All posts by TheTraumaPro

How Do You Dress YOUR Trauma Team?

Over the years, I’ve seen the trauma teams at quite a few hospitals in action. One thing I have noticed is that most just don’t pay attention to what they wear. I’m talking about wearing personal protective equipment again. It’s one of those things, like hand washing, that everyone knows that they are supposed to do.

There are two reasons to put all that stuff on:

  • To keep potentially contaminated body fluids from getting on you
  • To prevent you from contaminating your patient’s open wounds

The minimum equipment that MUST be worn is a cap of some sort (to keep your hair from falling on the patient), mask and eye protection (mucus membrane protection), gown (protects your clothes), and gloves (obvious). Shoe protection is optional, in my opinion, unless you wear Christian Louboutin to work.

So you’ve been lax with your team. How do you get them to put everything on now? It’s like getting your child to wear a bicycle helmet when they are fourteen.

  • Create an expectation that everyone wear it and empower everyone to point it out. No exceptions. Physicians, this means you.
  • Put all equipment just outside the trauma room door. The farther away it is, the less likely it is to be used.
  • Assign an enforcer. Everyone entering the room must be dressed, or this person will speak up. Ideally, they should be a physician. If not, one of the docs must back this person up.
  • Occasionally, a badly hurt patient gets rolled into the room with little advance notice. In this case the fully dressed people need to relieve those who are not as soon as they dress and walk into the room.

The top picture shows part of our trauma team assembling before a trauma activation. Everyone is dressed. They know that someone will call them on it if they aren’t. Also, note the little pink sticker on the chest of physician at the head of the bed. We have a sticker for every role in the room (bottom picture). At the beginning of a resuscitation I scan the room to make sure everyone has one. It helps identify everyone and makes extraneous personnel stand out so they can be asked to leave the room.

Bottom line: Everyone has to wear their personal protective equipment on every trauma resuscitation. No exceptions.

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Best Of: Forensic Nursing

Forensic Nursing combines nursing science with the investigation of injuries or deaths that involve accidents, abuse, violence or criminal activity. Sexual Assault Nurse Examiners (SANE nurses) are one of the most recognized types of forensic nurses, but they have special training in one type of injury. Forensic nursing programs typically involve a broader set of skills, encompassing some or all of the following:

  • Interpersonal violence, including domestic violence, child and elder abuse/neglect, psychological abuse
  • Forensic mental health
  • Correctional nursing
  • Legal nurse consulting
  • Emergency/trauma services, including auto and pedestrian accidents, traumatic injuries, suicide attempts, work-related injuries, disasters
  • Patient care facility issues, including accidents/injuries/neglect, inappropriate treatments & meds
  • Public health and safety, including environmental hazards, alcohol and drug abuse, food and drug tampering, illegal abortion practices, epidemiology, and organ donation
  • Death investigation, including homicides, suicides, suspicious or accidental deaths, and mass disasters

Forensic nurses find that their additional training improves their basic nursing skills, and allows them to derive greater career satisfaction from helping patient in another rather unique way.

Approximately 37 training programs exist, ranging from certificate programs that require a specific number of hours of training, to degree programs (typically Masters level programs). Many of the certificate programs are available as online training. 

Source: International Association of Forensic Nurses (http://www.iafn.org/)

Minority Report In The OR

The movie “Minority Report” showed an interesting way to manipulate visual data using hand gestures. It required a special glove and used large transparent display surfaces. Microsoft has helped make this achievement both easy and cheap using their Kinect controller using a combination of visual and infrared imaging.

Now Siemens Healthcare has embraced this technology and developed a hands-off image manipulation system for use in the OR. The Kinect system projects an infrared grid into the room and records them using an offset camera. This allows the system to construct a 3D representation of objects in the room. The Kinect software can identify movements and objects using this data.

Siemens is using special software with the Kinect that allows it to detect and interpret fine movement of a surgeon’s hands in the operating room. The final product will allow a surgeon to browse, pan and zoom relevant patient images while they remain scrubbed and sterile, just by gesturing with their hands. This product will be tested in two hospitals in the near future.

Here’s my prediction: why will we need a big, clunky robotic system interface like DaVinci? Just have the surgeon sit in a comfortable chair, waving their hands to move the laparoscopic camera and instruments. I see especially interesting applications of this technology in military settings and in space!

