Yesterday, I talked about the new 30-minute rules for orthopedics and neurosurgery in general terms. Today, I’ll write about the who and what.

The rules state that a service representative “must be present and respond within 30 minutes based on institutional-specific criteria.” The response needs to be in person and not by phone. But who can it be? The Clarification Document states that the response can be met by an orthopedic surgery resident, mid-level provider, or the orthopedic surgeon. However, if a resident or midlevel respond, they must document their communication with the orthopedic surgeon in their note.

The neurosurgery service representative is not as clearly spelled out. However, it is presumed that this person meets the same requirements as for orthopedics: resident, midlevel, or neurosurgeon.

The most important issue the trauma program must address is the selection of the actual criteria.  Here are some tips to guide you:

• Select only a few. Three is a good number. Any more than this will tax your specialists.
• Choose good criteria that your orthopedic surgeon or neurosurgeon would absolutely want to be there  in 30 minutes for. See my examples below.
• Make sure they are very specific. Vague terms like “TBI” or “open fracture” would result in your specialist being called in way too often.
• Ensure that the criteria do not rely on the judgement of the specialist. For example, language such as “a subdural requiring operative intervention” requires the neurosurgeon to pass judgment from home and should be avoided.
• One exception to the previous point: futile neurotrauma care. Your neurosurgeon may review the images from outside the trauma bay and pronounce the care futile. However, they should document this clearly in a note in the chart as soon as possible. And they had better not change their mind later.
• Avoid vague language like “when requested by the trauma team.”

So what are some good criteria? Here are a few:

• Ortho
  • Mangled extremity
  • Dysvascular limb
  • Compartment syndrome
  • Unstable pelvic fracture
  • Open pelvic fracture with external hemorrhage
• Neurosurgery (you/they pick the exact numbers)
  • Subdural/epidural > x mm
  • Subdural/epidural with midline shift > x mm
  • Subdural/epidural with impending herniation
  • Open skull fracture with brain extrusion
  • Brain extrusion from nose/ear
  • Decrease in GCS of > x points
  • Unilateral dilated pupil with GCS < x points
  • Spinal cord injury with unstable spine

This is not a comprehensive, list, but hopefully you get the idea. Each center needs to develop their own list, with input from their specialists. Once agreed upon, these should be put into policy and approved at the trauma program operations committee.

Tomorrow: call and response.