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Trauma center best practices
u r i n g t h e p a s t several years, I h a v e b e e n fortunate to b e i n v i t e d as a t r a u m a site surveyor at several hospitals. T h e e x p e r i e n c e is always e d u c a t i o n a l , a n d I learn s o m e t h i n g n e w from every survey. Some of the hospitals t h a t I v i s i t e d still s t a n d out i n m y m i n d as excellent t r a u m a centers. This c o l u m n identifies those p r a c t i c e s that, in m y opinion, lend t h e m s e l v e s to t r a u m a c e n t e r excellence. First a n d foremost is the p r e s e n c e of a d e d i c a t e d s u r g e o n to h e a d t h e t r a u m a service. T h e e x t e n t of the t r a u m a director's i n v o l v e m e n t i n the r u n n i n g of t h e t r a u m a p r o g r a m is always i m m e d i a t e l y a p p a r e n t duri n g a site survey. The b e s t t r a u m a c e n t e r s h a v e a t r a u m a director w h o h a s the power, authority, a n d interest to effectively i m p l e m e n t all t r a u m a c e n t e r r e q u i r e m e n t s . This authority i n c l u d e s the ability to r e m o v e s u r g e o n s from the t r a u m a call roster for n o n c o m p l i a n c e w i t h s t a n d a r d s or for p e r f o r m a n c e issues. W h e n the t r a u m a director's role is s e c o n d a r y to private p r a c t i c e or to other surgical interests, the imp o r t a n c e of t r a u m a in a hospital is also secondary. The b e s t t r a u m a c e n t e r s have a t r a u m a coordinator w h o works in collaboration w i t h t h e t r a u m a director. T h e t r a u m a coordinator reports directly to one of the hospital vice p r e s i d e n t s rather t h a n to the m a n a g e r s of t h e e m e r g e n c y d e p a r t m e n t or critical care d e p a r t m e n t . This r e p o r t i n g line to the vice presi d e n t reflects the h o s p i t a l ' s u n d e r s t a n d i n g of the i n t e r d e p a r t m e n t a l n a t u r e of t r a u m a - r e l a t e d issues. This t y p e of r e p o r t i n g gives t h e t r a u m a coordinator t h e l a t i t u d e t h a t is n e e d e d to a d d r e s s m u l t i d e p a r t m e n t a l issues. A t r a u m a c e n t e r b e s t p r a c t i c e is the p r e s e n c e of a t r a u m a s u r g e o n at b o t h major r e s u s c i t a t i o n a n d all operative procedures. T r a u m a is a surgical " d i s e a s e " a n d is b e s t m a n a g e d b y a surgeon. If the hospital is a n a c a d e m i c m e d i c a l center, t h e faculty s u r g e o n is p r e s e n t to provide oversight a n d c o u n s e l to the residents. A n o t h e r hallmark of a n excellent t r a u m a c e n t e r is the c o m b i n a t i o n of critical care boards a n d surgical b o a r d s for t h e t r a u m a surgeons. Most hospitals
D
treat m a n y more p a t i e n t s w i t h b l u n t t r a u m a injuries t h a n p a t i e n t s w i t h p e n e t r a t i n g injuries. P a t i e n t s w i t h b l u n t injuries often require critical care. Such care is b e s t delivered b y a s u r g e o n w h o u n d e r s t a n d s v e n tilators, n u t r i t i o n a l needs, a n d m u l t i s y s t e m o r g a n failure. It also is i m p o r t a n t to h a v e a s u r g e o n who m a i n t a i n s a h i g h i n d e x of s u s p i c i o n for possible occult injuries.
