The number of new survey completions is starting to dwindle, so I will be closing the ED thoracotomy survey this Friday at midnight Central time. I’ll pick apart the results and publish them in the next couple of weeks.
I am trying to determine who could and who actually does perform ED thoracotomy across the various trauma hospitals around the world. For those of you who have already completed it, thanks! For everyone else, please take the 2 minutes to finish it soon!
How do you get patients out of their clothes during a trauma resuscitation? Most of the time, I bet your answer is “with a pair of scissors.” And once they are off, what do you do with them? Admit it. You just throw them on the floor. And sometime later, someone’s job is to find it all, put it in a bag, and store it or hand it over to the police.
There are more problems than you might think with this approach. First, and most importantly to the patient, their stuff can get lost. Swept up with all the other detritus from a trauma activation. And second, their belongings may become evidence and it’s just been contaminated.
So here’s an easy solution. Create a specific place to put the clothes. Make it small, with a tiny footprint in your trauma room. Make it movable so it can be kept out of the way. And make sure it is shaped so it can contain a large paper bag to preserve evidence without contamination.
And here’s the answer:
Yes, it’s a plain old laundry basket. The perfect solution. And best of all, these are dirt cheap when you are used to seeing what hospitals charge for stuff. So your ED can buy several ($14.29 ea on Amazon.com) in case they can’t be cleaned anymore or just disappear.
I spent the last two posts discussing the size of your trauma bay and how to measure it. This can obviously be helpful if you are updating or building new resuscitation rooms. But what about all the stuff that goes into it? Where is the best place to put it? If you are in the enviable position of being able to stock a brand new room, here are some tips.
Figure out what you really need in the trauma bay. You don’t have to put everything and the kitchen stove in there. It’s fine to have less commonly used equipment somewhere else, but it must be close! You don’t want someone to have to walk 50 yards to look for something you need right now.
Here’s a list of the critical stuff:
Temperature and light controls. These must be inside the room for easy and rapid access. And the doors should close to contain the heat. Resus rooms that are used frequently should be kept warm, doors closed, at all times.
Personal protective equipment. This should be located just inside the room (if space is available) or just outside. It absolutely must be near the entrance and easily accessible or no one will wear it.
Airway cart and video laryngoscope. These items must always be located near the head of the bed for immediate availability.
Difficult airway cart. These are not used frequently, so need not be placed inside the room. But make sure it is close by.
Travel ventilator. This can be stored outside unless you have lots of space available.
IV start/blood draw carts. One of these should be stationed on either side of the patient.
Rapid infuser. This may be located inside or outside of your trauma room based on the number of times it is typically needed.
Procedure packs. These should be located inside the trauma bay, and clearly organized inside cabinets.
Medication dispenser. This must be inside the room. Period.
Other commonly usedequipment/supplies. These should be placed intuitively in the bay and/or cabinets depending on frequency of usage of each item. Clear marking is essential.
Scribe stand. Don’t forget the scribe. They obviously have to be in the room, and need some space for the (preferably) paper trauma flow sheet.
Pediatric cart. This can be stored inside or outside the resus room, but should be nearby. Make sure that the measuring card that translates child size into equipment size is easily located.
Blood refrigerator. This item is optional, but is becoming more common. It can be located inside or close outside the trauma bay depending on space available.
Blanket and sheet warmer. These are nice to have, wherever you have room to put one. The patients will appreciate it.
Procedure lights. Ceiling mounted are best because they don’t take up floor space. However, these are notorious for developing a mind of their own as they age. After a while, they never seem to stay focused on your field.
Forced air warming blanket unit. This is important here in Minnesota, but also anywhere your patients can get cold. Which is pretty much everywhere. The airflow unit itself is relatively small and can usually be tucked under a counter somewhere. Otherwise, keep it nearby.
Linens hamper. You need to get rid of that gown / those sheets and blankets / or whatever. There’s no reason to take up space in the room for this. Park it outside.
Laundry basket. This is a valuable item that is generally overlooked. What do you usually do with all that stuff you cut off the patient? Drop it on the floor, right? This is setting you up to lose your patient’s stuff. Get a cheap plastic laundry basket from Target and put it under one of the counters. Toss clothing, shoes, etc in it as they are removed.