Reference: Siemens Game Console Technology

EMR vs Trauma flow Sheet: The User’s Perspective

Well, you’ve read me railing against the (current) use of an electronic medical record in place of a paper trauma flow sheet for days. I’d like to share some comments from an end user (nurse) who started using the Epic Trauma Navigator last year:

I am really not impressed with the Trauma Narrator for a few reasons: 

  • Bulky & cumbersome to access during a trauma team activation. Our build team promised us that this would be an efficient model of documentation, however, that has not been the case. It takes more steps to document than before and the output is in so many different places review of the chart is extremely difficult to do. You need to know exactly where to look for this information.
  • While the rest of Epic has a feature that allows for the automatic integration of vital signs from cardiac and NIBP monitors, Epic does not allow this feature in the Trauma Narrator.  All vitals need to be entered manually which can be time consuming. Knowing this up front, I think I would have advocated for not using the Trauma Narrator at all.
  • Vital signs and GCS are not displayed within the same flowsheet in Epic. You can find VS in several places, however GCS are in one specific location and if you don’t have the secret treasure map to find them, you will be searching the high seas of frustration for a long period of time.
  • During our build, there were several requests that were not included in the build. I am told that the once Epic goes live, there is a lock-out of up to 12 months before any “optimization” occurs. My advice to you all who are going to Epic is to be adamant about what you want and ensure it is there before go-live. We are missing small things like “logroll time” and level of activation among other “simple” items.
  • Massive transfusions are difficult to document as you need to address each blood component separately and there are several steps in the process for each component. Again, not a user-friendly system at this point for that.
  • Our training was done concurrently with our build so our training was on a generic template/flowsheet within the Epic playground that did not mirror our live version. This was not at all what our production/end-user system looked like at all, so our employees had to be retrained on the job on how to document with the Trauma Narrator.
  • Order sets are available within Epic, however not all staff use the trauma order sets. This creates confusion and the incorrect items being ordered. Again, bird-dogging is required to assure compliance.
  • Once the patient is “arrived” within the Epic system (aka patient chart is noted as the patient actually being in the ED) you cannot go back and document on the EMS radio/report sheet. Staff need to be diligent to assure that documentation is completed before the patient arrives. We have had scenarios where there have been multiple trauma patients arriving and once the nurse begins the documentation of the trauma team, the ED Charge nurse could not go back and enter the radio report in the proper section. 

… remember, Epic is a documentation tool, and as a tool, it depends on the user. Some will continue to document incredibly well and others not so much.

Bottom line: I have absolutely nothing against Epic. I consider it to be one of the best EMRs out there, and I’ve been exposed to quite a few. As you can see though, even it suffers from many of the input problems I’ve written about in the past. And trauma flow products on other EMRs don’t even come close to this one. So for now, buyer beware! Wait until the input technologies and report capabilities become so intuitive that anyone can use them.

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Yet More On The EMR / Trauma Flow Sheet Debate

My opinions about using an electronic medical record (EMR) system for recording trauma activations are well known. I received this well thought out response that I wanted to share and comment on:

My quote: “I defy any of them to come to a trauma resuscitation and rapidly and accurately transcribe all of the information presented, or try to review a PI case based on a printed EMR report.”

Their response: I’m a nurse informaticist, I’ve been a trauma nurse for 15 years, and I review PI cases using the electronic record. I work in an inner city Level 1 trauma center that’s associated with a large academic institution. We have recently implemented an ED Information System in our department and I have documented major traumas electronically. My trauma charts beat my colleagues written flowsheet in accuracy, comprehensiveness, and detail, hands down.

Your blog entry on this topic seems very close-minded. The “flowsheet” is not the silver bullet for trauma documentation. I agree that an EMR can be lengthy but it, by far, surpasses the flowsheet in thoroughness in detail. They both have their pros and cons, why be so quick to pick one? Yes, flowsheet data might be convenient for the reviewer but have you considered the effect on workflow for the frontline staff? An ED that has a comprehensive information system (CPOE, electronic tracking, physician and nurse documentation) must pull out a piece of paper and write on it so that a reviewer can find things easier retrospectively? It seems to me the priority should be the appropriate care for the patient and positive outcomes versus a reviewer being inconvenienced by having to read a long chart.

My response: My main problem with using an EMR to record a trauma activation is that the current human interface technology (keyboard, mouse) do not allow for rapid data entry and movement between different screens of input boxes. If a scribe such as yourself becomes extremely familiar with the system, it is certainly possible to overcome these difficulties with sheer skill and familiarity. However, your response implies that you are the only one capable of doing this. Your colleagues must still use the written trauma flow sheet.

The purpose of the flow sheet is to allow any scribe to record meaningful data that can be used to document patient care and to review and rebuild a complex resuscitation for performance improvement purposes. It is not designed to please trauma center reviewers. But the process the reviewers use to reconstruct a trauma activation is the same one that the hospital’s trauma program must use to dig into the events that occur in a trauma activation. If the input data is faulty because the scribe could not keep up in the EMR or had to enter it later, or if the output is dozens of pages of data that is difficult to sift through, the trauma program manager must spend an inordinate amount of time trying to figure out exactly what happened. The “thoroughness and detail” you mention in the EMR can be a hindrance if the quantity of data eclipses its quality. I have reviewed EMR records with 30 pages in the trauma flow sheet report!

The reviewers look for some kind of trauma flow data that they can use to rapidly rebuild what happened in the trauma room. If the reviewers can’t do it, then the trauma program probably can’t do it either. Neither I nor any of the other reviewers I have worked with have found an EMR trauma flow sheet that matches the utility of paper. Yet. The day will come, but it’s not here yet.

I welcome any additional opinions on this debate. Please leave a comment!

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