicle. These nurses were empowered and encouraged to immediately page the trauma team when patients met criteria. The TRN could be consulted by the triage nurse for support and assistance.
Barriers Results
After the pilot phase, overtriage and undertriage rates, along with staff feedback, were evaluated. Qualitative and quantitative methodologies were used. Qualitative data (Figure 4) were gathered via 2 questionnaires; one to the multidisciplinary trauma team and one specific to the
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In many process improvement projects, change is met with resistance. This project was no different. Prehospital providers expressed concern because they were no longer assigning trauma triage levels. They also voiced dissatisfaction about waiting for the TRN to take report. However, real-time data showed delays of less than 1 minute. A
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Post pilot implementation results Percentage of respondents who were “satisfied” or “very satisfied”
Compared to pre-TRN pilot, I have more knowledge about the incoming trauma patients.
40% 65%
The TRN was helpful to me despite not taking a patient assignment. Since the pilot started my workload has remained the same.
50% 68% 14% 6 weeks post implementation (N=7-10)
46%
It seemed to me the TRN was able to maintain global awareness of the ED critical area (situational awareness).
40% 79%
I feel an ED RN is the appropriate person to level trauma patients.
15 months post implementation (N=23-28)
60% 82%
I feel the TRN is the appropriate nurse in the ED to take trauma report.
40% 89% 0%
20%
40%
60%
80% 100%
General Comments: 6 weeks: • This role has created animosity between critical nurses. The charge nurse has had years of experience and needs to be informed to get the help needed in critical, the charge nurse can keep the critical team leader informed. • I think it is too much to expect from the team leader in critical. The critical care Dr. has to accept on the phone and hears the story already I think it was fine the way it was. • I like the immediacy of rerouting about the traumas coming to CC and triage, like the organization. • Created tension among other in critical as to their pt load. 15 months: • The nurses in the critical team leader role have done an excellent job. • There is better control in critical care with a leader. • I think the nurses currently doing the TRN role are exceptional and are doing a great job. • This has been a very good change to our practice. • I do feel there is clear direction and better communication in the critical area w/having a TRN. • I believe triage nurses should be very aware and able to level trauma patients – you never know what comes through the front door.
FIGURE 4 Qualitative data 6 weeks and 15 months after the trauma report nurse (TNR) pilot phase. CC, Critical care; pt, patient. a Data provided by the Mayo Clinic Trauma Center.
small subset of physicians believed that trauma triage should be the responsibility of the EM critical care physician, but they were willing to proceed with the pilot phase to see the results. Radio communication proved to be another barrier. Outdated headsets and the physical location of the radio led to inefficiencies, frustrating the senders and receivers of report. Both of these issues were addressed immediately. In addition, radio etiquette was a new skill for some TRNs, requiring realtime feedback regarding appropriate radio transmission (eg, “Copy patient report. Please verify BP.”). Despite the barriers
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encountered, good teamwork and problem solving occurred among all disciplines, leading to a successful implementation.
Ongoing Improvements
The TRN role and trauma activation process has continued to evolve, prompting several other practice improvements. First, a policy was developed that officially gave the TRN ultimate authority to determine the patient level and activate the trauma team.
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Under triage percentages pre and post implementation (P<0.001)
FIGURE 5 Undertriage rates 6 months before, 6 months after, and 3 years after trauma report nurse (TRN) implementation. a Data provided by the Mayo Clinic Trauma Center.
Second, a change was made to the trauma team notification process. With more than 1000 patients being referred to Mayo Clinic Trauma Centers on an annual basis, a great need for earlier notification existed. The advanced warning times were identical, whether coming from another hospital or directly from a scene. Now, once a trauma patient is accepted, a prealert is sent via pager to the entire trauma team, including estimated time of arrival and trauma level. This earlier notification gives individual trauma team disciplines time to plan resource allocation prior to the patient’s arrival. Significant time improvements were noted, with averages between the first notification and patient arrival increasing from 16 minutes to just over 52 minutes. For pediatric traumas, the in-house adult trauma surgeon served as the initial staff surgeon 42% of the time. Now, with earlier notification, the pediatric trauma surgeon is at the bedside 71% of the time prior to the patient’s arrival. Third, many referring facilities are able to send radiographic images electronically. The TRN has also been charged with notifying the trauma surgeon when images are available. This process allows multidisciplinary planning prior to the patient’s arrival. The plan is then discussed with the entire trauma team, creating a shared mental model. The establishment of a common strategy allows preparation time for lifesaving interventions and improves patient throughput. Finally, a direct phone line to the trauma surgeon was also established with an easily recalled phone number of “71GUN.” This direct phone line allowed TRNs to provide earlier report, which facilitated surgeon
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planning for competing patient priorities, including those in the operating room and ICU.