A trauma center best p r a c t i c e is t h e p r e s e n c e of a t r a u m a s u r g e o n at b o t h m a j o r r e s u s c i t a t i o n a n d all operative procedures. T r a u m a is a s u r g i c a l " d i s e a s e " a n d is b e s t managed by a surgeon. The p r e s e n c e of n u r s e s t h r o u g h o u t the emerg e n c y d e p a r t m e n t , i n t e n s i v e care unit, operating room, p o s t a n e s t h e s i a care unit, a n d m e d i c a l surgical n u r s e s w h o are skilled a n d e d u c a t e d in the n u a n c e s of t r a u m a care c o n t r i b u t e to t r a u m a c e n t e r excellence. There is e v i d e n c e at excellent t r a u m a centers that the front-line n u r s e s w h o provide initial care to the p a t i e n t in t h e first 24 hours after injury have a t t e n d e d a T r a u m a N u r s i n g Core Course, h a v e A d v a n c e d Cardiac Life Support certification, a n d have m a n d a t o r y r e q u i r e m e n t s for o n g o i n g a n n u a l t r a u m a education. Medical surgical u n i t n u r s e s w h o care for t r a u m a pat i e n t s d e m o n s t r a t e that t h e y h a v e received both orie n t a t i o n to t h e care of the t r a u m a p a t i e n t a n d some o n g o i n g a n n u a l e d u c a t i o n in t r a u m a care. J EMERGNURS1995;21:469-70 Copyright 9 1995 by the Emergency Nurses Association. 0099-1767/95 $5.00 + 0
18/9/66479
October 1995
469
JOURNAL OF E M E R G E N C Y NURSING/Southard
A n o t h e r t r a u m a c e n t e r b e s t p r a c t i c e i s t h e limit a t i o n of p a r t i c i p a t i o n in t r a u m a r e s u s c i t a t i o n b y n u r s e s w h o are n o t e x p e r i e n c e d a n d who h a v e not att e n d e d T r a u m a N u r s i n g Core Course or A d v a n c e d Cardiac Life Support courses. E x p e r i e n c e d n u r s e s w h o p o s s e s s t h e k n o w l e d g e a n d skill n e c e s s a r y to collaborate i n the i m m e d i a t e care of the injured p a t i e n t assist i n t r a u m a r e s u s c i t a t i o n s . The staffing in the e m e r g e n c y d e p a r t m e n t is a d e q u a t e to s u p p o r t t r a u m a resuscitation, a n d t h e r e are c o n t i n g e n c y plans to o b t a i n a d d i t i o n a l staff if t h e e m e r g e n c y d e p a r t m e n t becomes overwhelmed with trauma admissions. The b e s t t r a u m a c e n t e r s also have m a d e a comm i t m e n t to injury p r e v e n t i o n activities. This c o m m i t m e n t is e v i d e n c e d b y t h e hospital p e r s o n n e l ' s initiation a n d p a r t i c i p a t i o n i n c o m m u n i t y injury p r e v e n t i o n programs. Injury p r e v e n t i o n activities are n o t limited to t h e t r a u m a coordinator p r e s e n t i n g every class a n d a t t e n d i n g every safety fair. Rather, there is a large group of n u r s e s , p h y s i c i a n s , a n d other hospital pers o n n e l w h o p a r t i c i p a t e i n s u c h programs. N o t e w o r t h y level I t r a u m a c e n t e r s are active in t r a u m a - r e l a t e d research. A n o t e b o o k u s e d d u r i n g the site survey lists all the t r a u m a - r e l a t e d p u b l i c a t i o n s for t h e p a s t 2 years. The p u b l i c a t i o n s are c o m p r e h e n s i v e a n d reflect n o t only r e s e a r c h f i n d i n g s b u t also public a t i o n s from t h e t r a u m a coordinators or other hospital staff w h o h a v e w r i t t e n a b o u t t r a u m a - r e l a t e d issues. T r a u m a - r e l a t e d e d u c a t i o n is a n o t h e r area t h a t
s h i n e s d u r i n g t h e site survey. The e d u c a t i o n is directed t o w a r d all m e m b e r s of t h e t r a u m a t e a m from prehospital t h r o u g h rehabilitation. There are multidisciplinary t r a u m a c o n f e r e n c e s with d e m o n s t r a t e d a t t e n d a n c e of p e r s o n n e l r e p r e s e n t i n g all a s p e c t s of t r a u m a care. T h e professional e d u c a t i o n reflects att e n d a n c e at t r a u m a - r e l a t e d c o n f e r e n c e s a n d the att a i n m e n t of initial A d v a n c e d T r a u m a Life Support verification b y e m e r g e n c y p h y s i c i a n s a n d surgeons. The quality m a n a g e m e n t portion of a site survey of the b e s t t r a u m a c e n t e r s is t h e c r o w n i n g touch. A n e x a m i n a t i o n of quality activities shows honest, thorough, a n d o n g o i n g review of all a s p e c t s of care. During t h e survey, the r e v i e w shows that some d e a t h s were d e t e r m i n e d to b e either potentially prev e n t a b l e or frankly p r e v e n t a b l e . However, e a c h of t h e s e d e a t h s w e r e s t u d i e d i n detail a n d action plans were developed to a d d r e s s the identified deficiencies. The action p l a n s r a n g e from e d u c a t i o n a l p r e s e n t a tions on p r o b l e m areas to s e n d i n g a p h y s i c i a n for specialized training. The "loop" is closed on quality problems, a n d a r e m o n i t o r i n g s c h e d u l e is in place. I believe t h a t the s u m m a t i o n of t h e s e factors equals t r a u m a c e n t e r excellence. W h e n all of t h e s e are i n place on a site survey visit, I k n o w that it is a hospital I would t r u s t to care for a n y injured patient. T h e s e hospitals h a v e t a k e n the extra s t e p in c o m m i t m e n t to t r a u m a care t h a t m a k e s t h e m the gold s t a n d a r d for t r a u m a c e n t e r excellence.
