Monthly Archives: March 2012

Procedures

How Do You Dress YOUR Trauma Team?

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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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General

Best Of: Forensic Nursing

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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/)

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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

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EMR vs Trauma flow Sheet: The User’s Perspective

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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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