Conclusion
After the 3-month pilot phase, the TRN role became standard practice. External validation was provided by the American College of Surgeon’s site reviewers during a trauma reverification, satisfying a recommendation to have a core group of trauma nurses. Multidisciplinary team members internally validated not only the process, but positive patient outcomes. For example, Donald H. Jenkins, MD, Consultant, Division of Trauma, Critical Care and General Surgery, Associate Professor of Surgery, College of Medicine, and Medical Director, Trauma Center, Mayo Clinic, Rochester, MN, said, “This model, built of necessity for more timely and accurate trauma triage, has now become the model for all emergency triage and has improved our communication and preparation immensely.” Dawn King, BSN, RN, CEN, Staff Nurse and TRN, Saint Marys Emergency Department, noted, “The TRN is an essential link in closing the loop of communication between the prehospital providers and preparing resources needed for our critically ill patients before their arrival. Timeliness of care is essential to optimize positive patient outcomes.” In an ongoing effort to improve trauma patient care, the TRN role was created. Through multidisciplinary
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teamwork and problem solving, this cutting-edge role has demonstrated continued success, withstood the test of time, and ultimately benefited patients.
2. Moore K. Trauma triage: right person, right place, right time. J Emerg Nurs. 2012;38(2):193-4.
REFERENCES
3. Demetriades D, Kimbrell B, Salim A. Trauma deaths in a mature urban trauma system: is “trimodal” distribution a valid concept? J Am Coll Surg. 2005;201(3):343-8.
1. Mohan D, Barnato AE, Rosengart MR, Angus DC, Smith KJ. Optimal approach to improving trauma triage decisions: a cost-effectiveness analysis. Am J Manag Care. 2012;18(3):139.
4. Dehli T, Fredriksen K, Osbakk S, Bartnes K. Evaluation of a university hospital trauma team activation protocol. Scand J Trauma Resusc Emerg Med. 2011;19:18.
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THE TRAUMA REPORT NURSE: A TRAUMA TRIAGE PROCESS IMPROVEMENT PROJECT Authors: Lisa Jelinek, BSN, RN, CEN, CFRN, NREMT-B, Carol Fahje, MS, RN, BC, Carol Immermann, BSN, RN, CEN, and Terri Elsbernd, MS, RN, CEN, CPEN, Rochester, MN Introduction: Accurate trauma triage is imperative to facilitate
appropriate resource mobilization for severely injured trauma patients. A critical window of opportunity exists to prevent secondary injury or death. Timely assessment with a multidisciplinary trauma team is essential to facilitate rapid diagnosis and treatment. However, consistent and accurate trauma triage proved daunting at our institution, resulting in instances of undertriage.
pediatric trauma patients. In parallel, improvements were made to the prehospital report format, increasing standardization and clarifying hand-off verbiage. Results: Undertriage rates dropped from 14% to 4.8%.
Qualitative data demonstrated acceptance and support of the TRN role among physicians, nurses and nursing and ancillary staff.
Methods: A process improvement strategy aimed at improving trauma triage accuracy was implemented. An innovative role, the trauma report nurse (TRN), was created and became the trauma nurse expert. The TRN was responsible for assigning a trauma triage level to all incoming adult and
Discussion: Designating trauma triage to an ED registered
ore than 30 million people seek trauma care in the United States annually. 1 A critical window of opportunity exists to stop bleeding and the irreversible damage that ensues. 2 Severe chest and abdominal trauma can result in death within 60 minutes of injury. 3 Assessment with a multidisciplinary trauma team is essential for the severely injured patient because it facilitates rapid diagnosis and treatment. However, patients with lesser injuries may not require a full team response. Although a certain amount of overtriage is required to ensure that potential life-threatening injuries are not missed, overactivation can divert providers from other critically ill patients. Correct trauma triage is important for optimal resource utilization. 4
M
Trauma triage is a process of matching patient presentation with defined objective criteria, based on the American College of Surgeons recommendations, to determine the appropriate resource response. Nationally, nomenclature for defining trauma team responses is quite variable (eg, level 1, trauma red, and highest tier). At our hospital, patients are triaged into 1 of 3 categories, with level 1 being the most severely injured and level 3 the least severely injured. Timely and accurate triage had proven to be a daunting task for many years. Six months prior to the process change, undertriage rates averaged an unacceptable 14%. This article will describe a process improvement strategy that was put in place to increase the trauma triage accuracy and properly direct our trauma team response to these high-acuity patients.