AVAHABII/FY OF JOUSNALBACK ISSUEs
As a service to our subscribers, copies of back issues of JOURNALOFEMERGENCYNURSINGfor the preceding 5 years are maintained and are available for purchase from the publisher, Mosby-Year Book, Inc., at a cost of $10.00 per issue. The following quantity discounts are available: 25% off on quantities of 12 to 23, and one third off on quantities of 24 or more. Please write to Mosby-Year Book, Inc., Subscription Services, 11830 Westline Industrial Drive, St. Louis, MO 63146-3318, or call (800) 453-4351 or (314) 453-4351 for information on availabilityof particular issues. If unavailable from the publisher, photocopies of complete issues are available from UMI, 300 N. Zeeb Rd., Ann Arbor, MI 48106; (313) 761-4700.
470
Volume 21, Number 5
D
treat m a n y more p a t i e n t s w i t h b l u n t t r a u m a injuries t h a n p a t i e n t s w i t h p e n e t r a t i n g injuries. P a t i e n t s w i t h b l u n t injuries often require critical care. Such care is b e s t delivered b y a s u r g e o n w h o u n d e r s t a n d s v e n tilators, n u t r i t i o n a l needs, a n d m u l t i s y s t e m o r g a n failure. It also is i m p o r t a n t to h a v e a s u r g e o n who m a i n t a i n s a h i g h i n d e x of s u s p i c i o n for possible occult injuries.
A trauma center best p r a c t i c e is t h e p r e s e n c e of a t r a u m a s u r g e o n at b o t h m a j o r r e s u s c i t a t i o n a n d all operative procedures. T r a u m a is a s u r g i c a l " d i s e a s e " a n d is b e s t managed by a surgeon. The p r e s e n c e of n u r s e s t h r o u g h o u t the emerg e n c y d e p a r t m e n t , i n t e n s i v e care unit, operating room, p o s t a n e s t h e s i a care unit, a n d m e d i c a l surgical n u r s e s w h o are skilled a n d e d u c a t e d in the n u a n c e s of t r a u m a care c o n t r i b u t e to t r a u m a c e n t e r excellence. There is e v i d e n c e at excellent t r a u m a centers that the front-line n u r s e s w h o provide initial care to the p a t i e n t in t h e first 24 hours after injury have a t t e n d e d a T r a u m a N u r s i n g Core Course, h a v e A d v a n c e d Cardiac Life Support certification, a n d have m a n d a t o r y r e q u i r e m e n t s for o n g o i n g a n n u a l t r a u m a education. Medical surgical u n i t n u r s e s w h o care for t r a u m a pat i e n t s d e m o n s t r a t e that t h e y h a v e received both orie n t a t i o n to t h e care of the t r a u m a p a t i e n t a n d some o n g o i n g a n n u a l e d u c a t i o n in t r a u m a care. J EMERGNURS1995;21:469-70 Copyright 9 1995 by the Emergency Nurses Association. 0099-1767/95 $5.00 + 0
18/9/66479
October 1995
469
JOURNAL OF E M E R G E N C Y NURSING/Southard
A n o t h e r t r a u m a c e n t e r b e s t p r a c t i c e i s t h e limit a t i o n of p a r t i c i p a t i o n in t r a u m a r e s u s c i t a t i o n b y n u r s e s w h o are n o t e x p e r i e n c e d a n d who h a v e not att e n d e d T r a u m a N u r s i n g Core Course or A d v a n c e d Cardiac Life Support courses. E x p e r i e n c e d n u r s e s w h o p o s s e s s t h e k n o w l e d g e a n d skill n e c e s s a r y to collaborate i n the i m m e d i a t e care of the injured p a t i e n t assist i n t r a u m a r e s u s c i t a t i o n s . The staffing in the e m e r g e n c y d e p a r t m e n t is a d e q u a t e to s u p p o r t t r a u m a resuscitation, a n d t h e r e are c o n t i n g e n c y plans to o b t a i n a d d i t i o n a l staff if t h e e m e r g e n c y d e p a r t m e n t becomes overwhelmed with trauma admissions. The b e s t t r a u m a c e n t e r s also have m a d e a comm i t m e n t to injury p r e v e n t i o n activities. This c o m m i t m e n t is e v i d e n c e d b y t