Cast cart. These are typically huge. They can be anywhere else but inside the trauma bay. Roll it outside the door when needed.
Now where do you put all this stuff? Most trauma centers already have an established layout and flow in their existing trauma bays. When you are moving to a new one, plan ahead! Hopefully you will have more room, so you’ll have some additional flexibility as to where to place everything.
But designing the placement and flow on paper alone is of limited use. You must try it out in advance! How do you do this? Have your contractor mock up a space exactly the size of your new resuscitation room. Move actual carts, cabinets, and equipment into it. If it’s not possible to cart the exact stuff into it, have the contractor build mock-ups of them and place them in the bay.
Now have actual trauma team members practice simulations of common types of resuscitation: basic no frills, basic with intubation, basic with splinting/casting, advanced with all of the above plus multiple procedures. Take careful notes of flow and any glitches that arise. Then move your stuff around to fix any problems, and try again!
Yesterday I detailed some standard info on trauma bay size. Today, I’ll describe what I found when I brought in my trusty tape measure today to check out my trauma bays at Regions Hospital. I came up with several helpful measurements to help gauge the relative utility of the rooms.
Here are the indices that I came up with:
TBTA: Trauma Bay Total Area. This is the total square footage (meterage?) measured wall to wall.
TBWA: Trauma Bay Working Area. This is the area that excludes equipment carts next to a wall, and areas under countertops that extend away from the wall.
TBAA: Trauma Bay Available Area. This is the TBWA less any other unusable areas in the room. We have an equipment post near one corner that eats up 16.5 sq ft of space. Also remember to subtract the area taken up by the patient bed, as this area is not available to the trauma team, either.
TBSI: Trauma Bay Space Index. This value is derived by dividing the TBAA by the number of team members in the room. It gives an indication of how much space is available for each trauma team member to work in.
Values in my trauma center:
TBTA: 291 sq ft
TBWA: 220.5 sq ft
TBAA: 186.5 sq ft
What does it all mean? Hard to say without more info from you for comparison. For my team, it means we each have a 4×4 foot square to move around in, on average. This is fairly tight, I would say.
Why don’t you generate some comparison data? Tomorrow is “take a tape measure to work” day! Calculate these constants in your own resuscitation room. Then post them by leaving comments below, or tweet/email me the values for the metrics listed above. If I get enough, I’ll post the data here!
I recently received a reader request regarding trauma bay design. Today, I’ll rerun my article on trauma bay size. Tomorrow, I’ll describe my system for quantifying the space in your trauma bay. Finally, next week I will address equipment layout in the resuscitation room.
Trauma resuscitation rooms vary tremendously. They can range from very spacious…
to very tight…
Most trauma bays that I have visited were somewhere between 225 and 300 square feet (21-28 sq meters), although some were quite large (Rashid Hospital in Dubai at nearly 50 sq meters!).
Interestingly, I did manage to find a set of published guidelines on this topic. The Facility Guidelines Institute (FGI) develops detailed recommendations for the design of a variety of healthcare facilities. Here are their guidelines for adult trauma bays:
Single patient room: The clear floor area should be 250 sq ft (23 sq m), with a minimum clearance of 5 feet on all sides of the patient stretcher.
Multiple patient room: The clear floor area should be 200 sq ft (18.5 sq m) with curtains separating patient areas. Minimum clearance of 5 feet on all sides of the patient stretcher should be maintained.
The FGI “clear floor area” corresponds to my “Trauma Bay Working Area”, which is the area that excludes all the carts, cabinets, and countertops scattered about the usual trauma room. California’s guideline of 280 sq feet seems pretty reasonable as the “Trauma Bay Total Area”, if you can keep your wasted space down to about 30 sq feet.
Bottom line: Once again, don’t try to figure out everything from scratch. Somebody has probably already done it (designed a trauma bay, developed a practice guideline, etc). But remember, a generic guideline or even one developed for a specific institution may not completely fit your situation. In this case, the FGI guidelines say nothing about the trauma team size, which is a critical factor in space planning. Use the work of others as a springboard to jump start your own efforts at solving the problem.