Lisa Jelinek, Member, Zumbro Valley Chapter, is ED Registered Nurse, Mayo Clinic, Rochester, MN. Carol Fahje is ED Nursing Education Specialist, Mayo Clinic, Rochester, MN.
Clinical Setting
Carol Immermann is Trauma Center Nurse Manager, Mayo Clinic, Rochester, MN. Terri Elsbernd is Pediatric Trauma Coordinator, Mayo Clinic, Rochester, MN. For correspondence, write: Lisa Jelinek, BSN, RN, CEN, CFRN, NREMTB, 504 11th Ave NE, Stewartville, MN 55976; E-mail: [email protected].
nurse proved to reduce undertriage rates. By providing staff education, infrastructure improvements, and leadership support, the role continues to thrive, resulting in improved care for severely injured trauma patients.
Saint Marys Hospital–Mayo Clinic is a rural level I adult and pediatric trauma center located in Rochester, MN, serving southeast Minnesota, western Wisconsin, and northern Iowa. The trauma centers facilitate care of approximately 2500 patients per year, of which 50% are referred from other facilities.
J Emerg Nurs ■.
The Trauma Team 0099-1767/$36.00 Copyright © 2014 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2013.12.018
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A level 1 trauma activation elicits trauma surgeons, emergency medicine (EM) physicians, trauma residents, EM residents, respiratory therapists, pharmacists, emergency nurses,
WWW.JENONLINE.ORG
1
PRACTICE IMPROVEMENT/Jelinek et al
intravenous (IV) transfusion nurses, radiology technicians, laboratory technicians, operating room (OR) charge nurses, and anesthesia providers. The team is modified for a level 2 response with IV transfusion nurses, an OR charge nurse, and anesthesia providers “on call” but not required to report immediately. The trauma surgeon has up to 6 hours to see the patient, but generally evaluates him or her within an hour. For pediatric activations (ie, for patients younger than 15 years), the response to both levels includes pediatric specialists in the majority of the responder categories. A Need for Standardization
A review of trauma triage decisions identified several communication issues from the field to the trauma bay. All incoming radio traffic was taken by the Emergency Communication Center (ECC) and then relayed to the emergency department via multiple pathways (ie, text pages or phone calls). The ECC is located in a separate building across the street from the emergency department. This remote location, coupled with an intermediary who obtained the trauma patient report, posed a unique challenge, because the ED staff did not directly communicate with prehospital providers. Before the standardized process was implemented, trauma patients were triaged either by prehospital providers, EM physicians, or not at all. The EM physicians were already responsible for supervising the highest acuity patients in the emergency department and often were not available to take prehospital report. The variable levels of training, ranging from first responders to advanced flight nurses, proved to be another challenge. The result was providers with wide-ranging knowledge of the trauma activation criteria. The process and knowledge variability across the continuum resulted in a high level of undertriage. Decreasing the undertriage rate was the most sought-after outcome. Improving staff satisfaction was another goal of the implementation team. These outcomes would be measured by reviewing staff surveys and by comparing triage rates before and after the intervention with use of the Fisher exact test. Intervention DEFINING AND NAMING THE ROLE
An innovative role, the trauma report nurse (TRN), was created. This trauma nurse expert was responsible for assigning a trauma triage level to all injured adult and pediatric patients and activating the appropriate trauma team. The TRN maintained situational awareness over 12 ED critical care beds, prepared for incoming patients,
2
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mentored novice nurses, coordinated bed assignments, prepared the trauma bays/equipment, and facilitated patient dispositions. In essence, the TRN functioned as an assistant charge nurse of the ED critical area. TRN SELECTION PROCESS
TRN selection was based on one or more of the following criteria: charge nurse experience, involvement with the ED Nursing Trauma Committee, completion of the Advanced Trauma Care for Nurses course, and trauma ICU or prehospital experience. TRNs were also expected to have a positive attitude toward change, flexibility with an evolving process, and strong communication skills. Likewise, critical thinking skills and decisiveness were imperative to synthesize incoming information, utilize the trauma triage criteria (Figure 1) and activate the optimal team response. The initial group was limited to 28 nurses so changes to the pilot program could be made quickly and efficiently. This number was chosen to ensure each TRN would have adequate experience to develop proficiency while maintaining coverage 24 hours a day, 7 days a week. EDUCATION