h e hospital p e r s o n n e l ' s initiation a n d p a r t i c i p a t i o n i n c o m m u n i t y injury p r e v e n t i o n programs. Injury p r e v e n t i o n activities are n o t limited to t h e t r a u m a coordinator p r e s e n t i n g every class a n d a t t e n d i n g every safety fair. Rather, there is a large group of n u r s e s , p h y s i c i a n s , a n d other hospital pers o n n e l w h o p a r t i c i p a t e i n s u c h programs. N o t e w o r t h y level I t r a u m a c e n t e r s are active in t r a u m a - r e l a t e d research. A n o t e b o o k u s e d d u r i n g the site survey lists all the t r a u m a - r e l a t e d p u b l i c a t i o n s for t h e p a s t 2 years. The p u b l i c a t i o n s are c o m p r e h e n s i v e a n d reflect n o t only r e s e a r c h f i n d i n g s b u t also public a t i o n s from t h e t r a u m a coordinators or other hospital staff w h o h a v e w r i t t e n a b o u t t r a u m a - r e l a t e d issues. T r a u m a - r e l a t e d e d u c a t i o n is a n o t h e r area t h a t
s h i n e s d u r i n g t h e site survey. The e d u c a t i o n is directed t o w a r d all m e m b e r s of t h e t r a u m a t e a m from prehospital t h r o u g h rehabilitation. There are multidisciplinary t r a u m a c o n f e r e n c e s with d e m o n s t r a t e d a t t e n d a n c e of p e r s o n n e l r e p r e s e n t i n g all a s p e c t s of t r a u m a care. T h e professional e d u c a t i o n reflects att e n d a n c e at t r a u m a - r e l a t e d c o n f e r e n c e s a n d the att a i n m e n t of initial A d v a n c e d T r a u m a Life Support verification b y e m e r g e n c y p h y s i c i a n s a n d surgeons. The quality m a n a g e m e n t portion of a site survey of the b e s t t r a u m a c e n t e r s is t h e c r o w n i n g touch. A n e x a m i n a t i o n of quality activities shows honest, thorough, a n d o n g o i n g review of all a s p e c t s of care. During t h e survey, the r e v i e w shows that some d e a t h s were d e t e r m i n e d to b e either potentially prev e n t a b l e or frankly p r e v e n t a b l e . However, e a c h of t h e s e d e a t h s w e r e s t u d i e d i n detail a n d action plans were developed to a d d r e s s the identified deficiencies. The action p l a n s r a n g e from e d u c a t i o n a l p r e s e n t a tions on p r o b l e m areas to s e n d i n g a p h y s i c i a n for specialized training. The "loop" is closed on quality problems, a n d a r e m o n i t o r i n g s c h e d u l e is in place. I believe t h a t the s u m m a t i o n of t h e s e factors equals t r a u m a c e n t e r excellence. W h e n all of t h e s e are i n place on a site survey visit, I k n o w that it is a hospital I would t r u s t to care for a n y injured patient. T h e s e hospitals h a v e t a k e n the extra s t e p in c o m m i t m e n t to t r a u m a care t h a t m a k e s t h e m the gold s t a n d a r d for t r a u m a c e n t e r excellence.
AVAHABII/FY OF JOUSNALBACK ISSUEs
As a service to our subscribers, copies of back issues of JOURNALOFEMERGENCYNURSINGfor the preceding 5 years are maintained and are available for purchase from the publisher, Mosby-Year Book, Inc., at a cost of $10.00 per issue. The following quantity discounts are available: 25% off on quantities of 12 to 23, and one third off on quantities of 24 or more. Please write to Mosby-Year Book, Inc., Subscription Services, 11830 Westline Industrial Drive, St. Louis, MO 63146-3318, or call (800) 453-4351 or (314) 453-4351 for information on availabilityof particular issues. If unavailable from the publisher, photocopies of complete issues are available from UMI, 300 N. Zeeb Rd., Ann Arbor, MI 48106; (313) 761-4700.
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Volume 21, Number 5