All TRNs and ED charge nurses were required to attend a 1hour course. Formal staff education was conducted utilizing several methodologies. The class covered roles, responsibilities, leveling criteria, policies, procedures, and radio etiquette. Case studies applying the knowledge were also incorporated. These case studies included the patient’s age, mechanism of injury, vital signs, and injuries found. The TRN students were then required to assign a level and provide the rationale. ED charge nurses were included because they were the designated backup in the rare case the TRN was unavailable. Radio communication with prehospital providers was a new skill for many registered nurses (RNs). A script was developed to aid in this learning curve, which began with “Gold Cross Ambulance, this is the trauma nurse. Go ahead with report.” The following types of replies were possible: 1. If all the necessary information was received to accurately assign a triage level to the patient, a typical response was, “Copy patient report. See you in 10 minutes.” 2. If information was still needed, a typical response was, “Copy patient report. What is the patient’s GCS?” 3. If the report was unclear, a typical response was, “Copy patient report. Please verify BP.” After formal education was completed, several valuable strategies were incorporated into the pilot phase reinforcing
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Mayo Clinic Trauma Centers Trauma Team Activation Criteria LEVEL 1 Airway & Breathing Intubated patients Grunting or stridor in child Respiratory distress/flail chest Threatened or compromised airway Hypoxia (O2 saturation < 93%) with signs of respiratory distress Respiratory Rate 6 years – adult < 10 or > 30 2 - 5 years < 10 or > 40 12 – 24 months < 16 or > 50 0 – 12 months < 20 or > 60 Circulation Pulse > SBP (Age > 15 only) Transfer patients receiving blood to maintain vital signs Heart Rate Adult (> 18 years) >120 6 – 17 years <60 or >160 2 – 5 years <60 or >180 12 – 24 months <70 or >180 0 – 12 months <80 or >180 Hypotension – Confirmed SBP <90 at any time in adults or age specific in children > 6 years < 90 2 – 5 years < 80 12 – 24 months < 75 Infant under 1 < 70 LEVEL 2 Injuries found Open fractures 2 or more proximal long bone fractures (bilateral femur fractures = Level 1) Mechanism of Injury Ejection from motorized vehicle Pedestrian stuck by motor vehicle Death of restrained passenger in same vehicle Major auto deformity, intrusion into passenger compartment Fall > 20 feet Pediatric falls > twice their height
Disability GCS < 12 Open or depressed skull fracture Paralysis or focal neurologic deficit Mechanism of Injury Trauma with full thickness burns >10% body surface area High voltage electrocution (including lightning) Penetrating injury to torso, neck, head, or proximal to elbow or knee Gunshot wounds Stabbing Other Unstable pelvic fracture Bilateral femur fractures Pulseless extremity/threatened limb Traumatic amputation/mangled limb (excluding isolated hand/foot)
Consider activation for High Risk Patients: Age > 65 or < 5 Multiple co-morbidities Blood thinners or other bleeding/clotting disorders
FIGURE 1 Mayo Clinic Trauma Centers triage criteria. GCS, Glasgow Coma Scale; SBP, systolic blood pressure. a Data provided by the Mayo Clinic Trauma Center.
all educational components. These enhancements will be discussed in the procedure section. PROCEDURE
On April 27, 2009, a 3-month pilot phase was initiated. The TRNs were given a dedicated phone and were instructed that
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their priority was to answer all trauma calls. They were to remain in the emergency department rather than transporting patients to other areas for procedures. When prehospital crews called the ECC regarding a trauma patient, the ECC notified the TRN via the dedicated phone line. The TRN received radio report, then assigned a trauma level based on the established criteria. The ECC also listened to the report and
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FIGURE 2 The Vital signs, Origin (hospital vs. scene), Mechanism, Injuries, and Treatment (VOMIT) report tool used by prehospital providers, the trauma report nurse, and the entire trauma team. BP, Blood pressure; IV, intravenous; RA, room air; RR, respiratory rate; SAT, saturation; SBP, systolic blood pressure. a Data provided by the Mayo Clinic Trauma Center.
activated the trauma team via a text page, based on the level assigned by the TRN. All members of the trauma team received a text page including the transport agency, age, sex, reason for level (eg, “level 1 GSW to neck”), vital signs, and estimated time of arrival. Once the trauma team assembled in
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the trauma bay, the TRN provided prehospital report, which ideally occurred 15 minutes prior to the patient’s arrival. A standard prehospital report format was developed for giving and receiving trauma information. The data included Vital signs, Origin (hospital vs. scene), Mechanism, Injuries, and
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Gold Cross Ambulance calls in with the following report: 31 year old female restrained driver of a car highway speed front end impact Major auto deformity c/o chest and abdominal pain HR 124, RR 24, BP 101/64 + seatbelt sign GCS 15 Does the patient meet any activation criteria? Think about mechanism – major auto deformity Think about HR Think about HR as compared to SBP THIS PATIENT IS A LEVEL 1 BASED ON 2 FACTORS: HR > 120 in an adult patient is level 1 criteria HR > SBP in an adult patient is level 1 criteria What are your next steps? Page out Level 1 trauma (include time of injury) Call Trauma surgeon phone 71GUN (71486)
FIGURE 3 A sample case study provided during trauma report nurse ongoing training. BP, Blood pressure; c/o, complains of; GCS, Glasgow Coma Scale; HR, heart rate; RR, respiratory rate; SBP, systolic blood pressure. a Data provided by the Mayo Clinic Trauma Center.
Treatment (VOMIT). This framework was adopted by prehospital providers, the TRN, and the entire trauma team (Figure 2). During the pilot phase, all VOMIT report tools were reviewed. Analyses found gaps in the prehospital report causing suboptimal patient trauma triage. At other times, excessive report led to prolonged radio time and yielded little value-added information. To address these challenges, realtime feedback was provided by the implementation team, along with ongoing education through monthly case studies. The case studies highlighted unique and challenging scenarios that had been encountered by TRNs (Figure 3). The decision was made to collect feedback for the duration of the pilot phase before making significant changes to the process in an attempt to avoid knee-jerk reactions to initial feedback. An online blog was started that delivered weekly updates, answered frequently asked questions, and kept participants abreast of real-time issues.
TRN group. Quantitative data were measured to evaluate overtriage and undertriage rates (Figure 5). The pilot was deemed successful based on 2 metrics. First, ED nursing leadership witnessed increased acceptance and support of the TRN role. Second, the undertriage rates dropped from 14% to 10%. Demonstrating the overwhelming success of the role, undertriage rates decreased even further 3 years later to 4.8% (P b .001). The ED staff considered the TRNs very supportive and reported an increased knowledge of incoming trauma patients. Education on the trauma team activation process was also provided to triage nurses who were not serving in the TRN role regarding patients arriving via private vehicle. These nurses were empowered and encouraged to immediately page the trauma team when patients met criteria. The TRN could be consulted by the triage nurse for support and assistance.
Barriers Results
After the pilot phase, overtriage and undertriage rates, along with staff feedback, were evaluated. Qualitative and quantitative methodologies were used. Qualitative data (Figure 4) were gathered via 2 questionnaires; one to the multidisciplinary trauma team and one specific to the
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In many process improvement projects, change is met with resistance. This project was no different. Prehospital providers expressed concern because they were no longer assigning trauma triage levels. They also voiced dissatisfaction about waiting for the TRN to take report. However, real-time data showed delays of less than 1 minute. A
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Post pilot implementation results Percentage of respondents who were “satisfied” or “very satisfied”
Compared to pre-TRN pilot, I have more knowledge about the incoming trauma patients.
40% 65%
The TRN was helpful to me despite not taking a patient assignment. Since the pilot started my workload has remained the same.
50% 68% 14% 6 weeks post implementation (N=7-10)
46%
It seemed to me the TRN was able to maintain global awareness of the ED critical area (situational awareness).
40% 79%
I feel an ED RN is the appropriate person to level trauma patients.
15 months post implementation (N=23-28)
60% 82%
I feel the TRN is the appropriate nurse in the ED to take trauma report.
40% 89% 0%
20%
40%
60%
80% 100%
General Comments: 6 weeks: • This role has created animosity between critical nurses. The charge nurse has had years of experience and needs to be informed to get the help needed in critical, the charge nurse can keep the critical team leader informed. • I think it is too much to expect from the team leader in critical. The critical care Dr. has to accept on the phone and hears the story already I think it was fine the way it was. • I like the immediacy of rerouting about the traumas coming to CC and triage, like the organization. • Created tension among other in critical as to their pt load. 15 months: • The nurses in the critical team leader role have done an excellent job. • There is better control in critical care with a leader. • I think the nurses currently doing the TRN role are exceptional and are doing a great job. • This has been a very good change to our practice. • I do feel there is clear direction and better communication in the critical area w/having a TRN. • I believe triage nurses should be very aware and able to level trauma patients – you never know what comes through the front door.
FIGURE 4 Qualitative data 6 weeks and 15 months after the trauma report nurse (TNR) pilot phase. CC, Critical care; pt, patient. a Data provided by the Mayo Clinic Trauma Center.
small subset of physicians believed that trauma triage should be the responsibility of the EM critical care physician, but they were willing to proceed with the pilot phase to see the results. Radio communication proved to be another barrier. Outdated headsets and the physical location of the radio led to inefficiencies, frustrating the senders and receivers of report. Both of these issues were addressed immediately. In addition, radio etiquette was a new skill for some TRNs, requiring realtime feedback regarding appropriate radio transmission (eg, “Copy patient report. Please verify BP.”). Despite the barriers
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encountered, good teamwork and problem solving occurred among all disciplines, leading to a successful implementation.
Ongoing Improvements
The TRN role and trauma activation process has continued to evolve, prompting several other practice improvements. First, a policy was developed that officially gave the TRN ultimate authority to determine the patient level and activate the trauma team.
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Under triage percentages pre and post implementation (P<0.001)
FIGURE 5 Undertriage rates 6 months before, 6 months after, and 3 years after trauma report nurse (TRN) implementation. a Data provided by the Mayo Clinic Trauma Center.
Second, a change was made to the trauma team notification process. With more than 1000 patients being referred to Mayo Clinic Trauma Centers on an annual basis, a great need for earlier notification existed. The advanced warning times were identical, whether coming from another hospital or directly from a scene. Now, once a trauma patient is accepted, a prealert is sent via pager to the entire trauma team, including estimated time of arrival and trauma level. This earlier notification gives individual trauma team disciplines time to plan resource allocation prior to the patient’s arrival. Significant time improvements were noted, with averages between the first notification and patient arrival increasing from 16 minutes to just over 52 minutes. For pediatric traumas, the in-house adult trauma surgeon served as the initial staff surgeon 42% of the time. Now, with earlier notification, the pediatric trauma surgeon is at the bedside 71% of the time prior to the patient’s arrival. Third, many referring facilities are able to send radiographic images electronically. The TRN has also been charged with notifying the trauma surgeon when images are available. This process allows multidisciplinary planning prior to the patient’s arrival. The plan is then discussed with the entire trauma team, creating a shared mental model. The establishment of a common strategy allows preparation time for lifesaving interventions and improves patient throughput. Finally, a direct phone line to the trauma surgeon was also established with an easily recalled phone number of “71GUN.” This direct phone line allowed TRNs to provide earlier report, which facilitated surgeon
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planning for competing patient priorities, including those in the operating room and ICU.
Conclusion
After the 3-month pilot phase, the TRN role became standard practice. External validation was provided by the American College of Surgeon’s site reviewers during a trauma reverification, satisfying a recommendation to have a core group of trauma nurses. Multidisciplinary team members internally validated not only the process, but positive patient outcomes. For example, Donald H. Jenkins, MD, Consultant, Division of Trauma, Critical Care and General Surgery, Associate Professor of Surgery, College of Medicine, and Medical Director, Trauma Center, Mayo Clinic, Rochester, MN, said, “This model, built of necessity for more timely and accurate trauma triage, has now become the model for all emergency triage and has improved our communication and preparation immensely.” Dawn King, BSN, RN, CEN, Staff Nurse and TRN, Saint Marys Emergency Department, noted, “The TRN is an essential link in closing the loop of communication between the prehospital providers and preparing resources needed for our critically ill patients before their arrival. Timeliness of care is essential to optimize positive patient outcomes.” In an ongoing effort to improve trauma patient care, the TRN role was created. Through multidisciplinary
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teamwork and problem solving, this cutting-edge role has demonstrated continued success, withstood the test of time, and ultimately benefited patients.
2. Moore K. Trauma triage: right person, right place, right time. J Emerg Nurs. 2012;38(2):193-4.
REFERENCES
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1. Mohan D, Barnato AE, Rosengart MR, Angus DC, Smith KJ. Optimal approach to improving trauma triage decisions: a cost-effectiveness analysis. Am J Manag Care. 2012;18(3):139.
4. Dehli T, Fredriksen K, Osbakk S, Bartnes K. Evaluation of a university hospital trauma team activation protocol. Scand J Trauma Resusc Emerg Med. 2011;19:18.
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